What neonatal complications should the pediatrician be aware of in case of maternal gestational diabetes?

Gestational diabetes-related gut microbiome dysbiosis is not influenced by different Asian ethnicities and dietary interventions: a pilot study

Gut microbiome dysbiosis contributes to the pathophysiology of both gestational diabetes mellitus (GDM) and its associated adverse outcomes in the woman and offspring. Even though GDM prevalence, complications, and outcomes vary among different ethnic groups, limited information is available about the influence of ethnicity on gut microbiome dysbiosis in pregnancies complicated by GDM. This pilot prospective cohort study examined the impact of ethnicity on gut dysbiosis in GDM among three Asian ethnic groups (Chinese, Malay, Indian) living in Singapore, and investigated the potential modulatory roles of diet and lifestyle modifications on gut microbiome post-GDM diagnosis. Women with GDM (n = 53) and without GDM (n = 16) were recruited. Fecal samples were collected at 24-28- and 36-40-weeks' gestation and analyzed by targeted 16S rRNA gene-based amplicon sequencing. Permutational multivariate analysis of variance (PERMANOVA) analysis was performed to evaluate differences between groups. Differentially abundant taxa were identified by DeSeq2 based analysis. Functional prediction was performed using the phylogenetic investigation of communities by reconstruction of unobserved states (PICRUSt2). Among women with GDM, gut microbiome from different ethnicities harbored common microbial features. However, among those without GDM, there was contrasting microbiome composition between ethnic groups. Microbial members such as Collinsella, Blautia, Ruminococcus, Ruminococcus gnavus, Ruminococcus torques, and Eubacterium hallii groups were differentially enriched (p < 0.05) in women with GDM compared to those without. Among women with GDM, no differences in alpha- and beta- diversity were observed when comparing 24-28 weeks' samples with 36-40 weeks' samples, a period covering intense dietary and lifestyle modification, suggesting an inability to modulate gut microbiota through classic GDM management. Women with GDM have a distinct gut microbiome profile which harbours common features across different Asian ethnic groups, consistent with the notion that specific microbes are involved in the pathogenesis of insulin resistance, pro-inflammatory conditions, and other metabolic dysregulation known to be present in GDM.

Maternal Diabetes Mellitus and Neonatal Outcomes in Bisha: A Retrospective Cohort Study

BACKGROUND

Maternal diabetes mellitus (MDM) is associated with increased risks for adverse neonatal outcomes. However, the impact of MDM on neonatal outcomes in Bisha, a city in Saudi Arabia, is not well documented. This study aims to investigate the impact of MDM on neonatal outcomes in the Maternity and Children's Hospital (MCH), Bisha, Saudi Arabia.

METHODS

A retrospective cohort study was conducted on 181 pregnant women with diabetes and their neonates who were diagnosed at the Maternity and Children's Hospital (MCH), Bisha, Saudi Arabia, between 5 October 2020 and 5 November 2022. The primary outcome was a composite of adverse neonatal outcomes, including stillbirth, neonatal death, macrosomia, preterm birth, respiratory distress syndrome, hypoglycemia, and congenital anomalies. Logistic regression analyses were used to adjust for potential confounders.

RESULTS

The total sample size was 181. The average age of patients was 34 years (SD = 6.45). The majority of the patients were diagnosed with GDM, 147 (81.2%), and pre-GDM, 34 (18.8%). Neonates born to mothers with MDM had a higher risk of adverse neonatal outcomes compared to those born to mothers without MDM (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI]: 1.25-1.70). The risks of macrosomia (aOR = 1.74, 95% CI: 1.38-2.19), LBW (aOR = 1.32, 95% CI: 1.06-1.66), and RDS (aOR = 1.57, 95% CI: 1.28-1.93) were significantly higher among neonates born to mothers with MDM. The types of DM were statistically significant in terms of their correlation with the following neonatal outcomes: hypoglycemia (p-value = 0.017), macrosomia (p-value = 0.050), and neonatal death (p-value = 0.017).

CONCLUSIONS

MDM is associated with an increased risk of adverse neonatal outcomes in Bisha. The early identification and management of MDM may improve neonatal outcomes and reduce the burden of neonatal morbidity and mortality in this population.

Development and internal validation of a clinical score to predict neonatal hypoglycaemia in women with gestational diabetes

INTRODUCTION

Gestational diabetes (GD) is a risk factor for neonatal hypoglycaemia (NH), but other factors can increase this risk.

OBJECTIVES

To create a score to predict NH in women with GD.

METHODS

Retrospective study of women with GD with a live singleton birth between 2012 and 2017 from the Portuguese GD registry. Pregnancies with and without NH were compared. A logistic regression was used to study NH predictors. Variables independently associated with NH were used to score derivation. The model's internal validation was performed by a bootstrapping. The association between the score and NH was assessed by logistic regression.

RESULTS

We studied 10216 pregnancies, 410 (4.0%) with NH. The model's AUC was 0.628 (95%CI: 0.599-0.657). Optimism-corrected c-index: 0.626. Points were assigned to variables associated with NH in proportion to the model's lowest regression coefficient: insulin-treatment 1, preeclampsia 3, preterm delivery 2, male sex 1, and small-for-gestational-age 2, or large-for-gestational-age 3. NH prevalence by score category 0-1, 2, 3, 4, and ≥5 was 2.3%, 3.0%, 4.5%, 6.0%, 7.4%, and 11.5%, respectively. Per point, the OR for NH was 1.35 (95% CI: 1.27-1.42). A score of 2, 3, 4, 5 or ≥6 (versus ≤1) had a OR for NH of 1.67 (1.29-2.15), 2.24 (1.65-3.04), 2.83 (2.02-3.98), 3.08 (1.83-5.16), and 6.84 (4.34-10.77), respectively.

CONCLUSION

Per each score point, women with GD had 35% higher risk of NH. Those with ≥6 points had 6.8-fold higher risk of NH compared to a score ≤1. Our score may be useful for identifying women at a higher risk of NH.

Association between foetal sex and adverse neonatal outcomes in women with gestational diabetes

AIMS

Foetal male sex is associated with adverse perinatal outcomes. However, studies evaluating the impact of foetal sex on perinatal outcomes in women with gestational diabetes (GDM) are scarce. We studied whether male new-born sex is associated with neonatal outcomes, in women with GDM.

METHODS

This is a retrospective study based on the national Portuguese register of GDM. All women with live-born singleton pregnancies between 2012 and 2017 were eligible for study inclusion. Primary endpoints under analysis were neonatal hypoglycaemia, neonatal macrosomia, respiratory distress syndrome (RDS) and neonatal intensive care unit (NICU) admission. We excluded women with missing data on the primary endpoint. Pregnancy data and neonatal outcomes between female and male new-borns were compared. Multivariate logistic regression models were built.

RESULTS

We studied 10,768 new-borns in mothers with GDM, 5635 (52.3%) male, 438 (4.1%) had neonatal hypoglycaemia, 406 (3.8%) were macrosomic, 671 (6.2%) had RDS, and 671 (6.2%) needed NICU admission. Male new-borns were more frequently small or large for gestational age. No differences were observed on maternal age, body mass index, glycated haemoglobin, anti-hyperglycaemic treatment, pregnancy complications or gestational age at delivery. In the multivariate regression analysis, male sex was independently associated with neonatal hypoglycaemia [OR 1.26 (IC 95%: 1.04-1.54), p = 0.02], neonatal macrosomia [1.94 (1.56-2.41), p < 0.001], NICU admission [1.29 (1.07-1.56), p = 0.009], and RDS [1.35 (1.05-1.73, p = 0.02].

CONCLUSIONS

Male new-borns have an independent 26% higher risk of neonatal hypoglycaemia, 29% higher risk of NICU admission, 35% higher risk of RDS, and almost twofold higher risk of macrosomia, compared to female new-borns.

Continuous glucose monitoring metrics in pregnancy with type 1 diabetes mellitus

Managing diabetes during pregnancy is challenging, given the significant risk it poses for both maternal and foetal health outcomes. While traditional methods involve capillary self-monitoring of blood glucose level monitoring and periodic HbA1c tests, the advent of continuous glucose monitoring (CGM) systems has revolutionized the approach. These devices offer a safe and reliable means of tracking glucose levels in real-time, benefiting both women with diabetes during pregnancy and the healthcare providers. Moreover, CGM systems have shown a low rate of side effects and high feasibility when used in pregnancies complicated by diabetes, especially when paired with continuous subcutaneous insulin infusion pump as hybrid closed loop device. Such a combined approach has been demonstrated to improve overall blood sugar control, lessen the occurrence of preeclampsia and neonatal hypoglycaemia, and minimize the duration of neonatal intensive care unit stays. This paper aims to offer a comprehensive evaluation of CGM metrics specifically tailored for pregnancies impacted by type 1 diabetes mellitus.

Impact of vitamin D resistance genes on vitamin D deficiency during pregnancy among the South Indian population

Increasing evidence suggests that vitamin D (Vit-D) could be pivotal in maintaining normal glucose homeostasis. Low levels of Vit-D in early pregnancy are associated with a higher risk of gestational diabetes mellitus (GDM). Though several reports have highlighted the prevalence of vit-D deficiency among pregnant women, its underlying cause has not yet been fully elucidated. In this connection, a few studies have found the development of resistance to Vit-D, including the levels of Vitamin D receptor (VDR) and transcription regulators that modify VDR action, as well as the bioavailability of Vit-D. We aimed to determine the levels of Vit-D resistance genes such as 25-HydroxyVit-D-24-hydroxylase (CYP24A1), VDR repressor genes (SNAIL and SMRT) and their association between Vit-D concentrations in early pregnancy, and the risk of gestational diabetes mellitus (GDM). A prospective observational study was conducted on healthy pregnant women (NGDM; n = 50) and GDM (n = 50) attending routine antenatal care at SRM Medical College Hospital, Chennai, recruited at 12 weeks of gestation. We found that the serum levels of Vit-D were low in GDM subjects and negatively correlated with the fasting glucose levels. Further, increased expressions of Vit-D resistance genes such as CYP24A1, SNAIL, and SMRT were observed in GDM subjects and negatively correlated with the serum levels of Vit-D. Furthermore, we have validated the data using the trophoblast cell line, BeWo, exposed to calcitriol under a hyperglycemic environment. Our finding showed that increased expression of Vit-D resistance genes in pregnancy may be associated with a greater risk of adverse pregnancy outcomes, including GDM.

A Critical Review of Diagnostic Strategies and Maternal Offspring Complications in Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is a complex and significant health concern affecting pregnant individuals and their offspring. This review provides a comprehensive examination of GDM, focusing on diagnostic strategies and the associated maternal and offspring complications. We delve into the challenges and controversies surrounding GDM diagnosis, including the variability in diagnostic criteria, diagnostic accuracy and reproducibility issues, ethical considerations, and the influence of ethnicity and genetics. Maternal complications, such as preeclampsia, cesarean sections, long-term health implications, and neonatal complications like macrosomia, hypoglycemia, and respiratory distress syndrome, are explored in detail. Additionally, we investigate the long-term risks of childhood obesity and type 2 diabetes in offspring and potential cognitive and developmental outcomes. This review underscores the critical importance of early detection and effective management of GDM, the need for standardized diagnostic criteria, personalized care plans, and the ongoing pursuit of research to enhance our understanding of this complex condition. GDM remains a dynamic field where ongoing innovation and research promise to improve the health outcomes of pregnant individuals and their children.

Delivery mode and fetal outcome in attempted vaginal deliveries after previous cesarean section: a nationwide register-based cohort study in Finland

PURPOSE

Even though the risks and advantages of repeat Cesarean sections (CSs) and vaginal births after cesarean section (VBACs) are well studied, there is a scarcity of information on the effects of previous CS on maternal and fetal outcomes during subsequent deliveries. The aim of this study is to evaluate delivery mode and fetal outcomes in a trial of labor after cesarean section (TOLAC).

METHODS

In this nationwide retrospective cohort study, data from the National Medical Birth Register (MBR) were used to evaluate the outcomes of TOLACs. TOLACs were compared to the outcomes of the trial of labor after previous successful vaginal delivery. A multivariable logistic regression model was used to assess the primary outcomes (delivery mode, neonatal intensive care unit, and perinatal/neonatal mortality). Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used for comparison.

RESULTS

A total of 29 352 (77.0%) women attempted vaginal delivery in the TOLAC group. In the control group, 169 377 (97.2%) women attempted vaginal delivery. The adjusted odds for urgent CS (aOR 13.05, CI 12.59-13.65) and emergency CS (aOR 3.65, CI 3.26-4.08) were notably higher in the TOLAC group when compared to the control group. The odds for neonatal intensive care unit treatment (aOR 2.05, CI 1.98-2.14), perinatal mortality (aOR 2.15, CI 1.79-2.57), and neonatal mortality (aOR 1.75, CI 1.20-2.49) were higher in the TOLAC group.

CONCLUSIONS

The odds for emergency CS were higher among women who underwent TOLAC. The odds for neonatal intensive care and perinatal mortality were also higher, and further research is needed to identify those expecting women who are better suited for TOLAC to minimize the risk for a neonate. The results of this study should be acknowledged by the mother and the clinician when considering the possibility of vaginal births after cesarean section.

Optimally Controlled Diabetes and Its Influence on Neonatal Outcomes at a Level II Center: A Study on Infants Born to Diabetic Mothers

Background and Objectives: We investigated the effect of optimal maternal glycemic control on neonatal outcomes among infants born to mothers with diabetes. Materials and Methods: In this prospective study, we assessed 88 eligible mothers admitted to the obstetrics department for pregnancy evaluation. Our analysis included 46 infants born to diabetic mothers (IDMs) and 138 infants born to unaffected mothers, all admitted to the Level II Neonatal Intensive Care Unit (NICU). Results: Mothers affected by diabetes were generally older and exhibited a higher body mass index (BMI) and a greater number of gestations, although parity did not differ significantly. Cesarean section emerged as the most frequently chosen mode of delivery. A significantly higher proportion of infants in the affected group presented with respiratory disease (3% vs. 19.5%), which required NICU admission (4.3% vs. 23.9%), phototherapy (18.1% vs. 43.5%), and had congenital heart defects or myocardial hypertrophy (15.2% and 26% vs. 3% and 4.3%) compared to matched controls (p < 0.05). Conclusions: This study underscores the persistence of adverse neonatal outcomes in IDMs, even when maternal glycemic control is optimized. It calls for further investigation into potential interventions and strategies aimed at enhancing neonatal outcomes in this population.

Knowledge on gestational diabetes mellitus and associated factors among pregnant women attending antenatal care clinics of North Shewa zone public hospitals, Oromia region, Central Ethiopia: a cross-sectional study

BACKGROUND

Globally, the prevalence of gestational diabetes mellitus (GDM) is currently rising. Assessing GDM knowledge and taking various public health actions will help pregnant women know more about the condition, resulting in its prevention.

OBJECTIVE

To assess pregnant women's knowledge of GDM and associated factors at antenatal care clinics of public hospitals in the North Shewa zone, Oromia region, Central Ethiopia.

DESIGN

Cross-sectional study.

SETTING

Five public hospitals of North Shewa zone, Oromia regional state, Central Ethiopia.

PARTICIPANTS

A total of 417 pregnant women.

METHODS

A face-to-face interview was conducted. A 13-items tool was used to measure GDM knowledge. Multivariable binary logistic regression was fitted to identify factors associated with the knowledge of GDM. The adjusted OR (AOR) with 95% CI and a p<0.05 was used to determine statistical significance.

RESULTS

Overall, 48% (95% CI 43.4% to 52.8%) of pregnant women had sufficient knowledge about GDM. The level of sufficient knowledge for GDM risk factors, screening/treatment and its consequences were 48%, 54.4% and 99%, respectively. Age group 15-24 years (AOR 3.49, 95% CI 1.05 to 11.59), attending secondary and above education (AOR 4.27, 95% CI 1.29 to 14.070, women whose partners attended primary school (AOR 3.83, 95% CI 1.36 to 10.78), history of GDM (AOR 3.36, 95% CI 1.68 to 6.71), history of hypertension (AOR 2.42, 95% CI 1.21 to 4.84), receiving preconception care (AOR 3.02, 95% CI 1.74 to 5.22) and being multigravida (AOR 3.19, 95% CI 1.52 to 6.67) were factors significantly associated with sufficient knowledge about GDM.

CONCLUSION

Overall, more than half of pregnant women have insufficient knowledge about GDM. Significant association between GDM knowledge and women's age, women's and partners' educational status, preconception care, history of GDM and hypertension, and the number of pregnancies were detected. Therefore, to increase pregnant women's GDM knowledge, health education programmes in the community and healthcare facilities should target the identified factors.

Metabolic and molecular effects of dietary extra virgin olive oil in blood and placenta of women with GDM

Gestational diabetes mellitus (GDM) increases the risks of maternal, placental, and neonatal complications. Previously, we found that a diet enriched in extra virgin olive oil (EVOO) prevents increased maternal triglyceridemia and placental proinflammatory markers in a cohort of GDM patients. The aim of this work was to evaluate maternal circulating markers of insulin resistance, placental collagen, glycogen and lipid levels, and placental levels of proteins, mRNAs, and a microRNA involved in the endocytic pathway in the same cohort of control women and women with GDM who received or did not receive a diet enriched in EVOO (36 g/day) from weeks 24 to 28 of pregnancy until term.

Results

At term, the TG/HDL cholesterol ratio, fatty acid binding protein 4 circulating levels, and maternal BMI were increased in the GDM patients, alterations prevented by the maternal diet enriched in EVOO. Although there were no changes in placental lipid levels and lipid profile, GDM placentas were thicker than controls and showed increased glycogen and collagen content, alterations prevented by the EVOO enriched diet. GDM placentas showed increases in megalin levels, in the expression of several genes involved in the endocytic pathway, and in miR-199, which targets these genes, alterations prevented by the maternal diet enriched in EVOO.

Conclusions

We identified novel beneficial effects of an EVOO-enriched diet in GDM women, a diet capable of regulating maternal insulin resistance, the structure and metabolism of the placenta, and the placental endocytic pathway, suggesting effects that may be beneficial for fetal development.

Increased Apoptosis in Subcortical Regions of The Visual Pathway in Offspring Born to Diabetic Rats

OBJECTIVE

Diabetes in pregnancy is a prevalent disease that can affect the central nervous system of the fetus by hyperglycemia. This study aimed to investigate the impact of maternal diabetes on neuronal apoptosis in the superior colliculus (SC) and the lateral geniculate nucleus (LGN) in male neonates born to diabetic mothers.

MATERIALS AND METHODS

In this experimental study, female adult rats were separated into three groups: control, diabetic (induced using an intraperitoneal injection of streptozotocin), and insulin-treated diabetic [diabetes controlled by subcutaneous neutral protamine hagedorn (NPH)-insulin injection]. Male neonates from each group were euthanized on 0, 7, and 14 postnatal days (P0, P7, and P14, respectively), and apoptotic cells were identified using TUNEL staining.

RESULTS

The numerical density per unit area (NA) of apoptotic cells was significantly higher in SC and the dorsal LGN (dLGN) in neonates born to the diabetic rats compared to the control group at P0, P7, and P14. However, insulin treatment normalized the number of apoptotic cells.

CONCLUSION

This study demonstrated that maternal diabetes increased apoptosis in dLGN and SC of male neonates at P0, P7, and P14.

Intracranial hemorrhages in infants of diabetic mothers: A national cohort study

OBJECTIVE

To assess the association of maternal diabetes mellitus (DM) with intraventricular hemorrhage (IVH) and other intracranial hemorrhages (ICH) in newborns.

STUDY DESIGN

We analyzed the National Inpatient Sample dataset and compared prevalence of IVH and other subtypes of ICH in infants of diabetic mothers (IDMs) vs. those born to mothers without DM. Regression models were used to control for demographic and clinical confounding variables.

RESULT

A total of 11,318,691 infants were included. Compared to controls, IDMs had increased prevalence of IVH (aOR = 1.18, CI: 1.12-1.23, p < 0.001) and other ICH (aOR = 1.18, CI: 1.07-1.31, p = 0.001). Severe IVH (grades 3 & 4) was encountered less frequently in IDMs (aOR = 0.75, CI: 0.66-0.85, p < 0.001) than controls. Gestational DM was not associated with increased IVH after controlling for the demographic, clinical and perinatal confounders in the logistic regression model (aOR = 1.04, CI: 0.98-1.11, p = 0.22).

CONCLUSION

Chronic maternal DM is associated with increased neonatal IVH and other ICH but not severe IVH. This association needs to be confirmed in further studies.

Cardiometabolic effects of breastfeeding on infants of diabetic mothers

BACKGROUND

Breast milk is the best and principal nutritional source for neonates and infants. It may protect infants against many metabolic diseases, predominantly obesity and type 2 diabetes. Diabetes mellitus (DM) is a chronic metabolic and microvascular disease that affects all the body systems and all ages from intrauterine life to late adulthood. Breastfeeding protects against infant mortality and diseases, such as necrotizing enterocolitis, diarrhoea, respiratory infections, viral and bacterial infection, eczema, allergic rhinitis, asthma, food allergies, malocclusion, dental caries, Crohn's disease, and ulcerative colitis. It also protects against obesity and insulin resistance and increases intelligence and mental development. Gestational diabetes has short and long-term impacts on infants of diabetic mothers (IDM). Breast milk composition changes in mothers with gestational diabetes.

AIM

To investigate the beneficial or detrimental effects of breastfeeding on the cardiometabolic health of IDM and their mothers.

METHODS

We performed a database search on different engines and a thorough literature review and included 121 research published in English between January 2000 and December 15, 2022, in this review.

RESULTS

Most of the literature agreed on the beneficial effects of breast milk for both the mother and the infant in the short and long terms. Breastfeeding protects mothers with gestational diabetes against obesity and type 2 DM. Despite some evidence of the protective effects of breastfeeding on IDM in the short and long term, the evidence is not strong enough due to the presence of many confounding factors and a lack of sufficient studies.

CONCLUSION

We need more comprehensive research to prove these effects. Despite many obstacles that may enface mothers with gestational diabetes to start and maintain breastfeeding, every effort should be made to encourage them to breastfeed.

Influence of Adipose Tissue on Early Metabolic Programming: Conditioning Factors and Early Screening

BACKGROUND

Obesity and being overweight have become one of the world's most severe health issues, not only because of the pathology but also because of the development of related comorbidities. Even when children reach adulthood, the mother's environment during pregnancy has been found to have a significant impact on obesity prevention in children. Thus, both maternal dietary habits and other factors such as gestational diabetes mellitus, excessive weight gain during pregnancy, smoking, or endocrine factors, among others, could influence newborn growth, adiposity, and body composition at birth, in childhood and adolescence, hence programming health in adulthood.

METHODS

The aim of this review is to analyze the most recent human studies on the programming of fetal adipose tissue to determine which modifiable factors may influence adiposity and thus prevent specific disorders later in life by means of a bibliographic review of articles related to the subject over the last ten years.

CONCLUSIONS

The importance of a healthy diet and lifestyle not only during pregnancy and the first months of life but also throughout childhood, especially during the first two years of life as this is a period of great plasticity, where the foundations for optimal health in later life will be laid, preventing the emergence of noncommunicable diseases including obesity, diabetes mellitus type 2, hypertension, being overweight, and any other pathology linked to metabolic syndrome, which is so prevalent today, through health programs beginning at a young age.

Platelets and endothelial dysfunction in gestational diabetes mellitus

The prevalence of gestational diabetes mellitus (GDM) has increased in recent years, along with the higher prevalence of obesity in women of reproductive age. GDM is a pathology associated with vascular dysfunction in the fetoplacental unit. GDM-associated endothelial dysfunction alters the transfer of nutrients to the foetus affecting newborns and pregnant women. Various mechanisms for this vascular dysfunction have been proposed, of which the most studied are metabolic alterations of the vascular endothelium. However, different cell types are involved in GDM-associated endothelial dysfunction, including platelets. Platelets are small, enucleated cell fragments that actively take part in blood haemostasis and thrombus formation. Thus, they play crucial roles in pathologies coursing with endothelial dysfunction, such as atherosclerosis, cardiovascular diseases, and diabetes mellitus. Nevertheless, platelet function in GDM is understudied. Several reports show a potential relationship between platelet volume and mass with GDM; however, platelet roles and signaling mechanisms in GDM-associated endothelial dysfunction are unclear. This review summarizes the reported findings and proposes a link among altered amount, volume, mass, reactivity, and function of platelets and placenta development, resulting in fetoplacental vascular dysfunction in GDM.

Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

BACKGROUND

Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation.

OBJECTIVE

Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 minute Apgar score <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P<.05.

RESULTS

Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P<.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P<.0001).

CONCLUSION

Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

Common pregnancy complications and polyphenols intake: an overview

During pregnancy, the body undergoes a great amount of changes in order to support a healthy developing fetus. In this context, maternal dietary supplementation is widely encouraged to provide adequate nutrition for the newborn. In the past few years, studies have emerged highlighting the benefits of polyphenols intake during pregnancy. Indeed, despite differences among reports, such as experimental model, polyphenol employed, dosage and regimen of administration, there is no doubt that the ingestion of these molecules has a protective effect in relation to three pregnancy-associated diseases or conditions: preeclampsia, gestational diabetes and fetal growth restriction. In this review, we describe the effects of different polyphenols and polyphenol-rich extracts or juices on the main outcomes of these common pregnancy-associated complications, obtained in human, animal and in vitro studies. Therefore, this work provides a critical analysis of the literature, and a summary of evidences, from which future research using polyphenols can be designed and evaluated.

Bilious Emesis and Failure to Pass Meconium in the Nursery: A Case Study

We present a case of an infant born to a mother with COVID-19, who at 24 hours of life was treated with a glycerin suppository for failure to pass meconium and went on to develop bilious emesis and abdominal distention as feeding continued over the next several hours. After a barium enema identified the distal obstruction, the pediatric surgical team used rectal irrigation to remove a large meconium plug, which mimicked the appearance of the descending colon on plain film, in a case of small left colon syndrome. Although intestinal obstruction in the newborn is rare, it is imperative that it is promptly diagnosed and treated appropriately to avoid negative outcomes; which, even in perhaps the mildest form of functional distal obstruction, meconium plug syndrome, can lead to an impressive clinical illness with risk of intestinal perforation and subsequent meconium peritonitis if the obstruction is not relieved.

Association between microbial composition, diversity, and function of the maternal gastrointestinal microbiome with impaired glucose tolerance on the glucose challenge test

Over the last two decades, the incidence of gestational diabetes (GDM) has almost doubled resulting in almost 9% of pregnant women diagnosed with GDM. Occurring more frequently than GDM is impaired glucose tolerance (IGT), also known as pre-diabetes, but it has been understudied during pregnancy resulting in a lack of clinical recommendations of maternal and fetal surveillance. The purpose of this retrospective, cross-sectional study was to examine the association between microbial diversity and function of the maternal microbiome with IGT while adjusting for confounding variables. We hypothesized that reduced maternal microbial diversity and increased gene abundance for insulin resistance function will be associated with IGT as defined by a value greater than 140 mg/dL on the glucose challenge test. In the examination of microbial composition between women with IGT and those with normal glucose tolerance (NGT), we found five taxa which were significantly different. Taxa higher in participants with impaired glucose tolerance were Ruminococcacea (p = 0.01), Schaalia turicensis (p<0.05), Oscillibacter (p = 0.03), Oscillospiraceae (p = 0.02), and Methanobrevibacter smithii (p = 0.04). When we further compare participants who have IGT by their pre-gravid BMI, five taxa are significantly different between the BMI groups, Enterobacteriaceae, Dialister micraerophilus, Campylobacter ureolyticus, Proteobacteria, Streptococcus Unclassified (species). All four metrics including the Shannon (p<0.00), Simpson (p<0.00), Inverse Simpson (p = 0.04), and Chao1 (p = 0.04), showed a significant difference in alpha diversity with increased values in the impaired glucose tolerance group. Our study highlights the important gastrointestinal microbiome changes in women with IGT during pregnancy. Understanding the role of the microbiome in regulating glucose tolerance during pregnancy helps clinicians and researchers to understand the importance of IGT as a marker for adverse maternal and neonatal outcomes.

Impact of a tailored-care education programme on maternal and neonatal outcomes in pregnant women with gestational diabetes: a randomized controlled trial

Introduction

patient education is a key component of positive pregnancy and childbearing experiences, especially in women with gestational diabetes (GDM). Scant studies assessed the impact of tailored self-care education on pregnancy outcomes in pregnant women with gestational diabetes mellitus (GDM). This study aimed to assess the effect of a tailored-care education programme on maternal and neonatal outcomes in pregnant women with GDM during pregnancy and at birth.

Methods

this was a randomized controlled trial conducted in a university hospital in the centre of Tunisia, from October 2020 to May 2021. The intervention group (n=61) received a self-care education programme with the usual care plan for GDM, while the control group received only the usual care plan (n=60). This trial was registered in the Pan African Clinical Trials Registry under the registration number PACTR202106591503674.

Results

at baseline, there was no significant difference between groups in terms of sociodemographic and clinical characteristics. The findings showed that the intervention significantly reduced maternal and neonatal hospitalizations (p=0.000), caesarean section (p=0.002), preterm labour (p=0.002), macrosomia (p=0.000), foetal distress (p=0.001), newborn respiratory complication (p=0.01) and hypoglycaemia (p=0.000).

Conclusion

implementing a tailored-care education for pregnant women with GDM had a positive impact on mother and infant clinical outcomes. Midwives and endocrinologists should use this programme to reduce maternal and neonatal complications during and after pregnancy.

Cardiac Troponin T in Neonates from Normal and Gestational Diabetes Mellitus Pregnancy

This study is aimed at testing the hypothesis that serum analysis of high-sensitivity troponin T in neonates may serve as a diagnostic tool to predict the risk of gestational diabetes mellitus (GDM). 86 newborns were studied and stratified into two groups: healthy group; newborns with body weight ≥ 10th percentile, born in good condition (APG 8-10pts) of pregnancy not complicated by diabetes, and the GDM group; neonates born to mothers with type 1 or type 2 diabetes. Results. The study revealed minimal troponin levels in GDM, and healthy groups equal to 0.02 ng/mL and 0.028 ng/mL, respectively. The GDM group is defined by an interquartile range of hs-TnT higher than the healthy group. This study confirms previously reported upper levels of troponin in healthy children. There are possible health problems that can appear during infancy and influence the further development of a child affected by GDM.

The link between gestational diabetes and cardiovascular diseases: potential role of extracellular vesicles

Extracellular vesicles are critical mediators of cell communication. They encapsulate a variety of molecular cargo such as proteins, lipids, and nucleic acids including miRNAs, lncRNAs, circular RNAs, and mRNAs, and through transfer of these molecular signals can alter the metabolic phenotype in recipient cells. Emerging studies show the important role of extracellular vesicle signaling in the development and progression of cardiovascular diseases and associated risk factors such as type 2 diabetes and obesity. Gestational diabetes mellitus (GDM) is hyperglycemia that develops during pregnancy and increases the future risk of developing obesity, impaired glucose metabolism, and cardiovascular disease in both the mother and infant. Available evidence shows that changes in maternal metabolism and exposure to the hyperglycemic intrauterine environment can reprogram the fetal genome, leaving metabolic imprints that define life-long health and disease susceptibility. Understanding the factors that contribute to the increased susceptibility to metabolic disorders of children born to GDM mothers is critical for implementation of preventive strategies in GDM. In this review, we discuss the current literature on the fetal programming of cardiovascular diseases in GDM and the impact of extracellular vesicle (EV) signaling in epigenetic programming in cardiovascular disease, to determine the potential link between EV signaling in GDM and the development of cardiovascular disease in infants.

Association between gestational abnormal glucose tolerance and maternal-fetal outcomes

AIM

To investigate the relationship between abnormal glucose tolerance during pregnancy and maternal-fetal outcomes, after categorizing women into groups with different levels of gestational abnormal glucose tolerance.

METHODS

A total of 1858 pregnant women who received two-step screening for gestational diabetes mellitus (GDM) at Fooyin University Hospital were categorized into four groups, according to their glucose abnormalities, and their maternal-fetal outcomes were investigated from October 2015 to June 2020.

RESULTS

Among the groups having different levels of abnormal glucose tolerance, there were significant differences and trends in mother's age, currently married status, and prepregnancy overweight or obesity, incidences of cesarean section, preterm, and gestational hypertension or preeclampsia; and with respect to neonatal incidence of large for gestational age (LGA), average weight, and average height (p < 0.05). After adjusting for potential factors, there were higher incidences of cesarean section (AOR = 1.71; 95% confidence interval [CI]: 1.12-2.61), preterm (AOR = 2.20; 95% CI: 1.23-3.91), neonatal LGA (AOR = 4.94; 95% CI: 2.87-8.51), and neonatal intensive care unit (NICU) admission (AOR = 2.66; 95% CI: 1.14-6.24) in the GDM group, relative to the control group. Furthermore, the women in the oral glucose tolerance test (OGTT)-1 group had a higher incidence of neonatal LGA when compared with the women in the normal group (AOR = 2.31; 95% CI: 1.02-5.33).

CONCLUSIONS

We found higher incidences of cesarean section, preterm, and neonatal LGA and NICU admission in the GDM women, and a higher incidence of neonatal LGA in the OGTT-1 group, relative to control group.

The Influence of HbA1c and Gestational Weight Gain on Pregnancy Outcomes in Pregnant Women With Gestational Diabetes Mellitus

Background

To investigate the influence of HbA1c level and GWG on pregnancy outcomes in pregnant women with GDM.

Methods

A total of 2,171 pregnant women with GDM were retrospectively included and categorized as follows: (1) normal (HbA1c <6%) and elevated (HbA1c ≥6%) HbA1c groups according to the HbA1c level in the second trimester, and (2) inadequate, appropriate, and excessive GWG groups according to the IOM guidelines.

Results

In pregnant women with GDM, advanced age and high pre-pregnancy BMI were high-risk factors for elevated HbA1c. Pregnant women with elevated HbA1c had higher OGTT levels than those with normal HbA1c, and the risks of adverse pregnancy outcomes were higher (P < 0.05). The risks of primary cesarean section, hypertensive disorders during pregnancy, and macrosomia in pregnant women with excessive GWG were significantly higher than those with inadequate and appropriate GWG (P < 0.05). When GWG was appropriate, the risk of hypertensive disorders during pregnancy in the elevated HbA1c group was higher than that in the normal HbA1c group. When GWG was excessive, the risks of postpartum hemorrhage, macrosomia, and neonatal asphyxia in the elevated HbA1c group were significantly higher than in the normal HbA1c group (P < 0.05).

Conclusion

Monitoring and controlling blood glucose levels have shown effectiveness in reducing the adverse pregnancy outcomes in women with GDM, particularly for those who had excessive GWG.

Outcomes of Moderately Preterm Infants of Insulin-Dependent Diabetic Mothers

OBJECTIVE

 Little is known about the hospital outcomes of moderately preterm (MPT; 29 0/7-33 6/7 weeks gestational age) infants born to insulin-dependent diabetic mothers (IDDMs). We evaluated characteristics and outcomes of MPT infants born to IDDMs compared with those without IDDM (non-IDDM).

STUDY DESIGN

 Cohort study of infants from 18 centers included in the MPT infant database from 2012 to 2013. We compared characteristics and outcomes of infants born to IDDMs and non-IDDMs.

RESULTS

 Of 7,036 infants, 527 (7.5%) were born to IDDMs. Infants of IDDMs were larger at birth, more often received continuous positive pressure ventilation in the delivery room, and had higher risk of patent ductus arteriosus (adjusted relative risk or aRR: 1.49, 95% confidence interval [CI]: 1.20-1.85) and continued hospitalization at 40 weeks postmenstrual age (aRR: 1.55, 95% CI: 1.18-2.05).

CONCLUSION

 MPT infants of IDDM received more respiratory support and prolonged hospitalizations, providing further evidence of the important neonatal health consequences of maternal diabetes.

KEY POINTS

· Little data are available on moderate preterm infants of IDDMs.. · MPT infants of IDDMs need more respiratory support.. · Longer neonatal intensive care unit stays among MPT infants of IDDMs..

Cardio-Obstetrics: the Next Frontier in Cardiovascular Disease Prevention

Purpose of Review

Internationally, cardiovascular disease (CVD) is the leading cause of death in women. With risk factors for CVD continuing to rise, early identification and management of chronic diseases such as hypertension, diabetes, and obstructive sleep apnea is necessary for prevention. Pregnancy is a natural stress test for women with risk factors who may be predisposed to CVD and offers a unique opportunity to not only recognize disease but also implement effective and long-lasting strategies for prevention.

Recent Findings

Prevention begins before pregnancy, as preconception screening, counseling, and optimization of chronic diseases can improve maternal and fetal outcomes. Throughout pregnancy, women should maintain close follow-up, continued reevaluation of risk factors, with counseling when necessary. Continued healthcare engagement during the “fourth trimester,” 3 months following delivery, allows clinicians to continue monitoring the evolution of chronic diseases, encourage ongoing lifestyle counseling, and connect women with primary care and appropriate specialists if needed. Unfortunately, this postpartum period represents a major care gap, as a significant proportion of most women do not attend their scheduled visits. Social determinants of health including decreased access to care and economic instability lead to increased risk factors throughout pregnancy but particularly play a role in poor compliance with postpartum follow-up. The use of telemedicine clinics and remote monitoring may prove to be effective interventions, bridging the gap between physicians and patients and improving follow-up for at-risk women.

Summary

While many clinicians are beginning to understand the impact of CVD on women, screening and prevention strategies are not often implemented until much later in life. Pregnancy creates an opportunity to begin engaging women in cardiovascular protective strategies before the development of the disease.

Delayed secretory activation and low milk production in women with gestational diabetes: a case series

Background

Gestational diabetes mellitus (GDM) is major pregnancy complication that is associated with short- and long-term consequences for both mother and infant, including increased risk of diabetes later in life. A longer breastfeeding duration has been associated with a reduced risk of diabetes, however, women with GDM are less likely to exclusively breastfeed and have shorter breastfeeding duration. While the timing of breastfeeding initiation and milk removal frequency affects subsequent breastfeeding outcomes, little is known about early infant feeding practices and milk production in women with GDM. This case series offers detailed prospective breastfeeding initiation data, as well as the first report of objective measures of milk production in women with GDM.

Case presentation

In this case series, we present the early infant feeding practices of eight women with GDM that gave birth at term gestation. Women recorded the timing of initiation of breastfeeding and secretory activation, as well as their breastfeeding, expression and formula feeding frequencies on postpartum days 1, 7 and 21. Measurement of 24 h milk production volume was performed at 3 weeks postpartum using the test weight method. We observed a delayed first breastfeed (> 1 h) in 6 (75%) cases, formula use in hospital in 5 (63%) cases and delayed secretory activation in 3 (38%) cases. At 3 weeks postpartum, 2 cases had measured milk productions that were insufficient to sustain adequate infant weight gain.

Conclusions

Our data suggest that despite early and frequent milk removal, women with GDM are at greater risk of delayed secretory activation and low milk supply. Cohort studies that consider co-morbidities such as obesity are needed to determine the lactation outcomes of women with GDM.

Maternal and newborn effects of gestational diabetes mellitus: A prospective cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) is a high glucose level detected during pregnancy and usually it disappears after 42 days of post partum. The aim of this research was to assess the maternal and newborn effects of GDM in resource limited settings.

METHODS

A prospective cohort was implemented in the five referral hospitals of Amhara region. Data were collected using both primary data collection tool and reviewing the patients' charts. Descriptive statistics were used to describe the effects of GDM on the pregnancy outcomes, fractional regression was used to estimate the proportion of weight gain in the first 3 months, Poisson regression was used to identify the effects of GDM on the episodes of childhood infectious diseases, independent sample t-test was used to estimate the effects of GDM on the newborn serum zinc and vitamin D levels.

RESULTS

A total of 3459 women were included with a response rate of 85.56%. Cesarean section rate among GDM mother was 40.3% and among GDM free mothers was 7.1%. In the first 3 months, the weight gains of infant born from GDM mothers were 53% higher than infant born from GDM free mothers. GDM increases the risk of infectious disease episodes by 4 folds. GDM decreases the neonatal serum zinc and vitamin D levels.

CONCLUSION

GDM increases the maternal complications of pregnancy; GDM significantly depletes the newborn micronutrient levels and increase the episodes of infectious diseases during the infancy periods.

Management of neonatal complications of macrosomia: A case report at a tertiary hospital in a developing country

Fetal macrosomia can present with numerous complications. We report a case of a term baby girl with a birthweight of 5.31 kg admitted with respiratory distress and suffered several complications of macrosomia. There is a need to closely monitor neonates for early diagnosis and management of complications of macrosomia.

Prevalence and Trends in Gestational Diabetes Mellitus Among Women in the United States, 2006-2017: A Population-Based Study

The prevalence of gestational diabetes mellitus (GDM) has increased with the increasing rate of obesity. However, national data on the prevalence and secular trends of GDM during the past decade in the United States are lacking. This study included 37,357 women aged more than 18 years and who had ever been pregnant from the National Health Interview Survey (NHIS). We examined GDM prevalence in 2006, 2016, and 2017, with age-standardized to the US population in 2000. We found that the prevalence of GDM per 100 people increased from 4.6 (95% CI, 4.1-5.1) in 2006 to 8.2 (95% CI, 7.5-8.9) in 2016 (test for difference; P <0.001), with a relatively increased rate of 78%. Non-Hispanic white women tended to have a lower increase (2.8%) than non-Hispanic black women (3.8%), Hispanic women (4.1%), and women of other race/ethnicity (8.4%). The prevalence of GDM in non-Hispanic white women was higher than that in non-Hispanic black women in 2006 (4.8% vs 3.5%, P = 0.006); such differences became non-significant in 2016 (P = 0.72). Additionally, the increase of GDM from 2006 to 2016 tended to be more evident among women who were overweight (25≤ BMI ≤30 kg/m²), physically inactive, and with family income below the poverty threshold than women in other BMI ranges, with more physical activity, and with higher incomes. The prevalence of GDM per 100 people in 2017 was 8.4 (7.6-9.2), and there was no significant change in the overall and subgroup prevalence compared with 2016. Collectively, in the United States, the prevalence of GDM continuously increased, nearly doubled, from 2006 to 2016, and then leveled off in 2017. The increase appeared more marked among the minority populations and subpopulations with overweight people, insufficient activity, and family incomes below the poverty threshold.

Downregulation of large-conductance Ca2+-activated K+ channels in human umbilical arterial smooth muscle cells in gestational diabetes mellitus

AIMS

We investigated the changes in large-conductance Ca²⁺-activated K⁺ (BK_Ca) channels from human umbilical arterial smooth muscle cells experiencing gestational diabetes mellitus (GDM).

MAIN METHODS

Whole-cell patch-clamp technique, arterial tone measurement, RT-PCR, Quantitative real-time PCR, western blot were performed in human umbilical arterial smooth muscle cells.

KEY FINDINGS

Whole-cell BK_Ca current density was decreased in the GDM group compared with the normal group. The vasorelaxant effects of the synthetic BK_Ca channel activator NS-1619 (10 μM) were impaired in the GDM group compared with the normal group. Reverse-transcription polymerase chain reaction (RT-PCR), real-time RT-PCR, and western blot analyses suggested that the mRNA, total RNA, and protein expression levels of the BK_Ca channel were decreased in the GDM group relative to the normal group. In addition, the expression levels of protein kinase A and protein kinase G, which regulate BK_Ca channel activity, remained unchanged between the groups. Applying the BK_Ca channel inhibitor paxilline (10 μM) induced vasoconstriction and membrane depolarization of isolated umbilical arteries in the normal group but showed less of an effect on umbilical arteries in the GDM group.

SIGNIFICANCE

Our results demonstrate for the first time impaired BK_Ca current and BK_Ca channel-induced vasorelaxation activities that were not caused by impaired BK_Ca channel-regulated protein kinases, but by decreased expression of the BK_Ca channels, in the umbilical arteries of GDM patients.

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.

Effectiveness of carbohydrate counting and Dietary Approach to Stop Hypertension dietary intervention on managing Gestational Diabetes Mellitus among pregnant women who used metformin: A randomized controlled clinical trial

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common complication of pregnancy that has significant impacts on both mother and her offspring health. The present study aimed to examine the effect of carbohydrate counting, carbohydrate counting combined with DASH, and control dietary interventions on glycemic control, and maternal and neonatal outcomes.

METHODS

A total of 75 pregnant women with GDM at 24th - 30th week of gestation were enrolled and randomized to follow one of the three diets: control or carbohydrate counting, or carbohydrate counting combined with Dietary Approach to Stop Hypertension (DASH). Only 70 of them completed the study until delivery. Fasting blood samples were taken at baseline and the end of the study to measure fasting blood glucose (FBG), fasting insulin, glycated hemoglobin (HbA1c), and fructosamine. Homeostatic model assessment-insulin resistance (HOMA-IR) score was calculated using HOMA2 calculator program. The participants recorded at least four blood glucose readings per day. Maternal and neonatal outcomes were collected from medical records. Dietary intake was assessed by three-day food records at the baseline and the end of the study.

RESULTS

Adherence to the three dietary interventions, resulted in decreased FBG levels significantly among all the participants (P < 0.05). Consumption of the carbohydrate counting combined with the DASH diet showed significant reduction in serum insulin levels and HOMA-IR score compared to carbohydrate counting group and control group. Means of fructosamine and HbA1c did not differ significantly among the three intervention diet groups. Overall mean of 1-h postprandial glucose (1 h PG) level was significantly lower in the carbohydrate counting combined with DASH group compared with that in the carbohydrate counting group and the control group (P < 0.001). The number of women who were required to commence insulin therapy after dietary intervention was significantly lower in carbohydrate counting group and carbohydrate counting combined with DASH group (P = 0.026). There were no significant differences in other maternal and neonatal outcomes among the three dietary intervention groups.

CONCLUSIONS

The carbohydrate counting and the carbohydrate counting combined with DASH dietary interventions resulted in beneficial effects on FBG and 1 h PG compared with the control diet. The three dietary interventions produced similar maternal and neonatal outcomes in women with GDM.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov under the identification code: NCT03244579. https://clinicaltrials.gov/ct2/show/NCT03244579.

Acetone Ingestion Mimics a Fasting State to Improve Glucose Tolerance in a Mouse Model of Gestational Hyperglycemia

Gestational diabetes mellitus results, in part, from a sub-optimal β-cell mass (BCM) during pregnancy. Artemisinins were reported to increase BCM in models of diabetes by α- to β-cell conversion leading to enhanced glucose tolerance. We used a mouse model of gestational glucose intolerance to compare the effects of an artemisinin (artesunate) on glycemia of pregnant mice with vehicle treatment (acetone) or no treatment. Animals were treated daily from gestational days (GD) 0.5 to 6.5. An intraperitoneal glucose tolerance test was performed prior to euthanasia at GD18.5 or post-partum. Glucose tolerance was significantly improved in both pregnant and non-pregnant mice with both artesunate and vehicle-alone treatment, suggesting the outcome was primarily due to the acetone vehicle. In non-pregnant, acetone-treated animals, improved glucose tolerance was associated with a higher BCM and a significant increase in bihormonal insulin and glucagon-containing pancreatic islet cells, suggesting α- to β-cell conversion. BCM did not differ with treatment during pregnancy or post-partum. However, placental weight was higher in acetone-treated animals and was associated with an upregulation of apelinergic genes. Acetone-treated animals had reduced weight gain during treatment despite comparable food consumption to non-treated mice, suggesting transient effects on nutrient uptake. The mean duodenal and ileum villus height was reduced following exposure to acetone. We conclude that acetone treatment may mimic transient fasting, resulting in a subsequent improvement in glucose tolerance during pregnancy.

Metabolites involved in purine degradation, insulin resistance, and fatty acid oxidation are associated with prediction of Gestational diabetes in plasma

INTRODUCTION

Gestational diabetes mellitus (GDM) significantly increases maternal and fetal health risks, but factors predictive of GDM are poorly understood.

OBJECTIVES

Plasma metabolomics analyses were conducted in early pregnancy to identify potential metabolites associated with prediction of GDM.

METHODS

Sixty-eight pregnant women with overweight/obesity from a clinical trial of a lifestyle intervention were included. Participants who developed GDM (n = 34; GDM group) were matched on treatment group, age, body mass index, and ethnicity with those who did not develop GDM (n = 34; Non-GDM group). Blood draws were completed early in pregnancy (10-16 weeks). Plasma samples were analyzed by UPLC-MS using three metabolomics assays.

RESULTS

One hundred thirty moieties were identified. Thirteen metabolites including pyrimidine/purine derivatives involved in uric acid metabolism, carboxylic acids, fatty acylcarnitines, and sphingomyelins (SM) were different when comparing the GDM vs. the Non-GDM groups (p < 0.05). The most significant differences were elevations in the metabolites' hypoxanthine, xanthine and alpha-hydroxybutyrate (p < 0.002, adjusted p < 0.02) in GDM patients. A panel consisting of four metabolites: SM 14:0, hypoxanthine, alpha-hydroxybutyrate, and xanthine presented the highest diagnostic accuracy with an AUC = 0.833 (95% CI: 0.572686-0.893946), classifying as a "very good panel".

CONCLUSION

Plasma metabolites mainly involved in purine degradation, insulin resistance, and fatty acid oxidation, were altered in early pregnancy in connection with subsequent GDM development.

Plant-based snacking: research and practical applications of pistachios for health benefits

Pistachio nuts are a nutrient-dense source of good quality plant protein, commonly consumed as a minimally processed snack food or ingredient. The present paper is based on a symposium held during the 13th FENS (Federation of European Nutrition Societies) 2019 conference in Dublin that explored recent research and practical applications of pistachios as a plant-based snack, in particular, for appetite control and healthy weight management; and for glycaemic control during pregnancy. Individual nut types, whilst similar in nutritional composition, have unique characteristics which may have a significant impact on potential health effects. Recognising this, the further purpose here is to explore future research needs for pistachios, based on work completed to date and the discussion that ensued among researchers at this event, in order to advance the full scope of health benefits from pistachios, in particular, taking into account of both sustainability and nutritional health.

Epicardial fat thickness in infants of diabetic mothers

BACKGROUND

Epicardial fat thickness (EFT) in adults and children has been related to the metabolic syndrome and other cardiovascular risk factors; however, scarce studies have evaluated it in infants of diabetic mothers (IDM) in whom, alterations in the thickness of the interventricular septum have been reported. This study compares the EFT in IDM versus infants of non-diabetic mothers (INDM) and its association with others echocardiographic parameters.

METHODS

We performed a cross sectional study in 93 infants (64 IDM and 29 INDM). To evaluate EFT dimensions, an echocardiogram was performed within the first 24h of extrauterine life in both groups. In diabetic mothers, HbA1c was also determined.

RESULTS

There was no significant difference in birth weight between the groups although gestational age was lower in IDM. The EFT (3.6 vs. 2.5 mm, p <  0.0001), the interventricular septum thickness (IVST) (6.2 vs. 5.2 mm, p <  0.0001) and the IVST / left ventricle posterior wall (1.3 vs. 1.1, p = 0.001) were higher in the IDM; while the left ventricular expulsion fraction [LVFE] (71.1 vs. 77.8; p <  0.0001) was lower than in the INDM, respectively. We found a positive correlation between EFT with IVST (r = 0.577; p = 0.0001), LVPW (r = 0.262; p = 0.011), IVST/LVPW index (r = 0.353; p = 0.001), and mitral integral early velocity (r = 0.313; p = 0.002), while a negative correlation with LVFE was observed (r = -0.376; p = 0.0001).

CONCLUSIONS

The EFT is higher in IDM than in INDM. It was positively related with echocardiographic parameters of left ventricular thickness and negatively with left ventricular ejection function.

Metabolic Adaptations to Pregnancy in Healthy and Gestational Diabetic Pregnancies: The Pancreas - Placenta Axis

Normal pregnancy is associated with increased insulin resistance as a metabolic adaptation to the nutritional demands of the placenta and fetus, and this is amplified in obese mothers. Insulin resistance is normally compensated for by an adaptive increase in pancreatic β-cell mass together with enhanced glucose-stimulated insulin release. Placentally-derived hormones and growth factors are central to the altered pancreatic morphology and function. A failure of β-cells to undergo adaptive change after the first trimester has been linked with gestational diabetes. In the pregnant mouse, an increase in β-cell replication contributes to a 2-3-fold increase in mass peaking in late gestation, depending on the proliferation of existing β-cells, the differentiation of resident progenitor β-cells, or islet cell transdifferentiation. Using mouse models and human studies placenta- and islet of Langerhans-derived molecules have been identified that are likely to contribute to the metabolic adaptations to pregnancy and whose physiology is altered in the obese, glucose-intolerant mother. Maternal obesity during pregnancy can create a pro-inflammatory environment that can disrupt the response of the β-cells to the endocrine signals of pregnancy and limit the adaptive changes in β-cell mass and function, resulting in an increased risk of gestational diabetes.

Antenatal Corticosteroids: Extending the Practice for Late-Preterm and Scheduled Early-Term Deliveries?

Respiratory distress in late-preterm and early term infants generally may warrant admission to a special care nursery or an intensive care unit. In particular, respiratory distress syndrome and transient tachypnea of the newborn are the two most common respiratory morbidities. Antenatal corticosteroids (ACS) facilitate surfactant production and lung fluid resorption. The use of ACS has been proven to be beneficial for preterm infants delivered at less than 34 weeks' gestation. Literature suggests that the benefits of giving antenatal corticosteroids may extend to late-preterm and early term infants as well. This review discusses the short-term benefits of ACS administration in reducing respiratory morbidities, in addition to potential long term adverse effects. An update on the current practices of ACS use in pregnancies greater than 34 weeks' gestation and considerations of possibly extending versus restricting this practice to certain settings will also be provided.

Lactoferrin and Immunoglobulin Concentrations in Milk of Gestational Diabetic Mothers

Gestational diabetes mellitus (GDM) is associated with an increased risk of having a high-care newborn and has an impact on maternal wellbeing. This study aimed to assess the effect of GDM on the lactoferrin (LF), secretory immunoglobulin A (SIgA), immunoglobulin G (IgG), and immunoglobulin M (IgM) concentrations in early colostrum, colostrum, and transitional milk samples of hyperglycemic (n = 53) and normoglycemic (n = 49) mothers using enzyme-linked immunosorbent assay (ELISA). The concentrations of milk lactoferrin and SIgA, but not IgG and IgM, from hyperglycemic and normoglycemic mothers, showed a similar negative correlation with lactation from the first to the fifteenth day. Apart from early colostral IgG, there were no differences in concentrations of LF and immunoglobulins in milk from hyperglycemic and normoglycemic mothers. For hyperglycemia compensated by diet (GDM G1) or insulin treatment (GDM G2), slight differences were seen for LF and IgG, but not for SIgA and IgM, during an early stage of lactation only. Early colostral IgG and colostral LF of insulin-treated mothers were higher (10.01 ± 4.48 mg/L and 11.50 ± 0.58 g/L, respectively) than for diet-control diabetic mothers (7.65 ± 5.67 mg/L and 8.05 ± 1.38 g/L, respectively). GDM of mothers does not have a significant impact on immunological quality of early milk.

Increased alpha and beta cell mass during mouse pregnancy is not dependent on transdifferentiation

Maternal pancreatic beta-cell mass (BCM) increases during pregnancy to compensate for relative insulin resistance. If BCM expansion is suboptimal, gestational diabetes mellitus can develop. Alpha-cell mass (ACM) also changes during pregnancy, but there is a lack of information about α-cell plasticity in pregnancy and whether α- to β-cell transdifferentiation can occur. To investigate this, we used a mouse model of gestational glucose intolerance induced by feeding low-protein (LP) diet from conception until weaning and compared pregnant female offspring to control diet-fed animals. Control and LP pancreata were collected for immunohistochemical analysis and serum glucagon levels were measured. In order to lineage trace α- to β-cell conversion, we utilized transgenic mice expressing yellow fluorescent protein behind the proglucagon gene promoter (Gcg-Cre/YFP) and collected pancreata for histology at various gestational timepoints. Alpha-cell proliferation increased significantly at gestational day (GD) 9.5 in control pregnancies resulting in an increased ACM at GD18.5, and this was significantly reduced in LP animals. Despite these changes, serum glucagon was higher in LP mice at GD18.5. Pregnant Gcg-Cre/YFP mice showed no increase in the abundance of insulin+YFP+glucagon- cells (phenotypic β-cells). A second population of insulin+YFP+glucagon+ cells was identified which also did not alter during pregnancy. However, there was an altered anatomical distribution within islets with fewer insulin+YFP+glucagon- cells but more insulin+YFP+glucagon+ cells being present in the islet mantle at GD18.5. These findings demonstrate that dynamic changes in ACM occur during normal pregnancy and were altered in glucose-intolerant pregnancies.

Patterns of respiratory health services utilization from birth to 5 years of children who experienced adverse birth outcomes

Introduction

Adverse birth outcomes have important consequences for future lung health. We evaluated patterns of respiratory health services utilization in early childhood among children born preterm (PTB), small and large for gestational age at term (SGA and LGA, respectively), and appropriate-for-gestational age at term.

Materials and methods

We conducted a population-based retrospective cohort study using administrative health data of all singleton live births in Alberta, Canada between 2005–2010. Data on hospitalizations and emergency department (ED) visits from birth to 5 years were collected for asthma, bronchitis, bronchiolitis, croup, influenza, pneumonia, and other acute upper and lower respiratory tract infections (other URTI and other LRTI, respectively). Adjusted rate ratios were estimated for respiratory ED visits and hospitalizations for adverse birth outcomes using the appropriate-for-gestational age at term group as reference. Age-specific trajectories of total respiratory health services utilization rates for each group were estimated in Poisson models.

Results

A total of 293,764 episodes of respiratory care from 206,994 children were analyzed. Very PTB children had the highest rates of health services use for all respiratory conditions, particularly for asthma, pneumonia, and bronchiolitis hospitalizations. Moderate/late PTB children also had elevated ED visits and hospitalizations for all respiratory conditions. Children born SGA showed high rates of ED visits for other LRTI, and of hospitalizations for bronchitis, bronchiolitis, and other URTI. Children born LGA had high rates of croup and other URTI ED visits, and of bronchiolitis and bronchiolitis hospitalizations. Age-specific trajectories showed a decreasing trend in the rates of total respiratory health service utilization from birth to five years of age for all groups studied. Children born PTB and LGA at term significantly required more respiratory health services over time compared to the reference group.

Conclusion

Patterns of paediatric respiratory health services utilization vary according to gestational age and fetal growth.

Association between pregestational diabetes and mortality among appropriate-for-gestational age birthweight infants

BACKGROUND/OBJECTIVE

Existing studies have shown that pregestational diabetes is a significant risk factor for adverse birth outcomes. However, it is unclear, whether pregestational diabetes and neonatal birthweight that is appropriate for the gestational age (AGA), a proxy for overall adequate glycemic control, is associated with higher infant mortality. To address this controversy, this study investigated the relationship between pregestational diabetes and infant mortality in appropriate-for-gestational age infants in the United States.

METHODS

Data from the National Vital Statistics System-Linked Birth-Infant Death dataset, including 6,962,028 live births between 2011 and 2013 were analyzed. The study was conducted in the US and data were analyzed in Milwaukee, Wisconsin. The outcome was mortality among AGA newborns, defined as annual deaths per 1000 live births with birthweights between the 10th and 90th percentiles for gestational age delivering at ≥37 weeks. The exposure was pregestational diabetes. Covariates were maternal demographics, behavioral/clinical, and infant factors. Logistic regression was used with p values <.05 considered statistically significant.

RESULTS

A total of 6,962,028 live births met inclusion criteria. Of these, a total of 11,711 (1.0%) term AGA birthweight infants died before their first birthday. About 35,689 (0.5%) mothers were diagnosed with pregestational diabetes prior to pregnancy with 0.3% of infants whose mothers had diabetes dying in their first year of life. In the unadjusted model, pregestational diabetes had a significant association with increased odds of mortality in term AGA infants (OR: 1.9, 95% CI: 1.6 - 2.3). AGA mortality remained significantly higher for women with pregestational diabetes compared to controls, after adjusting for maternal demographics (OR: 1.9, 95% CI: 1.6-2.3), behavioral/clinical characteristics (OR: 1.6, 95% CI: 1.3-2.0), and infant factors (OR: 1.3, 95% CI: 1.1-1.6).

CONCLUSIONS

In term pregnancies, pregestational diabetes was significantly associated with 30% higher mortality among AGA birthweight infants. Our study is innovative in its focus on AGA infants that overall is associated with good maternal glycemic control during pregnancy and in theory should confer a risk for infant mortality that is similar to pregnancies not complicated by pregestational diabetes. Despite this, we still found that even term AGA infants have higher risk of mortality in the setting of maternal pregestational diabetes. Implications of our findings underscore the importance of close antepartum surveillance and optimization of glycemic control preconception, identification of treatment targets, and health policies to reduce infant mortality. The results from this study may assist other researchers and clinicians understand how best to target future interventions to reduce term infant mortality and the burden of pregestational diabetes in the United States.

Effect of Lactobacillus rhamnosus Probiotic in Early Pregnancy on Plasma Conjugated Bile Acids in a Randomised Controlled Trial

We have previously shown that probiotic supplementation with Lactobacillus rhamnosus HN001 (HN001) led to a reduced incidence of gestational diabetes mellitus (GDM). Here we investigate whether HN001 supplementation resulted in alterations in fasting lipids, insulin resistance, or bile acids (BAs) during pregnancy. Fasting plasma samples collected at 24-30 weeks' gestation, from 348 women randomised at 14-16 weeks' gestation to consume daily probiotic HN001 (n = 172) or a placebo (n = 176) were analysed for lipids, insulin, glucose and BAs. Women supplemented with HN001 had lower fasting glucose compared with placebo (p = 0.040), and lower GDM. Significant differences were found in fasting insulin, HOMA-IR, low density lipoprotein-cholesterol (LDL-c), high density lipoprotein (HDL)-c, triglycerides, total cholesterol, and BAs by GDM status. Lower fasting conjugated BAs were seen in women receiving HN001. A significant decrease of glycocholic acid (GCA) was found in older (age ≥ 35) women who received HN001 (p = 0.005), while GDM women showed significant reduced taurodeoxycholic acid (TDCA) (p = 0.018). Fasting conjugated BA was positively correlated with fasting glucose (r = 0.136, p = 0.020) and fasting insulin (r = 0.113, p = 0.036). Probiotic HN001 supplementation decreases conjugated BAs and might play a role in the improvement of glucose metabolism in women with pregnancy.

Impact of being large-for-gestational-age on neonatal mortality and morbidities in extremely premature infants

BACKGROUND

Small for gestational age (SGA) infants have an increased risk for neonatal mortality and morbidities. However, few studies have examined the risk of large for gestational age (LGA) on these factors. We compared the risk of mortality and morbidities in LGA premature infants with those of appropriate for gestational age (AGA) infants.

METHODS

Premature infants who were born between 2003 and 2012 at <26 weeks of gestational age were included. Relative risks of mortality and morbidities were evaluated between LGA and AGA infants.

RESULTS

From 6898 extremely premature infants, 357 (5.2%), 5530 (80.2%), and 1011 (14.7%) were LGA, AGA, and SGA, respectively. A total of 5887 infants (5530 AGA and 357 LGA) were examined after excluding infants with congenital anomalies, unknown sex, and deficient data. The risk of mortality in LGA and AGA infants did not differ (relative risk (95% confidence interval) 1.04 (0.83-1.32)). Compared to AGA infants, LGA infants did not increase the risk of morbidities, including intraventricular hemorrhage, cystic periventricular leukomalacia, treated retinopathy of prematurity, necrotizing enterocolitis, and bronchopulmonary dysplasia.

CONCLUSIONS

This study demonstrates that being born LGA does not correlate with an increased risk of mortality and morbidities in extremely premature infants.

IMPACT

It is currently unknown if being large for gestational age is a risk for neonatal morbidity. A total of 6898 preterm infants born <26 weeks gestational age were included in the study. It was found that being large for gestational age was not related to increased risk of mortality and morbidities.

Characterization of women with gestational diabetes who failed to achieve glycemic control by lifestyle modifications

PURPOSE

To identify specific characteristics of women diagnosed with gestational diabetes who failed to achieve good glycemic control by lifestyle modifications only.

METHODS

Retrospective analysis of women carrying a singleton pregnancy diagnosed with gestational diabetes. The cohort included 314 women who achieved good glycemic control by lifestyle modifications and 328 women who required anti-diabetic medications. Lifestyle modifications included medical nutrition therapy and physical exercise recommendations. Anti-diabetic medications included either oral treatment with metformin or glyburide and\or insulin.

RESULTS

Women in the lifestyle modifications group were younger (32.87 vs. 33.79 years, p = 0.012) and had lower pre-pregnancy body-mass-index (25.86 vs. 27.93 kg/m², p < 0.001). Glucose challenge test (GCT) was significantly lower in the lifestyle modifications group (158.31 vs. 171.04 mg/dL in the anti-diabetic treatment group, p < 0.001). Moreover, fasting oral-glucose-tolerance-test (fOGTT) results were significantly lower in the lifestyle modifications group (88.22 vs. 96.34 mg/dL in the anti-diabetic treatment group, p < 0.001). In a receiver-operator-curve analysis, GCT + 4*fOGTT, was the best model to predict lifestyle modifications failure with an area under the curve of 0.7419. Higher rates of vaginal delivery and lower rates of maternal hypoglycemia in the lifestyle modifications group were observed.

CONCLUSIONS

Maternal baseline characteristics and diabetes diagnostic parameters may predict which women will fail to achieve good glycemic control solely by lifestyle modifications.

Evaluation of hemodynamics in healthy term neonates using ultrasonic cardiac output monitor

BACKGROUND

Transition from intrauterine to extrauterine life is a critical phase during which several changes occur in cardiovascular system. In clinical practice, it is important to have a method that allows an easy, rapid and precise evaluation of hemodynamic status of a newborn for clinical management. We here propose a rapid, broadly applicable method to monitor cardiovascular function using ultrasonic cardiac output monitoring (USCOM).

METHODS

We here present data obtained from a cohort of healthy term newborns (n = 43) born by programmed cesarean section at Fondazione MBBM, Ospedale San Gerardo. Measurements were performed during the first hour of life, then at 6 + 2, at 12-24, and 48 h of life. We performed a screening echocardiography to identify a patent duct at 24 h and, if patent, it was repeated at 48 h of life.

RESULTS

We show that physiologically, during the first 48 h of life, blood pressure and systemic vascular resistance gradually increase, while there is a concomitant reduction in stroke volume, cardiac output, and cardiac index. The presence of patent ductus arteriosus significantly reduces cardiac output (p = 0.006) and stroke volume (p = 0.023). Furthermore, newborns born at 37 weeks of gestational age display significantly lower cardiac output (p < 0.001), cardiac index (p = 0.045) and stroke volume (p < 0.001) compared to newborns born at 38 and ≥ 39 weeks. Finally, birth-weight (whether adequate, small or large for gestational age) significantly affects blood pressure (p = 0.0349), stroke volume (p < 0.0001), cardiac output (p < 0.0001) and cardiac index (p = 0.0004). In particular, LGA infants display a transient increase in cardiac index, cardiac output and stroke volume up to 24 h of life; showing a different behavior from AGA and SGA infants.

CONCLUSIONS

Compared to previous studies, we expanded measurements to longer time-points and we analyzed the impact of commonly used clinical variables on hemodynamics during transition phase thus making our data clinically applicable in daily routine. We calculate reference values for each population, which can be of clinical relevance for quick bedside evaluation in neonatal intensive care unit.