Atlantic Diabetes in Pregnancy (DIP): the prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria

Association between thyroid function and risk of gestational diabetes mellitus in assisted pregnancies: A retrospective cohort study

AIMS

To explore the association between thyroid function and gestational diabetes mellitus (GDM) risk in assisted pregnancies.

METHODS

We screened 57,386 pregnant women treated from February 2013 to October 2017, and 2211 patients were retrospectively enrolled, and their data were analyzed based on quintile groups constituted based on serum thyroid-stimulating hormone (TSH), free thyroxine (FT4), and thyroid peroxidase antibody (TPOAb) levels. Odds ratios (ORs) of GDM were analyzed by multivariate logistic regression, adjusted for maternal age and pre-pregnancy body mass index (BMI).

RESULTS

The prevalence rate of GDM was 20.1%. Lower FT4 levels were associated with an increased risk of GDM (OR_Q2 = 1.512, 95% confidence interval [CI] 1.073-2.132, p = 0.018; OR_Q1 = 1.620, 95% CI 1.161-2.261, p = 0.005), but this association disappeared after adjustments. TPOAb+ titer was associated with an increased risk of GDM (aOR = 1.472, 95% CI 1.068-2.028, p = 0.018). Higher TSH (aOR_Q5 = 2.882, 95% CI 1.919-6.975, p = 0.019) or lower FT4 (aOR_Q1 = 3.156, 95% CI 1.088-9.115, p = 0.034) levels were associated with an increased risk of GDM in assisted pregnancies for TPOAb+ patients.

CONCLUSION

TPOAb+ is an independent risk factor for GDM in patients with assisted pregnancies. Higher TSH or lower FT4 levels, with TPOAb+ detection, are risk factors for GDM in assisted pregnancies.

A Review of the Pathophysiology and Management of Diabetes in Pregnancy

Diabetes is a common metabolic complication of pregnancy and affected women fall into two subgroups: women with pre-existing diabetes and those with gestational diabetes mellitus (GDM). When pregnancy is affected by diabetes, both mother and infant are at increased risk for multiple adverse outcomes. A multidisciplinary approach to care before, during, and after pregnancy is effective in reducing these risks. The PubMed database was searched for English language studies and guidelines relating to diabetes in pregnancy. The following search terms were used alone and in combination: diabetes, pregnancy, gestational diabetes, GDM, prepregnancy, and preconception. A date restriction was not applied. Results were reviewed by the authors and selected for inclusion based on relevance to the topic. Additional articles were identified by manually searching reference lists of included articles. Using data from this search we herein summarize the evidence relating to pathophysiology and management of diabetes in pregnancy. We discuss areas of controversy including the method and timing of diagnosis of GDM, and choice of pharmacologic agents to treat hyperglycemia during pregnancy. Therefore, this review is intended to serve as a practical guide for clinicians who are caring for women with diabetes and their infants.

All thresholds of maternal hyperglycaemia from the WHO 2013 criteria for gestational diabetes identify women with a higher genetic risk for type 2 diabetes

Background: Using genetic scores for fasting plasma glucose (FPG GS) and type 2 diabetes (T2D GS), we investigated whether the fasting, 1-hour and 2-hour glucose thresholds from the WHO 2013 criteria for gestational diabetes (GDM) have different implications for genetic susceptibility to raised fasting glucose and type 2 diabetes in women from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) and Atlantic Diabetes in Pregnancy (DIP) studies. Methods: Cases were divided into three subgroups: (i) FPG ≥5.1 mmol/L only, n=222; (ii) 1-hour glucose post 75 g oral glucose load ≥10 mmol/L only, n=154 (iii) 2-hour glucose ≥8.5 mmol/L only, n=73; and (iv) both FPG ≥5.1 mmol/L and either of a 1-hour glucose ≥10 mmol/L or 2-hour glucose ≥8.5 mmol/L, n=172. We compared the FPG and T2D GS of these groups with controls (n=3,091) in HAPO and DIP separately. Results: In HAPO and DIP, the mean FPG GS in women with a FPG ≥5.1 mmol/L, either on its own or with 1-hour glucose ≥10 mmol/L or 2-hour glucose ≥8.5 mmol/L, was higher than controls (all P <0.01). Mean T2D GS in women with a raised FPG alone or with either a raised 1-hour or 2-hour glucose was higher than controls (all P <0.05). GDM defined by 1-hour or 2-hour hyperglycaemia only was also associated with a higher T2D GS than controls (all P <0.05). Conclusions: The different diagnostic categories that are part of the WHO 2013 criteria for GDM identify women with a genetic predisposition to type 2 diabetes as well as a risk for adverse pregnancy outcomes.

Comparison of Effectiveness of Routine Antenatal Care with a Midwife-Managed Clinic Service in Prevention of Gestational Diabetes Mellitus in Early Pregnancy at a Hospital in China

Background

Women with normal fasting glucose (FPG) range (5.1 ≤FPG <6.09 mmol/L) in early pregnancy are at high risk of gestational diabetes mellitus (GDM). The aim of this study was to compare the effectiveness of routine antenatal care with a midwife-managed clinic service in the prevention of GDM in early pregnancy at a hospital in China.

Material/Methods

We designed a prospective observational clinical study among pregnancy women with normal fasting glucose (FPG) range (5.1 ≤FPG <6.09 mmol/L) in early pregnancy. Routine antenatal care was compared with a midwife-managed clinic service providing diet and exercise education before week 16. A 75-g OGTT was performed at weeks 24–28 for both groups. Results of OGTT and gestational weight gain were compared between the 2 groups.

Results

Of the 592 eligible women, 296 women received the antenatal nursing clinic service and 296 were enrolled in a control group. Thirty-three women were lost to follow-up during the study, leaving 279 in the intervention group and 280 in the control group. Baseline demographic characteristics were similar between the 2 groups. GDM was diagnosed in 115 participants (41.2%) in the intervention group and 141 (50.4%) in the control group. Subgroup analysis showed a significantly lower rate of GDM in the intervention group among the No-IVF population (37.8% vs. 49.0%, P=0.01%). For pre-pregnancy BMI, significant differences were found in the incidence of GDM and maternal hypertension between the different groups, showing that the overweight group benefited most from the midwife-managed antenatal clinic service.

Conclusions

The midwife-managed clinic service was feasible and effective in the prevention of GDM.

All thresholds of maternal hyperglycaemia from the WHO 2013 criteria for gestational diabetes identify women with a higher genetic risk for type 2 diabetes

Background: Using genetic scores for fasting plasma glucose (FPG GS) and type 2 diabetes (T2D GS), we investigated whether the fasting, 1-hour and 2-hour glucose thresholds from the WHO 2013 criteria for gestational diabetes (GDM) have different implications for genetic susceptibility to raised fasting glucose and type 2 diabetes in women from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) and Atlantic Diabetes in Pregnancy (DIP) studies. Methods: Cases were divided into three subgroups: (i) FPG ≥5.1 mmol/L only, n=222; (ii) 1-hour glucose post 75 g oral glucose load ≥10 mmol/L only, n=154 (iii) 2-hour glucose ≥8.5 mmol/L only, n=73; and (iv) both FPG ≥5.1 mmol/L and either of a 1-hour glucose ≥10 mmol/L or 2-hour glucose ≥8.5 mmol/L, n=172. We compared the FPG and T2D GS of these groups with controls (n=3,091) in HAPO and DIP separately. Results: In HAPO and DIP, the mean FPG GS in women with a FPG ≥5.1 mmol/L, either on its own or with 1-hour glucose ≥10 mmol/L or 2-hour glucose ≥8.5 mmol/L, was higher than controls (all P <0.01). Mean T2D GS in women with a raised FPG alone or with either a raised 1-hour or 2-hour glucose was higher than controls (all P <0.05). GDM defined by 1-hour or 2-hour hyperglycaemia only was also associated with a higher T2D GS than controls (all P <0.05). Conclusions: The different diagnostic categories that are part of the WHO 2013 criteria for GDM identify women with a genetic predisposition to type 2 diabetes as well as a risk for adverse pregnancy outcomes.

Short- and long-term outcomes of gestational diabetes and its treatment on fetal development

Globally the prevalence of gestational diabetes mellitus (GDM) is rising mainly due to the increase in maternal obesity. A number of different methods to screen for and diagnose GDM have been described although consensus on the preferred methods does not yet exist. GDM has significant short- and long-term health risks for the mother, developing fetus and the children born to mothers with GDM. Short-term risks for the fetus include macrosomia (excessive birthweight), shoulder dystocia, birth trauma, and hypoglycaemia in the immediate postpartum period. Long-term risks for offspring born to mothers with GDM include increased rates of childhood and adulthood obesity and an increased cardiometabolic risk. A number of pharmacological treatments for GDM have been identified, these include insulin and oral glucose-lowering drugs metformin and glibenclamide. Whilst these oral glucose-lowering drugs show similar short-term childhood outcomes to insulin there is increasing evidence that these drugs may have adverse long-term outcomes on children and adults exposed to the drugs in utero. Future research on treatments for GDM should include long-term follow- up of children exposed to glucose lowering medication in utero to determine the long-term cardiometabolic risk in the offspring born to mothers with GDM.

Two criteria of oral glucose tolerance test to diagnose gestational diabetes mellitus

OBJECTIVE

To evaluate two different criteria, one or two cut-off values, of oral glucose tolerance test with 75g of glucose for the diagnosis of gestational diabetes mellitus.

METHODS

A cross-sectional study involving 120 records of pregnant women who received prenatal care at the service of a Brazilian university was carried out. Bivariate analysis of obstetric and perinatal outcomes was performed using the chi-square test.

RESULTS

Considering criterion I, 12.5% of patients were diagnosed with gestational diabetes mellitus. Patients were 3.57 times more likely to have a large fetus for the gestational age at birth (p=0.038). Using criterion II, gestational diabetes mellitus was diagnosed in 5.8% of patients, macrosomia was 7.73 times more likely to be found in the presence of gestational diabetes mellitus (p=0.004), and a large fetus for the gestational age at birth was 8.17 times more likely (p=0.004).

CONCLUSIONS

There was a difference in the prevalence of gestational diabetes mellitus between the two criteria analyzed. The new criterion proposed increased prevalence.

Maternal health and non-communicable disease prevention: An investment case for the post COVID-19 world and need for better health economic data

An integrated approach to population health, disease surveillance, and preventive care will dominate the health agenda in the post COVID‐19 world. Because of their huge burden and the vulnerability imposed during a health crisis, prevention and care of non‐communicable diseases (NCDs) will need to be prioritized even further. Maternal and child health are inextricably linked with NCDs and their risk factors. The intergenerational impact of poor maternal nutrition and health conditions during pregnancy, particularly NCD‐related pregnancy complications, can be considered as a multiplier of the ongoing pandemic of NCDs. The economic cost of poor maternal health and NCD‐related pregnancy complications is likely very high, but is not adequately researched or documented in the context of long‐term population health. Interventions to address NCDs in pregnancy have beneficial effects on short‐term pregnancy outcomes; but even more importantly, identifying “at‐risk” mothers and offspring opens up the opportunity for targeted early preventive action. Preventive actions to address obesity, hypertension, type 2 diabetes, and cardiovascular diseases have a common lifestyle approach—identifying any one of these problems in pregnancy provides an opportunity to address them all. Cost–benefit analyses that only focus on the short‐term and on one condition do not capture the full value of downstream, long‐term benefits for population health. This requires urgent attention from FIGO.

Integrated action on maternal health and non‐communicable disease prevention is an investment for future population health that requires more health economic data.

A core outcome set for studies of gestational diabetes mellitus prevention and treatment

AIMS/HYPOTHESIS

The aim of this systematic review was to develop core outcome sets (COSs) for trials evaluating interventions for the prevention or treatment of gestational diabetes mellitus (GDM).

METHODS

We identified previously reported outcomes through a systematic review of the literature. These outcomes were presented to key stakeholders (including patient representatives, researchers and clinicians) for prioritisation using a three-round, e-Delphi study. A priori consensus criteria informed which outcomes were brought forward for discussion at a face-to-face consensus meeting where the COS was finalised.

RESULTS

Our review identified 74 GDM prevention and 116 GDM treatment outcomes, which were presented to stakeholders in round 1 of the e-Delphi study. Round 1 was completed by 173 stakeholders, 70% (121/173) of whom went on to complete round 2; 84% (102/121) of round 2 responders completed round 3. Twenty-two GDM prevention outcomes and 30 GDM treatment outcomes were discussed at the consensus meeting. Owing to significant overlap between included prevention and treatment outcomes, consensus meeting stakeholders agreed to develop a single prevention/treatment COS. Fourteen outcomes were included in the final COS. These consisted of six maternal outcomes (GDM diagnosis, adherence to the intervention, hypertensive disorders of pregnancy, requirement and type of pharmacological therapy for hyperglycaemia, gestational weight gain and mode of birth) and eight neonatal outcomes (birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, neonatal hypoglycaemia, neonatal death and stillbirth).

CONCLUSIONS/INTERPRETATION

This COS will enable future GDM prevention and treatment trials to measure similar outcomes that matter to stakeholders and facilitate comparison and combination of these studies.

TRIAL REGISTRATION

This study was registered prospectively with the Core Outcome Measures in Effectiveness Trials (COMET) database: http://www.comet-initiative.org/studies/details/686/.

Factors associated with macrosomia, hypoglycaemia and low Apgar score among Fijian women with gestational diabetes mellitus

Background

Gestational diabetes mellitus (GDM) in Fiji is a serious public health issue. However, there are no recent studies on GDM among pregnant women in Fiji. The aim of this study was to examine prevalence of, and sociodemographic factors associated with adverse neonatal outcomes among Fijian women with GDM.

Methods

We used cross-sectional data of 255 pregnant women with GDM who gave birth to singleton infants at Colonial War Memorial Hospital (CWMH) in Suva city. Women underwent testing for GDM during antenatal clinic visits and were diagnosed using modified International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Multivariable logistic regression analysis was used to investigate factors associated with neonatal outcomes.

Results

Women with a previous baby weighing > 4 kg were 6.08 times more likely to experience neonatal macrosomia (Adjusted odds ratio (AOR) = 6.08; 95%CI: 2.46, 15.01). Compared to unmarried women, the odds of macrosomia among married women reduced by 71% (AOR = 0.29; 95%CI: 0.11, 0.77). Compared with delivery before 38 weeks of gestation, the infants of women who delivered between 38 and 41 weeks of gestation were 62 and 86% less likely to experience neonatal hypoglycaemia and Apgar score < 7 at 5 mins, respectively. The offspring of women who were overweight and obese had higher odds of neonatal hypoglycaemia. Late booking in gestation (≥28 weeks) was significantly associated with Apgar score < 7 at 5 min (AOR = 7.87; 95%CI: 1.11, 55.75). Maternal pre-eclampsia/pregnancy induced hypertension was another factor associated with low Apgar score in infants.

Conclusions

The study found high rates of adverse neonatal outcomes among off springs of Fijian women with GDM and showed that interventions targeting pregnant women who are overweight, had a previous baby weighing > 4 kg, had pre-eclampsia, delivered before 38 weeks of gestation, and those who booked later than 13 weeks in gestation, are needed to improve pregnancy outcomes.

Visceral Adipose Tissue Inflammatory Factors (TNF-Alpha, SOCS3) in Gestational Diabetes (GDM): Epigenetics as a Clue in GDM Pathophysiology

Gestational diabetes (GDM) is among the most challenging diseases in westernized countries, affecting mother and child, immediately and in later life. Obesity is a major risk factor for GDM. However, the impact visceral obesity and related epigenetics play for GDM etiopathogenesis have hardly been considered so far. Our recent findings within the prospective ‘EaCH’ cohort study of women with GDM or normal glucose tolerance (NGT), showed the role, critical factors of insulin resistance (i.e., adiponectin, insulin receptor) may have for GDM pathophysiology with epigenetically modified expression in subcutaneous (SAT) and visceral (VAT) adipose tissues. Here we investigated the expression and promoter methylation of key inflammatory candidates, tumor necrosis factor-alpha (TNF-α) and suppressor of cytokine signaling 3 (SOCS3) in maternal adipose tissues collected during caesarian section (GDM, n = 19; NGT, n = 22). The mRNA expression of TNF-α and SOCS3 was significantly increased in VAT, but not in SAT, of GDM patients vs. NGT, accompanied by specific alterations of respective promoter methylation patterns. In conclusion, we propose a critical role of VAT and visceral obesity for the pathogenesis of GDM, with epigenetic alterations of the expression of inflammatory factors as a potential factor.

Glucokinase Deficit Prevalence in Women With Diabetes in Pregnancy: A Matter of Screening Selection

Introduction: The prevalence among pregnant women with diabetes of monogenic diabetes due to glucokinase deficit (GCK-MODY) varies from 0 to 80% in different studies, based on the chosen selection criteria for genetic test. New pregnancy-specific Screening Criteria (NSC), validated on an Anglo-Celtic pregnant cohort, have been proposed and include pre-pregnancy BMI <25 kg/m² and fasting glycemia >99 mg/dl. Our aim was to estimate the prevalence of GCK-MODY and to evaluate the diagnostic performance of NSC in our population of women with diabetes in pregnancy. Patients and Methods: We retrospectively selected from our database of 468 diabetic pregnant patients in Sant'Andrea Hospital, in Rome, from 2010 to 2018, all the women who received a genetic test for GCK deficit because of specific clinical features. We estimated the prevalence of GCK-MODY among tested women and the minimum prevalence in our entire population with non-autoimmune diabetes. We evaluated diagnostic performance of NSC on the tested cohort and estimated the eligibility to genetic test based on NSC in the entire population. Results: A total of 409 patients had diabetes in pregnancy, excluding those with autoimmune diabetes; 21 patients have been tested for GCK-MODY, 8 have been positive and 13 have been negative (2 of them had HNF1-alfa mutations and 1 had HNF4-alfa mutation). We found no significant differences in clinical features between positive and negative groups except for fasting glycemia, which was higher in the positive group. The minimum prevalence of monogenic diabetes in our population was 2.4%. The minimum prevalence of GCK-MODY was 1.95%. In the tested cohort, the prevalence of GCK-MODY was 38%. In this group, NSC sensitivity is 87% and specificity is 30%, positive predictive value is 43%, and negative predictive value is 80%. Applying NSC on the entire population of women with non-autoimmune diabetes in pregnancy, 41 patients (10%) would be eligible for genetic test; considering a fasting glycemia >92 mg/dl, 85 patients (20.7%) would be eligible. Discussion: In our population, NSC have good sensitivity but low specificity, probably because there are many GDM with GCK-MODY like features. It is mandatory to define selective criteria with a good diagnostic performance on Italian population, to avoid unnecessary genetic tests.

Visceral adipose tissue alteration of PI3KR1 expression is associated with gestational diabetes but not promoter DNA methylation

Obesity and diabetes are at an epidemic rate, as well as growing incidences of gestational diabetes mellitus (GDM) which causes pregnancy risks, and harm in both maternal and child health. It remains unclear which molecular mechanisms are driving the functional differences between visceral and subcutaneous fat and how these types directly affect an individual’s health outcome. Paired abdominal subcutaneous and omental visceral adipose tissue were collected from women with GDM (n = 20) and with normal glucose tolerance (NGT, n = 22) during planned caesarian section. Both groups had similar maternal age (average 32.5 years) and BMI at delivery (average 33.3 kg/m²). Adipose tissue mRNA expression analyses of insulin signalling genes: PI3KCA, PI3KR1, IRS1 and IRS2 showed significantly decreased PI3KR1 expression (−23%) in visceral fat in GDM with no association to promoter DNA methylation. Reduced visceral fat PI3KR1 expression appears to be a pathogenic factor in GDM but not through altered promoter methylation.

Projections of the prevalence of hyperglycaemia in pregnancy in 2019 and beyond: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIM

Hyperglycaemia in pregnancy (HIP) is one of the most common complications of pregnancy. This study aims to examine the projected HIP prevalence in 2030 and 2045 using multiple methods.

METHODS

The International Diabetes Federation Diabetes Atlas 2019 prevalence was projected to 2030 and 2045 by: (1) carrying forward the 2019 age-adjusted prevalence rates; (2) applying a linear regression of the past four editions of the IDF Diabetes Atlas; (3) applying a regression of the previous editions with the most consistent trend, followed by extrapolation from the 9th edition HIP estimate.

RESULTS

Respectively, for 2030 and 2045, Method 1 projected a declining HIP rate with prevalences of 14.0% and 13.3%, Method 2 projected an increasing HIP prevalence at 16.5% and 18.3%, Method 3 predicted stabilisation of the rate from 16.0% to 15.8%.

CONCLUSION

Assuming other factors remain unchanged, our best estimation of age-adjusted HIP will show stabilisation between 2019 and 2045 of 15.8% to 16.0%. However, this estimate is confounded by the heterogeneity of studies and the influence of different gestational diabetes mellitus diagnostic criteria. To provide accurate future comparisons we recommend standardising the diagnostic criteria to the International Association of Diabetes in Pregnancy Study Groups.

Follow-up at 1 year and beyond of women with gestational diabetes treated with insulin and/or oral glucose-lowering agents: a core outcome set using a Delphi survey

AIMS/HYPOTHESIS

Gestational diabetes mellitus (GDM) is linked with a higher lifetime risk for the development of impaired fasting glucose, impaired glucose tolerance, type 2 diabetes, the metabolic syndrome, cardiovascular disease, postpartum depression and tumours. Despite this, there is no consistency in the long-term follow-up of women with a previous diagnosis of GDM. Further, the outcomes selected and reported in the research involving this population are heterogeneous and lack standardisation. This amplifies the risk of reporting bias and diminishes the likelihood of significant comparisons between studies. The aim of this study is to develop a core outcome set (COS) for RCTs and other studies evaluating the long-term follow-up at 1 year and beyond of women with previous GDM treated with insulin and/oral glucose-lowering agents.

METHODS

The study consisted of three work packages: (1) a systematic review of the outcomes reported in previous RCTs of the follow-up at 1 year and beyond of women with GDM treated with insulin and/or oral glucose-lowering agents; (2) a three-round online Delphi survey with key stakeholders to prioritise these outcomes; and (3) a consensus meeting where the final COS was decided.

RESULTS

Of 3344 abstracts identified and evaluated, 62 papers were retrieved and 25/62 papers were included in this review. A total of 121 outcomes were identified and included in the Delphi survey. Delphi round 1 was emailed to 835 participants and 288 (34.5%) responded. In round 2, 190 of 288 (65.9%) participants responded and in round 3, 165 of 190 (86.8%) participants responded. In total, nine outcomes were selected and agreed for inclusion in the final COS: assessment of glycaemic status; diagnosis of type 2 diabetes since the index pregnancy; number of pregnancies since the index pregnancy; number of pregnancies with a diagnosis of GDM since the index pregnancy; diagnosis of prediabetes since the index pregnancy; BMI; post-pregnancy weight retention; resting blood pressure; and breastfeeding.

CONCLUSIONS/INTERPRETATION

This study identified a COS that will help bring consistency and uniformity to outcome selection and reporting in clinical trials and other studies involving the follow-up at 1 year and beyond of women diagnosed with GDM treated with insulin and/or oral glucose-lowering agents during pregnancy.

Sex-specific epigenetic alterations of the hypothalamic Agrp-Pomc system do not explain 'diabesity' in the offspring of high-fat diet (HFD) overfed maternal rats

Maternal high-fat diet (HFD) overfeeding pre- and during pregnancy and lactation may 'program' a 'diabesity' predisposition in the offspring, for inconclusive reasons. Acquired alterations of the hypothalamic promoter methylation and mRNA expression of the satiety neurohormone Pomc are possibly of critical importance here. We investigated within one developmental approach, including male and female rats, the sex-specific DNA methylation pattern and corresponding mRNA expression of both Pomc and its endogenous functional antagonist Agrp in the hypothalamus of adult HFD offspring. Obesity and diabetic disturbances occurred in both male and female HFD offspring, accompanied by altered Pomc promoter methylation pattern. However, this was not related to significant Pomc mRNA expression alterations. In contrast, male-specific alterations of Agrp promoter methylation were found, even associated with reduced mRNA expression of this orexigenic/anabolic Pomc antagonist. In conclusion, acquired epigenetic alterations of the hypothalamic Agrp-Pomc system hardly explain the 'diabesity' phenotype in HFD offspring, while distinct vulnerability and functionality of Agrp promoter and related genomic regions methylation should be further investigated.

Diabetes distress is associated with adverse pregnancy outcomes in women with gestational diabetes: a prospective cohort study

BACKGROUND

Around 12% of pregnant women develop gestational diabetes mellitus (GDM), which is associated with increased health risks for both mother and child and pre- and postpartum depression. Little is known about the relationship of GDM with diabetes-specific emotional distress (diabetes distress). The aims of this study are to assess the prevalence of diabetes distress in GDM and its association with adverse pregnancy outcomes.

METHODS

A prospective cohort study was carried out in an Amsterdam based teaching hospital with an ethnic diverse population. Women diagnosed with GDM completed a set of questionnaires at three time points. Questionnaires consisted of Problem Areas in Diabetes Scale 5 (PAID-5) for diabetes distress (T0-T1), Patient Health Questionnaire 9 (PHQ-9) for depressive symptoms (T0-T2), and questions to assess adverse pregnancy outcomes (T2). Adverse pregnancy outcomes (collected via self-report and if feasible from the medical records) were defined as hypertension, pre-eclampsia, caesarean section, severe perineal tearing, postpartum hemorrhage, postpartum depression, shoulder dystocia, neonatal hospitalization, macrosomia, jaundice, hypoglycemia and other (among which low heart rate, fever, hypoxia). Adverse pregnancy outcomes were dichotomized into none and 1 or more. Additional information was collected from the medical charts. Missing data were imputed via predictive mean matching and a multivariable logistic regression analysis was performed with diabetes distress, depressive symptoms, socioeconomic status, parity and ethnicity as predictors and age, HbA1c, and BMI as covariates.

RESULTS

A total of 100 women were included, mean age 32.5 (4.1), mean BMI 26.7 (4.8), 71% were of non-Dutch ethnic background. Elevated diabetes distress (PAID score ≥ 8) was reported by 36% of the women. Multivariable logistic regression analyses revealed that both high diabetes distress (OR 4.70, p = .02) and parity (OR 0.21, p = .02) but not antepartum depressive symptoms were related to adverse pregnancy outcomes.

CONCLUSIONS

Diabetes distress is likely in women with GDM and our findings suggest an association between both diabetes distress, parity and adverse pregnancy outcomes in women with GDM. This warrants replication and further research into the underlying mechanisms explaining the impact of diabetes distress in GDM and potential interventions to reduce distress.

Suboptimal Nocturnal Glucose Control Is Associated With Large for Gestational Age in Treated Gestational Diabetes Mellitus

OBJECTIVE

Continuous glucose monitoring (CGM) provides far greater detail about fetal exposure to maternal glucose across the 24-h day. Our aim was to examine the role of temporal glucose variation on the development of large for gestational age (LGA) infants in women with treated gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

We performed a prospective observational study of 162 pregnant women with GDM in specialist multidisciplinary antenatal diabetes clinics. Participants undertook 7-day masked CGM at 30-32 weeks' gestation. Standard summary indices and glycemic variability measures of CGM were calculated. Functional data analysis was applied to determine differences in temporal glucose profiles. LGA was defined as birth weight ≥90th percentile adjusted for infant sex, gestational age, maternal BMI, ethnicity, and parity.

RESULTS

Mean glucose was significantly higher in women who delivered an LGA infant (6.2 vs. 5.8 mmol/L, P = 0.025, or 111.6 mg/dL vs. 104.4 mg/dL). There were no significant differences in percentage time in, above, or below the target glucose range or in glucose variability measures (all P > 0.05). Functional data analysis revealed that the higher mean glucose was driven by a significantly higher glucose for 6 h overnight (0030-0630 h) in mothers of LGA infants (6.0 ± 1.0 mmol/L vs. 5.5 ± 0.8 mmol/L, P = 0.005, and 108.0 ± 18.0 mg/dL vs. 99.0 ± 14.4 mg/dL).

CONCLUSIONS

Mothers of LGA infants run significantly higher glucose overnight compared with mothers without LGA infants. Detecting and addressing nocturnal glucose control may help to further reduce rates of LGA in women with GDM.

Lessons learned from lifestyle prevention trials in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is associated with an increased risk of adverse outcomes for mother and infant both at birth and later in life. A large body of evidence is now available relating to antenatal prevention of GDM. Overall, despite some individual trials of a variety of lifestyle interventions revealing benefit, many more have shown no effect from the second trimester onwards, even with significant gestational weight gain limitation. At-risk women often seem reluctant to engage in lifestyle changes and frequently cannot adhere to recommended interventions even within a clinical trial setting. Many trials have not considered the heterogeneity of diabetes first discovered in pregnancy, something of importance into the future. Future work should focus on designing interventions acceptable to the population at risk, whether those taking place before or during the first trimester of pregnancy are effective, and whether greater individualization can identify those women most likely to benefit.

Objectively measured sleep duration and plasma glucose values following an oral glucose tolerance test amongst pregnant women with obesity in the UK

BACKGROUND/OBJECTIVES

Short sleep duration has been linked to maternal hyperglycaemia following a 1-h 50 g oral glucose tolerance test (OGTT) in observational studies conducted primarily in the USA. Our objective was to examine the relationship between objectively measured sleep duration and plasma glucose values following the 2-h 75 g OGTT routinely used in the UK amongst women with obesity.

METHODS

Sleep and OGTT data were available for 49 pregnant women who wore wrist actigraphs for at least two nights, and took a 2-h 75 g OGTT at the end of their second trimester. Multivariable regression was used to evaluate associations between sleep duration and OGTT results.

RESULTS

Higher 2-h plasma glucose values were significantly associated with shorter sleep duration and higher maternal age and BMI, with no association observed between wake after sleep onset (WASO) and 2-h plasma glucose values. No associations were observed between fasting plasma glucose values and any sleep parameters.

CONCLUSIONS

We found that shorter sleep duration, as measured using actigraphy, is associated with higher 2-h plasma glucose values following a 2-h 75 g OGTT in the UK. These findings are in keeping with those observed elsewhere in the world, employing alternative OGTT protocols. Future studies should investigate sleep extension as a potential candidate for inclusion in future RCTs aiming to improve glucose tolerance and prevent GDM amongst those at risk.

Metabolic follow-up at one year and beyond of women with gestational diabetes treated with insulin and/or oral hypoglycaemic agents: study protocol for the identification of a core outcomes set using a Delphi survey

BACKGROUND

Gestational diabetes (GDM) is associated with an increased lifetime risk for the development of glucose abnormalities, metabolic syndrome, cardiovascular disease, depression and tumours. Despite this high risk of additional comorbidities, there is no standardised approach to the long-term follow-up of women with a previous diagnosis of GDM. Also, there is no standardisation of outcome selection and reporting in studies involving this population. This increases the risk of reporting bias and reduces the possibility of meaningful comparisons between studies. The aim of this study is to develop a protocol for a core outcome set (COS) for the metabolic follow-up at 1 year and beyond of women with previous GDM treated with insulin and/or oral hypoglycaemic agents.

METHODS/DESIGN

This protocol will describe the steps that will be taken in order to develop the COS. The study will consist of three parts: (1) A systematic review of the literature of the outcomes reported in previous randomised controlled trials of the follow-up at 1 year and beyond of women with GDM treated with insulin and/or oral hypoglycaemic agents; (2) A three-round, online Delphi survey with key stakeholders in order to prioritise these outcomes; and (3) A consensus meeting where the final COS will be decided.

DISCUSSION

The proposed protocol is the first step in developing a COS that will bring consistency and uniformity to outcome selection and reporting in GDM women treated with insulin and/or oral hypoglycaemic agents.

Reduced Insulin Receptor Expression and Altered DNA Methylation in Fat Tissues and Blood of Women With GDM and Offspring

CONTEXT

Altered expression of the insulin receptor (IR) in adipose tissue (AT) could contribute to gestational diabetes mellitus (GDM) etiopathogenesis. Transcriptional regulation via epigenetic mechanisms (e.g., DNA methylation) may play a critical role. However, the human IR promoter DNA methylation patterns and involvement in gene expression are unknown.

OBJECTIVE

We evaluated IR mRNA and protein expression accompanied by targeted DNA methylation analyses in AT and blood cells of women with GDM and their offspring.

DESIGN

Prospective observational study.

SETTING

Academic clinic and research unit.

PARTICIPANTS

GDM-affected (n = 25) and matched control (n = 30) mother-child dyads.

MAIN OUTCOME MEASURES

Maternal IR gene and protein expression in paired subcutaneous (SAT) and visceral adipose tissue samples (VAT). DNA methylation levels in IR promoter and intronic regions in maternal AT and blood cells of mother-offspring pairs.

RESULTS

In SAT and VAT, IR mRNA/protein expressions were significantly reduced in women with GDMs (P < 0.05). The decrease in VAT was more pronounced and independent of maternal body mass index. VAT IR protein levels were inversely associated with key maternal and neonatal anthropometric and metabolic parameters (P < 0.05). DNA methylation patterns were similar across tissues, with significant yet small size alterations between groups in mothers and offspring (P < 0.05).

CONCLUSION

Decreased IR levels in AT may be a relevant pathogenic factor in GDM, affecting materno-fetal metabolism. Further investigation of causal factors for IR dysregulation is necessary, especially in VAT. Potential functional and/or clinical roles of altered DNA methylation also should be evaluated.

The impact of diagnostic criteria for gestational diabetes on its prevalence: a systematic review and meta-analysis

BACKGROUND

The absence of universal gold standards for screening of gestational diabetes (GDM) has led to heterogeneity in the identification of GDM, thereby impacting the accurate estimation of the prevalence of GDM. We aimed to evaluate the effect of different diagnostic criteria for GDM on its prevalence among general populations of pregnant women worldwide, and also to investigate the prevalence of GDM based on various geographic regions.

METHODS

A comprehensive literature search was performed in PubMed, Scopus and Google-scholar databases for retrieving articles in English investigating the prevalence of GDM. All populations were classified to seven groups based-on their diagnostic criteria for GDM. Heterogeneous and non-heterogeneous results were analyzed using the fixed effect and random-effects inverse variance model for calculating the pooled effect. Publication bias was assessed by Begg's test. The Meta-prop method was used for the pooled estimation of the prevalence of GDM. Meta-regression was conducted to explore the association between prevalence of GDM and its diagnostic criteria. Modified Newcastle-Ottawa Quality Assessment Scale for nonrandomized studies was used for quality assessment of the studies included; the ROBINS and the Cochrane Collaboration's risk of bias assessment tools were used to evaluate the risk of bias.

RESULTS

We used data from 51 population-based studies, i.e. a study population of 5,349,476 pregnant women. Worldwide, the pooled overall-prevalence of GDM, regardless of type of screening threshold categories was 4.4%, (95% CI 4.3-4.4%). The pooled overall prevalence of GDM in the diagnostic threshold used in IADPSG criteria was 10.6% (95% CI 10.5-10.6%), which was the highest pooled prevalence of GDM among studies included. Meta-regression showed that the prevalence of GDM among studies that used the IADPSG criteria was significantly higher (6-11 fold) than other subgroups. The highest and lowest prevalence of GDM, regardless of screening criteria were reported in East-Asia and Australia (Pooled-P = 11.4%, 95% CI 11.1-11.7%) and (Pooled-P = 3.6%, 95% CI 3.6-3.7%), respectively.

CONCLUSION

Over the past quarter century, the diagnosis of gestational diabetes has been changed several times; along with worldwide increasing trend of obesity and diabetes, reducing the threshold of GDM is associated with a significant increase in the incidence of GDM. The harm and benefit of reducing the threshold of diagnostic criteria on pregnancy outcomes, women's psychological aspects, and health costs should be evaluated precisely.

The risk stratification of adverse neonatal outcomes in women with gestational diabetes (STRONG) study

AIMS

To assess the risk of adverse neonatal outcomes in women with gestational diabetes (GDM) by identifying subgroups of women at higher risk to recognize the characteristics most associated with an excess of risk.

METHODS

Observational, retrospective, multicenter study involving consecutive women with GDM. To identify distinct and homogeneous subgroups of women at a higher risk, the RECursive Partitioning and AMalgamation (RECPAM) method was used. Overall, 2736 pregnancies complicated by GDM were analyzed. The main outcome measure was the occurrence of adverse neonatal outcomes in pregnancies complicated by GDM.

RESULTS

Among study participants (median age 36.8 years, pre-gestational BMI 24.8 kg/m²), six miscarriages, one neonatal death, but no maternal death was recorded. The occurrence of the cumulative adverse outcome (OR 2.48, 95% CI 1.59-3.87), large for gestational age (OR 3.99, 95% CI 2.40-6.63), fetal malformation (OR 2.66, 95% CI 1.00-7.18), and respiratory distress (OR 4.33, 95% CI 1.33-14.12) was associated with previous macrosomia. Large for gestational age was also associated with obesity (OR 1.46, 95% CI 1.00-2.15). Small for gestational age was associated with first trimester glucose levels (OR 1.96, 95% CI 1.04-3.69). Neonatal hypoglycemia was associated with overweight (OR 1.52, 95% CI 1.02-2.27) and obesity (OR 1.62, 95% CI 1.04-2.51). The RECPAM analysis identified high-risk subgroups mainly characterized by high pre-pregnancy BMI (OR 1.68, 95% CI 1.21-2.33 for obese; OR 1.38 95% CI 1.03-1.87 for overweight).

CONCLUSIONS

A deep investigation on the factors associated with adverse neonatal outcomes requires a risk stratification. In particular, great attention must be paid to the prevention and treatment of obesity.

A genetic variant in LINGO2 contributes to the risk of gestational diabetes mellitus in a Chinese population

Genome-wide association studies (GWASs) showed that three single nucleotide polymorphisms (SNPs; rs10968576, rs1412239, and rs824248) in the leucine-rich repeat and Ig domain containing 2 (LINGO2) were associated with obesity or type 2 diabetes (T2D). We aimed to determine the influence of the LINGO2 variants on the gestational diabetes mellitus (GDM) risk. Thus, we performed a case-control study including 964 GDM cases and 1,021 controls to test the associations between the three LINGO2 variants (rs10968576, rs1412239, and rs824248) and susceptibility to GDM. Logistic regression analyses showed no significant association between LINGO2 variations (rs10968576 and rs1412239) and GDM susceptibility, but we observed that LINGO2 rs824248 A > T was significantly associated with an increased risk of GDM using the dominant model (TT/AT vs. AA: adjusted odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.05-1.51; p = 0.012) and the additive model (TT vs. AT vs. AA: adjusted OR = 1.16, 95% CI = 1.03-1.31; p = 0.016). In the additive model, a stronger risk effect of rs824248 was observed among obese women (prepregnancy body mass index [BMI] > 22 kg/m² , adjusted OR = 1.34, 95% CI = 1.12-1.59) compared with that in lean women (prepregnancy BMI ≤ 22 kg/m² , adjusted OR = 1.0² , 95% CI = 0.86-1.21; p = 0.029 for heterogeneity test). Further interactive analyses also detected a significant multiplicative interaction between rs824248 and prepregnancy BMI for the risk of GDM (p = 0.041). These findings indicate that LINGO2 rs824248 may serve as a susceptibility marker for GDM in Chinese females.

C-Reactive Protein Levels at the Midpregnancy Can Predict Gestational Complications

Although essential for a successful pregnancy, a growing body of evidence suggests that maternal inflammation, when dysregulated, may represent a risk factor for both maternal and neonatal outcomes. Here, we assessed the accuracy of maternal C-reactive protein (CRP) concentrations at the middle phase of pregnancy in the identification of maternal adverse outcomes (MAO) until delivery. A correlation between CRP and a complicated pregnancy including both maternal and neonatal adverse outcomes has been investigated, too. In this retrospective study, conducted at the Diabetology Unit of IRCCS Ospedale Policlinico San Martino, Genoa (Italy), 380 outpatient pregnant women have been enrolled at the prenatal visit before performing a 75 g oral glucose tolerance test at 24th-26th gestational week for gestational diabetes mellitus (GDM) screening. Demographic, medical, and reproductive history has been obtained by verbal interview. Data about pregnancy and delivery have been retrieved from medical records. The median value of maternal baseline serum CRP was 3.25 μg/mL. Women experiencing MAO were older, more frequently suffering from hypertension, and showed higher CRP concentrations, with a cutoff value >1.86 μg/mL found by a ROC curve analysis to be accurately predictive for MAO. By a logistic regression analysis, serum CRP levels >1.86 μg/mL have been found to predict MAO also considering maternal age, hypertension, and GDM. Maternal CRP levels have been positively associated with overall pregnancy adverse outcomes (maternal and neonatal), too. In conclusion, in pregnant women serum levels of CRP can early recognize subjects at higher risk for maternal and neonatal complications needing a more stringent follow-up.

Gestational Diabetes Mellitus: Mechanisms, Treatment, and Complications

Gestational diabetes mellitus (GDM) is the most common metabolic disturbance during pregnancy. The prevalence is rising and correlates with the increase in maternal obesity over recent decades. The etiology of GDM is complex, with genetic and environmental factors implicated in mechanistic and epidemiological studies. GDM begets important short- and long-term health risks for the mother, developing fetus, and offspring. This includes the high likelihood of subsequent maternal type 2 diabetes (T2DM), and possible adverse cardiometabolic phenotypes in the offspring. The most clinically and cost-effective methods of screening for GDM remain uncertain. Whilst treatments with lifestyle and pharmacological interventions have demonstrated short-term benefits, the long-term impact for the offspring of intrauterine exposure to antidiabetic medication remains unclear.

Alterations of adiponectin gene expression and DNA methylation in adipose tissues and blood cells are associated with gestational diabetes and neonatal outcome

Background

Adiponectin critically contributes to metabolic homeostasis, especially by insulin-sensitizing action. Gestational diabetes mellitus (GDM) is characterized by insulin resistance leading to materno-fetal hyperglycemia and detrimental birth outcomes. By investigating paired subcutaneous (SAT) and visceral adipose tissue (VAT) as well as blood (cell) samples of GDM-affected (n = 25) vs. matched control (n = 30) mother-child dyads of the prospective “EaCH” cohort study, we addressed whether alterations of adiponectin plasma, mRNA, and DNA methylation levels are associated with GDM and offspring characteristics.

Results

Hypoadiponectinemia was present in women with GDM, even after adjustment for body mass index (BMI). This was accompanied by significantly decreased mRNA levels in both SAT and VAT (P < 0.05), independent of BMI. Maternal plasma adiponectin showed inverse relations with glucose and homeostatic model assessment of insulin resistance (both P < 0.01). In parallel to reduced mRNA expression in GDM, significant (P < 0.05) yet small alterations in locus-specific DNA methylation were observed in maternal fat (~ 2%) and blood cells (~ 1%). While newborn adiponectin levels were similar between groups, DNA methylation in GDM offspring was variously altered (~ 1–4%; P < 0.05).

Conclusions

Reduced adiponectin seems to be a pathogenic co-factor in GDM, even independent of BMI, affecting materno-fetal metabolism. While altered maternal DNA methylation patterns appear rather marginally involved, functional, diagnostic, and/or predictive implications of cord blood DNA methylation should be further evaluated.

Electronic supplementary material

The online version of this article (10.1186/s13148-018-0567-z) contains supplementary material, which is available to authorized users.

Geographic diversity in genotype frequencies and meta-analysis of the association between rs1801282 polymorphisms and gestational diabetes mellitus

AIMS

To derive a better understanding of the association between peroxisome proliferator-activated receptor gamma (PPAR-γ) rs1801282 polymorphisms and gestational diabetes mellitus (GDM) in general and in racial and ethnic subgroups and to illustrate geographic distribution of the protective of G allele of rs1801282 in women with and without GDM.

METHODS

ProQuest, PubMed, Medline, Web of Science, and Wanfang Data were systematically searched. Case-control studies on association between rs1801282 polymorphisms and GDM were selected. Comprehensive Meta-Analysis 2.0 statistical software was used to determine the relationship between GDM and rs1801282 polymorphism. Race/ethnicity-based and country-based stratified analysis was conducted.

RESULTS

Sixteen studies involving 3129 cases and 7168 controls were included. Significant associations were observed between rs1801282 polymorphisms and GDM under the dominant, heterozygote, and allele models. The G allele of rs1801282 polymorphism was associated with a reduced risk of GDM in Asian, especially Chinese, populations. Data revealed significant geographic diversity in frequency of the protective G allele in women with and without GDM.

CONCLUSIONS

The rs1801282 polymorphism may not be associated with genetic susceptibility to GDM in whites. The G allele of rs1801282 polymorphism was associated with reduced risk of GDM in Asians, especially Chinese, but not South Koreans.

Presence of diabetes-specific autoimmunity in women with gestational diabetes mellitus (GDM) predicts impaired glucose regulation at follow-up

PURPOSE

Gestational diabetes mellitus (GDM) is the most frequent complication of pregnancy; around 10% of GDM cases may be determined by autoimmunity, and our aims were to establish the role of autoimmunity in a population of Sardinian women affected by GDM, to find predictive factors for autoimmune GDM, and to determine type 1 diabetes (T1D) auto-antibodies (Aabs) together with glucose tolerance after a mean 21.2 months of follow-up.

METHODS

We consecutively recruited 143 women affected by GDM and 60 without GDM; clinical data and pregnancy outcomes were obtained by outpatient visit or phone recall. T1D auto-antibodies GADA, IA2-A, IAA, ZnT8-A were measured in the whole population at baseline, and in the Aab-positive women at follow-up.

RESULTS

The overall prevalence of autoimmunity was 6.4% (13/203). No significant difference was found in the prevalence of auto-antibodies between GDM (5.6%) and control (8.3%) women, neither in antibody titres. Highest titres for GADA and ZnT8-A were observed in the control group; no phenotypic factors were predictive for autoimmune GDM. Diabetes-related autoantibodies were still present in all the GDM women at follow-up, and their presence was associated with a 2.65 (p < 0.0016) relative risk (RR) of glucose impairment.

CONCLUSION

We observed a low prevalence (5.6%) of diabetes-related autoimmunity in our GDM cohort, consistent with the prevalence reported in previous studies. It was not possible to uncover features predictive of autoimmune GDM. However, given the significant risk of a persistent impaired glycemic regulation at follow-up, it is advisable to control for glucose tolerance in GDM women with diabetes-related autoimmunity.

Systematic review and meta-analysis of diagnosing gestational diabetes mellitus with one-step or two-step approaches and associations with adverse pregnancy outcomes

BACKGROUND

There is an ongoing discussion about the optimal diagnostic strategy for gestational diabetes mellitus (GDM).

OBJECTIVE

To assess the magnitude of the association between GDM diagnosed with the one-step (International Association of Diabetes and Pregnancy Study Groups criteria) or two-step (Carpenter and Coustan criteria) approach and selected adverse pregnancy outcomes.

SEARCH STRATEGY

Five electronic databases were searched up to October 2017 using Medical Subject Headings for each adverse outcome combined with the term "gestational diabetes."

SELECTION CRITERIA

Observational studies assessing the one-step versus the two-step diagnostic approach in GDM.

DATA COLLECTION AND ANALYSIS

Relative risks were extracted and random-effects models were used to estimate pooled relative risks (RRs).

MAIN RESULTS

A total of 41 663 participants from nine studies were included. Gestational diabetes mellitus was significantly associated with pre-eclampsia (RR 1.68 vs RR 1.77), cesarean delivery (RR 1.28 vs RR 1.33), and large for gestational age (RR 1.44 vs RR 1.68) when diagnosed with the one-step versus the two-step approach. A one-step diagnosis also increased the risks of neonatal intensive care unit admission and gestational hypertension, whereas a two-step diagnosis increased the incidence of macrosomia.

CONCLUSIONS

Women with GDM diagnosed with either the one-step or the two-step approach were at increased risk for selected adverse pregnancy outcomes. The associations with the two-step method were slightly stronger.

Maternal overweight is not an independent risk factor for increased birth weight, leptin and insulin in newborns of gestational diabetic women: observations from the prospective 'EaCH' cohort study

BACKGROUND

Both gestational diabetes mellitus (GDM) as well as overweight/obesity during pregnancy are risk factors for detrimental anthropometric and hormonal neonatal outcomes, identified to 'program' adverse health predispositions later on. While overweight/obesity are major determinants of GDM, independent effects on critical birth outcomes remain unclear. Thus, the aim of the present study was to evaluate, in women with GDM, the relative/independent impact of overweight/obesity vs. altered glucose metabolism on newborn parameters.

METHODS

The prospective observational 'Early CHARITÉ (EaCH)' cohort study primarily focuses on early developmental origins of unfavorable health outcomes through pre- and/or early postnatal exposure to a 'diabetogenic/adipogenic' environment. It includes 205 mother-child dyads, recruited between 2007 and 2010, from women with treated GDM and delivery at the Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, Germany. Recruitment, therapy, metabolite/hormone analyses, and data evaluation were performed according to standardized guidelines and protocols. This report specifically aimed to identify maternal anthropometric and metabolic determinants of anthropometric and critical hormonal birth outcomes in 'EaCH'.

RESULTS

Group comparisons, Spearman's correlations and unadjusted linear regression analyses initially confirmed that increased maternal prepregnancy body-mass-index (BMI) is a significant factor for elevated birth weight, cord-blood insulin and leptin (all P < 0.05). However, consideration of and adjustment for maternal glucose during late pregnancy showed that no maternal anthropometric parameter (weight, BMI, gestational weight gain) remained significant (all n.s.). In contrast, even after adjustment for maternal anthropometrics, third trimester glucose values (fasting and postprandial glucose at 32nd and 36th weeks' gestation, HbA1c in 3rd trimester and at delivery), were clearly positively associated with critical birth outcomes (all P < 0.05).

CONCLUSIONS

Neither overweight/obesity nor gestational weight gain appear to be independent determinants of increased birth weight, insulin and leptin. Rather, 3rd trimester glycemia seems to be crucial for respective neonatal outcomes. Thus, gestational care and future research studies should greatly consider late pregnancy glucose in overweight/obese women with or without GDM, for evaluation of critical causes and interventional strategies against 'perinatal programming of diabesity' in the offspring.

The mediating effects of gestational diabetes on fetal growth and adiposity in women who are overweight and obese: secondary analysis of the LIMIT randomised trial

OBJECTIVE

To describe the mediating effect of maternal gestational diabetes on fetal biometry and adiposity measures among overweight or obese pregnant women.

DESIGN

Secondary analysis of the LIMIT randomised trial.

SETTING

Public hospitals, metropolitan Adelaide, South Australia.

POPULATION

Pregnant women with body mass index (BMI) ≥25 kg/m² and singleton gestation.

METHODS

Fetal ultrasound measures at 36 weeks of gestation and baseline BMI from women randomised to the LIMIT trial Standard Care group (n = 912 women) were used to conduct causal mediation analyses using regression-based methods.

MAIN OUTCOMES MEASURES

Ultrasound measures of fetal biometry and adiposity at 36 weeks of gestation.

RESULTS

Increased maternal BMI was associated with increased measures of fetal head circumference [direct (unmediated) effect 0.18 (95% CI: 0.05-0.31), P = 0.005; total effect 0.17 (95% CI: 0.02-0.31), P = 0.018], abdominal circumference [direct effect 0.26 (95% CI: 0.11-0.41), P = 0.001; total effect 0.26 (95% CI: 0.11-0.42), P = 0.001] and estimated fetal weight [direct effect 0.22 (95% CI: 0.08-0.35), P = 0.002; total effect 0.22 (95% CI: 0.08-0.35), P = 0.002], with no evidence of mediation by treated gestational diabetes. There was no apparent association between maternal BMI and fetal adiposity measures, or mediation by treated gestational diabetes.

CONCLUSIONS

We show an important association between increased maternal BMI and fetal growth, not mediated by treated gestational diabetes. There was no association between increased maternal BMI and fetal adiposity measures, or mediation by treated gestational diabetes. Whether these findings represent 'saturation' in the effect of maternal BMI on fetal growth or the effect of treatment of GDM is unclear.

FUNDING

This project was funded by a 4-year project grant from the National Health and Medical Research Council (NHMRC), Australia (ID 519240); The Channel 7 Children's Research Foundation, South Australia; and the US National Institutes of Health (R01 HL094235-01).

TWEETABLE ABSTRACT

Increased fetal growth associated with maternal obesity is not mediated by gestational diabetes.

Pregnancy outcomes in women with gestational diabetes mellitus diagnosed according to the WHO-2013 and WHO-1999 diagnostic criteria: a multicentre retrospective cohort study

BACKGROUND

The World Health Organization (WHO) adopted more stringent diagnostic criteria for GDM in 2013, to improve pregnancy outcomes. However, there is no global consensus on these new diagnostic criteria, because of limited evidence. The objective of the study was to evaluate maternal characteristics and pregnancy outcomes in two cohorts in the Netherlands applying different diagnostic criteria for GDM i.e. WHO-2013 and WHO-1999.

METHODS

A multicenter retrospective study involving singleton GDM pregnancies in two regions, between 2011 and 2016. Women were diagnosed according to the WHO-2013 criteria in the Deventer region (WHO-2013-cohort) and according to the WHO-1999 criteria in the Groningen region (WHO-1999-cohort). After GDM diagnosis, all women were treated equally based on the national guideline. Maternal characteristics and pregnancy outcomes were compared between the two groups.

RESULTS

In total 1386 women with GDM were included in the study. Women in the WHO-2013-cohort were older and had a higher pre-gestational body mass index. They were diagnosed earlier (24.9 [IQR 23.3-29.0] versus 27.7 [IQR 25.9-30.7] weeks, p = < 0.001) and less women were treated with additional insulin therapy (15.6% versus 43.4%, p = < 0.001). Rate of spontaneous delivery was higher in the WHO-2013-cohort (73.1% versus 67.4%, p = 0.032). The percentage large-for-gestational-age (LGA) neonates (birth weight > 90th percentile, corrected for sex, ethnicity, parity, and gestational age) was lower in the WHO-2013- cohort, but not statistical significant (16.5% versus 18.5%, p = 0.379). There were no differences between the cohorts regarding stillbirth, birth trauma, low Apgar score, and preeclampsia.

CONCLUSIONS

Using the new WHO-2013 criteria resulted in an earlier GDM diagnosis, less women needed insulin treatment and more spontaneous deliveries occurred when compared to the cohort diagnosed with WHO-1999 criteria. No differences were found in adverse pregnancy outcomes.

The Influence of Maternal Obesity on Pregnancy Complications and Neonatal Outcomes in Diabetic and Nondiabetic Women

Introduction

This study aimed to investigate the influence of obesity on pregnancy complications and neonatal outcomes in diabetic and nondiabetic women.

Materials and Methods

This retrospective case control study was conducted on 1193 pregnant women and their neonates at a tertiary level maternity hospital between March 2007 and 2011. The pregnant women were classified into 2 groups according to the presence of diabetes mellitus. Six hundred and seven patients with gestational diabetes or pregestational diabetes formed the diabetic group (study group) and 586 patients were in the nondiabetic group (control group). Demographic characteristics, body mass index, gestational weight gain, obstetric history, smoking status, type of delivery, gestational ages, pregnancy complications, neonatal outcomes were recorded for each patient. Multivariable logistic regression analysis was performed to evaluate the effect of obesity and diabetes on the pregnancy complications and neonatal outcomes.

Results

The mean age and pre-pregnancy body mass indices of women with diabetes mellitus were significantly higher than the control groupʼs (p < 0.001). Gestational weight gain and number of smokers were similar among the groups. Multiparity and obesity were more prevalent in the diabetic group compared to controls (both p < 0.001). Although gestational age at birth was earlier in the diabetic group, birth weights were higher in this group than in the control group (both p < 0.001). Cesarean delivery rates, the incidence of macrosomia, and neonatal intensive care unit admission rates were significantly higher in the diabetes group both with normal and increased body mass index (all p < 0.001). However, adverse pregnancy outcomes were comparable between the groups (p = 0.279). Multivariable logistic regression analysis showed that obesity is a significant risk factor for pregnancy complications (OR = 1.772 [95% CI, 1.283 – 2.449], p = 0.001) but not for adverse neonatal outcomes (OR = 1.068 [95% CI, 0.683 – 1.669], p = 0.773).

Conclusion

While obesity increases risk of developing a pregnancy complication, diabetes worsens neonatal outcomes.

New diagnostic criteria for gestational diabetes mellitus and their impact on the number of diagnoses and pregnancy outcomes

AIMS/HYPOTHESIS

Detection and management of gestational diabetes mellitus (GDM) are crucial to reduce the risk of pregnancy-related complications for both mother and child. In 2013, the WHO adopted new diagnostic criteria for GDM to improve pregnancy outcomes. However, the evidence supporting these criteria is limited. Consequently, these new criteria have not yet been endorsed in the Netherlands. The aim of this study was to determine the impact of these criteria on the number of GDM diagnoses and pregnancy outcomes.

METHODS

Data were available from 10,642 women who underwent a 75 g OGTT because of risk factors or signs suggestive of GDM. Women were treated if diagnosed with GDM according to the WHO 1999 criteria. Data on pregnancy outcomes were obtained from extensive chart reviews from 4,431 women and were compared between women with normal glucose tolerance (NGT) and women classified into the following groups: (1) GDM according to WHO 1999 criteria; (2) GDM according to WHO 2013 criteria; (3) GDM according to WHO 2013 fasting glucose threshold, but not WHO 1999 criteria; and (4) GDM according to WHO 1999 2 h plasma glucose threshold (2HG), but not WHO 2013 criteria.

RESULTS

Applying the new WHO 2013 criteria would have increased the number of diagnoses by 45% (32% vs 22%) in this population of women at higher risk for GDM. In comparison with women with NGT, women classified as having GDM based only on the WHO 2013 threshold for fasting glucose, who were not treated for GDM, were more likely to have been obese (46.1% vs 28.1%, p < 0.001) and hypertensive (3.3% vs 1.2%, p < 0.001) before pregnancy, and to have had higher rates of gestational hypertension (7.8% vs 4.9%, p = 0.003), planned Caesarean section (10.3% vs 6.5%, p = 0.001) and induction of labour (34.8% vs 28.0%, p = 0.001). In addition, their neonates were more likely to have had an Apgar score <7 at 5 min (4.4% vs 2.6%, p = 0.015) and to have been admitted to the Neonatology Department (15.0% vs 11.1%, p = 0.004). The number of large for gestational age (LGA) neonates was not significantly different between the two groups. Women potentially missed owing to the higher 2HG threshold set by WHO 2013 had similar pregnancy outcomes to women with NGT. These women were all treated for GDM with diet and 20.5% received additional insulin.

CONCLUSIONS/INTERPRETATION

Applying the WHO 2013 criteria will have a major impact on the number of GDM diagnoses. Using the fasting glucose threshold set by WHO 2013 identifies a group of women with an increased risk of adverse outcomes compared with women with NGT. We therefore support the use of a lower fasting glucose threshold in the Dutch national guideline for GDM diagnosis. However, adopting the WHO 2013 criteria with a higher 2HG threshold would exclude women in whom treatment for GDM seems to be effective.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

NCT01174875 . Registered 1 July 2010 (retrospectively registered).

The World Health Organization (WHO) versus The International Association of Diabetes and Pregnancy Study Group (IADPSG) diagnostic criteria of gestational diabetes mellitus (GDM) and their associated maternal and neonatal outcomes

Background Gestational diabetes mellitus (GDM) is a common medical complication in pregnancy. The aim of this study was to compare the prevalence of GDM using the World Health Organization (WHO) criteria and the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria in our population. We further compared the incidence of adverse maternal and neonatal outcomes in women diagnosed with GDM using these criteria and determined whether the IADPSG criteria is suitable in our population. Methods This randomized controlled trial was conducted at our antenatal clinic involving 520 patients from 1st February 2015 until 30th September 2017. They were randomized into the WHO and the IADPSG groups. All eligible women underwent a standard oral glucose tolerance test with 75 g glucose, their fasting and 2 h post prandial glucose levels were taken. The primary outcome was the prevalence of GDM. The secondary outcomes were the incidence of primary cesarean section, gestational hypertension or preeclampsia, preterm delivery <37 weeks, fetal macrosomia, neonatal hypoglycemia and shoulder dystocia or birth injury. Results The prevalence of GDM in both groups were similar (37.9% vs. 38.6%). GDM women in the WHO group had a significantly higher incidence of gestational hypertension or preeclampsia (p = 0.004) and neonatal hypoglycemia (p = 0.042). In contrast, GDM women in the IADPSG group had a significantly higher incidence of fetal macrosomia (p = 0.027) and cesarean section (p = 0.012). Conclusion The IADPSG diagnostic criteria for GDM may not be suitable for use in our population as it resulted in women being diagnosed later and being undertreated, thus leading to adverse maternal and neonatal outcomes.

The identification and treatment of women with hyperglycaemia in pregnancy: an analysis of individual participant data, systematic reviews, meta-analyses and an economic evaluation

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with a higher risk of important adverse outcomes. Practice varies and the best strategy for identifying and treating GDM is unclear.

AIM

To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with GDM.

METHODS

We analysed individual participant data (IPD) from birth cohorts and conducted systematic reviews to estimate the association of maternal glucose levels with adverse perinatal outcomes; GDM prevalence; maternal characteristics/risk factors for GDM; and the effectiveness and costs of treatments. The cost-effectiveness of various strategies was estimated using a decision tree model, along with a value of information analysis to assess where future research might be worthwhile. Detailed systematic searches of MEDLINE^® and MEDLINE In-Process & Other Non-Indexed Citations^®, EMBASE, Cumulative Index to Nursing and Allied Health Literature Plus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database, Maternity and Infant Care database and the Cochrane Methodology Register were undertaken from inception up to October 2014.

RESULTS

We identified 58 studies examining maternal glucose levels and outcome associations. Analyses using IPD alone and the systematic review demonstrated continuous linear associations of fasting and post-load glucose levels with adverse perinatal outcomes, with no clear threshold below which there is no increased risk. Using IPD, we estimated glucose thresholds to identify infants at high risk of being born large for gestational age or with high adiposity; for South Asian (SA) women these thresholds were fasting and post-load glucose levels of 5.2 mmol/l and 7.2 mmol/l, respectively and for white British (WB) women they were 5.4 and 7.5 mmol/l, respectively. Prevalence using IPD and published data varied from 1.2% to 24.2% (depending on criteria and population) and was consistently two to three times higher in SA women than in WB women. Lowering thresholds to identify GDM, particularly in women of SA origin, identifies more women at risk, but increases costs. Maternal characteristics did not accurately identify women with GDM; there was limited evidence that in some populations risk factors may be useful for identifying low-risk women. Dietary modification additional to routine care reduced the risk of most adverse perinatal outcomes. Metformin (Glucophage,^® Teva UK Ltd, Eastbourne, UK) and insulin were more effective than glibenclamide (Aurobindo Pharma - Milpharm Ltd, South Ruislip, Middlesex, UK). For all strategies to identify and treat GDM, the costs exceeded the health benefits. A policy of no screening/testing or treatment offered the maximum expected net monetary benefit (NMB) of £1184 at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year (QALY). The NMB for the three best-performing strategies in each category (screen only, then treat; screen, test, then treat; and test all, then treat) ranged between -£1197 and -£1210. Further research to reduce uncertainty around potential longer-term benefits for the mothers and offspring, find ways of improving the accuracy of identifying women with GDM, and reduce costs of identification and treatment would be worthwhile.

LIMITATIONS

We did not have access to IPD from populations in the UK outside of England. Few observational studies reported longer-term associations, and treatment trials have generally reported only perinatal outcomes.

CONCLUSIONS

Using the national standard cost-effectiveness threshold of £20,000 per QALY it is not cost-effective to routinely identify pregnant women for treatment of hyperglycaemia. Further research to provide evidence on longer-term outcomes, and more cost-effective ways to detect and treat GDM, would be valuable.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004608.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Correlation of adipokines and markers of oxidative stress in women with gestational diabetes mellitus and their newborns

AIM

We have shown that some markers of oxidative stress were higher in women with gestational diabetes mellitus (GDM). This study examines the relationship between adipokines and oxidative stress and their potential effects in pregnant women.

METHODS

Three markers of oxidative stress (malondialdehyde, 8-isoprostane and xanthine oxidase) and three adipokines (leptin, adiponectin and resistin) were measured in maternal plasma, cord plasma and placenta of 208 pregnant women.

RESULTS

Among all these women, 105 were diagnosed with GDM while the other 103 were controls. Leptin, resistin, malondialdehyde, xanthine oxidase and 8-isoprostane in maternal plasma, cord plasma and placenta were significantly higher while maternal adiponectin significantly lower in women with GDM (P < 0.05). Adipokines in maternal plasma, cord plasma and placenta were positively correlated with markers of oxidative stress. Both markers of oxidative stress and adipokines were correlated inversely with homeostasis model assessment of insulin resistance whereas positively with quantitative insulin sensitivity check index (P < 0.01). Adiponectin is negatively correlated with leptin and resistin. Placental/cord leptin and cord resistin levels were higher in the macrosomia while maternal adiponectin level was lower (P < 0.05) than normal birthweight newborns. Both markers of oxidative stress and adipokines in maternal and cord plasma are negatively correlated with newborn birthweight (P < 0.05).

CONCLUSION

Adipokines interact with markers of oxidative stress, both of which lead to insulin resistance, GDM and macrosomia. It has long been known that placenta involves in the development of GDM. Adipokines might participate in this process and need to be confirmed by further studies.

Are women positive for the One Step but negative for the Two Step screening tests for gestational diabetes at higher risk for adverse outcomes?

INTRODUCTION

The aim of this study was to evaluate if women meeting criteria for gestational diabetes mellitus (GDM) by the One Step test as per International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria but not by other less strict criteria have adverse pregnancy outcomes compared with GDM-negative controls. The primary outcome was the incidence of macrosomia, defined as birthweight > 4000 g.

MATERIAL AND METHODS

Electronic databases were searched from their inception until May 2017. All studies identifying pregnant women negative at the Two Step test, but positive at the One Step test for IADPSG criteria were included. We excluded studies that randomized women to the One Step vs. the Two Step tests; studies that compared different criteria within the same screening method; randomized studies comparing treatments for GDM; and studies comparing incidence of GDM in women doing the One Step test vs. the Two Step test.

RESULTS

Eight retrospective cohort studies, including 29 983 women, were included. Five study groups and four control groups were identified. The heterogeneity between the studies was high. Gestational hypertension, preeclampsia and large for gestational age, as well as in some analyses cesarean delivery, macrosomia and preterm birth, were significantly more frequent, and small for gestational age in some analyses significantly less frequent, in women GDM-positive by the One Step, but not the Two Step.

CONCLUSION

Women meeting criteria for GDM by IADPSG criteria but not by other less strict criteria have an increased risk of adverse pregnancy outcomes such as gestational hypertension, preeclampsia and large for gestational age, compared with GDM-negative controls. Based on these findings, and evidence from other studies that treatment decreases these adverse outcomes, we suggest screening for GDM using the One Step IADPSG criteria.

Homeostatic model assessment of beta cell function predicting abnormal oral glucose tolerance testing in pregnancy: a systematic review and meta-analysis

BACKGROUND

Gestational diabetes mellitus (GDM) complicates 1-14% of pregnancies and relates to increased risk of adverse obstetric outcomes. Currently GDM is diagnosed using an oral glucose tolerance test (OGTT), which is burdensome and time intensive.

OBJECTIVE

To compare current literature on whether the homeostatic model assessment beta cell function (HOMA-β) is an accurate predictor of an abnormal OGTT in pregnant women.

METHODS

Pubmed, Cochrane and Embase were searched. Included studies evaluated pregnant women at risk for GDM using the homeostatic model assessment of beta cell function (HOMA-β) for the assessment of beta cell function and the OGTT. Studies with animals, non-pregnant women, women with type 2 diabetes and post-partum diabetes were excluded. The QUADAS-2 criteria were used to assess the methodological quality of studies.

RESULTS

A total of 12 studies were included, reporting on 7292 women. Seven studies showed a difference in beta cell function between women with impaired glucose tolerance compared to healthy pregnant women. HOMA-β is significantly lower in impaired glucose tolerance (p < 0.001).

CONCLUSIONS

Although HOMA-β is lower in women with abnormal OGTT in pregnancy, given the high degree of heterogeneity of studies, we do not propagate HOMA-β as a sole diagnostic tool replacing OGTT to diagnose GDM.

Diabetes in pregnancy: worse medical outcomes in type 1 diabetes but worse psychological outcomes in gestational diabetes

BACKGROUND

Women with diabetes experience an increased risk of adverse pregnancy outcomes.

AIM

We aim to describe and quantify the psychological impact of the diagnosis of diabetes in pregnant women with type 1 diabetes and gestational diabetes mellitus (GDM) compared to each other and to their counterparts without diabetes.

DESIGN

This is a survey-based study with prospective collection of pregnancy outcome data.

METHODS

A total of 218 pregnant women (50% with diabetes) were administered questionnaires relating to psychological health. Maternal and neonatal characteristics and pregnancy outcomes were collected. Associations between key psychometric and health outcome variables were examined.

RESULTS

At least 25% of women in all three pregnancy groups had scores indicating affective distress in at least one domain. Compared to those with type 1 diabetes, women with GDM evidenced a greater number of uplifts in pregnancy (U = 94, P = 0.041), but also higher levels of overall anxiety (U = 92, P = 0.03) and stress (U = 82, P < 0.01). Women with GDM also had significantly elevated overall depression scores, compared with the control group (U = 34, P = 0.02). Both groups of women with diabetes had clinically elevated levels of diabetes-related distress. There were no associations between maternal psychological variables and pregnancy outcomes.

CONCLUSIONS

This work highlights a potential role for targeted psychological interventions to address and relieve symptoms of anxiety and depression among pregnant women with diabetes.

Different methods and settings for glucose monitoring for gestational diabetes during pregnancy

BACKGROUND

Incidence of gestational diabetes mellitus (GDM) is increasing worldwide. Blood glucose monitoring plays a crucial part in maintaining glycaemic control in women with GDM and is generally recommended by healthcare professionals. There are several different methods for monitoring blood glucose which can be carried out in different settings (e.g. at home versus in hospital).

OBJECTIVES

The objective of this review is to compare the effects of different methods and settings for glucose monitoring for women with GDM on maternal and fetal, neonatal, child and adult outcomes, and use and costs of health care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-randomised controlled trials (qRCTs) comparing different methods (such as timings and frequencies) or settings, or both, for blood glucose monitoring for women with GDM.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, and extracted data. Data were checked for accuracy.We assessed the quality of the evidence for the main comparisons using GRADE, for:- primary outcomes for mothers: that is, hypertensive disorders of pregnancy; caesarean section; type 2 diabetes; and- primary outcomes for children: that is, large-for-gestational age; perinatal mortality; death or serious morbidity composite; childhood/adulthood neurosensory disability;- secondary outcomes for mothers: that is, induction of labour; perineal trauma; postnatal depression; postnatal weight retention or return to pre-pregnancy weight; and- secondary outcomes for children: that is, neonatal hypoglycaemia; childhood/adulthood adiposity; childhood/adulthood type 2 diabetes.

MAIN RESULTS

We included 11 RCTs (10 RCTs; one qRCT) that randomised 1272 women with GDM in upper-middle or high-income countries; we considered these to be at a moderate to high risk of bias. We assessed the RCTs under five comparisons. For outcomes assessed using GRADE, we downgraded for study design limitations, imprecision and inconsistency. Three trials received some support from commercial partners who provided glucose meters or financial support, or both. Main comparisons Telemedicine versus standard care for glucose monitoring (five RCTs): we observed no clear differences between the telemedicine and standard care groups for the mother, for:- pre-eclampsia or pregnancy-induced hypertension (risk ratio (RR) 1.49, 95% confidence interval (CI) 0.69 to 3.20; 275 participants; four RCTs; very low quality evidence);- caesarean section (average RR 1.05, 95% CI 0.72 to 1.53; 478 participants; 5 RCTs; very low quality evidence); and- induction of labour (RR 1.06, 95% CI 0.63 to 1.77; 47 participants; 1 RCT; very low quality evidence);or for the child, for:- large-for-gestational age (RR 1.41, 95% CI 0.76 to 2.64; 228 participants; 3 RCTs; very low quality evidence);- death or serious morbidity composite (RR 1.06, 95% CI 0.68 to 1.66; 57 participants; 1 RCT; very low quality evidence); and- neonatal hypoglycaemia (RR 1.14, 95% CI 0.48 to 2.72; 198 participants; 3 RCTs; very low quality evidence).There were no perinatal deaths in two RCTs (131 participants; very low quality evidence). Self-monitoring versus periodic glucose monitoring (two RCTs): we observed no clear differences between the self-monitoring and periodic glucose monitoring groups for the mother, for:- pre-eclampsia (RR 0.17, 95% CI 0.01 to 3.49; 58 participants; 1 RCT; very low quality evidence); and- caesarean section (average RR 1.18, 95% CI 0.61 to 2.27; 400 participants; 2 RCTs; low quality evidence);or for the child, for:- perinatal mortality (RR 1.54, 95% CI 0.21 to 11.24; 400 participants; 2 RCTs; very low quality evidence);- large-for-gestational age (RR 0.82, 95% CI 0.50 to 1.37; 400 participants; 2 RCTs; low quality evidence); and- neonatal hypoglycaemia (RR 0.64, 95% CI 0.39 to 1.06; 391 participants; 2 RCTs; low quality evidence). Continuous glucose monitoring system (CGMS) versus self-monitoring of glucose (two RCTs): we observed no clear differences between the CGMS and self-monitoring groups for the mother, for:- caesarean section (RR 0.91, 95% CI 0.68 to 1.20; 179 participants; 2 RCTs; very low quality evidence);or for the child, for:- large-for-gestational age (RR 0.67, 95% CI 0.43 to 1.05; 106 participants; 1 RCT; very low quality evidence) and- neonatal hypoglycaemia (RR 0.79, 95% CI 0.35 to 1.78; 179 participants; 2 RCTs; very low quality evidence).There were no perinatal deaths in the two RCTs (179 participants; very low quality evidence). Other comparisons Modem versus telephone transmission for glucose monitoring (one RCT): none of the review's primary outcomes were reported in this trial Postprandial versus preprandial glucose monitoring (one RCT): we observed no clear differences between the postprandial and preprandial glucose monitoring groups for the mother, for:- pre-eclampsia (RR 1.00, 95% CI 0.15 to 6.68; 66 participants; 1 RCT);- caesarean section (RR 0.62, 95% CI 0.29 to 1.29; 66 participants; 1 RCT); and- perineal trauma (RR 0.38, 95% CI 0.11 to 1.29; 66 participants; 1 RCT);or for the child, for:- neonatal hypoglycaemia (RR 0.14, 95% CI 0.02 to 1.10; 66 participants; 1 RCT).There were fewer large-for-gestational-age infants born to mothers in the postprandial compared with the preprandial glucose monitoring group (RR 0.29, 95% CI 0.11 to 0.78; 66 participants; 1 RCT).

AUTHORS' CONCLUSIONS

Evidence from 11 RCTs assessing different methods or settings for glucose monitoring for GDM suggests no clear differences for the primary outcomes or other secondary outcomes assessed in this review.However, current evidence is limited by the small number of RCTs for the comparisons assessed, small sample sizes, and the variable methodological quality of the RCTs. More evidence is needed to assess the effects of different methods and settings for glucose monitoring for GDM on outcomes for mothers and their children, including use and costs of health care. Future RCTs may consider collecting and reporting on the standard outcomes suggested in this review.

Application of One-Step IADPSG Versus Two-Step Diagnostic Criteria for Gestational Diabetes in the Real World: Impact on Health Services, Clinical Care, and Outcomes

PURPOSE OF REVIEW

This paper seeks to summarize the impact of the one-step International Association of Diabetes and Pregnancy Study Groups (IADPSG) versus the two-step gestational diabetes mellitus (GDM) criteria with regard to prevalence, outcomes, healthcare delivery, and long-term maternal metabolic risk.

RECENT FINDINGS

Studies demonstrate a 1.03-3.78-fold rise in the prevalence of GDM with IADPSG criteria versus baseline criteria. Women with GDM by IADPSG criteria have more adverse pregnancy outcomes than women with normal glucose tolerance (NGT). Treatment of GDM by IADPSG criteria may be cost effective. Use of the fasting glucose as a screen before the 75-g oral glucose tolerance test to rule out GDM with fasting plasma glucose (FPG) < 4.4 (80 mg/dl) and rule in GDM with FPG ≥ 5.1 mmol/l (92 mg/dl) reduces the need for OGTT by 50% and its cost and inconvenience. The prevalence of postpartum abnormal glucose metabolism is higher for women with GDM diagnosed by IADPSG criteria versus that for women with NGT. Data support the use of IADPSG criteria, if the cost of diagnosis and treatment can be controlled and if lifestyle can be optimized to reduce the risk of future diabetes.

Prevalence of gestational diabetes mellitus in Europe: A meta-analysis

AIMS

Estimates of the prevalence of gestational diabetes vary widely. It is important to have a clear understanding of the prevalence of this condition to be able to plan interventions and health care provision. This paper describes a meta-analysis of primary research data reporting the prevalence of gestational diabetes mellitus in the general pregnant population of developed countries in Europe.

METHODS

Four electronic databases were systematically searched in May 2016. English language articles reporting gestational diabetes mellitus prevalence using universal screening in general pregnant population samples from developed countries in Europe were included. All papers identified by the search were screened by one author, and then half screened independently by a second author and half by a third author. Data were extracted by one author. Values for the measures of interest were combined using a random effects model and analysis of the effects of moderator variables was carried out.

RESULTS

A total of 3258 abstracts were screened, with 40 studies included in the review. Overall prevalence of gestational diabetes mellitus was 5.4% (3.8-7.8). Maternal age, year of data collection, country, area of Europe, week of gestation at testing, and diagnostic criteria were found to have a significant univariate effect on GDM prevalence, and area, week of gestation at testing and year of data collection remained statistically significant in multivariate analysis. Quality category was significant in multivariate but not univariate analysis.

CONCLUSIONS

This meta-analysis shows prevalence of GDM that is at the upper end of previous estimates in Europe.