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Ruby E, McDonald SD, Berger H, Melamed N, Li J, Darling EK, Geary M, Barrett J, Murray-Davis B. A Social-Ecological Model Exploring Gestational Diabetes Mellitus Screening Practices Among Antenatal Health Care Providers. HEALTH EDUCATION & BEHAVIOR 2024; 51:748-756. [PMID: 38406976 PMCID: PMC11411845 DOI: 10.1177/10901981241232651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.
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Affiliation(s)
- Emma Ruby
- McMaster University, Hamilton, Ontario, Canada
| | | | | | - Nir Melamed
- University of Toronto, Toronto, Ontario, Canada
| | - Jenifer Li
- McMaster University, Hamilton, Ontario, Canada
| | | | | | - Jon Barrett
- McMaster University, Hamilton, Ontario, Canada
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Thorius IH, Petersen J, Husemoen LLN, Alibegovic AC, Gall MA, Damm P, Mathiesen ER. Glycemic Control and Risk of Congenital Malformations in Women With Type 1 Diabetes. Obstet Gynecol 2024:00006250-990000000-01143. [PMID: 39236320 DOI: 10.1097/aog.0000000000005722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/02/2024] [Indexed: 09/07/2024]
Abstract
OBJECTIVE To investigate the association between maternal glycemic control and the risk of congenital malformations in offspring of women with type 1 diabetes and to examine whether there is a hemoglobin A1C (Hb A1C) threshold value at which the risk for malformations increases significantly. METHODS Analyses were performed on data from a multinational, observational cohort of 1,908 liveborn offspring of women with type 1 diabetes recruited in early pregnancy from 17 countries between 2013 and 2018. Offspring with malformations were identified according to European Surveillance of Congenital Anomalies version 1.4 and categorized as having one or more major malformations or minor malformations exclusively. The association between first-trimester Hb A1C levels and the risk of congenital malformations was investigated with splines in crude and adjusted logistic regression models. RESULTS In total, 11.9% of the offspring (n=227) of women with type 1 diabetes had congenital malformations, including 2.1% (n=40) with at least one severe malformation. Women giving birth to offspring with malformations had a higher prevalence of psychiatric disorders (13.2% vs 7.2%, P<.01), thyroid disorders (33.0% vs 26.7%, P<.05), and folic acid supplementation (87.1% vs 77.7%, P<.01). The Hb A1C levels in the first trimester were similar (median 6.8% [interquartile range 6.3-7.6%] vs 6.7% [6.2-7.6%], P=.13) compared with women giving birth to offspring without malformations. The spline analysis illustrated a curvilinear association between Hb A1C levels and the risk of malformations with no clear threshold values. Higher first-trimester Hb A1C levels were associated with an increased risk of malformations (crude odds ratio [OR] 1.13, 95% CI, 1.01-1.27, adjusted odds ratio [aOR] 1.29, 95% CI, 1.10-1.51) and major malformations (crude OR 1.49, 95% CI, 1.23-1.81, aOR 1.57, 95% CI, 1.15-2.09). CONCLUSION An increased risk for congenital malformations was curvilinearly associated with higher Hb A1C levels in early pregnancy among women with type 1 diabetes without any threshold values identified. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT01892319.
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Affiliation(s)
- Ida Holte Thorius
- Departments of Endocrinology and Obstetrics, Center for Pregnant Women With Diabetes, Rigshospitalet, and the Department of Clinical Medicine and the Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Novo Nordisk A/S, Søborg, and the Copenhagen Phase IV Unit, Department of Clinical Pharmacology, and the Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark
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Feig DS, Artani A, Asaf A, Li P, Booth GL, Shah BR. Long-term Neurobehavioral and Metabolic Outcomes in Offspring of Mothers With Diabetes During Pregnancy: A Large, Population-Based Cohort Study in Ontario, Canada. Diabetes Care 2024; 47:1568-1575. [PMID: 38820461 DOI: 10.2337/dc24-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/03/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Offspring of women with diabetes are at increased risk of developing neurobehavioral and cardiometabolic disorders, but there is scant evidence regarding the association between glycemic level during pregnancy and these long-term offspring outcomes. RESEARCH DESIGN AND METHODS We conducted a population-based, cohort study of deliveries in Ontario between April 1991 and March 2018. Women had preexisting diabetes, gestational diabetes, or no diabetes. We applied a Cox proportional hazard model to examine the risk of developing attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and cardiometabolic outcomes in offspring and assessed the association between pregnancy HbA1c levels and risk of outcomes, adjusting for confounders. RESULTS A total of 3,407,961 mother-infant pairs were followed up to 29 years. Using a Cox proportional hazard model, offspring of women with type 1 diabetes had the highest risk of ADHD (adjusted hazard ratio [aHR] 1.43 [95% CI 1.36-1.49]), ASD (aHR 1.94 [1.80-2.09]), diabetes (aHR 4.73 [4.34-5.16]), hypertension (aHR 2.32 [2.07-2.61]), and cardiovascular disease (CVD) (aHR 1.72 [1.56-1.90]), followed by offspring of women with type 2 diabetes and gestational diabetes compared with those unexposed. Among women with preexisting diabetes, there was an association between level of pregnancy HbA1c and offspring diabetes (aHR 1.22 [95% CI 1.12-1.32]), hypertension (aHR 1.42 [1.29-1.57]), and CVD (aHR 1.20 [1.11-1.29]) but no statistically significant association with neurobehavioral outcomes. CONCLUSIONS In utero exposure to maternal diabetes was associated with an increase in ADHD, ASD, and cardiometabolic outcomes in offspring, with differences seen across diabetes subtypes. Pregnancy glycemia was associated with cardiometabolic outcomes, but not neurobehavioral outcomes, and provides a potentially modifiable risk factor to decrease cardiometabolic outcomes in offspring.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Azmina Artani
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Ayesha Asaf
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Ping Li
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Gillian L Booth
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Baiju R Shah
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Diab YH, Saade G, Kawakita T. Continuous glucose monitoring vs. self-monitoring in pregnant individuals with type 1 diabetes: an economic analysis. Am J Obstet Gynecol MFM 2024; 6:101413. [PMID: 38908796 DOI: 10.1016/j.ajogmf.2024.101413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 05/31/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy. OBJECTIVE To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus. STUDY DESIGN We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations. RESULTS In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15. CONCLUSION Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.
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Affiliation(s)
- Yara Hage Diab
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA.
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Luo R, Fell DB, Corsi DJ, Taljaard M, Wen SW, Walker MC. Temporal Trends in Gestational Diabetes Mellitus and Associated Risk Factors in Ontario, Canada, 2012-2020: A Population-Based Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102573. [PMID: 38848894 DOI: 10.1016/j.jogc.2024.102573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/16/2024] [Accepted: 05/16/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVES The prevalence of gestational diabetes mellitus (GDM) has been increasing globally over recent decades; however, underlying reasons for the increase remain unclear. We analyzed trends in GDM rates and evaluated risk factors associated with the observed trends in Ontario, Canada. METHODS We conducted a retrospective population-based cohort study using the Better Outcomes Registry and Network Ontario, linked with the Canadian Institute for Health Information Discharge Abstract Database. All pregnant individuals who had a singleton hospital delivery from 1 April 2012 to 31 March 2020 were included. We calculated rates and 95% CIs for GDM by year of delivery and contrasted fiscal year 2019/20 with 2012/13. Temporal trends in GDM were quantified using crude and adjusted risk ratios by modified Poisson regression. We further quantified the temporal increase attributable to changes in maternal characteristics by decomposition analysis. RESULTS Among 1 044 258 pregnant individuals, 82 896 (7.9%) were diagnosed with GDM over the 8 years. GDM rate rose from 6.1 to 10.4 per 100 deliveries between fiscal years 2012/13 and 2019/20. The risk of GDM in 2019/20 was 1.53 times (95% CI 1.50-1.56) higher compared with 2012/13. 27% of the increase in GDM was due to changes in maternal age, 8 BMI, and Asian ethnicity. CONCLUSIONS The GDM rate has been consistently increasing in Ontario, Canada. The contribution of increasing maternal age, pre-pregnancy obesity, and Asian ethnicity to the recent increase in GDM is notable. Further investigation is required to better understand the contributors to increasing GDM.
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Affiliation(s)
- Rong Luo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON
| | - Deshayne B Fell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON
| | - Daniel J Corsi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON; BORN Ontario, Children's Hospital of Eastern Ontario, Ottawa, ON
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON
| | - Shi Wu Wen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON; Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, ON.
| | - Mark C Walker
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON; BORN Ontario, Children's Hospital of Eastern Ontario, Ottawa, ON; Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, ON; International and Global Health Office, University of Ottawa, Ottawa, ON.
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Xiu X, Lin Y, Chen Z, Lin L, Zu Y, Yan J. Serum parameters of inflammatory markers as prognostic biomarkers with maternal-neonatal outcome in patients with GDM. Front Med (Lausanne) 2024; 11:1406492. [PMID: 38978779 PMCID: PMC11228299 DOI: 10.3389/fmed.2024.1406492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/03/2024] [Indexed: 07/10/2024] Open
Abstract
Objective Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy, which is increasing annually. GDM can cause serious harm to both the mother and the offspring. However, the clinical indicators that predict pregnancy outcomes with GDM remain limited. Methods This study included 3,229 pregnancies. Inflammatory markers were defective in the mother's peripheral blood. Also, the Chi-square test, logistic regression analyses and Spearman rank correlation coefficient were performed to evaluate inflammatory markers with pregnancy outcomes. The association between inflammatory markers and pregnancy outcomes was analyzed. The optimal cut-off values of inflammatory markers were calculated. Results Finally, 3,229 women were included. 1852 (57.36%) participants suffered good pregnancy outcomes. This study revealed that the maternal age, the baseline BMI (kg/m2), the times of parity, and the level of lymphocyte, SII and SIRI significantly increased in poor pregnancy outcomes groups. Additionally, inflammatory markers, such as white blood cells (WBC), neutrophils, monocytes, platelet counts, lymphocytes, systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI) were related to pregnancy outcomes. Furthermore, the results revealed that the SII level had the highest odd rates (OR) [OR = 6.957; 95% CI (5.715-8.468)], followed by SIRI level [OR = 2.948; 95% CI (2.382-3.649)], the WBC counts [OR = 1.930; 95% CI (0.901-2.960)], the lymphocyte counts [OR = 1.668; 95% CI (1.412-1.970)], and baseline BMI [OR = 1.050; 95% (1.021-1.080)]. Conclusion This study presented that the baseline SII and SIRI levels can be valuable biochemical markers to predict the pregnancy outcome with GDM with non-invasive procedures. They can help identify high-risk pregnant women with GDM early, provide a personalized intervention in time, and enhance perinatal surveillance.
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Affiliation(s)
- Xiaoyan Xiu
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yingying Lin
- Department of Healthcare, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Zhiwei Chen
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Lin Lin
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yizheng Zu
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jianying Yan
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, China
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Benhalima K, Beunen K, Van Wilder N, Ballaux D, Vanhaverbeke G, Taes Y, Aers XP, Nobels F, Marlier J, Lee D, Cuypers J, Preumont V, Siegelaar SE, Painter RC, Laenen A, Gillard P, Mathieu C. Comparing advanced hybrid closed loop therapy and standard insulin therapy in pregnant women with type 1 diabetes (CRISTAL): a parallel-group, open-label, randomised controlled trial. Lancet Diabetes Endocrinol 2024; 12:390-403. [PMID: 38697182 DOI: 10.1016/s2213-8587(24)00089-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Advanced hybrid closed loop (AHCL) therapy can improve glycaemic control in pregnant women with type 1 diabetes. However, data are needed on the efficacy and safety of AHCL systems as these systems, such as the MiniMed 780G, are not currently approved for use in pregnant women. We aimed to investigate whether the MiniMed 780G can improve glycaemic control with less hypoglycaemia in pregnant women with type 1 diabetes. METHODS CRISTAL was a double-arm, parallel-group, open-label, randomised controlled trial conducted in secondary and tertiary care specialist endocrinology centres at 12 hospitals (11 in Belgium and one in the Netherlands). Pregnant women aged 18-45 years with type 1 diabetes were randomly assigned (1:1) to AHCL therapy (MiniMed 780G) or standard insulin therapy (standard of care) at a median of 10·1 (IQR 8·6-11·6) weeks of gestation. Randomisation was done centrally with minimisation dependent on baseline HbA1c, insulin administration method, and centre. Participants and study teams were not masked to group allocation. The primary outcome was proportion of time spent in the pregnancy-specific target glucose range (3·5-7·8 mmol/L), measured by continuous glucose monitoring (CGM) at 14-17 weeks, 20-23 weeks, 26-29 weeks, and 33-36 weeks. Key secondary outcomes were overnight time in target range, and time below glucose range (<3·5 mmol/L) overall and overnight. Analyses were conducted on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov (NCT04520971). FINDINGS Between Jan 15, 2021 and Sept 30, 2022, 101 participants were screened, and 95 were randomly assigned to AHCL therapy (n=46) or standard insulin therapy (n=49). 43 patients assigned to AHCL therapy and 46 assigned to standard insulin therapy completed the study. At baseline, 91 (95·8%) participants used insulin pumps, and the mean HbA1c was 6·5% (SD 0·6). The mean proportion of time spent in the target range (averaged over four time periods) was 66·5% (SD 10·0) in the AHCL therapy group compared with 63·2% (12·4) in the standard insulin therapy group (adjusted mean difference 1·88 percentage points [95% CI -0·82 to 4·58], p=0·17). Overnight time in the target range was higher (adjusted mean difference 6·58 percentage points [95% CI 2·31 to 10·85], p=0·0026), and time below range overall (adjusted mean difference -1·34 percentage points [95% CI, -2·19 to -0·49], p=0·0020) and overnight (adjusted mean difference -1·86 percentage points [95% CI -2·90 to -0·81], p=0·0005) were lower with AHCL therapy than with standard insulin therapy. Participants assigned to AHCL therapy reported higher treatment satisfaction. No unanticipated safety events occurred with AHCL therapy. INTERPRETATION In pregnant women starting with tighter glycaemic control, AHCL therapy did not improve overall time in target range but improved overnight time in target range, reduced time below range, and improved treatment satisfaction. These data suggest that the MiniMed 780G can be safely used in pregnancy and provides some additional benefits compared with standard insulin therapy; however, it will be important to refine the algorithm to better align with pregnancy requirements. FUNDING Diabetes Liga Research Fund and Medtronic.
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Affiliation(s)
- Katrien Benhalima
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium; Department of Endocrinology, UZ Leuven, Leuven, Belgium.
| | - Kaat Beunen
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Nancy Van Wilder
- Department of Endocrinology, University Hospital Brussels, Jette, Belgium
| | - Dominique Ballaux
- Department of Endocrinology, Vitaz Campus Sint-Niklaas Moerland, Sint-Niklaas, Belgium
| | - Gerd Vanhaverbeke
- Department of Endocrinology, General Hospital Groeninge Kortrijk, Kortrijk, Belgium
| | - Youri Taes
- Department of Endocrinology, General Hospital Sint-Jan Brugge, Brugge, Belgium
| | - Xavier-Philippe Aers
- Department of Endocrinology, General Hospital Delta Campus Rumbeke, Roeselare, Belgium
| | - Frank Nobels
- Department of Endocrinology, OLV Hospital Aalst, Aalst, Belgium
| | - Joke Marlier
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - Dahae Lee
- Department of Endocrinology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Joke Cuypers
- Department of Endocrinology, General Hospital Turnhout Campus Sint-Jozef, Turnhout, Belgium
| | - Vanessa Preumont
- Department of Endocrinology, University Hospital Saint-Luc, Brussel, Belgium
| | - Sarah E Siegelaar
- Department of Endocrinologyand Metabolism, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Rebecca C Painter
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centres, Amsterdam, Netherlands; Amsterdam Reproduction and Development, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Annouschka Laenen
- Center of Biostatics and Statistical bioinformatics, KU Leuven, Leuven, Belgium
| | - Pieter Gillard
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium; Department of Endocrinology, UZ Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium; Department of Endocrinology, UZ Leuven, Leuven, Belgium
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Hochberg A, Bazarah MS, Baghlaf HA, Badeghiesh AM, Dahan MH. The effect of bariatric surgery on polycystic ovary syndrome patients' obstetric and neonatal outcomes: a population-based study. J Assist Reprod Genet 2024; 41:1687-1697. [PMID: 38689082 PMCID: PMC11224218 DOI: 10.1007/s10815-024-03123-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/15/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE To examine the effect of bariatric surgery (BS) on obstetric and neonatal outcomes in patients with polycystic ovary syndrome (PCOS). METHODS A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, including women who delivered in the third trimester or had a maternal death in the USA (2004-2014). We compared obstetric and neonatal outcomes between groups in three analyses: (1) Primary analysis-women with an ICD-9 PCOS diagnosis who underwent BS compared to pregnant PCOS patients without BS. (2) Sub-group analysis-PCOS women with BS compared to obese PCOS women (body mass index (BMI) ≥ 30 kg/m2) without BS. (3) Women with and without PCOS who underwent BS. RESULT In the primary analysis, pregnant PCOS women who underwent BS (N = 141), compared to pregnant PCOS women without BS (N = 14,741), were less likely to develop pregnancy-induced hypertension (PIH) (9.2% vs. 16.2%, respectively, aOR 0.39, 95% CI 0.21-0.72) and gestational diabetes mellitus (GDM) (9.9% vs. 18.8, aOR 0.40, 95% CI 0.23-0.70). In the sub-group analysis, PCOS women with BS, compared to obese PCOS women without BS (N = 3231), were less likely to develop gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension (P < 0.05). Lastly, PCOS patients with BS had a higher cesarean section rate when compared to non-PCOS patients with BS (N = 9197) (61.7% vs. 49.2%, aOR 1.48, 95% CI 1.05-2.09), with otherwise comparable obstetric and neonatal outcomes. CONCLUSIONS BS in PCOS patients was associated with reduced risks for GDM and PIH when compared to PCOS controls without BS and reduced risk for gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension when compared to obese PCOS controls without BS. Moreover, BS was associated with reduced inherent pregnancy risks of PCOS, almost equating them to those of non-PCOS counterparts.
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Affiliation(s)
- Alyssa Hochberg
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada.
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Mohammed S Bazarah
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada
| | - Haitham A Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Ahmad M Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada
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Costa RM, Cerqueira DM, Francis L, Bruder-Nascimento A, Alves JV, Sims-Lucas S, Ho J, Bruder-Nascimento T. In utero exposure to maternal diabetes exacerbates dietary sodium intake-induced endothelial dysfunction by activating cyclooxygenase 2-derived prostanoids. Am J Physiol Endocrinol Metab 2024; 326:E555-E566. [PMID: 38446637 PMCID: PMC11376489 DOI: 10.1152/ajpendo.00009.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/08/2024]
Abstract
Prenatal exposure to maternal diabetes has been recognized as a significant cardiovascular risk factor, increasing the susceptibility to the emergence of conditions such as high blood pressure, atherosclerosis, and heart disease in later stages of life. However, it is unclear if offspring exposed to diabetes in utero have worse vascular outcomes on a high-salt (HS) diet. To test the hypothesis that in utero exposure to maternal diabetes predisposes to HS-induced vascular dysfunction, we treated adult male wild-type offspring (DM_Exp, 6 mo old) of diabetic Ins2+/C96Y mice (Akita mice) with HS (8% sodium chloride, 10 days) and analyzed endothelial function via wire myograph and cyclooxygenase (COX)-derived prostanoids pathway by ELISA, quantitative PCR, and immunochemistry. On a regular diet, DM_Exp mice did not manifest any vascular dysfunction, remodeling, or inflammation. However, HS increased aortic contractility to phenylephrine and induced endothelial dysfunction (analyzed by acetylcholine-induced endothelium-dependent relaxation), vascular hydrogen peroxide production, COX2 expression, and prostaglandin E2 (PGE2) overproduction. Interestingly, ex vivo antioxidant treatment (tempol) or COX1/2 (indomethacin) or COX2 (NS398) inhibitors improved or reverted the endothelial dysfunction in DM_Exp mice fed a HS diet. Finally, DM_Exp mice fed with HS exhibited greater circulating cytokines and chemokines accompanied by vascular inflammation. In summary, our findings indicate that prenatal exposure to maternal diabetes predisposes to HS-induced vascular dysfunction, primarily through the induction of oxidative stress and the generation of COX2-derived PGE2. This supports the concept that in utero exposure to maternal diabetes is a cardiovascular risk factor in adulthood.NEW & NOTEWORTHY Using a unique mouse model of prenatal exposure to maternal type 1 diabetes, our study demonstrates the novel observation that prenatal exposure to maternal diabetes results in a predisposition to high-salt (HS) dietary-induced vascular dysfunction and inflammation in adulthood. Mechanistically, we demonstrated that in utero exposure to maternal diabetes and HS intake induces vascular oxidative stress, cyclooxygenase-derived prostaglandin E2, and inflammation.
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Affiliation(s)
- Rafael M Costa
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Center for Pediatrics Research in Obesity and Metabolism, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Endocrinology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Institute of Health Sciences, Federal University of Jatai, Jatai, Goiás, Brazil
| | - Débora Malta Cerqueira
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Nephrology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Lydia Francis
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Nephrology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Ariane Bruder-Nascimento
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Center for Pediatrics Research in Obesity and Metabolism, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Endocrinology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Institute of Health Sciences, Federal University of Jatai, Jatai, Goiás, Brazil
| | - Juliano V Alves
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Center for Pediatrics Research in Obesity and Metabolism, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Endocrinology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Institute of Health Sciences, Federal University of Jatai, Jatai, Goiás, Brazil
| | - Sunder Sims-Lucas
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Nephrology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Jacqueline Ho
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Nephrology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Thiago Bruder-Nascimento
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Center for Pediatrics Research in Obesity and Metabolism, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Endocrinology Division, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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10
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Cruciat G, Florian AR, Chaikh-Sulaiman MS, Staicu A, Caracostea GV, Procopciuc LM, Stamatian F, Muresan D. TCF7L2 Polymorphism rs7903146 (C/T) and Gestational Diabetes Influence on Obstetric Outcome: A Romanian Case-Control Study. Int J Mol Sci 2024; 25:4039. [PMID: 38612849 PMCID: PMC11012241 DOI: 10.3390/ijms25074039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Gestational diabetes mellitus (GDM) is one of the most frequent predictors of obstetric outcome among Romanian pregnant women. Thus, we aimed to investigate the role of rs7903146 (C/T) TCF7L2 gene polymorphism in the presence of GDM and to evaluate the influence on maternal-fetal outcomes in a cohort of pregnant women from Northern Transylvania. Our prospective case-control study was performed in a tertiary maternity center on 61 patients diagnosed with GDM and 55 normal pregnant patients. The patients were genotyped for rs7903146 (C/T) polymorphism of the TCF7L2 gene using the PCR-RFLP method between 24 and 28 weeks of gestation. The minor T allele was associated with a high risk of developing GDM (OR 1.71 [95% CI 0.82-3.59]) if both heterozygote and homozygote types were considered. Also, a higher risk of developing GDM was observed in homozygous carriers (OR 3.26 [95% CI 1.10-9.68]). Women with the TT genotype were more likely to require insulin therapy during pregnancy than other genotypes with a 5.67-fold increased risk ([1.61-19.97], p = 0.015). TT homozygote type was significantly associated with fetal macrosomia for birth weights greater than the 95th percentile (p = 0.034). The homozygous TT genotype is associated with an increased risk of developing GDM. Also, rs7903146 (C/T) TCF7L2 variant is accompanied by a high probability of developing insulin-dependent gestational diabetes mellitus (ID-GDM). The presence of at least one minor T allele was associated with a higher risk of fetal macrosomia.
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Affiliation(s)
- Gheorghe Cruciat
- Mother and Child Department, Obstetrics and Gynecology I, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania; (G.C.); (A.R.F.); (M.-S.C.-S.); (A.S.); (G.V.C.); (D.M.)
| | - Andreea Roxana Florian
- Mother and Child Department, Obstetrics and Gynecology I, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania; (G.C.); (A.R.F.); (M.-S.C.-S.); (A.S.); (G.V.C.); (D.M.)
| | - Mariam-Suzana Chaikh-Sulaiman
- Mother and Child Department, Obstetrics and Gynecology I, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania; (G.C.); (A.R.F.); (M.-S.C.-S.); (A.S.); (G.V.C.); (D.M.)
| | - Adelina Staicu
- Mother and Child Department, Obstetrics and Gynecology I, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania; (G.C.); (A.R.F.); (M.-S.C.-S.); (A.S.); (G.V.C.); (D.M.)
| | - Gabriela Valentina Caracostea
- Mother and Child Department, Obstetrics and Gynecology I, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania; (G.C.); (A.R.F.); (M.-S.C.-S.); (A.S.); (G.V.C.); (D.M.)
| | - Lucia Maria Procopciuc
- Department of Medical Biochemistry, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania
| | | | - Daniel Muresan
- Mother and Child Department, Obstetrics and Gynecology I, “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, 400347 Cluj-Napoca, Romania; (G.C.); (A.R.F.); (M.-S.C.-S.); (A.S.); (G.V.C.); (D.M.)
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11
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Tschirhart H, Landeen J, Yost J, Nerenberg KA, Sherifali D. Perceptions of diabetes distress during pregnancy in women with type 1 and type 2 diabetes: a qualitative interpretive description study. BMC Pregnancy Childbirth 2024; 24:232. [PMID: 38570742 PMCID: PMC10988880 DOI: 10.1186/s12884-024-06370-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/25/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Diabetes distress is commonly seen in adults with pre-existing diabetes and is associated with worsened glycemic management and self-management practices. While a majority of women report increased stress during pregnancy, it is unknown how women with type 1 or type 2 diabetes experience diabetes distress during this unique and transitional time. PURPOSE This study aimed to understand the experiences and perceptions of diabetes distress in women with pre-existing diabetes during pregnancy. METHODS A qualitative study using an interpretive description approach was conducted. In-depth, one to one interviewing was used to capture rich descriptions of the pregnancy experience. Nested, stratified, and theoretical sampling was used to recruit 18 participants with type 1 and type 2 diabetes from the quantitative strand of this mixed methods study. Constant comparative analysis was used to inductively analyze the data and develop themes. FINDINGS Four themes, each with several subthemes, emerged under the main finding of "Diabetes Distress": 1) Worry for Baby's Health - "What's this going to do to the baby?"' 2) Feeling Overwhelmed with Diabetes Management-"It just seemed unattainable"; 3) Living with Diabetes - "There's no way out" and 4) Cycle of Diabetes Distress. CONCLUSIONS The findings from this study identify the sources and experiences of diabetes distress during pregnancy in women with pre-existing diabetes. Diabetes distress often presents as cyclical and multifaceted during pregnancy, with elements of fear for the unborn baby, difficulties with diabetes management, and having negative lived experiences of diabetes. Further work is needed to develop appropriate screening tools for pregnancy and interventions to mitigate diabetes distress. Diabetes educators are well-positioned provide emotional support and person-centred self-management education to individuals with diabetes.
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Affiliation(s)
- Holly Tschirhart
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Canada.
| | - Janet Landeen
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jennifer Yost
- M. Louise Fitzpatrick College of Nursing, Villanova University, Pennsylvania, USA
| | - Kara A Nerenberg
- Departments of Medicine, Obstetrics & Gynecology, and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Diana Sherifali
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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12
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Gill G, Giannakeas V, Read S, Lega IC, Shah BR, Lipscombe LL. Risk of Breast Cancer After Diabetes in Pregnancy: A Population-based Cohort Study. Can J Diabetes 2024; 48:171-178.e1. [PMID: 38160937 DOI: 10.1016/j.jcjd.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Diabetes is associated with an increased risk of several cancers, including postmenopausal breast cancer. The evidence for higher breast cancer risk after diabetes in pregnancy is conflicting. We compared the incidence of breast and other cancers between pregnant women with and without diabetes. METHODS This work was a propensity-matched, retrospective cohort study using population-based health-care databases from Ontario, Canada. Those deliveries with gestational diabetes mellitus (GDM) and pregestational diabetes mellitus (pregestational DM) were identified and matched to deliveries without diabetes mellitus (non-DM). Deliveries from each diabetes cohort were matched 1:2 on age, parity, year of delivery, and propensity score to non-DM deliveries. Matched subjects were followed from delivery for incidence of breast cancer as a primary outcome, and other site-specific cancers as secondary outcomes. We performed Cox proportional hazards regression to compare rates of breast cancer between matched groups. RESULTS Over a median of 8 (interquartile range 4 to 13) years of follow-up, compared with non-DM deliveries, the incidence of breast cancer was significantly lower for GDM but similar for pregestational DM deliveries (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.82 to 0.98; and HR 0.92, 95% CI 0.80 to 1.07, respectively). GDM was associated with a significantly higher incidence of pancreatic and hepatocellular cancer, and pregestational DM was associated with a higher incidence of thyroid, hepatocellular, and endometrial cancers. CONCLUSIONS Diabetes in pregnancy does not have a higher short-term risk of subsequent breast cancer, but there may be a higher incidence of other cancers.
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Affiliation(s)
- Gurjot Gill
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Vasily Giannakeas
- ICES, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Read
- ICES, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Iliana C Lega
- ICES, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R Shah
- ICES, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lorraine L Lipscombe
- ICES, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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13
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He R, Hornberger LK, Kaur A, Crawford S, Boehme C, McBrien A, Eckersley L. Risk of major congenital heart disease in pregestational maternal diabetes is modified by hemoglobin A1c. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:378-384. [PMID: 37594210 DOI: 10.1002/uog.27456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVES The association between pregestational diabetes mellitus (PDM) and risk of congenital heart disease (CHD) is well recognized; however, the importance of glycemic control and other coexisting risk factors during pregnancy is less clear. We sought to determine the relative risk (RR) of major CHD (mCHD) among offspring from pregnancies complicated by PDM and the effect of first-trimester glycemic control on mCHD risk. METHODS We determined the incidence of mCHD (requiring surgery within 1 year of birth or resulting in pregnancy termination or fetal demise) among registered births in Alberta, Canada. Linkage of diabetes status, maximum hemoglobin A1c (HbA1c) at < 16 weeks' gestation and other covariates was performed using data from the Alberta Perinatal Health Program registry. Risk of mCHD according to HbA1c was estimated as an adjusted RR (aRR), calculated using log-binomial modeling. RESULTS Of 1412 cases of mCHD in 594 773 (2.37/1000) births in the study period, mCHD was present in 48/7497 with PDM (6.4/1000; RR, 2.8 (95% CI, 2.1-3.7); P < 0.0001). In the entire cohort, increased maternal age (aRR, 1.03 (95% CI, 1.02-1.04); P < 0.0001) and multiple gestation (aRR, 1.37 (95% CI, 1.1-1.8); P = 0.02) were also associated with mCHD risk, whereas maternal prepregnancy weight > 91 kg was not. The stratified risk for mCHD associated with HbA1c ≤ 6.1%, > 6.1-8.0% and > 8.0% was 4.2/1000, 6.8/1000 and 17.1/1000 PDM/gestational diabetes mellitus births, respectively; the aRR of mCHD associated with PDM and HbA1c > 8.0% was 8.5 (95% CI, 5.0-14.4) compared to those without diabetes and 5.5 (95% CI, 1.6-19.4) compared to PDM with normal HbA1c (≤ 6.1%). CONCLUSIONS PDM is associated with a RR of 2.8 for mCHD, increasing to 8.5 in those with HbA1c > 8%. These data should facilitate refinement of referral indications for high-risk pregnancy screening. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R He
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - A Kaur
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - S Crawford
- Alberta Perinatal Health Program, Alberta Health Services, AB, Canada
| | - C Boehme
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - A McBrien
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
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14
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Field C, Grobman WA, Yee LM, Johnson J, Wu J, McNeil B, Mercer B, Simhan H, Reddy U, Silver RM, Parry S, Saade G, Chung J, Wapner R, Lynch CD, Venkatesh KK. Community-level social determinants of health and pregestational and gestational diabetes. Am J Obstet Gynecol MFM 2024; 6:101249. [PMID: 38070680 PMCID: PMC11184512 DOI: 10.1016/j.ajogmf.2023.101249] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/20/2023] [Accepted: 12/04/2023] [Indexed: 01/02/2024]
Abstract
BACKGROUND Individual adverse social determinants of health are associated with increased risk of diabetes in pregnancy, but the relative influence of neighborhood or community-level social determinants of health is unknown. OBJECTIVE This study aimed to determine whether living in neighborhoods with greater socioeconomic disadvantage, food deserts, or less walkability was associated with having pregestational diabetes and developing gestational diabetes. STUDY DESIGN We conducted a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be. Home addresses in the first trimester were geocoded at the census tract level. The exposures (modeled separately) were the following 3 neighborhood-level measures of adverse social determinants of health: (1) socioeconomic disadvantage, defined by the Area Deprivation Index and measured in tertiles from the lowest tertile (ie, least disadvantage [T1]) to the highest (ie, most disadvantage [T3]); (2) food desert, defined by the United States Department of Agriculture Food Access Research Atlas (yes/no by low income and low access criteria); and (3) less walkability, defined by the Environmental Protection Agency National Walkability Index (most walkable score [15.26-20.0] vs less walkable score [<15.26]). Multinomial logistic regression was used to model the odds of gestational diabetes or pregestational diabetes relative to no diabetes as the reference, adjusted for age at delivery, chronic hypertension, Medicaid insurance status, and low household income (<130% of the US poverty level). RESULTS Among the 9155 assessed individuals, the mean Area Deprivation Index score was 39.0 (interquartile range, 19.0-71.0), 37.0% lived in a food desert, and 41.0% lived in a less walkable neighborhood. The frequency of pregestational and gestational diabetes diagnosis was 1.5% and 4.2%, respectively. Individuals living in a community in the highest tertile of socioeconomic disadvantage had increased odds of entering pregnancy with pregestational diabetes compared with those in the lowest tertile (T3 vs T1: 2.6% vs 0.8%; adjusted odds ratio, 2.52; 95% confidence interval, 1.41-4.48). Individuals living in a food desert (4.8% vs 4.0%; adjusted odds ratio, 1.37; 95% confidence interval, 1.06-1.77) and in a less walkable neighborhood (4.4% vs 3.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.04-1.71) had increased odds of gestational diabetes. There was no significant association between living in a food desert or a less walkable neighborhood and pregestational diabetes, or between socioeconomic disadvantage and gestational diabetes. CONCLUSION Nulliparous individuals living in a neighborhood with higher socioeconomic disadvantage were at increased odds of entering pregnancy with pregestational diabetes, and those living in a food desert or a less walkable neighborhood were at increased odds of developing gestational diabetes, after controlling for known covariates.
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Affiliation(s)
- Christine Field
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH (Drs Field and Grobman, Mr Wu, and Drs Lynch and Venkatesh).
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH (Drs Field and Grobman, Mr Wu, and Drs Lynch and Venkatesh)
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL (Dr Yee)
| | - Jasmine Johnson
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN (Dr Johnson)
| | - Jiqiang Wu
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH (Drs Field and Grobman, Mr Wu, and Drs Lynch and Venkatesh)
| | | | - Brian Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH (Dr Mercer)
| | - Hyagriv Simhan
- Department of Obstetrics and Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA (Dr Simhan)
| | - Uma Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Reddy and Wapner)
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT (Dr Silver)
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA (Dr Parry)
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX (Dr Saade)
| | - Judith Chung
- Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Irvine, CA (Dr Chung)
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Reddy and Wapner)
| | - Courtney D Lynch
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH (Drs Field and Grobman, Mr Wu, and Drs Lynch and Venkatesh)
| | - Kartik K Venkatesh
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH (Drs Field and Grobman, Mr Wu, and Drs Lynch and Venkatesh)
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15
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Karkia R, Giacchino T, Watson H, Gough A, Ramadan G, Akolekar R. Maternal and neonatal complications in pregnancies with and without pre-gestational diabetes mellitus. J Perinat Med 2024; 52:30-40. [PMID: 37677847 DOI: 10.1515/jpm-2023-0183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To compare pregnancy complications in pregnancies with and without pre-gestational diabetes mellitus (DM) managed in a multidisciplinary high-risk diabetes antenatal clinic. METHODS This screening cohort study was undertaken at a large maternity unit in the United Kingdom between January 2010 and December 2022. We included singleton pregnancies that booked at our unit at 11-13 weeks' gestation. Univariate and multivariate logistic regression analysis was carried out to determine risks of complications in pregnancies with type 1 and type 2 DM after adjusting for maternal and pregnancy characteristics. Effect sizes were expressed as absolute risks (AR) and odds ratio (OR) (95 % confidence intervals [CI]). RESULTS The study population included 53,649 singleton pregnancies, including 509 (1.0 %) with pre-existing DM and 49,122 (99.0 %) without diabetes. Multivariate logistic regression analysis demonstrated that there was a significant contribution from pre-existing DM in prediction of adverse outcomes, including antenatal complications such as fetal defects, stillbirth, preterm delivery, polyhydramnios, preeclampsia and delivery of large for gestational age (LGA) neonates; intrapartum complications such as caesarean delivery (CS) and post-partum haemorrhage; and neonatal complications including admission to neonatal intensive care unit, hypoglycaemia, jaundice and hypoxic ischaemic encephalopathy (HIE). In particular, there was a 5-fold increased risk of stillbirth and HIE. CONCLUSIONS The maternal and neonatal complications in pregnancies with pre-existing DM are significantly increased compared to those without DM despite a decade of intensive multidisciplinary antenatal care. Further research is required to investigate strategies and interventions to prevent morbidity and mortality in pregnancies with pre-gestational DM.
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Affiliation(s)
- Rebecca Karkia
- Department of Obstetrics, Medway NHS Foundation Trust, Kent, UK
- Institute of Medical Sciences, Canterbury Christ Church University, Kent, UK
| | - Tara Giacchino
- Institute of Medical Sciences, Canterbury Christ Church University, Kent, UK
- Medway Fetal and Maternal Medicine Centre, Medway NHS Foundation Trust, Kent, UK
| | - Helen Watson
- Department of Obstetrics, Medway NHS Foundation Trust, Kent, UK
| | - Andrew Gough
- Department of Endocrinology and Diabetes, Medway NHS Foundation Trust, Kent, UK
| | - Ghada Ramadan
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | - Ranjit Akolekar
- Institute of Medical Sciences, Canterbury Christ Church University, Kent, UK
- Medway Fetal and Maternal Medicine Centre, Medway NHS Foundation Trust, Kent, UK
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16
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Sushko K, Strachan P, Butt M, Nerenberg K, Sherifali D. Supporting self-management in women with pre-existing diabetes in pregnancy: a mixed-methods sequential comparative case study. BMC Nurs 2024; 23:1. [PMID: 38163872 PMCID: PMC10759746 DOI: 10.1186/s12912-023-01659-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION Maternal glycemia is associated with pregnancy outcomes. Thus, supporting the self-management experiences and preferences of pregnant women with type 1 and type 2 diabetes is crucial to optimize glucose control and perinatal outcomes. RESEARCH DESIGN AND METHODS This paper describes the mixed methods integration of a sequential comparative case study. The objectives are threefold, as we integrated the quantitative and qualitative data within the overall mixed methods design: (1) to determine the predictors of glycemic control during pregnancy; (2) to understand the experience and diabetes self-management support needs during pregnancy among women with pre-existing diabetes; (3) to assess how self-management and support experiences helpe to explain glycemic control among women with pre-existing diabetes in pregnancy. The purpose of the mixing was to integrate the quantitative and qualitative data to develop rich descriptive cases of how diabetes self-management and support experiences and preferences in women with type 1 and type 2 diabetes during pregnancy help explain glucose control. A narrative approach was used to weave together the statistics and themes and the quantitative results were integrated visually alongside the qualitative themes to display the data integration. RESULTS The quantitative results found that women achieved "at target" glucose control (mean A1C of the cohort by the third visit: 6.36% [95% Confidence Interval 6.11%, 6.60%]). The qualitative findings revealed that feelings of fear resulted in an isolating and mentally exhausting pregnancy. The quantitative data also indicated that women reported high levels of self-efficacy that increased throughout pregnancy. Qualitative data revealed that women who had worked hard to optimize glycemia during pregnancy were confident in their self-management. However, they lacked support from their healthcare team, particularly around self-management of diabetes during labour and delivery. CONCLUSIONS The achievement of optimal glycemia during pregnancy was motivated by fear of pregnancy complications and came at a cost to women's mental health. Mental health support, allowing women autonomy, and the provision of peer support may improve the experience of diabetes self-management during pregnancy. Future work should focus on developing, evaluating and implementing interventions that support these preferences.
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Affiliation(s)
- Katelyn Sushko
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Patricia Strachan
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Michelle Butt
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Kara Nerenberg
- Departments of Medicine and Obstetrics & Gynecology, University of Calgary, Calgary, AB, Canada
| | - Diana Sherifali
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
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Austin BA, McFarling KM, Likins B, Chapman A, Cuff RD, Head B, Finneran MM. Impact on Neonatal Outcomes with Late Preterm and Early Term Delivery in Women with Diabetes. Am J Perinatol 2024; 41:122-126. [PMID: 37696290 DOI: 10.1055/s-0043-1774311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVE Late preterm and early term deliveries are common in pregnancies complicated by diabetes due to higher rates of obstetric complications including increased stillbirth risk. However, early delivery is associated with multiple neonatal adverse outcomes, which may be further increased by maternal diabetes. We examined whether there is an additive effect on adverse neonatal outcomes in the setting of maternal diabetes in the late preterm and early term periods. STUDY DESIGN This was a retrospective cohort study of women with a singleton, nonanomalous pregnancy delivering at a single academic medical center in the late preterm (340/7-366/7 weeks) or early term (370/7-386/7 weeks) period between 2010 and 2019. Women were categorized by diabetes status: no diabetes, type 1 (T1DM), type 2 (T2DM), or gestational diabetes (GDM). Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for risk of both mild and severe composite neonatal outcome with delivery in the late preterm or early term period using pregnancies without diabetes as the referent. RESULTS A total of 8,072 pregnancies were included with T1DM, T2DM, and GDM complicating 1.8, 5.6, and 9.9% of pregnancies, respectively. Expected demographic differences were seen among groups including higher rates of non-Hispanic Black race, chronic hypertension, and higher body mass index in women with T2DM. The probability of severe composite adverse neonatal outcome was significantly increased in women with T1DM in the late preterm (aOR: 4.4; CI: 2.4-8.1) and early term (aOR: 1.6; CI: 1.1-2.3) periods, largely driven by the need for mechanical ventilation. The mild composite outcome was increased among all women with diabetes with early term delivery but highest in women with T1DM. CONCLUSION Pregnancies complicated by diabetes, particularly T1DM, have higher rates of neonatal adverse outcomes independent of gestational age at delivery, which is an important consideration when late preterm or early term delivery is planned. KEY POINTS · Diabetes in pregnancy increases risk of early delivery.. · Adverse neonatal outcomes are higher with diabetes, especially T1DM.. · Adverse neonatal outcomes are independent of gestational age..
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Affiliation(s)
- Brittany A Austin
- Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Kelli M McFarling
- Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Benjamin Likins
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Alison Chapman
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Ryan D Cuff
- Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Barbara Head
- Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Matthew M Finneran
- Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, South Carolina
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Gaglia JL, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Selvin E, Stanton RC, Gabbay RA. 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S20-S42. [PMID: 38078589 PMCID: PMC10725812 DOI: 10.2337/dc24-s002] [Citation(s) in RCA: 131] [Impact Index Per Article: 131.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Monteith H, Mamakeesick M, Rae J, Galloway T, Harris SB, Birken C, Hamilton J, Maguire JL, Parkin P, Zinman B, Hanley AJG. Determinants of Anishinabeck infant and early childhood growth trajectories in Northwestern Ontario, Canada: a cohort study. BMC Pediatr 2023; 23:641. [PMID: 38115010 PMCID: PMC10729431 DOI: 10.1186/s12887-023-04449-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND The Developmental Origins of Health and Disease (DOHaD) paradigm emphasizes the significance of early life factors for the prevention of chronic health conditions, like type 2 diabetes (T2DM) and obesity, which disproportionately affect First Nations communities in Canada. Despite increasing DOHaD research related to maternal health during pregnancy, early childhood growth patterns, and infant feeding practices with many populations, data from First Nations communities in Canada are limited. In partnership with Sandy Lake First Nation, the aims of this project were to characterize birthweights and growth patterns of First Nations infants/children over the first 6 years of life and to study the impact of maternal and infant social and behavioral factors on birthweight and growth trajectories. METHODS We recruited 194 families through community announcements and clinic visits. Infant/child length/height and weight were measured at 1 and 2 weeks; 1, 2, 6, 12, and 18 months; and 2, 3, 4, 5 and 6 years. Maternal and infant/child questionnaires captured data about health, nutrition, and social support. Weight-for-Age z-score (WAZ), Height-for-Age z-score (HAZ), and BMI-for-Age z-score (BAZ) were calculated using WHO reference standards and trajectories were analyzed using generalized additive models. Generalized estimating equations and logistic regression were used to determine associations between exposures and outcomes. RESULTS WAZ and BAZ were above the WHO mean and increased with age until age 6 years. Generalized estimating equations indicated that WAZ was positively associated with age (0.152; 95% CI 0.014, 0.29), HAZ was positively associated with birthweight (0.155; 95% CI 0.035, 0.275), and BAZ was positively associated with caregiver's BMI (0.049; 95% CI 0.004, 0.090). There was an increased odds of rapid weight gain (RWG) with exposure to gestational diabetes (OR: 7.47, 95% CI 1.68, 46.22). Almost 70% of parents initiated breastfeeding, and breastfeeding initiation was modestly associated with lower WAZ (-0.18; 95% CI -0.64, 0.28) and BAZ (-0.23; 95% CI -0.79, 0.34). CONCLUSIONS This work highlights early life factors that may contribute to T2DM etiology and can be used to support community and Indigenous-led prevention strategies.
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Affiliation(s)
- Hiliary Monteith
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, University of Toronto Medical Sciences Building, 5Th Floor, Room 5253A, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | | | - Joan Rae
- Sandy Lake First Nation, Sandy Lake, ON, P0V 1V0, Canada
| | - Tracey Galloway
- Department of Anthropology, University of Toronto Mississauga Campus, Terrence Donnelly Health Sciences Complex, Room 354, 3359 Mississauga Rd, Mississauga, ON, L5L 1C6, Canada
| | - Stewart B Harris
- Schulich School of Medicine and Dentistry, Western Centre for Public Health & Family Medicine, Western University, 1465 Richmond St, London, N6G 2M1, ON, Canada
| | - Catherine Birken
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, University of Toronto Medical Sciences Building, 5Th Floor, Room 5271, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Jill Hamilton
- Division of Endocrinology, Hospital for Sick Children, Department of Nutritional Sciences, University of Toronto, 555 University Ave, Toronto, ON, M5S 1X8, Canada
| | - Jonathon L Maguire
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, University of Toronto Medical Sciences Building, 5Th Floor, Room 5271, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Patricia Parkin
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, University of Toronto Medical Sciences Building, 5Th Floor, Room 5271, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Bernard Zinman
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, 600 University Ave, Toronto, ON, M5G 1X5, Canada
| | - Anthony J G Hanley
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, University of Toronto Medical Sciences Building, 5Th Floor, Room 5253A, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
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20
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Chou HH, Chen CC, Tsai CF, Kuo PL, Chiou YY. Associations between maternal chronic diseases and congenital anomalies of the kidney and urinary tract in offspring: a population-based cohort study. Clin Kidney J 2023; 16:2652-2660. [PMID: 38046024 PMCID: PMC10689185 DOI: 10.1093/ckj/sfad217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Indexed: 12/05/2023] Open
Abstract
Background The relationship between maternal chronic diseases and congenital anomalies of the kidneys and urinary tract (CAKUT) in offspring still needs elucidation. This study aimed to comprehensively evaluate the associations between maternal chronic disease and CAKUT in their offspring. Methods Data of mothers and children were extracted from the Taiwan Maternal and Child Health Database and National Health Insurance Research Database. The concept of developmental origins of health and disease (DOHaD) was used to select maternal chronic diseases. Results The study cohort included 1 196 175 mothers and 1 628 706 offspring. Analysis showed that maternal chronic diseases, especially type 1 diabetes, type 2 diabetes, gestational diabetes, connective tissue disorders and CAKUT were highly associated with CAKUT in the offspring. Higher maternal age, abnormal birthweight (>3500 g or <2500 g), gestational age <36 weeks and birth order <2 were all associated with a higher risk of CAKUT. Maternal chronic hypertension and taking angiotensin-related drugs increased the odds ratios of obstructive kidney disease in the offspring. Offspring tended to have the same type of CAKUT as their mothers. Conclusion Maternal chronic diseases, older maternal age and abnormal birthweight are risk factors for CAKUT. Also, a percentage of patients with CAKUT were not full-term newborns. Results support prenatal counselling and health management of pregnant women with chronic diseases and extra care for infants with a high risk of anomalies. It is strongly recommended that prevention of CAKUT in offspring should start with care of the mothers' prenatal chronic diseases.
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Affiliation(s)
- Hsin-Hsu Chou
- Department of Pediatrics, Ditmanson Medical Foundation Chiayi Christian Hospital, Chia-Yi City, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung City, Taiwan
| | - Chih-Chia Chen
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- Department of Pediatrics, Division of Pediatric Nephrology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Ching-Fang Tsai
- Department of Medical Research, Clinical Data Center, Ditmanson Medical Foundation Chiayi Christian Hospital, Chia-Yi City, Taiwan
| | - Pao-Lin Kuo
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Yuan-Yow Chiou
- Department of Pediatrics, Division of Pediatric Nephrology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
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Ngwezi DP, Savu A, Yeung RO, Butalia S, Kaul P. Temporal Trends in Type 1, Type 2, and Gestational Diabetes in Pregnancy: Impact of Rural Residence, Ethnicity, and Material Deprivation. Can J Diabetes 2023; 47:672-679.e3. [PMID: 37474099 DOI: 10.1016/j.jcjd.2023.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/24/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Our aim in this study was to implement a newly validated algorithm to identify pregnant women with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM), and to identify temporal trends in rates over the last decade. We also compared obstetric and neonatal outcomes of pregnancies with and without diabetes mellitus (DM). METHODS Among women with live births between 2005 and 2018 in Alberta, we calculated yearly rates of T1DM, T2DM, and GDM, overall, and stratified by ethnicity, urban or rural residence, material deprivation score, and maternal age. RESULTS Between 2005 and 2018, GDM rates increased from 42.3 to 101.8 per 1,000 deliveries (p<0.0001), T2DM rates increased from 2.6 to 6.4 per 1,000 deliveries (p<0.0001), whereas T1DM remained constant at 3.0 per 1,000 deliveries each year (p=0.4301). Higher GDM and T2DM rates were observed among Chinese and South Asian women, respectively, and among women who were materially deprived and living in urban areas. Women with T2DM were older and had the highest rates of pre-existing hypertension (16%). In contrast, women with T1DM were younger and had the highest rates of gestational hypertension (12%), pre-eclampsia (12%), and cesarean section deliveries (62%). Children of women with T1DM had the highest rates of large for gestational age (46%), neonatal hypoglycemia (41.1%), respiratory distress syndrome (7.7%), and jaundice (29.3%). CONCLUSIONS Diabetes-in-pregnancy rates have more than doubled over the last decade, driven primarily by increases in GDM and T2DM. These trends may have significant implications for the future health of mothers and children in Alberta.
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Affiliation(s)
- Deliwe P Ngwezi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, Edmonton, Alberta, Canada
| | - Roseanne O Yeung
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sonia Butalia
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Padma Kaul
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, Edmonton, Alberta, Canada.
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22
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Yoo JH, Kim JH. The Benefits Of Continuous Glucose Monitoring In Pregnancy. Endocrinol Metab (Seoul) 2023; 38:472-481. [PMID: 37821081 PMCID: PMC10613771 DOI: 10.3803/enm.2023.1805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/13/2023] Open
Abstract
Previous studies have consistently demonstrated the positive effects of continuous glucose monitoring (CGM) on glycemic outcomes and complications of diabetes in people with type 1 diabetes. Guidelines now consider CGM to be an essential and cost-effective device for managing type 1 diabetes. As a result, insurance coverage for it is available. Evidence supporting CGM continues to grow and expand to broader populations, such as pregnant people with type 1 diabetes, people with type 2 diabetes treated only with basal insulin therapy, and even type 2 diabetes that does not require insulin treatment. However, despite the significant risk of hyperglycemia in pregnancy, which leads to complications in more than half of affected newborns, CGM indications and insurance coverage for those patients are unresolved. In this review article, we discuss the latest evidence for using CGM to offer glycemic control and reduce perinatal complications, along with its cost-effectiveness in pregestational type 1 and type 2 diabetes and gestational diabetes mellitus. In addition, we discuss future prospects for CGM coverage and indications based on this evidence.
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Affiliation(s)
- Jee Hee Yoo
- Division of Endocrinology and Metabolism, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea
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23
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Palatnik A, Saffian E, Flynn KE, Pan AY, Yee LM, Basir MA, Cruz M. GAP (gestational diabetes and pharmacotherapy) - study protocol for a randomized controlled, two-arm, single-site trial. Contemp Clin Trials 2023; 131:107237. [PMID: 37245726 PMCID: PMC10527045 DOI: 10.1016/j.cct.2023.107237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Gestational diabetes (GDM) complicates 10% of pregnancies in the US. First-line treatment is medical nutrition therapy (MNT) and exercise. Second line is pharmacotherapy. The definition of what constitutes an unsuccessful trial of MNT and exercise has not been established. Tight glycemic control has been demonstrated to reduce GDM-related neonatal and maternal clinical complications. However, it could also increase rates of small-for-gestational age and carry negative effects on patient-reported outcomes such as anxiety and stress. We will study the effect of earlier and stricter pharmacotherapy in GDM on clinical and patient-reported outcomes. METHODS GDM and pharmacotherapy (GAP) study is a two-arm parallel, pragmatic randomized controlled trial, where 416 participants with GDM are randomized 1:1 to: 1) Intervention group - insulin initiation at 20% elevated glucose values on a weekly glucose log following MNT and exercise trial and insulin titration to keep elevated glucose values <20%; or 2) Active control group - insulin initiation at 40% elevated glucose values on a weekly log following MNT and exercise and insulin titration to keep elevated glucose values <40%. The primary outcome is a composite neonatal outcome of large-for-gestational-age, macrosomia, birth trauma, preterm birth, hypoglycemia, and hyperbilirubinemia. Secondary outcomes include preeclampsia, cesarean birth, small-for-gestational-age, maternal hypoglycemia, and patient-reported outcomes of anxiety, depression, perceived stress, and diabetes self-efficacy. CONCLUSIONS The GAP study will investigate the optimal glycemic threshold for pharmacotherapy addition to MNT and exercise in GDM. The GAP study will promote standardization in GDM management and will have direct relevance for clinical practice.
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Affiliation(s)
- Anna Palatnik
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States of America.
| | - Eleanor Saffian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Kathryn E Flynn
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Services, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University, Chicago, IL, United States of America
| | - Mir Abdul Basir
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Meredith Cruz
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
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Fazekas-Pongor V, Svébis MM, Major D, Pártos K, Dósa N, Mészáros Á, Horváth VJ, Domján BA, Zsirai L, Tabák AG. Trend of pregnancy outcomes in type 1 diabetes compared to control women: a register-based analysis in 1996-2018. Front Endocrinol (Lausanne) 2023; 14:1232618. [PMID: 37501784 PMCID: PMC10369353 DOI: 10.3389/fendo.2023.1232618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Introduction In 1989, the St Vincent declaration aimed to approximate pregnancy outcomes of diabetes to that of healthy pregnancies. We aimed to compare frequency and trends of outcomes of pregnancies affected by type 1 diabetes and controls in 1996-2018. Methods We used anonymized records of a mandatory nation-wide registry of all deliveries between gestational weeks 24 and 42 in Hungary. We included all singleton births (4,091 type 1 diabetes, 1,879,183 controls) between 1996 and 2018. We compared frequency and trends of pregnancy outcomes between type 1 diabetes and control pregnancies using hierarchical Poisson regression. Results The frequency of stillbirth, perinatal mortality, large for gestational age, caesarean section, admission to neonatal intensive care unit (NICU), and low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score was 2-4 times higher in type 1 diabetes compared to controls, while the risk of congenital malformations was increased by 51% and SGA was decreased by 42% (all p<0.05). These observations remained significant after adjustment for confounders except for low APGAR scores. We found decreasing rate ratios comparing cases and controls over time for caesarean sections, low APGAR scores (p<0.05), and for NICU admissions (p=0.052) in adjusted models. The difference between cases and controls became non-significant after 2009. No linear trends were observed for the other outcomes. Conclusions Although we found that the rates of SGA, NICU care, and low APGAR score improved in pregnancies complicated by type 1 diabetes, the target of the St Vincent Declaration was only achieved for the occurrence of low APGAR scores.
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Affiliation(s)
- Vince Fazekas-Pongor
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Mark M. Svébis
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - David Major
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Katalin Pártos
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Norbert Dósa
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Ágota Mészáros
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Viktor J. Horváth
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Beatrix A. Domján
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - László Zsirai
- Department of Gynecology and Family Planning, Istenhegyi Gene Diagnostic Center, Budapest, Hungary
| | - Adam G. Tabák
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- University College London (UCL) Brain Sciences, University College London, London, United Kingdom
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Britton LE, Arcia A, Kaur G, Sontan O, Marshall CJ, George M. "A patient should not have to ask": Women's experiences of patient education about preconception care for type 2 diabetes. PATIENT EDUCATION AND COUNSELING 2023; 112:107739. [PMID: 37094436 PMCID: PMC10399209 DOI: 10.1016/j.pec.2023.107739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES To characterize perspectives and experiences regarding preconception care (PCC) patient education among women with type 2 diabetes. METHOD Descriptive, qualitative research design. Thirty-two English-speaking women with type 2 diabetes identifying as Black and/or Latina, ages 18-40 years old, participated. We conducted semi-structured interviews about PCC perspectives and experiences which we analyzed with conventional content analysis. To enhance rigor, we collected freelisting data from which we calculated salience scores. We triangulated our qualitative findings with salience scores. RESULTS We identified three themes. Our first theme concerned mismatch between women's desires for PCC counseling to be frequent in contrast with their experiences of its infrequency. Our second theme captured how women felt responsible for initiating care in the clinical encounter but uncertain about what they "should" be asking for. Our third theme characterized women's perspectives on receiving information about PCC and pregnancy planning. CONCLUSIONS Young adult women with type 2 diabetes who are Black and/or Latina welcome more education about how PCC can prevent obstetrical complications associated with diabetes, which disproportionately affect their communities. PRACTICE IMPLICATIONS Our findings provide actionable suggestions for improving acceptability and accessibility of PCC patient education in the United States where PCC awareness and uptake are low.
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Affiliation(s)
| | - Adriana Arcia
- University of San Diego, Hahn School of Nursing and Health Science, USA
| | - Guneet Kaur
- University of California Los Angeles David Geffen School of Medicine, David Geffen School of Medicine, USA
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Echouffo-Tcheugui JB, Guan J, Fu L, Retnakaran R, Shah BR. Incidence of Heart Failure Related to Co-Occurrence of Gestational Hypertensive Disorders and Gestational Diabetes. JACC. ADVANCES 2023; 2:100377. [PMID: 37476567 PMCID: PMC10358333 DOI: 10.1016/j.jacadv.2023.100377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/06/2023] [Accepted: 03/21/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The extent to which their co-occurrence of gestational hypertensive disorders (GHTD) and gestational diabetes mellitus (GDM) influences heart failure (HF) risk is unclear. OBJECTIVES The purpose of this study was to characterize the risk of HF related to concomitant GHTD and GDM. METHODS We conducted a population-based cohort study using the Ministry of Health and Long-Term Care of Ontario (Canada) health care administrative databases. We included women with a livebirth singleton delivery between July 1, 2007, and March 31, 2018, and excluded those with prepregnancy diabetes, hypertension, HF, or coronary artery disease. GDM, GHTD, peripartum cardiomyopathy (at index pregnancy) were identified using diagnosis coding. Incident HF was assessed from index pregnancy until March 31, 2020. We estimated associations of GDM and/or GHTD with peripartum cardiomyopathy and incident HF. RESULTS Among 885,873 women (mean age: 30 years, 54,015 with isolated GDM, 43,750 with isolated GHTD, 4,960 with GDM and GHTD), there were 489 HF events over 8 years. Compared to no-GDM and no-GHTD, isolated GDM (adjusted hazard ratio [aHR]: 1.44; 95% CI: 1.02-2.04) and isolated GHTD (aHR: 1.65; 95% CI: 1.17-2.31) were associated with a higher risk of incident HF. The co-occurrence of GDM and GHTD was associated with a higher HF risk (aHR: 2.64; 95% CI: 1.24-5.61). GDM and GHTD increased the risk of peripartum cardiomyopathy (adjusted risk ratio [aRR]: 7.30; 95% CI: 6.92-7.58), similarly to isolated GHTD (aRR: 7.40; 95% CI: 7.23-7.58). CONCLUSIONS The co-occurrence of GDM and GHTD was associated with a significantly high risk of incident HF.
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Affiliation(s)
| | - Jun Guan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Longdi Fu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ravi Retnakaran
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R. Shah
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Sushko K, Strachan P, Butt M, Nerenberg KA, Sherifali D. Understanding the self-management experiences and support needs during pregnancy among women with pre-existing diabetes: a qualitative descriptive study. BMC Pregnancy Childbirth 2023; 23:309. [PMID: 37131168 PMCID: PMC10152436 DOI: 10.1186/s12884-023-05542-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/23/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND With the increasing prevalence of pre-existing type 1 and type 2 diabetes in pregnancy and their associated perinatal risks, there is a need to focus on interventions to achieve optimal maternal glycemia to improve pregnancy outcomes. One strategy focuses on improving diabetes self-management education and support for expectant mothers with diabetes. This study's objective is to describe the experience of managing diabetes during pregnancy and identify the diabetes self-management education and support needs during pregnancy among women with type 1 and type 2 diabetes. METHODS Using a qualitative descriptive study design, we conducted semi-structured interviews with 12 women with pre-existing type 1 or 2 diabetes in pregnancy (type 1 diabetes, n = 6; type 2 diabetes, n = 6). We employed conventional content analyses to derive codes and categories directly from the data. RESULTS Four themes were identified that related to the experiences of managing pre-existing diabetes in pregnancy; four others were related to the self-management support needs in this population. Women with diabetes described their experiences of pregnancy as terrifying, isolating, mentally exhausting and accompanied by a loss of control. Self-management support needs reported included healthcare that is individualized, inclusive of mental health support and support from peers and the healthcare team. CONCLUSIONS Women with diabetes in pregnancy experience feelings of fear, isolation and a loss of control, which may be improved through personalized management protocols that avoid "painting everybody with the same brush" as well as peer support. Further examination of these simple interventions may yield important impacts on women's experience and sense of connection.
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Affiliation(s)
- Katelyn Sushko
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Patricia Strachan
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Michelle Butt
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Kara A Nerenberg
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Diana Sherifali
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
- Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, ON, Canada
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Sushko K, Menezes HT, Butt M, Nerenberg K, Strachan P, Usman MA, Sherifali D. Trends and Self-Management Predictors of Glycemic Control During Pregnancy in Women With Preexisting Type 1 or Type 2 Diabetes: A Cohort Study. Diabetes Spectr 2023; 36:182-192. [PMID: 37193202 PMCID: PMC10182963 DOI: 10.2337/ds22-0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Because much of diabetes management during pregnancy occurs at home, self-management factors such as self-efficacy, self-care activities, and care satisfaction may affect glycemia. Our objective was to explore trends in glycemic control during pregnancy in women with type 1 or type 2 diabetes; assess self-efficacy, self-care, and care satisfaction; and examine these factors as predictors of glycemic control. Methods We conducted a cohort study from April 2014 to November 2019 at a tertiary center in Ontario, Canada. Self-efficacy, self-care, care satisfaction, and A1C were measured three times during pregnancy (T1, T2, and T3). Linear mixed-effects modeling explored trends in A1C and examined self-efficacy, self-care, and care satisfaction as predictors of A1C. Results We recruited 111 women (55 with type 1 diabetes and 56 with type 2 diabetes). Mean A1C significantly decreased by 1.09% (95% CI -1.38 to -0.79) from T1 to T2 and by 1.14% (95% CI -1.43 to -0.86) from T1 to T3. Self-efficacy significantly predicted glycemic control for women with type 2 diabetes and was associated with a mean change in A1C of -0.22% (95% CI -0.42 to -0.02) per unit increase in scale. The exercise subscore of self-care significantly predicted glycemic control for women with type 1 diabetes and was associated with a mean change in A1C of -0.11% (95% CI -0.22 to -0.01) per unit increase in scale. Conclusion Self-efficacy significantly predicted A1C during pregnancy in a cohort of women with preexisting diabetes in Ontario, Canada. Future research will continue to explore the self-management needs and challenges in women with preexisting diabetes in pregnancy.
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Affiliation(s)
- Katelyn Sushko
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | | | - Michelle Butt
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Kara Nerenberg
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Patricia Strachan
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Muhammad Ali Usman
- Faculty of Health Sciences, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diana Sherifali
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Thorius IH, Husemoen LLN, Nordsborg RB, Alibegovic AC, Gall MA, Petersen J, Mathiesen ER. Congenital malformations among offspring of women with type 1 diabetes who use insulin pumps: a prospective cohort study. Diabetologia 2023; 66:826-836. [PMID: 36640191 DOI: 10.1007/s00125-022-05864-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/23/2022] [Indexed: 01/15/2023]
Abstract
AIMS/HYPOTHESIS Continuous subcutaneous insulin infusion by insulin pump is often superior in improving glycaemic control compared with conventional multiple daily insulin injection (MDI). However, whether pump treatment leads to improved pregnancy outcomes in terms of congenital malformations and perinatal death remains unknown. The present aim was to evaluate the risk of malformations and perinatal and neonatal death in pregnant women with type 1 diabetes treated with pump or MDI. METHODS We performed a secondary analysis of a prospective multinational cohort of 2088 pregnant women with type 1 diabetes in a real-world setting who were treated by pump (n=750) or MDI (n=1338). ORs for offspring with congenital malformations or perinatal or neonatal death were calculated using crude data and by logistic regression on propensity score-matched data. RESULTS At enrolment (gestational week 8; 95% CI 4, 14), pump users had a higher educational level (university degree: 37.3% vs 25.1%; p<0.001) and better glycaemic control (mean HbA1c: 51±10 mmol/mol [6.8±0.9%] vs 54±14 mmol/mol [7.1±1.3%], p<0.001) compared with MDI users. Moreover, a greater proportion of pump users had an HbA1c level below 75 mmol/mol (9%) (97.6% vs 91.9%, p<0.001), and more often reported taking folic acid supplementation (86.3% vs 74.8%; p<0.001) compared with MDI users. All clinically important potential confounders were balanced after propensity score matching, and HbA1c remained lower in pump users. The proportion of fetuses with at least one malformation was 13.5% in pump users vs 11.2% in MDI users (crude OR 1.23; 95% CI 0.94, 1.61; p=0.13; propensity score-matched (adjusted) OR 1.11; 95% CI 0.81, 1.52; p=0.52). The proportion of fetuses with at least one major malformation was 2.8% in pump users vs 3.1% in MDI users (crude OR 0.89; 95% CI 0.52, 1.51; p=0.66; adjusted OR 0.78; 95% CI 0.42, 1.45; p=0.43), and the proportions of fetuses carrying one or more minor malformations (but no major malformations) were 10.7% vs 8.1% (crude OR 1.36; 95% CI 1.00, 1.84; p=0.05; adjusted OR 1.23; 95% CI 0.87, 1.75; p=0.25). The proportions of perinatal and neonatal death were 1.6% vs 1.3% (crude OR 1.23; 95% CI 0.57, 2.67; p=0.59; adjusted OR 2.02; 95% CI 0.69, 5.93; p=0.20) and 0.3% vs 0.3% (n=2 vs n=4, p=not applicable), respectively. CONCLUSIONS/INTERPRETATIONS Insulin pump treatment was not associated with a lower risk of congenital malformations, despite better glycaemic control in early pregnancy compared with MDI. Further studies exploring the efficacy and safety of pump treatment during pregnancy are needed.
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Affiliation(s)
- Ida H Thorius
- Center for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- Novo Nordisk A/S, Søborg, Denmark.
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark.
| | | | | | | | | | - Janne Petersen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kattini R, Kelly L, Hummelen R. Systematic review of the use of metformin compared to insulin for the management of gestational diabetes: Implications for low-resource settings. CANADIAN JOURNAL OF RURAL MEDICINE 2023; 28:59-65. [PMID: 37005989 DOI: 10.4103/cjrm.cjrm_40_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
Introduction This systematic review examines the effectiveness of metformin treatment compared to insulin treatment for gestational diabetes within the context of a low-resource environment. Methods Electronic data searches of Medline, EMBASE, Scopus and Google scholar databases from 1 January, 2005 to 30 June, 2021 were performed using medical subject headings: 'gestational diabetes or pregnancy diabetes mellitus' AND 'Pregnancy or pregnancy outcomes' AND 'Insulin' AND 'Metformin Hydrochloride Drug Combination/or Metformin/or Hypoglycemic Agents' AND 'Glycemic control or blood glucose'. Randomized controlled trials were included if: participants were pregnant women with gestational diabetes mellitus (GDM); the interventions were metformin and/or insulin. Studies among women with pre-gestational diabetes, non-randomised control trials or studies with a limited description of the methodology were excluded. Outcomes included adverse maternal outcomes: weight gain, C-section, pre-eclampsia and glycaemic control and adverse neonatal outcomes: birth weight, macrosomia, pre-term birth and neonatal hypoglycaemia. The revised Cochrane Risk of Bias Assessment for randomised trials was used for the evaluation of bias. Results We screened 164 abstracts and 36 full-text articles. Fourteen studies met the inclusion criteria. The studies provide moderate to high-quality evidence demonstrating the effectiveness of metformin as an alternative therapy to insulin. Risk of bias was low; multiple countries and robust sample sizes improved external validity. All studies were from urban centres with no rural data. Conclusion These recent high quality studies comparing metformin to insulin for the treatment of GDM generally found either improved or equivalent pregnancy outcome and good glycaemic control for most patients, although many required insulin supplementation. Its ease of use, safety and efficacy suggest metformin may simplify the management of gestational diabetes, particularly in rural and other low-resource environments.
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Affiliation(s)
- Ribal Kattini
- Sioux Lookout Local Education Group, Sioux Lookout, Ontario, Canada; Medical Student, Monash University, Melbourne, Australia
| | - Len Kelly
- Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, Ontario, Canada
| | - Ruben Hummelen
- Division of Clinical Sciences, Northern Ontario School of Medicine, Sioux Lookout, Ontario, Canada
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Ruby E, McDonald SD, Berger H, Melamed N, Li J, Darling EK, Barrett J, G. Ray J, Geary M, Murray‐Davis B. Exploring patients' perspectives of gestational diabetes mellitus screening and counselling in Ontario: A grounded theory study. Health Expect 2023; 26:827-835. [PMID: 36651675 PMCID: PMC10010101 DOI: 10.1111/hex.13708] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/29/2022] [Accepted: 01/07/2023] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. Approaches to screening for GDM continue to evolve, introducing potential variability of care. This study explored the impact of these variations on GDM counselling and screening from the perspectives of pregnant individuals. METHODS Following a Corbin and Strauss approach to qualitative, grounded theory we recruited 28 individuals from three cities in Ontario, Canada who had a singleton pregnancy under the care of either a midwife, family physician or obstetrician. Convenience and purposive sampling techniques were used. Semi-structured telephone interviews were conducted and transcribed verbatim between March and December 2020. Transcripts were analysed inductively resulting in codes, categories and themes. RESULTS Three themes were derived from the data about GDM screening and counselling: 'informing oneself', 'deciding' and 'screening'. All participants, regardless of geographical region, or antenatal care provider, moved through these three steps during the GDM counselling and screening process. Differences in counselling approaches between pregnancy care providers were noted throughout the 'informing' and 'deciding' stages of care. Factors influencing these differences included communication, healthcare autonomy and patient motivation to engage with health services. No differences were noted within care provider groups across the three geographic regions. Participant experiences of GDM screening were influenced by logistical challenges and personal preferences towards testing. CONCLUSION Informing oneself about GDM may be a crucial step for facilitating decision-making and screening uptake, with an emphasis on information provision to facilitate patient autonomy and motivation. PATIENT OR PUBLIC CONTRIBUTION Participants of our study included patients and service users. Participants were actively involved in the study design due to the qualitative, patient-centred nature of the research methods employed. Analysis of results was structured according to the emergent themes of the data which were grounded in patient perspectives and experiences.
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Affiliation(s)
- Emma Ruby
- Department of Obstetrics and Gynecology, McMaster Midwifery Research CentreMcMaster UniversityHamiltonOntarioCanada
| | - Sarah D. McDonald
- Departments of Obstetrics and Gynecology Radiology and Clinical Epidemiology and Biostatistics, Division of Maternal‐Fetal MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Howard Berger
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, St. Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| | - Nir Melamed
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Jenifer Li
- Department of Obstetrics and Gynecology, McMaster Midwifery Research CentreMcMaster UniversityHamiltonOntarioCanada
| | - Elizabeth K. Darling
- Department of Obstetrics and Gynecology, McMaster Midwifery Research CentreMcMaster UniversityHamiltonOntarioCanada
| | - Jon Barrett
- Departments of Obstetrics and Gynecology Radiology and Clinical Epidemiology and Biostatistics, Division of Maternal‐Fetal MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Joel G. Ray
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, St. Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| | - Michael Geary
- Department of Obstetrics & GynaecologyRotunda HospitalDublinIreland
| | - Beth Murray‐Davis
- Department of Obstetrics and Gynecology, McMaster Midwifery Research CentreMcMaster UniversityHamiltonOntarioCanada
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Sekhon J, Graham D, Mehrotra C, Li I. Continuous glucose monitoring: A cost-effective tool to reduce pre-term birth rates in women with type one diabetes. Aust N Z J Obstet Gynaecol 2023; 63:146-153. [PMID: 35833262 DOI: 10.1111/ajo.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Women with type one diabetes experience poorer obstetric outcomes than normoglycaemic women in pregnancy. OBJECTIVE To investigate the cost and clinical effectiveness of continuous glucose monitoring (GCM) compared to self-monitoring of blood glucose in improving obstetric outcomes in women with type one diabetes during pregnancy. MATERIALS AND METHODS This retrospective cohort study included women with type one diabetes referred to a state-wide tertiary obstetric centre before and after the introduction of government-funded CGMs in Australia in March 2019. Forty-nine women using CGMs were propensity matched on a range of clinical features with a historical group of 49 women with type one diabetes who exclusively used intermittent self-monitoring of blood in the year prior to the introduction of funding of sensors. Medical records and administrative cost data were audited to quantify cost and clinical effectiveness. RESULTS There were significantly lower pre-term (95% CI 0.39-0.922; P = 0.026) and very pre-term birth rates (95% CI 1.002-1.184; P = 0.041) in the CGM group. There was a significant reduction in the length of antenatal inpatient hospital stay (P < 0.01) and adult special care unit stay (P = 0.013) and neonatal admission to the neonatal intensive care unit (P = 0.0262) in the continuous glucose monitoring group. CGMs represented a net cost saving to the health care sector of $12 063 per pregnancy where the device was used, with an incremental cost-effectiveness ratio of $3275 per prevented pre-term birth. CONCLUSIONS CGM use in pregnancy is a cost-effective intervention for reducing the risk of pre-term birth in women with type one diabetes, resulting in a net cost benefit to the health sector.
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Affiliation(s)
- Jasmin Sekhon
- King Edward Memorial Hospital, Perth, Western Australia, Australia
- The University of Western Australia, Perth, Western Australia, Australia
| | - Dorothy Graham
- King Edward Memorial Hospital, Perth, Western Australia, Australia
- The University of Western Australia, Perth, Western Australia, Australia
| | - Chhaya Mehrotra
- King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Ian Li
- The University of Western Australia, Perth, Western Australia, Australia
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Closed-loop insulin delivery in pregnant women with type 1 diabetes (CRISTAL): a multicentre randomized controlled trial - study protocol. BMC Pregnancy Childbirth 2023; 23:180. [PMID: 36927458 PMCID: PMC10018977 DOI: 10.1186/s12884-023-05481-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Despite increasing use of continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII, insulin pumps) in type 1 diabetes (T1D) in pregnancy, achieving recommended pregnancy glycaemic targets (3.5-7.8 mmol/L or 63-140 mg/dL) remains challenging. Consequently, the risk of adverse pregnancy outcomes remains high. Outside pregnancy, hybrid closed-loop (HCL) insulin delivery systems have led to a paradigm shift in the management of T1D, with 12% higher time in glucose target range (TIR) compared to conventional CSII. However, most commercially available HCL systems are currently not approved for use in pregnancy. This study aims to evaluate the efficacy, safety and cost-effectiveness of the MiniMed™ 780G HCL system (Medtronic) in T1D in pregnancy. METHODS In this international, open-label, randomized controlled trial (RCT), we will compare the MiniMed™ 780G HCL system to standard of care (SoC) in T1D in pregnancy. Women aged 18-45 years with T1D diagnosis of at least one year, HbA1c ≤ 86 mmol/mol (≤ 10%), and confirmed singleton pregnancy up to 11 weeks 6 days will be eligible. After providing written informed consent, all participants will wear a similar CGM system (Guardian™ 3 or Guardian™ 4 CGM) during a 10-day run-in phase. After the run-in phase, participants will be randomised 1:1 to 780G HCL (intervention) or SoC [control, continuation of current T1D treatment with multiple daily injections (MDI) or CSII and any type of CGM] stratified according to centre, baseline HbA1c (< 53 vs. ≥ 53 mmol/mol or < 7 vs. ≥ 7%), and method of insulin delivery (MDI or CSII). The primary outcome will be the time spent within the pregnancy glucose target range, as measured by the CGM at four time points in pregnancy: 14-17, 20-23, 26-29, and 33-36 weeks. Prespecified secondary outcomes will be overnight TIR, time below range (TBR: <3.5 mmol/L or < 63 mg/dL), and overnight TBR. Other outcomes will be exploratory. The planned sample size is 92 participants. The study will end after postpartum discharge from hospital. Analyses will be performed according to intention-to-treat as well as per protocol. DISCUSSION This large RCT will evaluate a widely used commercially available HCL system in T1D in pregnancy. Recruitment began in January 2021 and was completed in October 2022. Study completion is expected in May 2023. TRIAL REGISTRATION ClinicalTrials.gov: NCT04520971. Registration date: August 20, 2020. https://clinicaltrials.gov/ct2/show/NCT04520971.
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Piffer S, Pedron M, Rizzello R, Orrasch M, Zambotti F, Zardini S. Prevalence of gestational diabetes and recourse to postpartum oral glucose tolerance test in the Autonomous Province of Trento (Italy). Eur J Obstet Gynecol Reprod Biol 2023; 282:50-54. [PMID: 36634406 DOI: 10.1016/j.ejogrb.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 12/01/2022] [Accepted: 12/26/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The occurrence of gestational diabetes (GDM) is increasing worldwide, and such a diagnosis is important for women's health beyond pregnancy. Therefore, many guidelines suggest the re-evaluation of glucose tolerance with a postpartum oral glucose tolerance test (OGTT) in women with GDM. This study reports the prevalence of GDM and the use of a postpartum OGTT in women assisted at maternity units in the Autonomous Province of Trento in the years 2017-2018, investigating the socio-demographic and health-care variables that can facilitate access to the test. STUDY DESIGN For the diagnosis of GDM, the International Association of Diabetes and Pregnancy Study Group criteria were used. The Birth Assistance Certificate and the Hospital Information System were used to retrieve clinical and socio-demographic data. Univariate and multivariate analyses were performed to evaluate the stratification of the use of a postpartum OGTT. RESULTS In total, 8,308 pregnant women were assisted at the maternity units in Trento. There were 532 recorded cases of GDM (266 cases per year) and the overall average prevalence was 6.4 % (95 % CI, 5.90-6.90), 4.9 % of whom were Italian (95 % CI, 4.38-5.42) and 10.4 %, foreigners (95 % CI, 9.13-11.67). 135 women diagnosed with GDM and residing in Trento out of 513 were evaluated using a postpartum OGTT (26.3%, CI 95% 22.50-30.10), with pathological results in 61 cases (45.2%). In the multivariate analyses, insulin therapy during pregnancy, delivery at a third-level birth point, and a discharge letter informing of the presence of GDM and of the need for a postpartum OGTT were independent factors associated with the probability of carrying out a postpartum OGTT. CONCLUSIONS The prevalence of GDM in our study is lower than in previous Italian studies; however, it is consistent with European data. The proportion of women who were assessed using the postpartum OGTT is lower than that reported by previous studies. The health-care factors seem predominant among the socio-demographic characteristics of the cases in influencing access to the test. The awareness of women, the sharing of guidelines among the different sectors of the health system, and an optimal management of the discharge from the birth point are critical in ensuring an optimal follow-up in women with GDM.
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Affiliation(s)
- Silvano Piffer
- Clinical and Evaluative Epidemiology Service, Provincial Health Agency, Trento, Italy.
| | - Mariangela Pedron
- Clinical and Evaluative Epidemiology Service, Provincial Health Agency, Trento, Italy.
| | - Roberto Rizzello
- Clinical and Evaluative Epidemiology Service, Provincial Health Agency, Trento, Italy.
| | - Massimo Orrasch
- Diabetes Care Center, Provincial Health Agency, Trento, Italy.
| | | | - Sara Zardini
- Obstetrics and Gynecology Unit, Trento S. Chiara Hospital, Provincial Health Agency, Trento, Italy.
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Amniotic fluid and vaginal microbiota in pregnant women with gestational diabetes mellitus by metagenomics. MEDICINE IN MICROECOLOGY 2023. [DOI: 10.1016/j.medmic.2022.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Ahmed A, Rosella LC, Oskoui M, Watson T, Yang S. In utero Exposure to Maternal Diabetes and the Risk of Cerebral Palsy: A Population-based Cohort Study. Epidemiology 2023; 34:247-258. [PMID: 36722807 DOI: 10.1097/ede.0000000000001574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Evidence on the effects of in utero exposure to maternal diabetes on cerebral palsy (CP) in offspring is limited. We aimed to examine the effects of pregestational (PGDM) and gestational diabetes (GDM) separately on CP risk and the mediating role of increased fetal size. METHODS In a population-based study, we included all live births in Ontario, Canada, between 2002 and 2017 followed up through 2018 (n = 2,110,177). Using administrative health data, we estimated crude and adjusted associations between PGDM or GDM and CP using Cox proportional hazards models to account for unequal follow-up in children. For the mediation analysis, we used marginal structural models to estimate the controlled direct effect of PGDM (and GDM) on the risk of CP not mediated by large-for-gestational age (LGA). RESULTS During the study period, 5,317 children were diagnosed with CP (187 exposed to PGDM and 171 exposed to GDM). Children of mothers with PGDM showed an increased risk (hazard ratio [HR]: 1.84 [95% confidence interval (CI): 1.59, 2.14]) after adjusting for maternal sociodemographic and clinical factors. We found no associations between GDM and CP (adjusted HR: 0.91 [0.77, 1.06]). Our mediation analysis estimated that LGA explained 14% of the PDGM-CP association. CONCLUSIONS In this population-based birth cohort study, maternal pregestational diabetes was associated with increased risk of CP, and the increased risk was not substantially mediated by the increased fetal size.
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Affiliation(s)
- Asma Ahmed
- From the Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Temerty Faculty of Medicine, Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
| | - Maryam Oskoui
- McGill University Health Center Research Institute (RI-MUHC), Child Health and Human Development Program, Centre for Outcomes Research and Evaluation, Montreal, QC, Canada
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
- Department of Neurology & Neurosurgery, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Tristan Watson
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Seungmi Yang
- From the Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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Clements JN, Franks R, Isaacs D, Malloy K, Meade LT, Reece SM, Reid DJ, Ward ED. Significant publications in diabetes pharmacotherapy and technology in 2020. Expert Rev Endocrinol Metab 2023; 18:131-142. [PMID: 36882974 DOI: 10.1080/17446651.2023.2187779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/02/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION The most significant articles on diabetes pharmacotherapy and technology in the peer-reviewed literature from 2020, as determined by a panel of pharmacists with expertise in diabetes care and education, are summarized. AREAS COVERED Members of the Association of Diabetes Care and Education Specialists Pharmacy Community of Interest were selected to review articles published in prominent peer-reviewed journals in 2020 that most impacted diabetes pharmacotherapy and technology. A list of 37 nominated articles were compiled (22 in diabetes pharmacotherapy and 15 in diabetes technology). Based on discussion among the authors, the articles were ranked based on significant contribution, impact, and diversity to diabetes pharmacotherapy and technology. The top 10 highest ranked publications (n = 6 for diabetes pharmacotherapy and n = 4 in diabetes technology) are summarized in this article. EXPERT OPINION With the significant number of publications in diabetes care and education, it can be challenging and overwhelming to remain current with published literature. This review article may be helpful in identifying key articles in diabetes pharmacotherapy and technology from the year 2020.
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Affiliation(s)
- Jennifer N Clements
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Greenville, SC, USA
| | - Rachel Franks
- Department of Endocrinology, BayCare Health System, Tampa, FL, USA
| | - Diana Isaacs
- Department of Endocrinology and Metabolism, Cleveland Clinic Endocrinology & Metabolism Institute, Cleveland, OH, USA
| | - Kevin Malloy
- Department of Endocrinology and Metabolism, Cleveland Clinic Endocrinology & Metabolism Institute, Cleveland, OH, USA
| | - Lisa T Meade
- Department of Endocrinology, Piedmont Healthcare, Statesville, NC, USA
| | - Sara Mandy Reece
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine School of Pharmacy, Suwaneee, GA, USA
| | - Debra J Reid
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy and Pharmaceutical Sciences, Northeastern University, Bouvé College of Health Sciences, Boston, MA, USA
| | - Eileen D Ward
- Department of Pharmacy Practice, Presbyterian College School of Pharmacy, Clinton, SC, USA
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Field C, Lynch CD, Fareed N, Joseph JJ, Wu J, Thung SF, Gabbe SG, Landon MB, Grobman WA, Venkatesh KK. Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus. Am J Obstet Gynecol MFM 2023; 5:100898. [PMID: 36787839 DOI: 10.1016/j.ajogmf.2023.100898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined. OBJECTIVE This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes. STUDY DESIGN This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type. RESULTS Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability. CONCLUSION Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.
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Affiliation(s)
- Christine Field
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh).
| | - Courtney D Lynch
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
| | - Naleef Fareed
- Department of Biomedical Informatics, Ohio State University College of Medicine, Columbus, OH (Dr Fareed)
| | - Joshua J Joseph
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, OH (Dr Joseph)
| | - Jiqiang Wu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
| | - Stephen F Thung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
| | - Steven G Gabbe
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
| | - Mark B Landon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
| | - William A Grobman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
| | - Kartik K Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH (Drs Field and Lynch, Mr Wu, and Drs Thung, Gabbe, Landon, Grobman, and Venkatesh)
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Venkatesh KK, Joseph JJ, Clark A, Gabbe SG, Landon MB, Thung SF, Yee LM, Lynch CD, Grobman WA, Walker DM. Association of community-level food insecurity and glycemic control among pregnant individuals with pregestational diabetes. Prim Care Diabetes 2023; 17:73-78. [PMID: 36379871 PMCID: PMC10286113 DOI: 10.1016/j.pcd.2022.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
AIM To evaluate whether pregnant individuals with pregestational diabetes who live in a food-insecure community have worse glycemic control compared to those who do not live in a food-insecure community. METHODS A retrospective analysis of pregnant individuals with pregestational diabetes enrolled in a multidisciplinary prenatal and diabetes care program. The exposure was community-level food insecurity per the Food Access Research Atlas. The outcomes were hemoglobin A1c (A1c) < 6.0 % in early and late pregnancy, and an absolute decrease in A1c ≥ 2.0 % and mean change in A1c across pregnancy. RESULTS Among 418 assessed pregnant individuals with pregestational diabetes, those living in a food-insecure community were less likely to have an A1c < 6.0 % in early pregnancy compared to those living in a community without food insecurity [16 % vs. 30 %; adjusted risk ratio (aRR): 0.55; 95 % CI: 0.33-0.92]. Individuals living in a food-insecure community were more likely to achieve a decrease in A1c ≥ 2.0 % [35 % vs. 21 %; aRR: 1.55; 95 % CI: 1.06-2.28] and a larger mean decrease in A1c across pregnancy [mean: 1.46 vs. 1.00; adjusted beta: 0.47; 95 % CI: 0.06-0.87)]. CONCLUSIONS Pregnant individuals with pregestational diabetes who lived in a food-insecure community were less likely to enter pregnancy with glycemic control, but were more likely to have a reduction in A1c and achieve similar A1c status compared to those who lived in a community without food insecurity. Whether interventions that address food insecurity improve glycemic control and consequent perinatal outcomes remains to be studied.
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Affiliation(s)
- Kartik K Venkatesh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, the United States of America.
| | - Joshua J Joseph
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, The Ohio State University, Columbus, OH, the United States of America
| | - Aaron Clark
- Department of Family and Community Medicine, The Ohio State University, Columbus, OH, the United States of America
| | - Steven G Gabbe
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, the United States of America
| | - Mark B Landon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, the United States of America; Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, The Ohio State University, Columbus, OH, the United States of America; Department of Family and Community Medicine, The Ohio State University, Columbus, OH, the United States of America; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, the United States of America
| | - Stephen F Thung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, the United States of America; Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, The Ohio State University, Columbus, OH, the United States of America; Department of Family and Community Medicine, The Ohio State University, Columbus, OH, the United States of America; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, the United States of America
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, the United States of America
| | - Courtney D Lynch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, the United States of America
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, the United States of America
| | - Daniel M Walker
- Department of Family and Community Medicine, The Ohio State University, Columbus, OH, the United States of America
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Sushko K, Menezes HT, Wang QR, Nerenberg K, Fitzpatrick-Lewis D, Sherifali D. Patient-reported Benefits and Limitations of Mobile Health Technologies for Diabetes in Pregnancy: A Scoping Review. Can J Diabetes 2023; 47:102-113. [PMID: 36182614 DOI: 10.1016/j.jcjd.2022.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/28/2022] [Accepted: 08/02/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES For women with pre-existing and gestational diabetes, pregnancy involves specialized and intensive medical care to optimize maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. COVID-19-induced barriers to face-to-face care have identified the need for high-quality, patient-centred virtual health-care modalities, such as mobile health (mHealth) technologies. Our aim in this review was to identify the patient-reported benefits and limitations of mHealth technologies among women with diabetes in pregnancy. We also aimed to determine how the women's experiences aligned with the best practice standards for patient-centred communication. METHODS The framework presented by Arksey and O'Malley for conducting scoping reviews, with refinements by Levac et al, was used to guide this review. Relevant studies were identified through comprehensive database searches of MEDLINE, Embase, Emcare and PsycINFO. Thomas and Harden's methods for the thematic synthesis of qualitative research in systematic reviews guided the synthesis of patient-reported benefits and limitations of mHealth technology. RESULTS Overall, 19 studies describing the use of 16 unique mHealth technologies among 742 women were included in the final review. Patient-reported benefits of mHealth included convenience, support of psychosocial well-being and facilitation of diabetes self-management. Patient-reported limitations included lack of important technological features, perceived burdensome aspects of mHealth and lack of trust in virtual health care. CONCLUSIONS Women with diabetes report some benefits from mHealth use during pregnancy. Codesigning future technologies with end users may help address the perceived limitations and effectiveness of mHealth technologies.
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Affiliation(s)
- Katelyn Sushko
- Faculty of Health Sciences, School of Nursing, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada.
| | - Holly Tschirhart Menezes
- Faculty of Health Sciences, School of Nursing, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada
| | - Qi Rui Wang
- Faculty of Health Sciences, School of Nursing, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada
| | - Kara Nerenberg
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Donna Fitzpatrick-Lewis
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Diana Sherifali
- Faculty of Health Sciences, School of Nursing, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Diabetes Care and Research Program, The Boris Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Easton ZJW, Luo X, Li L, Regnault TRH. The impact of hyperglycemia upon BeWo trophoblast cell metabolic function: A multi-OMICS and functional metabolic analysis. PLoS One 2023; 18:e0283118. [PMID: 36930661 PMCID: PMC10022812 DOI: 10.1371/journal.pone.0283118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 02/23/2023] [Indexed: 03/18/2023] Open
Abstract
Pre-existing and gestationally-developed diabetes mellitus have been linked with impairments in placental villous trophoblast cell metabolic function, that are thought to underlie the development of metabolic diseases early in the lives of the exposed offspring. Previous research using placental cell lines and ex vivo trophoblast preparations have highlighted hyperglycemia is an important independent regulator of placental function. However, it is poorly understood if hyperglycemia directly influences aspects of placental metabolic function, including nutrient storage and mitochondrial respiration, that are altered in term diabetic placentae. The current study examined metabolic and mitochondrial function as well as nutrient storage in both undifferentiated cytotrophoblast and differentiated syncytiotrophoblast BeWo cells cultured under hyperglycemia conditions (25 mM glucose) for 72 hours to further characterize the direct impacts of placental hyperglycemic exposure. Hyperglycemic-exposed BeWo trophoblasts displayed increased glycogen and triglyceride nutrient stores, but real-time functional readouts of metabolic enzyme activity and mitochondrial respiratory activity were not altered. However, specific investigation into mitochondrial dynamics highlighted increased expression of markers associated with mitochondrial fission that could indicate high glucose-exposed trophoblasts are transitioning towards mitochondrial dysfunction. To further characterize the impacts of independent hyperglycemia, the current study subsequently utilized a multi-omics approach and evaluated the transcriptomic and metabolomic signatures of BeWo cytotrophoblasts. BeWo cytotrophoblasts exposed to hyperglycemia displayed increased mRNA expression of ACSL1, HSD11B2, RPS6KA5, and LAP3 and reduced mRNA expression of CYP2F1, and HK2, concomitant with increased levels of: lactate, malonate, and riboflavin metabolites. These changes highlighted important underlying alterations to glucose, glutathione, fatty acid, and glucocorticoid metabolism in BeWo trophoblasts exposed to hyperglycemia. Overall, these results demonstrate that hyperglycemia is an important independent regulator of key areas of placental metabolism, nutrient storage, and mitochondrial function, and these data continue to expand our knowledge on mechanisms governing the development of placental dysfunction.
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Affiliation(s)
- Zachary J W Easton
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Xian Luo
- The Metabolomics Innovation Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Liang Li
- The Metabolomics Innovation Centre, University of Alberta, Edmonton, Alberta, Canada
- Department of Chemistry, University of Alberta, Edmonton, Alberta, Canada
| | - Timothy R H Regnault
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Department of Obstetrics and Gynaecology, London Health Science Centre-Victoria Hospital, London, Ontario, Canada
- Children's Health Research Institute, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
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Desoye G, Ringholm L, Damm P, Mathiesen ER, van Poppel MNM. Secular trend for increasing birthweight in offspring of pregnant women with type 1 diabetes: is improved placentation the reason? Diabetologia 2023; 66:33-43. [PMID: 36287249 PMCID: PMC9607824 DOI: 10.1007/s00125-022-05820-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 12/13/2022]
Abstract
Despite enormous progress in managing blood glucose levels, pregnancy in women with type 1 diabetes still carries risks for the growing fetus. While, previously, fetal undergrowth was not uncommon in these women, with improved maternal glycaemic control we now see an increased prevalence of fetal overgrowth. Besides short-term implications, offspring of women with type 1 diabetes are more likely to become obese and to develop diabetes and features of the metabolic syndrome. Here, we argue that the increase in birthweight is paradoxically related to improved glycaemic control in the pre- and periconceptional periods. Good glycaemic control reduces the prevalence of microangiopathy and improves placentation in early pregnancy, which may lead to unimpeded fetal nutrition. Even mild maternal hyperglycaemia may then later result in fetal overnutrition. This notion is supported by circumstantial evidence that lower HbA1c levels as well as increases in markers of placental size and function in early pregnancy are associated with large-for-gestational age neonates. We also emphasise that neonates with normal birthweight can have excessive fat deposition. This may occur when poor placentation leads to initial fetal undergrowth, followed by fetal overnutrition due to maternal hyperglycaemia. Thus, the complex interaction of glucose levels during different periods of pregnancy ultimately determines the risk of adiposity, which can occur in fetuses with both normal and elevated birthweight. Prevention of fetal adiposity calls for revised goal setting to enable pregnant women to maintain blood glucose levels that are closer to normal. This could be supported by continuous glucose monitoring throughout pregnancy and appropriate maternal gestational weight gain. Future research should consider the measurement of adiposity in neonates.
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Affiliation(s)
- Gernot Desoye
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S19-S40. [PMID: 36507649 PMCID: PMC9810477 DOI: 10.2337/dc23-s002] [Citation(s) in RCA: 795] [Impact Index Per Article: 795.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Dłuski DF, Ruszała M, Rudziński G, Pożarowska K, Brzuszkiewicz K, Leszczyńska-Gorzelak B. Evolution of Gestational Diabetes Mellitus across Continents in 21st Century. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15804. [PMID: 36497880 PMCID: PMC9738915 DOI: 10.3390/ijerph192315804] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 06/17/2023]
Abstract
Over the last few decades, several definitions of gestational diabetes mellitus (GDM) have been described. There is currently not enough research to show which way is the best to diagnose GDM. Opinions differ in terms of the optimal screening and diagnostic measures, in part due to the differences in the population risks, the cost-effectiveness considerations, and the lack of an evidence base to support large national screening programs. The basic method for identifying the disease is the measurement of glucose plasma levels which may be determined when fasting, two hours after a meal, or simply at any random time. The currently increasing incidence of diabetes in the whole population, the altering demographics and the presence of lifestyle changes still require better methods of screening for hyperglycemia, especially during pregnancy. The main aim of this review is to focus on the prevalence and modifications to the screening criteria for GDM across all continents in the 21st century. We would like to show the differences in the above issues and correlate them with the geographical situation. Looking at the history of diabetes, we are sure that more than one evolution in GDM diagnosis will occur, due to the development of medicine, appearance of modern technologies, and the dynamic continuation of research.
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Affiliation(s)
- Dominik Franciszek Dłuski
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-954 Lublin, Poland
| | - Monika Ruszała
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-954 Lublin, Poland
| | - Gracjan Rudziński
- Faculty of Medicine, Medical University of Lublin, 20-059 Lublin, Poland
| | - Kinga Pożarowska
- Faculty of Medicine, Medical University of Lublin, 20-059 Lublin, Poland
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Luo S, Yan J, Yang D, Xiong S, Wang C, Guo Y, Yao B, Weng J, Zheng X. Current practice, attitude and views of providing pregnancy care for women with type 1 diabetes in China: a qualitative study. BMJ Open 2022; 12:e061657. [PMID: 36343990 PMCID: PMC9644323 DOI: 10.1136/bmjopen-2022-061657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Data are sparse on healthcare needs related to pregnancy among Chinese women with type 1 diabetes (T1D) or the gap between the needs and healthcare provision in China. We aimed to identify their needs and the gaps in pregnancy care provision. DESIGN This is a qualitative, face-to-face, one-to-one in-depth interview study. We recruited our participants using a purposive sampling strategy. Semistructural outlines were used to guide the interviews. The interviews were digitally recorded, transcribed and analysed using a thematic framework method with NVivo V.10.0. SETTING Guangdong Province in China. PARTICIPANTS This study involved three key stakeholders of pregnancy care for women with T1D: 29 women with T1D of childbearing age (aged 18-50 years), 16 family members (husbands, parents and parents-in-law of women with T1D) and 35 relevant healthcare providers (HCPs). RESULTS We found that women with T1D and the family members had a more pessimistic attitude towards pregnancy outcomes, which was different from the more positive view of HCPs. However, all three stakeholders shared the following perspectives regarding pregnancy-related care for women with T1D: (1) lack of knowledge and access to education, (2) lack of multidisciplinary cooperation, (3) education should be started earlier in adulthood, (3) positive role of peer support, and (4) hope for future training of HCPs for relevant knowledge and skills specified for T1D and pregnancy with T1D. CONCLUSIONS An immense gap was identified between the needs of women with T1D regarding pregnancy-related care and current care provision in China. These findings suggest that education be provided to patients and HCPs, and the role of professional and multidisciplinary support should be enhanced to optimise pregnancy care for women with T1D in China.
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Affiliation(s)
- Sihui Luo
- Department of Endocrinology, Institute of Endocrine and Metabolic Diseases, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Jinhua Yan
- Department of Endocrinology and Metabolism, the Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Daizhi Yang
- Department of Endocrinology and Metabolism, the Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Shanshan Xiong
- Department of Endocrinology and Metabolism, the Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Chaofan Wang
- Department of Endocrinology and Metabolism, the Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Yan Guo
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Bin Yao
- Department of Endocrinology and Metabolism, the Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Jianping Weng
- Department of Endocrinology, Institute of Endocrine and Metabolic Diseases, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
- Department of Endocrinology and Metabolism, the Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Xueying Zheng
- Department of Endocrinology, Institute of Endocrine and Metabolic Diseases, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
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Echouffo Tcheugui JB, Guan J, Fu L, Retnakaran R, Shah BR. Association of Concomitant Gestational Hypertensive Disorders and Gestational Diabetes With Cardiovascular Disease. JAMA Netw Open 2022; 5:e2243618. [PMID: 36416822 PMCID: PMC9685489 DOI: 10.1001/jamanetworkopen.2022.43618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Accruing evidence suggests that gestational hypertensive disorders (GHTD) and gestational diabetes (GD) are each associated with an increased risk of cardiovascular disease (CVD). However, the extent to which the co-occurrence of GHTD and GD is associated with the risk of CVD remains largely unknown. OBJECTIVE To estimate the individual and joint associations of GHTD and GD with incident CVD. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used the Ministry of Health and Long-Term Care of Ontario (Canada) health care administrative databases. All women in Ontario with a GHTD and/or GD diagnosis, and a live-birth singleton delivery between July 1, 2007, and March 31, 2018, were considered for inclusion. Women with pregravid diabetes, hypertension, or cardiovascular disease were excluded. Statistical analysis was performed from November 2021 to September 2022. EXPOSURES GD and/or GHTD, defined using diagnosis coding. MAIN OUTCOMES AND MEASURES Individual and joint associations of GHTD and GD with incident CVD (including a composite of myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy), estimated using Cox regression models, adjusting for relevant cardiometabolic risk factors. The follow-up extended from the index pregnancy until March 31, 2020. RESULTS Among 886 295 eligible women (mean [SD] age, 30 [5.6] years; 43 861 [4.9%] with isolated GHTD, 54 061 [6.1%] with isolated GD, and 4975 [0.6%] with GHTD and GD), there were 1999 CVD events over 12 years of follow-up. In the early postpartum phase (first 5 years post partum), there was no association of co-occurrence of GTHD and GD (adjusted hazard ratio [aHR], 1.42, 95% CI, 0.78-2.58) or GD alone (aHR, 0.80; 95% CI, 0.60-1.06) with CVD; there was an association between isolated GTHD and incident CVD compared with no GTHD and no GD (aHR, 1.90; 95% CI, 1.51-2.35). In the late postpartum period (after the initial 5 years post partum), compared with no GD and no GHTD, isolated GHTD (aHR, 1.41, 95% CI, 1.12-1.76) and co-occurrence of GHTD and GD (aHR, 2.43, 95% CI, 1.60-3.67) were each associated with a higher risk of incident CVD. There was no association between isolated GD and incident CVD. CONCLUSIONS AND RELEVANCE In this cohort study, GHTD was associated with a high risk of CVD post partum, and the co-occurrence of GD and GHTD was associated with a much greater postpartum CVD risk. These findings suggest that CVD preventive care is particularly needed in the aftermath of combined GD and GHTD.
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Affiliation(s)
- Justin B. Echouffo Tcheugui
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jun Guan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Longdi Fu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ravi Retnakaran
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R. Shah
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Gupta A, Immanuel J, Ho V, Dalal R, Symons P, Simmons D. Placental abnormalities in type 1 and type 2 diabetes mellitus: a systematic review and metaanalysis of shear wave elastography. Am J Obstet Gynecol MFM 2022; 4:100736. [PMID: 36049626 DOI: 10.1016/j.ajogmf.2022.100736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 08/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to describe the placental changes occurring in women with preexisting diabetes mellitus and to determine if elastography can detect placental changes in vivo. DATA SOURCES PubMed, Embase, Medline, and Cochrane were searched to identify English language studies published until July 2020. STUDY ELIGIBILITY CRITERIA 1) For key question 1, studies that described histopathologic changes in placentas from women with known diabetes mellitus and 2) for key question 2, those that described structural-placental changes detectable by elastography in high-risk pregnancies (eg, those complicated by preeclampsia and/or fetal growth restriction), were included. METHODS For key question 1, we grouped placental pathologies using the Amsterdam International Consensus Group definitions. For key question 2, we conducted a metaanalysis including all data from studies reporting placental stiffness in meters per second (m/s) or kilopascals (kPa). The mean difference (95% confidence interval) was calculated using a random effects model. RESULTS Data were extracted from 14 studies of placental histopathology in women with known diabetes. In this group, a wide variety of placental histopathologic changes are described, though none are considered pathognomonic. The histopathologic changes including maternal vascular malperfusion, fetal vascular malperfusion, and/or infectious/inflammatory/other changes were divided into 3 broad categories on the basis of presumed etiology. A total of 15 studies reported the placental stiffness scores in women with a high-risk pregnancy vs those with a normal pregnancy. Only 1 reported stiffness scores for placentas in women with preexisting diabetes mellitus (N<10 women). Pooled analysis of 14 studies with available data included 478 "high-risk pregnancies" and 828 control or healthy pregnancies. Maternal-derived pathologies resulted in higher placental stiffness (mean difference 4.5 kPa [95% confidence interval, 3.16-5.87]) compared with control or healthy pregnancies. Fetal-derived pathologies also resulted in higher placental stiffness (mean difference of 6.5 kPa [95% confidence interval, 1.08-11.86]) compared with control or healthy pregnancies. CONCLUSION Shear wave elastography may provide an in vivo approximation of placental histopathology in women with certain kinds of high-risk pregnancies. A high-risk pregnancy may involve maternal- and fetal-derived pathologies. Further studies, particularly in women with preexisting diabetes, are needed to confirm this observation.
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Affiliation(s)
- Akhil Gupta
- Macarthur Clinical School of Medicine, Western Sydney University, New South Wales, Australia (Drs Gupta, Immanuel, Ho, Dalal, and Simmons); Department of Medicine, Campbelltown Hospital, Sydney, New South Wales, Australia (Drs Gupta, Ho, and Simmons); Department of Diabetes and Endocrinology, Blacktown Hospital, Sydney, New South Wales, Australia (Dr Gupta).
| | - Jincy Immanuel
- Macarthur Clinical School of Medicine, Western Sydney University, New South Wales, Australia (Drs Gupta, Immanuel, Ho, Dalal, and Simmons)
| | - Vincent Ho
- Macarthur Clinical School of Medicine, Western Sydney University, New South Wales, Australia (Drs Gupta, Immanuel, Ho, Dalal, and Simmons)
| | - Raiyomand Dalal
- Macarthur Clinical School of Medicine, Western Sydney University, New South Wales, Australia (Drs Gupta, Immanuel, Ho, Dalal, and Simmons)
| | - Patricia Symons
- South Western Sydney Clinical School, UNSW Medicine, Warwick Farm, Australia (Dr Symons)
| | - David Simmons
- Macarthur Clinical School of Medicine, Western Sydney University, New South Wales, Australia (Drs Gupta, Immanuel, Ho, Dalal, and Simmons); Department of Medicine, Campbelltown Hospital, Sydney, New South Wales, Australia (Drs Gupta, Ho, and Simmons); Department of Anatomical Pathology, Liverpool Hospital, Sydney, New South Wales, Australia (Dr Symons).
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Feig DS. Epidemiology and Therapeutic Strategies for Women With Preexisting Diabetes in Pregnancy: How Far Have We Come? The 2021 Norbert Freinkel Award Lecture. Diabetes Care 2022; 45:2484-2491. [PMID: 37579297 DOI: 10.2337/dci21-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
The field of diabetes in pregnancy has witnessed tremendous changes over the past 30 years, with an explosive growth in case numbers along with new and exciting opportunities to affect outcomes. Type 1 diabetes in pregnancy has increased by 40%, but type 2 diabetes in pregnancy, rarely seen 30 years ago, has more than doubled and, in some cases, tripled in prevalence. Compared with women with type 2 diabetes, women with type 1 diabetes have higher HbA1c, more large-for-gestational-age infants, and more preterm births. Women with type 2 diabetes have more chronic hypertension, more socioeconomic deprivation, and higher rates of perinatal mortality. Large randomized trials in women with diabetes in pregnancy have helped us understand the effectiveness of new technologies (i.e., continuous glucose monitoring) in women with type 1 diabetes, and the addition of metformin to insulin in women with type 2 diabetes, in improving pregnancy outcomes. Future endeavors, including artificial pancreas systems in women with type 1 diabetes and the use of continuous glucose monitoring, a better understanding of nutrition during pregnancy, and approaches to improve preconception and pregnancy self-care in women with type 2 diabetes, may lead to further improved outcomes.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
- Sinai Health System, Mount Sinai Hospital, Toronto, Canada
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Sushko K, Sherifali D, Nerenberg K, Strachan PH, Butt M. Supporting self-management in women with pre-existing diabetes in pregnancy: a protocol for a mixed-methods sequential comparative case study. BMJ Open 2022; 12:e062777. [PMID: 36253034 PMCID: PMC9577889 DOI: 10.1136/bmjopen-2022-062777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 09/28/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION For women with pre-existing type 1 and type 2 diabetes, glycaemic targets are narrow during the preconception and prenatal periods to optimise pregnancy outcomes. Women aim to achieve glycaemic targets during pregnancy through the daily tasks of diabetes self-management. Diabetes self-management during pregnancy involves frequent self-monitoring of blood glucose and titration of insulin based on glucose measures and carbohydrate intake. Our objective is to explore how self-management and support experiences help explain glycaemic control among women with pre-existing diabetes in pregnancy. METHODS AND ANALYSIS We will conduct a four-phased mixed-methods sequential comparative case study. Phase I will analyse the data from a prospective cohort study to determine the predictors of glycaemic control during pregnancy related to diabetes self-management among women with pre-existing diabetes. In phase II, we will use the results of the cohort analysis to develop data collection tools for phase III. Phase III will be a qualitative description study to understand women's diabetes education and support needs during pregnancy. In phase IV, we will integrate the results of phases I and III to generate unique cases representing the ways in which self-management and support experiences explain glycaemic control in pregnancy. ETHICS AND DISSEMINATION The phase I cohort study received approval from our local ethics review board, the Hamilton Integrated Ethics Review Board. We will seek ethics approval for the phase III qualitative study prior to its commencement. Participants will provide informed consent before study enrolment. We plan to publish our results in peer-reviewed journals and present our findings to stakeholders at relevant conferences/symposia.
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Affiliation(s)
- Katelyn Sushko
- School of Nursing, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Diana Sherifali
- School of Nursing, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Kara Nerenberg
- Medicine, Obstetrics & Gynaecology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Patricia H Strachan
- Nursing, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Michelle Butt
- School of Nursing, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
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Desoye G, Carter AM. Fetoplacental oxygen homeostasis in pregnancies with maternal diabetes mellitus and obesity. Nat Rev Endocrinol 2022; 18:593-607. [PMID: 35902735 DOI: 10.1038/s41574-022-00717-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 11/09/2022]
Abstract
Despite improvements in clinical management, pregnancies complicated by pre-existing diabetes mellitus, gestational diabetes mellitus or obesity carry substantial risks for parent and offspring. Some of the endocrine and metabolic changes in parent and fetus in diabetes mellitus and obesity lead to fetal oxygen deficit, mostly due to insulin-induced accelerated fetal metabolism. The human fetus deals with reduced oxygenation through a wide range of adaptive responses that act at various levels in the placenta as well as the fetus. These responses ensure adequate oxygen delivery to the fetus, increase the oxygen transport capacity of fetal blood and redistribute oxygen-rich blood to vital organs such as the brain and heart. The liver has a central role in adapting to reduced oxygenation by increasing its oxygen extraction and stimulating erythropoietin synthesis to increase haematocrit. The type of adaptive response depends on the onset and duration of hypoxia and the severity of the metabolic disturbance. In pregnancies characterized by diabetes mellitus or obesity, these adaptive systems come under additional strain owing to the increased maternal supply of glucose and resultant fetal hyperinsulinaemia, both of which stimulate oxidative metabolism. In the rare situation that the adaptive responses are overwhelmed, stillbirth can ensue.
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Affiliation(s)
- Gernot Desoye
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
- Center for Pregnant Women with Diabetes, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Anthony M Carter
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
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