(12) Management of diabetes in pregnancy

The duration of intrapartum maternal hyperglycaemia predicts neonatal hypoglycaemia in women with pre-existing diabetes

AIM

There is a high incidence of neonatal hypoglycaemia in neonates born to mothers with pre-existing diabetes. This often necessitates admission to the neonatal intensive care. Guidelines suggest maintaining intrapartum blood glucose levels (BGLs) of 4-7 mmol/l in women with diabetes to reduce the risk of neonatal hypoglycaemia. This study assessed whether intrapartum BGLs in women with pre-gestational Type 1 and 2 diabetes were predictive of neonatal hypoglycaemia.

METHODS

A retrospective analysis of 261 births delivered at a tertiary hospital in Australia from 2009 to 2014.

RESULTS

There were 122 cases of neonatal hypoglycaemia (glucose ≤ 2.6 mmol/l) in 261 births (47%). The mothers in the neonatal hypoglycaemia group spent less time with BGL in the range 4-7 mmol/l [55 ± 37% vs. 65 ± 35%, P = 0.02; odds ratio (OR) 0.992, P = 0.03] and more time with BGL in the 7-10 mmol/l range (31 ± 34% vs. 18 ± 27%, P = 0.003; OR 1.013, P = 0.003) compared with those without neonatal hypoglycaemia. Although statistically significant, receiver operating characteristic (ROC) curve analysis showed that time spent with maternal BGLs in the range 4-7 mmol/l [area under the curve (AUC) = 0.58] or 7-10 mmol (AUC = 0.60) was not strong enough to be a useful clinical predictor of neonatal hypoglycaemia. HbA_1c in the second trimester of pregnancy (P = 0.02, OR 1.42) and percentage time spent in BGL range of 7-10 mmol/l (P = 0.001, OR 1.02) were both associated with a risk of neonatal hypoglycaemia in a logistic regression model. HbA_1c in the third trimester (P = 0.07, OR 1.28) approached, but did not reach, significance.

CONCLUSIONS

These data support a BGL range of 4-7 mmol/l as an intrapartum target. Glycaemic control in the second trimester is associated with neonatal hypoglycaemia. Improvement in ante- and intrapartum glycaemic control may reduce neonatal hypoglycaemia in women with pre-existing diabetes.

Translating HbA1c measurements into estimated average glucose values in pregnant women with diabetes

AIMS/HYPOTHESIS

This study aimed to examine the relationship between average glucose levels, assessed by continuous glucose monitoring (CGM), and HbA_1c levels in pregnant women with diabetes to determine whether calculations of standard estimated average glucose (eAG) levels from HbA_1c measurements are applicable to pregnant women with diabetes.

METHODS

CGM data from 117 pregnant women (89 women with type 1 diabetes; 28 women with type 2 diabetes) were analysed. Average glucose levels were calculated from 5-7 day CGM profiles (mean 1275 glucose values per profile) and paired with a corresponding (±1 week) HbA_1c measure. In total, 688 average glucose-HbA_1c pairs were obtained across pregnancy (mean six pairs per participant). Average glucose level was used as the dependent variable in a regression model. Covariates were gestational week, study centre and HbA_1c.

RESULTS

There was a strong association between HbA_1c and average glucose values in pregnancy (coefficient 0.67 [95% CI 0.57, 0.78]), i.e. a 1% (11 mmol/mol) difference in HbA_1c corresponded to a 0.67 mmol/l difference in average glucose. The random effects model that included gestational week as a curvilinear (quadratic) covariate fitted best, allowing calculation of a pregnancy-specific eAG (PeAG). This showed that an HbA_1c of 8.0% (64 mmol/mol) gave a PeAG of 7.4-7.7 mmol/l (depending on gestational week), compared with a standard eAG of 10.2 mmol/l. The PeAG associated with maintaining an HbA_1c level of 6.0% (42 mmol/mol) during pregnancy was between 6.4 and 6.7 mmol/l, depending on gestational week.

CONCLUSIONS/INTERPRETATION

The HbA_1c-average glucose relationship is altered by pregnancy. Routinely generated standard eAG values do not account for this difference between pregnant and non-pregnant individuals and, thus, should not be used during pregnancy. Instead, the PeAG values deduced in the current study are recommended for antenatal clinical care.

The Impact of Kidney Development on the Life Course: A Consensus Document for Action

Hypertension and chronic kidney disease (CKD) have a significant impact on global morbidity and mortality. The Low Birth Weight and Nephron Number Working Group has prepared a consensus document aimed to address the relatively neglected issue for the developmental programming of hypertension and CKD. It emerged from a workshop held on April 2, 2016, including eminent internationally recognized experts in the field of obstetrics, neonatology, and nephrology. Through multidisciplinary engagement, the goal of the workshop was to highlight the association between fetal and childhood development and an increased risk of adult diseases, focusing on hypertension and CKD, and to suggest possible practical solutions for the future. The recommendations for action of the consensus workshop are the results of combined clinical experience, shared research expertise, and a review of the literature. They highlight the need to act early to prevent CKD and other related noncommunicable diseases later in life by reducing low birth weight, small for gestational age, prematurity, and low nephron numbers at birth through coordinated interventions. Meeting the current unmet needs would help to define the most cost-effective strategies and to optimize interventions to limit or interrupt the developmental programming cycle of CKD later in life, especially in the poorest part of the world.

[Metabolic and Reproductive Consequences of the Polycystic Ovary Syndrome (PCOS)]

Polycystic ovarian syndrome represents the most common endocrine disease of women of reproductive age. Symptoms include metabolic, gynecologic and cosmetic features. Genetic factors seem to contribute to the disease, affecting not only women but also male relatives of patients with similar symptoms. Besides, lifestyle factors play a central role impacting clinical PCOS appearance. Following we present an overview of the syndrome, its epidemiology, metabolic and gynecological aspects, gender and genetic factors and its therapy.

Risk factors of cerebral ischemia in infants born to mothers with gestational diabetes

OBJECTIVES

Gestational diabetes mellitus (GDM) is carbohydrate intolerance that occurs during pregnancy. The present study was arranged to determine the risk of cerebral ischemia (CI) in infants born to mothers with gestational diabetes mellitus and MTHFR gene polymorphism.

MATERIAL AND METHODS

The study includes 70 pregnant women with GDM, divided into two groups depending on existence of cerebral ischemia (CI) in newborn infants. All patients were tested for coagulation cascade components, polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene and assessed by thromboelastography (TEG).

RESULTS

We observed that there was an increased frequency (74.2%) of 1298С MTHFR genotype carriers among women with CI newborns. The state of hypercoagulation according to both coagulation cascade tests and TEG data was diagnosed in women of this group.

CONCLUSIONS

The results of this study suggest that hyperglycemia may program the development of cerebral ischemia in infants born to women with 1298С MTHFR gene polymorphism.

Large-for-gestational-age (LGA) neonate predicts a 2.5-fold increased odds of neonatal hypoglycaemia in women with type 1 diabetes

OBJECTIVE

The objective of the study is to assess the impact of maternal glycaemic control and large-for-gestational-age (LGA) infant size on the risk of developing neonatal hypoglycaemia in offspring of women with type 1 diabetes and to determine possible predictors of neonatal hypoglycaemia and LGA.

RESEARCH METHODS AND DESIGN

This retrospective cohort study evaluated pregnancies in 161 women with type 1 diabetes mellitus at a large urban centre between 2006 and 2010. Mean trimester A_1c values were categorized into five groups. Multiple logistic regression analyses were used to examine predictors of neonatal hypoglycaemia and large-for-gestational-age (LGA).

RESULTS

Hypoglycaemia occurred in 36.6% of neonates. There was not a linear association between trimester specific A_1c and LGA. After adjusting for maternal age, body mass index (BMI), smoking and premature delivery, neonatal hypoglycaemia was not linearly associated with A_1c in the first, second or third trimesters. LGA was the only significant predictor for neonatal hypoglycaemia (OR, 95% CI 2.51 [1.10, 5.70]) in logistic regression analysis that adjusted for glycaemic control, maternal age, smoking, prematurity and BMI. An elevated third trimester A_1c increased the odds of LGA (1.81 [1.03, 3.18]) after adjustment for smoking, parity and maternal BMI.

CONCLUSIONS

Large-for-gestational-age imparts a 2.5-fold increased odds of hypoglycaemia in neonates of women with type 1 diabetes and may be a better predictor of neonatal hypoglycaemia than maternal glycaemic control. Our data suggest that LGA neonates of women with type 1 diabetes should prompt increased surveillance for neonatal hypoglycaemia and that the presence of optimum maternal glycaemic control should not reduce this surveillance. Copyright © 2016 John Wiley & Sons, Ltd.

Postpartum glucose follow-up and lifestyle management after gestational diabetes mellitus: general practitioner and patient perspectives

Background

Incidence of type 2 diabetes is high after gestational diabetes mellitus (GDM). We aimed to evaluate the adherence to follow-up six-weeks postpartum visits in secondary care after GDM and glucose monitoring in primary care longer than 12–14 months after delivery and the years thereafter. In addition, we examined the women’s lifestyle after delivery.

Methods

A cross-sectional follow-up survey among women with a history of GDM and their general practitioners (GP). Rates of attendance at the six-weeks postpartum visit and glucose testing were obtained from hospital records, over the period 2011–2012. Rates of annual follow-up postpartum glucose testing were assessed by a survey among their GP’s. Lifestyle of the women on diet and exercise was assessed by questionnaire in 2015.

Results

In total 197 women were eligible for the study. Of these, 156 (79%) attended the six-weeks postpartum visit at the diabetes outpatient clinic and in 145 (93%) of these women glucose testing was performed. In total 77 (39%) women responded to the invitation to participate in this study and filled in the lifestyle questionnaire. About one third of the women met the recommendations for sufficient physical activity. A majority of them did not fulfil the Dutch guidelines on healthy diet – fruit intake 35.1%, vegetables intake 7.8%. Of the 74 invited GP’s, 61 responded (82%), only 12 (20%) reported that they had performed a follow-up glucose testing within >12–14 months postpartum. Of these women, five were tested only in the first year of follow-up, five also in the second year, and two were tested for three consecutive years.

Conclusions

Despite the high attendance rate of six-weeks postpartum visit and glucose testing, we observed low rates of longer-term follow-up regarding postpartum glucose testing. Moreover, we found a suboptimal adherence to healthy lifestyle for women with a history of GDM.

Diagnostic value of haemoglobin A1c in post-partum screening of women with gestational diabetes mellitus

AIMS

The aim of this study was to evaluate whether women with gestational diabetes mellitus could be screened using HbA_1c for glucose metabolism status at 6-12 weeks post-partum.

METHODS

We enrolled 699 pregnant women diagnosed with gestational diabetes mellitus from October 2005 to December 2013. A 75-g oral glucose tolerance test (OGTT) and HbA_1c measurement were performed at 6-12 weeks after delivery.

RESULTS

The prevalence of overt diabetes and pre-diabetes were 5.2% (n = 36) and 49.1% (n = 343), respectively, when using the 75-g OGTT as the gold standard. HbA_1c alone identified 2.9% (n = 20) as having overt diabetes and 32.2% (n = 225) as having pre-diabetes. When American Diabetes Association cut-offs were applied, the sensitivity and specificity for HbA_1c to diagnose overt diabetes were 19.4% and 98.0%, respectively. Pre-diabetes, according to the HbA_1c criterion, had 41.2% sensitivity and 72.2% specificity. The misclassifications identified 97 positive differences, 233 negative differences and 369 ties (P < 0.05). The area under the receiver operating characteristic curves for detecting diabetes and pre-diabetes were 0.615 [95% confidence interval (95% CI), 0.515 to 0.716] and 0.588 (95% CI, 0.545 to 0.630), respectively.

CONCLUSIONS

HbA_1c may not be sensitive enough for an accurate diagnosis, but it is highly specific for diagnosing overt diabetes at 6-12 weeks post-partum in women with previous gestational diabetes mellitus.

Gestational Diabetes Mellitus:current knowledge and unmet needs

Gestational diabetes mellitus (GDM) is a global health concern, not only because its prevalence is high and on the increase, but also because of the potential implications for the health of mothers and their offspring. Unfortunately, there is considerable controversy in the literature surrounding the diagnosis and treatment of GDM, as well as the possible long-term consequences for the offspring. As a result, worldwide there is a lack of uniformly accepted diagnostic criteria and the advice regarding the treatment of GDM, including diet, insulin therapy, and the use of oral blood glucose-lowering agents, is highly variable. In this review we provide an overview of the important issues in the field of GDM, including diagnostic criteria, different treatment regimens available, and the long-term consequences of GDM in the offspring.

Insulin detemir versus glyburide in women with gestational diabetes mellitus

AIM

To evaluate the safety, efficacy and pregnancy outcomes of insulin detemir (IDet) versus glyburide treatment in women with gestational diabetes mellitus (GDM).

METHODS

We conducted a retrospective cohort study of women with GDM who were treated with either glyburide or IDet for GDM in a university-affiliated tertiary hospital.

RESULTS

Ninety-one patients with GDM were enrolled, 62 were administered glyburide and 29 IDet. Maternal age, pregestational body mass index (BMI) and rate of abnormal oral glucose tolerance test (OGTT) blood glucose values were not significantly different between groups. Good glycemic control rates were comparable. Hypoglycemic episodes were reported only in the glyburide group (19.4% versus 0%, p = 0.01). Maternal weight gain during pregnancy was significantly higher among women in the glyburide group (8.8 ± 5.1 kg, p < 0.001) compared to those in the IDet group (2.1 ± 19.9 kg, p = 0.71).

CONCLUSIONS

To the best of our knowledge, this is the first study on IDet treatment in patients with GDM. By our preliminary results, IDet is a viable treatment option in women with GDM. Further large prospective studies are needed to determine the efficacy and safety of IDet in GDM patients.

Perspectives in obesity and pregnancy

Obesity is currently recognized as a health epidemic worldwide. Its prevalence has doubled in the last three decades. Obesity is a complex clinical picture associated with physical, physiologic, hormonal, genetic, cultural, socioeconomic and environmental factors. The rate of obesity is also increasing in the pregnant women population. Maternal obesity is associated with less than optimal obstetrical, fetal and neonatal outcomes. It is also associated with significant adverse long-term effects on both obese parturients and the infants born from obese women. A number of guidelines have been published to educate health care workers and the general population in an attempt to develop effective interventions on a large scale to prevent obesity. These guidelines are multiple, confusing and inconsistent. There are no standard recommendations regarding gestational weight gaining goals, nutrients and additional elements necessary for certain obese women who have been treated with bariatric surgical procedures, screening for metabolic diseases such as diabetes, additional preventive health care services indicated for obese women in the pregnancy planning stages, during prenatal care, in the immediate post-partum period and as a long-term approach for health preservation. In 2013, the American Medical Association supported by several US national medical specialty organizations published Resolution 420 (A-13) recognizing obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to improve its prevention and treatment. The goal of this decision was to encourage a broader spectrum of health care benefits insurance coverage for the prevention and treatment of obesity. There are a number of myths and misconceptions associated with obesity. These perspectives present our views and clinical experience with a partial review of recent bibliography addressing the associations between obese reproductive age women and their risks during pregnancy.

Perinatal outcome in pregnancies complicated with gestational diabetes mellitus and very preterm birth: case-control study

Preterm birth is defined as all births before 37 completed weeks of gestation. Preterm birth can be further sub-divided based on gestational age: extremely preterm (<28 weeks), very preterm (28 to <32 weeks) and moderate preterm (32 to <37 weeks). Retrospective observational case-control study review (1 year i.e., 2015) is to assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering very preterm (28 + 0/7 to 31 + 6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without GDM. In all, 30 women were included in the study, of whom 15 were diagnosed with GDM and 15 were not. All women had a cesarean delivery. Neonates of mothers with GDM had higher ponderal index. Birth weight had the positive associations with blood glucose of newborn (r = 0.37, p = 0.047) and term of births (r = 0.52, p = 0.003). Birth weight had the negative associations with maternal systolic pressure (r = -0.7, p < 0.05), pre-eclampsia (r = -0.6, p < 0.05) and maternal pre-pregnancy body mass index (r = -0.5, p < 0.05). There were no differences in mortality or other parameters for neonatal morbidity, including bronchopulmonary dysplasia, prematurity retinopathy, neonatal anemia. According to our data, very preterm delivery occurring in women with GDM does not confer an increased risk for neonatal complications.

Probable glucometer interference caused by topical iodine solution test site preparation

WHAT IS KNOWN AND OBJECTIVE

Use of disinfectants, such as alcohol prep pads, for test site preparation have demonstrated alterations in glucose readings. One case report details an overestimation of blood glucose (BG) readings when using Chemstrip bG and Visidex reagent test strips after cleaning test site with povidone-iodine swabs

CASE SUMMARY

We present a case of a clinically relevant probable drug-device interaction between topical iodine and a point-of-care glucometer in a 28 year old pregnant woman of Chinese descent. In this case, the use of 10% povidone-iodine solution on the testing site before lancing likely resulted in variable and inaccurate BG readings, which was not reproduced when the patient used hand washing instead of iodine.

WHAT IS NEW AND CONCLUSION

Our report expands on this prior knowledge by demonstrating that such an alteration associated with iodine can occur with modern electrochemical glucometers. In patients that have aberrant or variable BG readings, providers should investigate for improper testing technique.

Gestational age specific stillbirth risk among Indigenous and non-Indigenous women in Queensland, Australia: a population based study

Background

In Australia, significant disparity persists in stillbirth rates between Aboriginal and Torres Strait Islander (Indigenous Australian) and non-Indigenous women. Diabetes, hypertension, antepartum haemorrhage and small-for-gestational age (SGA) have been identified as important contributors to higher rates among Indigenous women. The objective of this study was to examine gestational age specific risk of stillbirth associated with these conditions among Indigenous and non-Indigenous women.

Methods

Retrospective population-based study of all singleton births of at least 20 weeks gestation or at least 400 grams birthweight in Queensland between July 2005 and December 2011 using data from the Queensland Perinatal Data Collection, which is a routinely-maintained database that collects data on all births in Queensland. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95 % confidence intervals, adjusting for maternal demographic and pregnancy factors.

Results

Of 360987 births analysed, 20273 (5.6 %) were to Indigenous women and 340714 (94.4 %) were to non-Indigenous women. Stillbirth rates were 7.9 (95 % CI 6.8–9.2) and 4.1 (95 % CI 3.9–4.3) per 1000 births, respectively. For both Indigenous and non-Indigenous women across most gestational age groups, antepartum haemorrhage, SGA, pre-existing diabetes and pre-existing hypertension were associated with increased risk of stillbirth. There were mixed results for pre-eclampsia and eclampsia and a consistently raised risk of stillbirth was not seen for gestational diabetes.

Conclusion

This study highlights gestational age specific stillbirth risk for Indigenous and non-Indigenous women; and disparity in risk at term gestations. Improving access to and utilisation of appropriate and responsive healthcare may help to address disparities in stillbirth risk for Indigenous women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0943-7) contains supplementary material, which is available to authorized users.

Pregnancy snapshot: a retrospective, observational case-control study to evaluate the potential effects of maternal diabetes treatment during pregnancy on macrosomia

OBJECTIVE

Pregnancy in women with diabetes is associated with increased incidence of macrosomia (high birth weight) versus women without diabetes. Macrosomia increases the risk of complications during delivery and neonatally. The potential effect on macrosomia incidence certain diabetes treatments may have is not fully established. This study aims to identify whether specific components of the prenatal care of mothers with diabetes are associated with increased macrosomia risk in a real-world U.S.

RESEARCH DESIGN AND METHODS

Retrospective, observational case-controlled study of mothers either without diabetes, or with type 1 (T1D), type 2 (T2D), or gestational diabetes mellitus (G.D.M.), using data from a U.S. insurance claims database. Treatment selection was at physician discretion.

MAIN OUTCOME MEASURE

Incidence of macrosomia.

RESULTS

For mothers with T2D, use of neutral protamine Hagedorn (N.P.H.) insulin and glyburide increased during pregnancy, from 3.4% to 33.3%, and 3.7% to 16.5%, respectively. The most common G.D.M. treatments during pregnancy were glyburide (15.5%), N.P.H. (12.9%), basal-bolus therapy (10.0%), and metformin (8.1%). Endocrinologist care during pregnancy was associated with insulin use - but not glyburide use - for mothers with G.D.M., and with insulin use for mothers with T1D and T2D (compared with mothers not visiting an endocrinologist). Glyburide was associated with higher odds for macrosomia: G.D.M. (odds ratio [O.R.] 1.53, 95% confidence interval [C.I.] 1.38-1.69, p < 0.0001); T2D (O.R. 1.93, 95% C.I. 1.51-2.47, p < 0.0001). Endocrinologist care was associated with lower odds for macrosomia overall (O.R. 0.86, 95% C.I. 0.81-0.92) and for mothers with G.D.M. (O.R. 0.85, 95% C.I. 0.75-0.97, p = 0.0156) when the sub-populations were examined in separate models.

CONCLUSIONS

Healthcare utilization and endocrinologist care were related to positive birth outcomes, especially with G.D.M. Further research into the safety and efficacy of glyburide in pregnancy is warranted. This study cannot infer causality and may not be representative of current U.S. healthcare practice.

Diabetes prevention: Reproductive age women affected by insulin resistance

In the United States, 29.1 million people are affected by diabetes, of which 95% have type 2 diabetes. There has been a fivefold increase in type 2 diabetes in the latter half of the 20th century, an increase strongly linked to the obesity epidemic in the United States. In addition, insulin resistance affects 86 million Americans, or more than one-third of the adult population, as manifested by impaired fasting glucose tolerance with random glucose values ranging from ⩾100 to <126 mg/dL. In all, 90% of those affected by impaired fasting glucose tolerance or pre-diabetes are unaware of their metabolic derangement. Although impaired fasting glucose tolerance increases one's risk of developing type 2 diabetes, once identified, application of lifestyle changes by affected individuals may avoid or delay the onset of type 2 diabetes. For reproductive age women who are found to have impaired fasting glucose tolerance, lifestyle changes may be an effective tool to diminish the reproductive health consequences of insulin resistance related diseases.

Diabetic retinopathy in pregnancy: a review

The prevalence of diabetes in pregnancy is increasing. Pre-existing diabetes is present in 1 in 167 pregnancies in Australia, divided equally between type 1 and type 2 diabetes. Diabetic retinopathy is a leading cause of blindness in women during their childbearing years, and pregnancy increases the short-term risk of diabetic retinopathy progression. We examine the risk factors for progression of diabetic retinopathy during pregnancy including duration of diabetes, baseline level of retinopathy, level of glycaemic control and hypertension. We also examine current screening and management guidelines and their levels of evidence, current treatment options for diabetic retinopathy and avenues for further research.

Stress exposure and psychological stress responses are related to glucose concentrations during pregnancy

OBJECTIVES

The role of stress in the development of gestational diabetes mellitus (GDM) has so far been neglected. We investigated the impact of stress exposure (pregnancy-related and pregnancy-unrelated major life events), psychological stress responses (perceived stress, subjective experience of stress, anxiety, depression, sleep), and physiological stress responses (salivary cortisol, plasma copeptin levels) on glucose concentrations during pregnancy.

DESIGN

Cross-sectional study, including 203 pregnant women at the maternity department of a Swiss university hospital.

METHODS

All women underwent routine screening for GDM with a 75-g oral glucose-tolerance test at 24-30 weeks of gestation. Pregnancy-related and pregnancy-unrelated major life events, perceived stress, general psychological distress, anxiety, depression, and amount of sleep were assessed by validated self-report questionnaires. Cortisol was measured using fasting and bedtime saliva samples, and copeptin using fasting plasma. All data were collected before communication of the screening test results.

RESULTS

Significant positive associations were found between the number of pregnancy-related major life events and fasting glucose, while there was no association with pregnancy-unrelated major life events. More anxiety and depressive symptoms, a higher general level of distress, and a shorter duration of sleep were related to fasting glucose, although the latter two were no longer significant when age and BMI were controlled for. However, physiological stress responses were not associated with glucose concentrations. When testing for unique associations with fasting glucose, more general distress and shorter duration of sleep independently accounted for higher fasting glucose levels. Finally, when comparing women with and without GDM, we found that women who subsequently received the diagnosis of GDM reported more pregnancy-related life events.

CONCLUSIONS

Some indicators of stress exposure and psychological stress responses were associated with fasting glucose concentrations in pregnant women, thus representing important risk factors for GDM development. Statement of contribution What is already known on this subject? Only approximately half of women with gestational diabetes mellitus (GDM) report any known risk factors. Women after GDM diagnosis reported more major life events compared to healthy pregnant controls. What does this study add? Stress exposure and psychological stress responses were associated with fasting glucose concentrations in pregnant before women were aware of their GDM diagnosis. These represent important risk factors for GDM development and potential targets for intervention.

Preeclampsia and the Risk of Future Vascular Disease and Mortality: A Review

INTRODUCTION

Preeclampsia increases a woman's long-term risk of vascular disease and/or death including chronic hypertension, myocardial infarction, heart failure, stroke, and venous thromboembolism. The literature suggests that maternity care providers may be unaware of this association.

METHODS

A database search was conducted examining the long-term effects of hypertensive disorders of pregnancy using MEDLINE, Scopus, CINAHL, ISI Web of Knowledge, and the Cochrane Database of Systematic Reviews. Inclusion criteria were: 1) English language, 2) peer-reviewed journals, 3) January 2000 to July 2015, 4) systematic reviews with or without meta-analyses, and 5) studies that addressed the relationship between hypertensive disorders of pregnancy and vascular disease such as hypertension, cardiovascular disease (CVD), and cerebrovascular diseases.

RESULTS

Three systematic reviews with meta-analysis qualified for this review. They represented 48 unique studies from 20 countries and included a total of 3,598,601 women. Preeclampsia was associated with a 3-fold increased risk for developing chronic hypertension. Compared with normotensive women, those with preeclampsia experienced double the risk, or more, for CVD or CVD-related mortality. Preeclampsia was also associated with approximately double the risk for fatal or nonfatal stroke.

DISCUSSION

Preeclampsia is associated with an increased risk for future chronic hypertension, CVD, cerebrovascular disease, and death. While evidence shows that women with cardiac risk factors may have a higher chance of developing preeclampsia, many women with preeclampsia have no CVD risk factors. Measures to prevent preeclampsia such as calcium supplementation for women with low calcium intake and low-dose aspirin for women with a history of more than one incident of preeclampsia or a preterm birth associated with preeclampsia are supported by evidence. Reduction of modifiable risks associated with CVD before, during, and after pregnancy is recommended. All care providers and women should be educated regarding these risks and the importance of pregnancy history to future health.

Predicting gestational diabetes mellitus during the first trimester using anthropometric measurements and HOMA-IR

PURPOSE

To determine the predictability of gestational diabetes mellitus (GDM) during the first trimester using the degree of insulin resistance and anthropometric measurements and to assign the risk of developing GDM by weight gained during pregnancy (WGDP).

METHODS

A total of 250 singleton pregnancies at 7-12 gestational weeks were studied. Body mass index (BMI), waist/hip ratio (WHR), quantitative insulin sensitivity check index (QUICKI), homeostasis model assessment-insulin resistance (HOMA-IR) scores and WGDP were determined. The backward stepwise method was applied to estimate possible associations with GDM. Cutoff points were estimated using receiver operating characteristic curve analysis.

RESULTS

GDM was found in 20 of 227 singleton pregnancies (8.8 %). The calculated HOMA-IR, QUICKI, BMI, WHR, WGDP, and parity were significantly associated with GDM. Logistic regression analyses showed that three covariates (HOMA-IR, BMI, WGDP) remained independently associated with GDM. It was calculated as OR 1.254 (95 % CI 1.006-1.563), AUC 0.809, sensitivity 90 %, specificity 61 % with cutoff = 2.08 for HOMA-IR; OR 1.157 (CI 1.045-1.281), AUC 0.723, sensitivity 80 %, specificity 58 % with cutoff = 25.95 for BMI; OR 1.221, (CI 1.085-1.374), AUC 0.654, sensitivity 80 %, specificity 46 % with cutoff = 4.7 for WGDP. Despite a HOMA-IR score of >3.1 in pregnant women, GDM was detected in only three of 29 patients (10.3 %) if WGDP was <4.7 kg at weeks 24-28.

CONCLUSIONS

First trimester screening for GDM can be achieved based on maternal anthropometric measurements and HOMA-IR. In particular, if BMI is >25.95 kg/m(2) and the HOMA-IR score >2.08, controlling weight gain may protect against GDM.

Management of Pregnant Women with Type 2 Diabetes Mellitus and the Consequences of Fetal Programming in Their Offspring

The obesity epidemic has fueled an epidemic of prediabetes and type 2 diabetes mellitus in women of childbearing age. This paper examines the state of the science on preconception and pregnancy management of women with type 2 diabetes to optimize outcomes for the women and their infants. In addition, the consequence of fetal programming as a result of suboptimal maternal glycemic control is discussed. The paper focuses on type 2 diabetes, not type 1 diabetes or gestational diabetes. Management of women with type 2 diabetes includes preconception counseling, preconception weight management and weight loss, proper weight gain during pregnancy, self-monitoring of blood glucose levels, medication, medical nutrition therapy, and exercise.

Impact of Systemic Inflammation on the Progression of Gestational Diabetes Mellitus

With increasing rates of obesity and new diagnostic criteria for gestational diabetes mellitus (GDM), the overall prevalence of GDM is increasing worldwide. Women with GDM have an increased risk of maternal and fetal complications during pregnancy as well as long-term risks including higher prevalence of type 2 diabetes mellitus and cardiovascular disease. In recent years, the role of immune activation and inflammation in the pathogenesis of GDM has gained increasing attention. This monograph explores the current state of the literature as regards the expression of markers of inflammation in the maternal circulation, placenta, and adipose tissue of women with GDM.

Social and Environmental Barriers to Nutrition Therapy for Diabetes Management Among Underserved Pregnant Women: A Qualitative Analysis

OBJECTIVE

To identify social and environmental barriers to nutrition therapy for diabetes management during pregnancy among a population of low-income, minority pregnant women.

DESIGN

Prospective, in-depth, semi-structured interviews performed serially during pregnancy and continued until thematic saturation was reached.

SETTING

Urban academic medical center.

PARTICIPANTS

Ten pregnant low-income, minority women with gestational diabetes and type 2 diabetes mellitus.

PHENOMENON OF INTEREST

Social and environmental barriers to nutrition therapy for diabetes management during pregnancy.

ANALYSIS

Qualitative analysis of interview data using electronic coding software was performed using theme analysis.

RESULTS

Participants perceived limited ability and self-efficacy to adopt nutrition recommendations. Specific themes identified as barriers included (1) feeling overwhelmed by the unfamiliar; (2) using and decoding nutrition labels; (3) managing nutrition choices and seeking control in the setting of food insecurity; (4) experiencing lack of control and motivation, and limited self-efficacy; (5) balancing recommendations with taste preferences and cultural food norms; (6) maintaining a healthy eating schedule; and (7) accommodating diabetes in family and social life.

CONCLUSIONS AND IMPLICATIONS

Pregnant women with diabetes encounter a number of knowledge-based, attitudinal, and resource-related barriers that reduce capacity for nutrition therapy adherence. Provision of culturally informed, practical nutrition support that addresses the needs of women in low-resource communities is an important component of comprehensive diabetes care during pregnancy.

Effects of Self-Efficacy and Locus of Control on Future Preconception Counseling Plans of Adult Women With Type 1 Diabetes

Objective. The American Diabetes Association (ADA) recommends that women with diabetes attend preconception counseling and improve blood glucose levels before pregnancy to decrease risks of adverse outcomes. However, two-thirds of women with diabetes do not plan their pregnancies. Research has examined views regarding preconception counseling of pregnant women with diabetes, but perceptions of women with diabetes who have never been pregnant have not been explored. The purpose of this study was to examine the relationship between women's locus of control, self-efficacy, and outcome expectations of preconception counseling. Design and Methods. A sample of 147 nulligravid women with type 1 diabetes (mean age 25.9 years) was recruited online to complete a self-report survey. Measures included a sociodemographics form, a study-specific questionnaire regarding diabetes management and education, the Reproductive Health Attitudes and Behaviors instrument, and the Diabetes-Specific Locus of Control measure. Results. A standard multiple linear regression analysis indicated that self-efficacy was positively associated with expectations of preconception counseling (P <0.001), whereas self-blame was negatively associated (P = 0.001). Three-fourths of the women reported not receiving preconception counseling from health care providers. Conclusion. Self-efficacy was positively associated with women's expectation of preconception counseling usefulness, whereas self-blame for poor disease management was inversely related. The low reported rates of preconception counseling demonstrate that ADA recommendations for starting preconception counseling at puberty have not been followed uniformly. Women with diabetes should be provided education to increase their belief that they have control over their disease, which may lead to positive perceptions of preconception counseling and healthier pregnancies.

Trends in the incidence of diabetes, its clinical sequelae, and associated costs in pregnancy

BACKGROUND

Increasing diabetes prevalence affects a substantial number of pregnant women in the United States. Our aims were to evaluate health outcomes, medical costs, risks and types of complications associated with diabetes in pregnancy for mothers and newborns.

METHODS

In this retrospective claims analysis, patients were identified from the Truven Health MarketScan(®) database (2004-2011 inclusive). Participants were aged 18-45 years, with ascertainable diabetes status [Yes/No], date of birth event >2005 and continuous health plan enrolment ≥21 months before and 3 months after the birth.

RESULTS

In total, 839 792 pregnancies were identified, and 66 041 (7.86%) were associated with diabetes mellitus [type 1 (T1DM), 0.13%; type 2 (T2DM), 1.21%; gestational (GDM), 6.29%; and GDM progressing to T2DM (patients without prior diabetes who had a T2DM diagnosis after the birth event), 0.23%]. Relative risk (RR) of stillbirth (2.51), miscarriage (1.28) and Caesarean section (C-section) (1.77) was significantly greater with T2DM versus non-diabetes. Risk of C-section was also significantly greater for other diabetes types [RR 1.92 (T1DM); 1.37 (GDM); 1.63 (GDM progressing to T2DM)]. Risk of overall major congenital (RR ≥ 1.17), major congenital circulatory (RR ≥ 1.19) or major congenital heart (RR ≥ 1.18) complications was greater in newborns of mothers with diabetes versus without. Mothers with T2DM had significantly higher risk (RR ≥ 1.36) of anaemia, depression, hypertension, infection, migraine, or cardiac, obstetrical or respiratory complications than non-diabetes patients. Mean medical costs were higher with all diabetes types, particularly T1DM ($27 531), than non-diabetes ($14 355).

CONCLUSIONS

Complications and costs of healthcare were greater with diabetes, highlighting the need to optimize diabetes management in pregnancy.

Aquaporins and Fetal Membranes From Diabetic Parturient Women: Expression Abnormalities and Regulation by Insulin

CONTEXT

During pregnancy, aquaporins (AQPs) expressed in fetal membranes are essential for controlling the homeostasis of the amniotic volume, but their regulation by insulin was never explored in diabetic women.

OBJECTIVE

The aim of our study was to investigate the involvement of AQPs 1, 3, 8, and 9 expressed in fetal membranes in diabetic parturient women and the control of their expression by insulin.

DESIGN AND PARTICIPANTS

From 129 fetal membranes in four populations (controls, type 1, type 2 [T2D], and gestational diabetes [GD]), we established an expression AQP profile. In a second step, the amnion was used to study the control of the expression and functions of AQPs 3 and 9 by insulin.

MAIN OUTCOMES AND MEASURES

The expression of transcripts and proteins of AQPs was studied by quantitative RT-PCR and ELISA. We analyzed the regulation by insulin of the expression of AQPs 3 and 9 in the amnion. A tritiated glycerol test enabled us to measure the impact of insulin on the functional characteristics. Using an inhibitor of phosphatidylinositol 3-kinase, we analyzed the insulin intracellular signaling pathway.

RESULTS

The expression of AQP3 protein was significantly weaker in groups T2D and GD. In nondiabetic fetal membranes, we showed for the amnion (but not for the chorion) a significant repression by insulin of the transcriptional expression of AQPs 3 and 9, which was blocked by a phosphatidylinositol 3-kinase inhibitor.

CONCLUSION

In fetal membranes, the repression of AQP3 protein expression and functions observed in vivo is allowed by the hyperinsulinism described in pregnant women with T2D or GD.

Diagnosis of gestational diabetes, defining the net, refining the catch

The blood glucose diagnostic thresholds for gestational diabetes remain controversial. In the UK the National Institute for Health and Care Excellence (NICE) has published updated guidance for its diagnosis based upon a health economic analysis using local population datasets, and treatment effects estimated from published intervention trials. The resulting thresholds differ from those of the WHO, and in this issue of Diabetologia (DOI: 10.1007/s00125-015-3647-z ), Meek et al have compared the impact of the two sets of diagnostic criteria on 25,543 pregnant women cared for at their unit in Cambridge, UK. This commentary discusses their paper and its implications for pregnant women in the UK.