Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2020

Maternal Metabolites Associated With Gestational Diabetes Mellitus and a Postpartum Disorder of Glucose Metabolism

CONTEXT

Gestational diabetes is associated with a long-term risk of developing a disorder of glucose metabolism. However, neither the metabolic changes characteristic of gestational diabetes in a large, multi-ancestry cohort nor the ability of metabolic changes during pregnancy, beyond glucose levels, to identify women at high risk for progression to a disorder of glucose metabolism has been examined.

OBJECTIVE

This work aims to identify circulating metabolites present at approximately 28 weeks' gestation associated with gestational diabetes mellitus (GDM) and development of a disorder of glucose metabolism 10 to 14 years later.

METHODS

Conventional clinical and targeted metabolomics analyses were performed on fasting and 1-hour serum samples following a 75-g glucose load at approximately 28 weeks' gestation from 2290 women who participated in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Postpartum metabolic traits included fasting and 2-hour plasma glucose following a 75-g glucose load, insulin resistance estimated by the homeostasis model assessment of insulin resistance, and disorders of glucose metabolism (prediabetes and type 2 diabetes) during the HAPO Follow-Up Study.

RESULTS

Per-metabolite analyses identified numerous metabolites, ranging from amino acids and carbohydrates to fatty acids and lipids, before and 1-hour after a glucose load that were associated with GDM as well as development of a disorder of glucose metabolism and metabolic traits 10 to 14 years post partum. A core group of fasting and 1-hour metabolites mediated, in part, the relationship between GDM and postpartum disorders of glucose metabolism, with the fasting and 1-hour metabolites accounting for 15.7% (7.1%-30.8%) and 35.4% (14.3%-101.0%) of the total effect size, respectively. For prediction of a postpartum disorder of glucose metabolism, the addition of circulating fasting or 1-hour metabolites at approximately 28 weeks' gestation showed little improvement in prediction performance compared to clinical factors alone.

CONCLUSION

The results demonstrate an association of multiple metabolites with GDM and postpartum metabolic traits and begin to define the underlying pathophysiology of the transition from GDM to a postpartum disorder of glucose metabolism.

The Closed-Loop System Improved the Control of a Pregnant Patient with Type 1 Diabetes Mellitus

Objective

Closed-loop insulin systems represent a technological advance in diabetes management but have rarely been studied in pregnancy. We report a case of a patient with type 1 diabetes mellitus who was previously a user of the Paradigm VEO pump and then migrated to Medtronic 670G. Research Design and Methods. We reviewed the case of a G1P0 patient with type 1 diabetes, treated with the Medtronic 670G system during pregnancy; a comparison with current literature was done.

Results

The patient achieved improved glycemic control as measured by time spent in different ranges as follows: <70 mg/dL, 8–4% and 70–180 mg/dL, 83–94%. Secondary outcomes included reduction of stress, anxiety, fear of hypoglycemia, and the psychological burden related to the disease. There were no obstetric or neonatal complications.

Conclusion

The Medtronic 670G closed-loop system was used safely in a pregnant woman; nevertheless, further research is needed to validate this system in this patient population.

Early Gestational Diabetes Mellitus: Diagnostic Strategies and Clinical Implications

Preexisting diabetes mellitus (DM) should be ruled out early in pregnancy in those at risk. During screening, a significant proportion of women do not reach the threshold for overt DM but fulfill the criteria used for diagnosing conventional gestational DM (cGDM). There is no consensus on the management of pregnancies with intermediate levels of hyperglycemia thus diagnosed. We have used the term early gestational DM (eGDM) for this condition and reviewed the currently available literature. Fasting plasma glucose (FPG), oral glucose tolerance test, and glycated hemoglobin (HbA1c) are the commonly employed screening tools in early pregnancy. Observational studies suggest that early pregnancy FPG and Hba1c correlate with the risk of cGDM and adverse perinatal outcomes. However, specific cut-offs, including those proposed by the International Association of the Diabetes and Pregnancy Study Group, do not reliably predict the development of cGDM. Emerging data, though indicate that FPG ≥ 92 mg/dL (5.1 mmol/L), even in the absence of cGDM, signals the risk for perinatal complication. Elevated HbA1c, especially a level ≥ 5.9%, also correlates with the risk of cGDM and worsened outcome. HbA1c as a diagnostic test is however besieged with the usual caveats that occur in pregnancy. The studies that explored the effects of intervention present conflicting results, including a possibility of fetal malnutrition and small-for-date baby in the early treatment group. Diagnostic thresholds and glycemic targets in eGDM may differ, and large multicenter randomized controlled trials are necessary to define the appropriate strategy.

The risk of small and large for gestational age newborns in women with gestational diabetes according to pre-gestational body mass index and weight gain

AIM

To explore the effects of pregestational body mass index (BMI) and gestational weight gain (GWG) on maternal and neonatal outcomes of women with gestational diabetes mellitus (GDM).

METHODS

We conducted retrospective cohort analyses of outcomes among women with GDM who delivered at Shamir Medical Center, Israel (2017-2018).

RESULTS

We included 673 women with GDM in our analysis, 217 (32.24%) with appropriate GWG (aGWG), 247 (36.7%) with excessive GWG (eGWG), and 209 (31%) with insufficient GWG (iGWG). Cesarean section (CS) was less prevalent among women with iGWG (19.6%), compared with women with eGWG (31.2%) and aGWG (31.1%) (p = .008). Small for gestational weight (SGA) newborns were more prevalent in women with iGWG 9.1%, compared with 2% and 0.9% for women with eGWG and aGWG, respectively (p<.001). Large for gestational age (LGA) newborns were significantly more prevalent in women with eGWG 17.4% compared with 4.8% and 9.7% in patients with iGWG and aGWG women, respectively (p<.001). SGA and LGA newborns were more prevalent in women with iGWG and e-GWG across all pre-gestational BMI groups >18.5 kg/m².

CONCLUSIONS

A complex interplay exists between pregestational weight, GWG, and GDM and pregnancy outcomes, specifically SGA and LGA newborns. A strict follow-up considering the pregestational BMI, GWG, blood glucose levels, treatment modality, and fetal abdominal circumference could assist in managing the complex interplay of patients with GDM for better neonatal outcomes.

Characteristics of gestational diabetes subtypes classified by oral glucose tolerance test values

BACKGROUND

In clinical practice, gestational diabetes mellitus (GDM) is treated as a homogenous disease but emerging evidence suggests that the diagnosis of GDM possibly comprises different metabolic entities. In this study, we aimed to assess early pregnancy characteristics of gestational diabetes mellitus entities classified according to the presence of fasting and/or post-load hyperglycaemia in the diagnostic oral glucose tolerance test performed at mid-gestation.

METHODS

In this prospective cohort study, 1087 pregnant women received a broad risk evaluation and laboratory examination at early gestation and were later classified as normal glucose tolerant (NGT), as having isolated fasting hyperglycaemia (GDM-IFH), isolated post-load hyperglycaemia (GDM-IPH) or combined hyperglycaemia (GDM-CH) according to oral glucose tolerance test results. Participants were followed up until delivery to assess data on pharmacotherapy and pregnancy outcomes.

RESULTS

Women affected by elevated fasting and post-load glucose concentrations (GDM-CH) showed adverse metabolic profiles already at beginning of pregnancy including a higher degree of insulin resistance as compared to women with normal glucose tolerance and those with isolated defects (especially GDM-IPH). The GDM-IPH subgroup had lower body mass index at early gestation and required glucose-lowering medications less often (28.9%) as compared to GDM-IFH (47.8%, P = .019) and GDM-CH (54.5%, P = .005). No differences were observed in pregnancy outcome data.

CONCLUSIONS

Women with fasting hyperglycaemia, especially those with combined hyperglycaemia, showed an unfavourable metabolic phenotype already at early gestation. Therefore, categorization based on abnormal oral glucose tolerance test values provides a practicable basis for clinical risk stratification.

Bihormonal dysregulation of insulin and glucagon contributes to glucose intolerance development at one year post-delivery in women with gestational diabetes: a prospective cohort study using an early postpartum 75-g glucose tolerance test

Gestational diabetes mellitus (GDM) is known to be a significant risk factor for the future development of type 2 diabetes. Here, we investigated whether a precise evaluation of β- and α-cell functions helps to identify women at high risk of developing glucose intolerance after GDM. Fifty-six women with GDM underwent a 75-g oral glucose tolerance test (OGTT) at early (6-12 weeks) postpartum. We measured their concentrations of glucose, insulin, proinsulin and glucagon at fasting and 30, 60 and 120 min. At 1-year post-delivery, we classified the women into a normal glucose tolerance (NGT) group or an impaired glucose tolerance (IGT)/diabetes mellitus (DM) group. Forty-three of the 56 women completed the study. At 1-year post-delivery, 17 women had developed IGT/DM and 26 women showed NGT. In the early-postpartum OGTTs, the IGT/DM group showed a lower insulinogenic index, a less glucagon suppression evaluated by the change from fasting to 30 min (ΔGlucagon 30 min), and a higher glucagon-to-insulin ratio at 30 min compared to the NGT group. There were no significant between-group differences in proinsulin levels or proinsulin-to-insulin ratios. Insulinogenic index <0.6 and ΔGlucagon 30 min >0 pg/mL were identified as predictors for the development of IGT/DM after GDM, independent of age, body mass index, and lactation intensity. These results suggest that the bihormonal disorder of insulin and glucagon causes the postpartum development of glucose intolerance. The measurement of plasma insulin and glucagon during the initial OGTT at early postpartum period can help to make optimal decisions regarding the postpartum management of women with GDM.

Effects of Telemetric Interventions on Maternal and Fetal or Neonatal Outcomes in Gestational Diabetes: Systematic Meta-Review

Background

In 2019, 1 of 6 births was affected by gestational diabetes mellitus (GDM) globally. GDM results in adverse maternal, fetal, and neonatal outcomes in the short and long term, such as pregnancy and birth complications, type 2 diabetes, metabolic syndrome, and cardiovascular disease. In the context of “transgenerational programming,” diabetes mellitus during pregnancy can contribute to “programming” errors and long-term consequences for the child. Therefore, early therapy strategies are required to improve the clinical management of GDM. The interest in digital therapy approaches, such as telemetry, has increased because they are promising, innovative, and sustainable.

Objective

This study aimed to assess the current evidence regarding the clinical effectiveness of telemetric interventions in the management of GDM, addressing maternal glycemic control, scheduled and unscheduled visits, satisfaction, diabetes self-efficacy, compliance, maternal complications in pregnancy and childbirth, as well as fetal and neonatal outcomes.

Methods

Medline via PubMed, Web of Science Core Collection, Embase, Cochrane Library, and CINAHL databases were systematically searched from January 2008 to April 2020. We included randomized controlled trials, systematic reviews, meta-analyses, and clinical trials in English and German. Study quality was assessed using “A MeaSurement Tool to Assess systematic Reviews” and “Effective Public Health Practice Project.”

Results

Our search identified 1116 unique studies. Finally, we included 11 suitable studies (including a total of 563 patients and 2779 patient cases): 4 systematic reviews or meta-analyses (1 of high quality and 3 of moderate quality), 6 randomized controlled trials (2 of high quality and 4 of moderate quality), and 1 low-quality nonrandomized controlled trial. We classified 4 “asynchronous interventions” and 3 “asynchronous and real-time interventions.” Our findings indicate that telemetric therapy clearly improves glycemic control and effectively reduces glycated hemoglobin A_1c levels. Furthermore, in 1 study, telemetry proved to be a significant predictor for a better glycemic control (hazard ratio=1.71, 95% CI 1.11-2.65; P=.02), significantly fewer insulin titrations were required (P=.04), and glycemic control was achieved earlier. Telemetric therapy significantly reduced scheduled and unscheduled clinic visits effectively, and women were highly satisfied with the treatment (P<.05). From fetal and neonatal short-term outcomes, some improving tendencies in favor of telemetry were determined. No long-term outcomes were detected.

Conclusions

Telemetric interventions clearly improved glycemic control, notably glycated hemoglobin A_1c levels, and reduced scheduled and unscheduled clinic visits effectively, which reinforces this digital approach in the treatment of GDM.

Early postpartum abnormal glucose metabolism subtype differs according to mid-trimester lipid profile in women with gestational diabetes mellitus

BACKGROUND

It is unknown whether early postpartum abnormal glucose metabolism (AGM) in women with previous gestational diabetes mellitus (GDM) is related to their mid-trimester lipid profile. The aim of this study was to characterize the mid-trimester lipid profile of women who experienced GDM and developed into different pathophysiologic subtypes of early postpartum AGM.

METHODS

A retrospective cohort study of 498 women with history of GDM was conducted. A 75-g oral glucose tolerance test (OGTT) and plasma lipid measurements were performed at 24-28 weeks of gestation and 6-12 weeks of postpartum. Insulin secretion and sensitivity were estimated using early postpartum OGTT-based indices.

RESULTS

Women in the mid-trimester dyslipidemia group had higher postpartum 30-min and 2-h plasma glucose, higher postpartum 2-h plasma insulin, higher postpartum triglyceride (TG), higher postpartum low density lipoprotein cholesterol (LDL-c) concentrations, lower postpartum 30-min insulinogenic index (IGI30), lower postpartum insulin sensitivity index (ISI), and lower postpartum disposition index than those in the normal lipid group (all P < 0.05). Abnormal mid-trimester TG and LDL-c concentrations were associated with postpartum AGM (adjusted odds ratio [OR] = 1.786, 95 % confidence interval [CI] = 1.142-2.425; and adjusted OR = 1.621, 95 % CI = 1.323-2.051, respectively; both P < 0.05). AGM women with low IGI30 and low ISI had higher mid-trimester total cholesterol and LDL-c concentrations, and AGM women with low ISI had higher mid-trimester TG concentrations than women with NGT or other subtypes of AGM (all P < 0.05).

CONCLUSIONS

GDM women with abnormal mid-trimester TG and LDL-c were predisposed to early postpartum AGM. Postpartum AGM women who experienced GDM had heterogeneous mid-trimester lipid profile when classified according to their pathophysiologic subtype.

Age at menarche: risk factor for gestational diabetes

This study examines the relationship between the age at menarche and gestational diabetes mellitus (GDM). This retrospective study included subjects who were diagnosed with GDM at a pregnancy polyclinic in Kocaeli, Turkey between 2014 and 2018. The mean ages at menarche were 12.6 and 13.03 years in the GDM group and control group, respectively. The analysis results showed that pre-pregnancy cycle duration, age at menarche and pre-pregnancy BMI are statistically significant in terms of the development of gestational diabetes. (p < .05).In our study showed that the risk of GDM was found to be 2.3 times higher in pregnant women with a menarche age of <12 years. If the pre-pregnancy BMI value is more than 25 kg/cm², the risk of GDM was found to be approximately 2 times higher. The study indicated that age at menarche, cycle duration, and BMI were risk factors for GDM. IMPACT STATEMENTWhat is already known on this subject? GDM has a lasting health impact on both the mother and the foetus. While several risk factors have previously been identified for GDM such as family history, obesity, advanced maternal age, significant gaps remain in our understanding of the risk factor and pathogenesis. Recent studies suggested that earlier menarche was significantly associated with an increased risk of GDM.What do the results of this study add? There might be ethnic differences on the relationship between the GDM and menarche age. There is no study examining the relationship between the age of menarche and GDM in Turkey. In presented study, we determined the risk factors of GDM including the age of menarche, cycle duration and BMI.What are the implications of these findings for clinical practice and / or further research? Therefore, a comprehensive evaluation of the menstrual history by healthcare professionals is important for future pregnancy risks. It is important to understand risk factors for GDM and to establish preventive strategies among high-risk populations. In addition, this study will shed light on future epidemiological and cohort studies.

Telemedical Approaches to Managing Gestational Diabetes Mellitus During COVID-19: Systematic Review

BACKGROUND

In 2019, a new coronavirus emerged in China, and the disease caused by the virus (COVID-19) was rapidly classified as a pandemic. Pregnant women with gestational diabetes mellitus (GDM) are considered to be at risk for severe COVID-19. In the context of the pandemic, there are serious concerns regarding adverse effects on maternal and neonatal outcomes for women with GDM. Effective treatments for patients with GDM are therefore particularly important. Due to contact restrictions and infection risks, digital approaches such as telemedicine are suitable alternatives.

OBJECTIVE

This systematic review aims to summarize currently available evidence on maternal and offspring outcomes of pregnant women with GDM and COVID-19 and to examine telemedical interventions to improve maternal glycemic control during the COVID-19 pandemic.

METHODS

Publications were systematically identified by searching the Cochrane Library, MEDLINE via PubMed, Web of Science Core Collection, Embase, and CINAHL databases for studies published up to March 2021. We sorted the COVID-19 studies by outcome and divided the telemedical intervention studies into web-based and app-based groups. We analyzed case reports (COVID-19) and both randomized and nonrandomized controlled clinical trials (telemedicine). To determine the change in glycated hemoglobin A_1c (HbA_1c), we pooled appropriate studies and calculated the differences in means, with 95% CIs, for the intervention and control groups at the end of the interventions.

RESULTS

Regarding COVID-19 studies, we identified 11 case reports, 3 letters, 1 case series, and 1 retrospective single-center study. In total, 41 patients with GDM and COVID-19 were analyzed. The maternal and neonatal outcomes were extremely heterogeneous. We identified adverse outcomes for mother and child through the interaction of GDM and COVID-19, such as cesarean deliveries and low Apgar scores. Furthermore, we selected 9 telemedicine-related articles: 6 were randomized controlled trials, 2 were clinical controlled trials, and 1 was a quasi-experimental design. In total, we analyzed 480 patients with GDM in the intervention groups and 494 in the control groups. Regarding the quality of the 9 telemedical studies, 4 were rated as strong, 4 as moderate, and 1 as weak. Telemedical interventions can contribute to favorable impacts on HbA_1c and fasting blood glucose values in the context of the COVID-19 pandemic. Meta-analysis revealed a mean difference in HbA_1c of -0.19% (95% CI 0.34% to 0.03%) for all telemedical interventions, -0.138% (95% CI -0.24% to -0.04%) for the web-based interventions, and -0.305% (96% CI -0.88% to 0.27%) for the app-based interventions.

CONCLUSIONS

Telemedicine is an effective approach in the context of COVID-19 and GDM because it enables social distancing and represents optimal care of patients with GDM, especially with regard to glycemic control, which is very important in view of the identified adverse maternal and neonatal outcomes. Further research is needed.

Study protocol for a mixed methods exploratory investigation of aftercare services for gestational diabetes in women to develop a new patient-centred model in Germany: the GestDiNa_basic study

INTRODUCTION

Women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus compared with women who never had GDM. Consequently, the question of structured aftercare for GDM has emerged. In all probability, many women do not receive care according to the guidelines. In particular, the process and interaction between obstetrical, diabetic, gynaecological, paediatric and general practitioner care lacks clear definitions. Thus, our first goal is to analyse the current aftercare situation for women with GDM in Germany, for example, the participation rate in aftercare diabetes screening, as well as reasons and attitudes stated by healthcare providers to offer these services and by patients to participate (or not). Second, we want to develop an appropriate, effective and patient-centred care model.

METHODS AND ANALYSIS

This is a population-based mixed methods study using both quantitative and qualitative research approaches. In various working packages, we evaluate data of the GestDiab register, of the Association of Statutory Health Insurance Physicians of North Rhine and the participating insurance companies (AOK Rheinland/Hamburg, BARMER, DAK Gesundheit, IKK classic, pronova BKK). In addition, quantitative (postal surveys) and qualitative (interviews) surveys will be conducted with randomly selected healthcare providers (diabetologists, gynaecologists, paediatricians and midwives) and affected women, to be subsequently analysed. All results will then be jointly examined and evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (Ethics Committee No.: 2019-738). Participants of the postal surveys and interviews will be informed in detail about the study and the use of data as well as the underlying data protection regulations before voluntarily participating. The study results will be disseminated through peer-reviewed journals, conferences and public information.

TRIAL REGISTRATION NUMBER

DRKS00020283.

Fat mass and obesity-associated (FTO) gene epigenetic modifications in gestational diabetes: new insights and possible pathophysiological connections

AIMS

Gestational diabetes mellitus (GDM) can lead to short- and long-term complications for the child. Epigenetic alterations could contribute to explaining the metabolic disturbances associated with foetal programming. Although the role of the FTO gene remains unclear, it affects metabolic phenotypes probably mediated by epigenetic mechanisms. The aim of this study was to assess whether placental DNA epigenetic modifications at FTO promoter-associated cysteine-phosphate-guanine (CpG) sites are correlated with GDM. A secondary aim was to evaluate the association between the placental FTO DNA methylation and the maternal metabolic traits in women with and without GDM.

METHODS

Socio-demographic characteristics, clinical parameters at the third trimester of pregnancy, Mediterranean diet adherence, and physical activity were assessed in 33 GDM women and 27 controls. Clinical information about the newborns was registered at birth. The FTO rs9939609 (T > A) was genotyped.

RESULTS

No association between FTO DNA methylation and GDM was found. DNA methylation on the maternal side at the CpG1 was associated with maternal smoking in GDM (p = 0.034), and DNA methylation at the CpG3 was correlated with smoking or former smoking in controls (p = 0.023). A higher level of TGs was correlated with higher foetal placental DNA methylation at the CpG2 (p = 0.036) in GDM. An inverse association between HDL-C and maternal placental DNA methylation at the CpG3 in controls (p = 0.045) was found. An association between FTO rs9939609 and neonatal birthweight (p = 0.033) was detected.

CONCLUSIONS

In the awareness that the obesity pathophysiology is complex, the study adds a piece to this intricate mosaic.

Gestational diabesity and foetoplacental vascular dysfunction

Gestational diabetes mellitus (GDM) shows a deficiency in the metabolism of D-glucose and other nutrients, thereby negatively affecting the foetoplacental vascular endothelium. Maternal hyperglycaemia and hyperinsulinemia play an important role in the aetiology of GDM. A combination of these and other factors predisposes women to developing GDM with pre-pregnancy normal weight, viz. classic GDM. However, women with GDM and prepregnancy obesity (gestational diabesity, GDty) or overweight (GDMow) show a different metabolic status than women with classic GDM. GDty and GDMow are associated with altered l-arginine/nitric oxide and insulin/adenosine axis signalling in the human foetoplacental microvascular and macrovascular endothelium. These alterations differ from those observed in classic GDM. Here, we have reviewed the consequences of GDty and GDMow in the modulation of foetoplacental endothelial cell function, highlighting studies describing the modulation of intracellular pH homeostasis and the potential implications of NO generation and adenosine signalling in GDty-associated foetal vascular insulin resistance. Moreover, with an increase in the rate of obesity in women of childbearing age worldwide, the prevalence of GDty is expected to increase in the next decades. Therefore, we emphasize that women with GDty and GDMow should be characterized with a different metabolic state from that of women with classic GDM to develop a more specific therapeutic approach for protecting the mother and foetus.

Use of contraception before and after a diabetes diagnosis: An observational matched cohort study

AIMS

To determine how a diabetes diagnosis affects contraception use.

METHODS

This retrospective cohort study used private insurance data from non-pregnant women aged 15-49 years, 2000-2014. We identified women with a new diabetes diagnosis and a control group without diabetes, matched on important potential confounders. We compared rates of prescription or procedural contraception use in the two groups before and after an index date (diabetes diagnosis and outpatient visit, respectively), yielding difference-in-differences estimates of the effect of a diabetes diagnosis on contraception use.

RESULTS

We identified 75,355 women with a new diabetes diagnosis and 7.5 million women without a diabetes diagnosis. Overall rates of contraception use did not increase in the year after diagnosis (absolute difference-in-difference: 0.4% [99.9% CI, -2.1% to 2.9%]; p < 0.001). In method-specific analyses, there was a decline in estrogen-containing and injectable contraceptives in the year after diagnosis (absolute difference-in-difference: -2.2% [-4.0% to -0.4%] and -0.8% [-1.5% to -0.1%], respectively; p < 0.001); no corresponding increase was noted for intrauterine contraception or subdermal implants.

CONCLUSIONS

Women with diabetes are less likely to use contraception after their diabetes diagnosis. Efforts are needed to ensure that women with diabetes receive the counseling and clinical services needed to carefully plan their pregnancies.

Association of higher HbA1c within the normal range with adverse pregnancy outcomes: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate the association between a relatively high HbA1c level within the normal range and the risk of adverse pregnancy outcomes.

METHODS

This retrospective cohort study was conducted between March 2018 and March 2019 at Women's Hospital, School of Medicine, Zhejiang University. Multiple logistic regression models after adjusting for plausible confounders were implemented to assess the relationships between the level of HbA1c and adverse pregnancy outcomes.

RESULTS

A total of 8585 women were included in our study. The rates of preterm birth, macrosomia and preeclampsia were 4.4% (380/8585), 5.3% (457/8585) and 1.7% (149/8585), respectively. After adjusting for potential confounding variables, an HbA1c range of 5.5-5.9% (37-41 mmol/mol) remained significantly associated with an increased risk of preterm delivery (a-OR 2.27; 95% CI, 1.50-3.43), macrosomia (a-OR 1.97; 95% CI, 1.32-2.94) and preeclampsia (a-OR 3.70; 95% CI, 2.07-6.60). GDM-negative pregnant women with an HbA1c level in the range of 5.5-5.9% (37-41 mmol/mol) had an increased risk of preterm delivery (a-OR 2.84; 95% CI, 1.71-4.71) and preeclampsia (a-OR 3.82; 95% CI, 1.81-8.04). However, GDM-positive pregnant women had an increased risk of macrosomia (a-OR 2.12; 95% CI, 1.13-3.97) and preeclampsia (a-OR 2.62; 95% CI, 1.01-6.81).

CONCLUSION

A higher HbA1c level within the normal range is an independent risk factor for preterm delivery and preeclampsia, especially among GDM-negative women. Therefore, relevant medical staff should enhance the awareness of risk and prevention to strengthen pregnancy monitoring.

Immunoendocrine Dysregulation during Gestational Diabetes Mellitus: The Central Role of the Placenta

Gestational Diabetes Mellitus (GDM) is a transitory metabolic condition caused by dysregulation triggered by intolerance to carbohydrates, dysfunction of beta-pancreatic and endothelial cells, and insulin resistance during pregnancy. However, this disease includes not only changes related to metabolic distress but also placental immunoendocrine adaptations, resulting in harmful effects to the mother and fetus. In this review, we focus on the placenta as an immuno-endocrine organ that can recognize and respond to the hyperglycemic environment. It synthesizes diverse chemicals that play a role in inflammation, innate defense, endocrine response, oxidative stress, and angiogenesis, all associated with different perinatal outcomes.

Glycemic Control in Pregnancies Complicated by Pre-Existing Diabetes Mellitus and Congenital Malformations: A Danish Population-Based Study

Purpose

To study the occurrence of major congenital abnormalities in children of women with type 1 and type 2 diabetes and investigate the association between glycated haemoglobin (HbA1c) and major congenital malformations according to type 1 diabetes and type 2 diabetes separately.

Patients and methods

In this register-based study, all singletons born alive from January 1, 2000 to December 31, 2015 in the North Denmark and Central Denmark regions of Denmark and their mothers were included. We used data from Danish health registers and the LABKA database. Logistic regression models were used to compute crude and adjusted prevalence odds ratios (cORs and aORs) with 95% confidence intervals (CIs) for major congenital malformations overall and for subtypes, by type of maternal pre-existing diabetes and HbA1c levels.

Results

Among 314,245 infants included, 2020 (0.64%) had mothers with type 1 diabetes and 498 (0.16%) had mothers with type 2 diabetes. We found an aOR of 2.9 (95% CI: 2.5, 3.5) and 1.9 (95% CI: 1.3; 2.8) for major malformations for type 1 and type 2 diabetes, respectively. The highest occurrence was seen for major congenital heart diseases, but we also observed higher occurrence of several other non-cardiac malformations. For both type 1 and type 2 diabetes, the prevalence of major congenital malformations increased with higher levels of maternal HbA1c with no safe threshold level. Mothers with type 1 diabetes had higher risks than those without diabetes irrespective of HbA1c, and women with HbA1c levels ≥9.5% had 8 times the odds of major congenital malformations [aOR 8.7 (95% CI: 5.4; 14.5)].

Conclusions

The prevalence of major congenital malformations progressively increased with poorer glycemic control during pregnancy, with no obvious safe threshold level, for both type 1 and type 2 diabetes.

Gestational Diabetes and Risk Assessment of Adverse Perinatal Outcomes and Newborns Early Motoric Development

Background and Objectives: The aim of this study was to analyze the presence of gestational diabetes mellitus (GDM) on maternal and fetal perinatal parameters, as well to evaluate the influence of GDM on neonatal early motoric development. Materials and Methods: In this prospective study, we evaluated 203 eligible participants that were admitted to obstetrics department for a labor. GDM was assessed by evaluation of maternal parameters, fetal parameters, as well its impact on infants early motoric development (Alberta Infant Motor Scale-AIMS). Results: Presence of GDM was significantly positively associated with: pre-pregnancy weight, obesity degree, weight at delivery, gestational weight gain (GWG), body mass index (BMI) at delivery, GWG and increased pre-pregnancy BMI, glucose levels in mother's venous blood after the delivery, positive family history for cardiovascular disease, pregnancy-related hypertension, congenital thrombophilia, drug use in pregnancy, large for gestational age (LGA), mode of delivery (Cesarean section and instrumental delivery). Likewise, GDM association was detected for tested ultrasound parameters (biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femoral length (FL)), length at birth, birth weight, newborn's head circumference, newborn's chest circumference, AIMS supination and pronation at three months, AIMS supination, pronation, sitting and standing at six months. Only Amniotic Fluid Index and AIMS supination at three months of infant's age remained significantly associated in multivariate regression model. Conclusions: The presence of significant positive association of numerous tested parameters in our study on perinatal outcomes and early motoric development, points to the necessity of establishing appropriate clinical decision-making strategies for all pregnant woman at risk and emphasize the importance of providing adequate glycaemia control options and further regular follow ups during the pregnancy.

TIMER: A Clinical Study of Energy Restriction in Women with Gestational Diabetes Mellitus

Medical nutrition therapy is an integral part of gestational diabetes mellitus (GDM) management; however, the prescription of optimal energy intake is often a difficult task due to the limited available evidence. The present pilot, feasibility, parallel, open-label and non-randomized study aimed to evaluate the effect of a very low energy diet (VLED, 1600 kcal/day), or a low energy diet (LED, 1800 kcal/day), with or without personalized exercise sessions, among women with GDM in singleton pregnancies. A total of 43 women were allocated to one of four interventions at GDM diagnosis: (1) VLED (n = 15), (2) VLED + exercise (n = 4), (3) LED (n = 16) or (4) LED + exercise (n = 8). Primary outcomes were gestational weight gain (GWG), infant birth weight, complications at delivery and a composite outcomes score. Secondary outcomes included type of delivery, prematurity, small- for-gestational-age (SGA) or large-for-gestational-age (LGA) infants, macrosomia, Apgar score, insulin use, depression, respiratory quotient (RQ), resting metabolic rate (RMR) and middle-upper arm circumference (MUAC). GWG differed between intervention groups (LED median: 12.0 kg; VLED: 5.9 kg). No differences were noted in the type of delivery, infant birth weight, composite score, prevalence of prematurity, depression, RQ, Apgar score, MUAC, or insulin use among the four groups. Regarding components of the composite score, most infants (88.4%) were appropriate-for-gestational age (AGA) and born at a gestational age of 37-42 weeks (95.3%). With respect to the mothers, 9.3% experienced complications at delivery, with the majority being allocated at the VLED + exercise arm (p < 0.03). The composite score was low (range 0-2.5) for all mother-infant pairs, indicating a "risk-free" pregnancy outcome. The results indicate that adherence to a LED or VLED induces similar maternal, infant and obstetrics outcomes.

Myoinositol Reduces Inflammation and Oxidative Stress in Human Endothelial Cells Exposed In Vivo to Chronic Hyperglycemia

Myo-inositol (Myo) improves insulin resistance, glucose metabolism, and helps gestational diabetes (GDM) management. GDM is associated with a pro-inflammatory state and increased oxidative stress, which are both involved in vascular damage in diabetes. Our aim was to study Myo anti-inflammatory/antioxidant potential effects on an in vitro model of human umbilical vein endothelial cells (HUVECs). To this end, monocyte cell adhesion to HUVECs, adhesion molecule membrane exposure, and oxidative stress levels were determined in cells from control (C-) and GDM women treated during pregnancy either with diet only (GD-) or with diet plus Myo (GD+Myo). To deeply study the vascular effects of Myo, the same evaluations were performed in C- and GD-HUVECs following 48 h in vitro stimulation with Myo. Notably, we first observed that GD-HUVECs obtained from women assuming Myo supplementation exhibited a significantly decreased number of monocytes that adhered to endothelial cells, less adhesion molecule exposure, and lower intracellular reactive oxygen species (ROS) levels in the basal state as compared to GD-HUVECs obtained from women treated by diet only. This Myo anti-inflammatory/antioxidant effect was confirmed by 48 h in vitro stimulation of GD-HUVECs as compared to controls. Altogether, these results strongly suggest that Myo may exert protective actions against chronic inflammation induced by endothelial dysfunction in diabetes.

Continuous glucose monitoring in obese pregnant women with no hyperglycemia on glucose tolerance test

Objective

The objective of the present study was to compare 24-hour glycemic levels between obese pregnant women with normal glucose tolerance and non-obese pregnant women.

Methods

In the present observational, longitudinal study, continuous glucose monitoring was performed in obese pregnant women with normal oral glucose tolerance test with 75 g of glucose between the 24^th and the 28^th gestational weeks. The control group (CG) consisted of pregnant women with normal weight who were selected by matching the maternal age and parity with the same characteristics of the obese group (OG). Glucose measurements were obtained during 72 hours.

Results

Both the groups were balanced in terms of baseline characteristics (age: 33.5 [28.7–36.0] vs. 32.0 [26.0–34.5] years, p = 0.5 and length of pregnancy: 25.0 [24.0–25.0] vs. 25.5 [24.0–28.0] weeks, p = 0.6 in the CG and in the OG, respectively). Pre-breakfast glycemic levels were 77.77 ± 10.55 mg/dL in the CG and 82.02 ± 11.06 mg/dL in the OG (p<0.01). Glycemic levels at 2 hours after breakfast were 87.31 ± 13.10 mg/dL in the CG and 93.48 ± 18.74 mg/dL in the OG (p<0.001). Daytime blood glucose levels were 87.6 ± 15.4 vs. 93.1 ± 18.3 mg/dL (p<0.001) and nighttime blood glucose levels were 79.3 ± 15.8 vs. 84.7 ± 16.3 mg/dL (p<0.001) in the CG and in the OG, respectively. The 24-hour, daytime, and nighttime values of the area under the curve were higher in the OG when compared with the CG (85.1 ± 0.16 vs. 87.9 ± 0.12, 65.6 ± 0.14 vs. 67.5 ± 0.10, 19.5 ± 0.07 vs. 20.4 ± 0.05, respectively; p<0.001).

Conclusion

The results of the present study showed that obesity in pregnancy was associated with higher glycemic levels even in the presence of normal findings on glucose tolerance test.

Perinatal Outcomes of Two Screening Strategies for Gestational Diabetes Mellitus: A Randomized Controlled Trial

OBJECTIVE

To evaluate differences in short-term perinatal outcomes between the two prominent screening strategies for gestational diabetes mellitus, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and Carpenter-Coustan.

METHODS

In this single-site, blinded, randomized, comparative effectiveness trial, participants received a nonfasting 50-g oral glucose tolerance test and, if less than 200 mg/dL (less than 11.1 mmol/L), were randomized to further screening with either IADPSG or Carpenter-Coustan criteria. Gestational diabetes treatment occurred per routine clinical care. The primary outcome was incidence of large-for-gestational-age (LGA) neonates. Prespecified secondary outcomes included small-for-gestational-age (SGA) neonates, cesarean birth, and neonatal and maternal composites of adverse perinatal outcomes. Assuming a 15% incidence of LGA neonates in the Carpenter-Coustan group, 782 participants provided more than 80% power to detect a 7% absolute risk reduction with the use of IADPSG; planned recruitment was 920 for anticipated attrition.

RESULTS

From June 2015 to February 2019, 1,016 participants were enrolled and 921 were randomized to IADPSG (n=461) or Carpenter-Coustan (n=460) groups. Gestational diabetes incidence (14.4% vs 4.5%, P<.001) and diabetes medication use (9.3% vs 2.4%; P<.001) were more common in the IADPSG group; there were no differences in LGA neonates, either overall (risk reduction 0.90, 97.5% CI 0.53-1.52) or among women without gestational diabetes (risk reduction 0.85, 97.5% CI 0.49-1.48). Those screened with IADPSG had higher rates of neonatal morbidity but fewer study-related adverse events. Rates of SGA neonates, cesarean birth, and maternal morbidity composite did not differ significantly between study groups.

CONCLUSIONS

The IADPSG screening criteria resulted in more women diagnosed and treated for gestational diabetes than Carpenter-Coustan without reducing the incidence of LGA birth weight or maternal or neonatal morbidity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02309138.

Using a consumer-based wearable activity tracker for physical activity goal setting and measuring steps in pregnant women with gestational diabetes mellitus: exploring acceptance and validity

BACKGROUND

Activity monitoring devices may be used to facilitate goal-setting, self-monitoring, and feedback towards a step-based physical activity (PA) goal. This study examined the performance of the wrist-worn Fitbit Charge 3™ (FC3) and sought opinions on walking and stepping-in-place from women with gestational diabetes (GDM).

METHODS

Participants completed six 2-min metronome-assisted over ground bouts that varied by cadence (67, 84, or 100 steps per minute) and mode (walking or stepping-in-place; N = 15), with the sequence randomized. Steps were estimated by FC3 and measured, in duplicate, by direct observation (hand-tally device, criterion). Equivalence testing by the two one-sided tests (TOST) method assessed agreement within ± 15%. Mean absolute percent error (MAPE) of steps were compared to 10%, the accuracy standard of the Consumer Technology Association (CTA)™. A subset (n = 10) completed a timed, 200-m self-paced walk to assess natural walking pace and cadence. All participants completed semi-structured interviews, which were transcribed and analyzed using descriptive and interpretive coding.

RESULTS

Mean age was 27.0 years (SD 4.2), prepregnancy BMI 29.4 kg/m² (8.3), and gestational age 32.8 weeks (SD 2.6). The FC3 was equivalent to hand-tally for bouts of metronome-assisted walking and stepping-in-place at 84 and 100 steps per minute (i.e., P < .05), although walking at 100 steps per minute (P = .01) was no longer equivalent upon adjustment for multiple comparisons (i.e., at P < .007). The FC3 was equivalent to hand-tally during the 200-m walk (i.e., P < .001), in which mean pace was 68.2 m per minute (SD 10.7), or 2.5 miles per hour, and mean cadence 108.5 steps per minute (SD 6.5). For walking at 84 and 100 steps per minute, stepping-in-place at 100 steps per minute, and the 200-m walk, MAPE was within 10%, the accuracy standard of the CTA™. Interviews revealed motivation for PA, that stepping-in-place was an acceptable alternative to walking, and competing responsibilities made it difficult to find time for PA.

CONCLUSIONS

The FC3 appears to be a valid step counter during the third trimester, particularly when walking or stepping-in-place at or close to women's preferred cadence.

Efficacy of flash glucose monitoring in pregnant women with poorly controlled pregestational diabetes (FlashMom): A randomized pilot study

BACKGROUND AND AIMS

Good glycemic control is crucial to reduce the risk of adverse pregnancy outcomes. Our aim was to evaluate the efficacy of Flash Glucose Monitoring (FGM) on glucose control in women with pregestational diabetes.

METHODS AND RESULTS

Forty women with inadequately controlled type 1 (T1D, n = 34) and type 2 (T2D, n = 6) diabetes at conception were randomly assigned to two arms: the Flash Glucose group (FG, n = 21) using FGM, and the control group (CG, n = 19) using self-monitoring of blood glucose (SMBG). Glycated hemoglobin (HbA1c, %), time in (TIR), below (TBR) and above (TAR) range, glucose variability as well as the occurrence of maternal and neonatal adverse outcomes, were evaluated. HbA1c decreased significantly (p < 0.01) and similarly (-0.65 ± 0.7 vs. -0.67 ± 0.8 for FG and CG, respectively; p = 0.89) in both groups during pregnancy. HbA1c reduction was positively associated with the number of daily FGM scans (p < 0.01). TBR (12.1 ± 2.0% vs. 19.6 ± 3.9%, p = 0.04) and the mean of the daily serum glucose difference (MODD) index (59.1 ± 5.4 vs. 77.7 ± 4.6, p = 0.02) were significantly lower in FG at second trimester. The rates of perinatal adverse outcomes were not different in the two studied groups.

CONCLUSIONS

In women with pregestational diabetes, FGM and SMBG had similar efficacy on glucose control during pregnancy. FGM showed additional advantages in terms of TBR and glucose variability. Achievement of good metabolic results depended on the adequate use of glucose sensor.

REGISTRATION

At ClinicalTrials.gov as NCT04666818 on December 14, 2020.

The diagnosis of Gestational Diabetes Mellitus and its impact on In Vitro Fertilization pregnancies. A pilot study

BACKGROUND

In Vitro Fertilization (IVF) is increasingly becoming a necessary mode of reproduction. This high risk group is prone to Gestational Diabetes Mellitus (GDM) which further exposes these pregnancies to an increased risk of adverse outcomes. In light of the limited data in the current literature, further investigation is needed regarding the time of GDM diagnosis in IVF pregnancies as well as the outcome of IVF pregnancies complicated by GDM.

METHODS

In this three center pilot cross sectional study, the data of 101 singleton IVF pregnancies complicated by GDM were analyzed. Prompt GDM diagnosis in IVF pregnancies was accomplished by self-blood glucose monitoring (SMBG) from the first antenatal visit and confirmed by an OGTT. To evaluate pregnancy outcome, maternal and fetal complications in the 101 GDM IVF group was compared to 101 IVF as well as 101 spontaneous conceptions (SC). The three groups were matched by age. The effect of demographic and glycemic parameters on the outcome of GDM IVF pregnancies was investigated.

RESULTS

GDM diagnosis was made before the 24th week in 37.6% of the GDM IVF group. The week of delivery was earlier for the GDM IVF group (37 ± 1.7) relative to the IVF (37.9 ± 0.9, p < 0.001) and the SC group (38.1 ± 0.8, p < 0.001). GDM IVF pregnancies exhibited greater preeclampsia rates and 84.8% underwent caesarian section. No significant difference regarding LGA and SGA birth weights was found. Complications of GDM IVF pregnancies were associated with the 1-h postprandial BG (r = 0.267, p = 0.007).

CONCLUSION

GDM screening in IVF pregnancies may be considered earlier than the 24th week. IVF pregnancies affected by GDM are prone to increased maternal and fetal complications which are associated with 1-h postprandial BG.

Different pre-analytical techniques and the results of 50 g oral glucose challenge tests

OBJECTIVE

We aimed to analyse the pre-analytical process and its effect of 50 g of oral glucose challenge test results for screening gestational diabetes mellitus.

RESEARCH DESIGN AND METHODS

The 50 g oral glucose challenge test was performed to 30 pregnant women, and the blood was collected as two samples for three tubes containing; serum separating jell (SSJ), sodium fluoride-potassium oxalate (NaF - KOx) and sodium citrate-containing tube. The first samples of the three tubes were centrifuged within 30 minutes, and second samples were centrifuged after 60 minutes and were analysed. One sample in SSJ tube and was analysed in the same day according to hospitals routine practice. The results were compared.

RESULTS

Among the 30 samples, the mean decrease in glucose levels was highest in the SSJ tube (0.38 mmol/L), followed by 0.16 mmol/L in Na citrate tube and 0.14 mmol/L in NaF-KOx tube. The hospital routine assessment with SSJ was 6.36 ± 1.90 mmol/L. The <30 and >60 minutes glucose results were 6.80 ± 1.88 mmol/L vs 6.42 ± 1.97 mmol/L for SSJ, 5.95 ± 1.60 mmol/L vs 5.78 ± 1.51 mmol/L for Na Citrate and 6.90 ± 1.86 mmol/L vs 6.75 ± 1.90 mmol/L for NaF-KOx mg/dL groups, respectively, and both the changes within time and the results between the tubes showed a statistically significant difference (P < .001).

CONCLUSION

In cases with longer assessment time and with different blood sample tubes, the clinician should also keep in mind that, especially with results under but close to the cut-off levels, an underdiagnosed gestational diabetes might be present.

The Clinical Characteristics of Gestational Diabetes Mellitus in Korea: A National Health Information Database Study

BACKGROUND

To investigate the clinical characteristics of gestational diabetes mellitus (GDM) in Korea, using a nationwide database.

METHODS

We analyzed 417,139 women who gave birth between 2011 and 2015 using the Korean National Health Information Database. They underwent the Korean National Health Screening Program within one year before pregnancy and were not prescribed drugs for diabetes nor diagnosed with diabetes mellitus before 280 days antepartum. Patients with GDM were defined as those who visited the outpatient clinic more than twice with GDM codes.

RESULTS

The prevalence of GDM was 12.70% and increased with increasing maternal age, prepregnancy body mass index (BMI), waist circumference (WC), and fasting plasma glucose (FPG) (P for trend <0.05). As compared with those aged <25 years, the odds ratio for women with GDM aged ≥40 years were 4.804 (95% confidence interval [CI], 4.436 to 5.203) after adjustment for covariates. Women with prepregnancy BMI ≥30 kg/m2 were at 1.898 times (95% CI, 1.736 to 2.075) greater risk for GDM than those with prepregnancy BMI <18.5 kg/m2. Women with WC of ≥95 cm were at 1.158 times (95% CI, 1.029 to 1.191) greater risk for GDM than women with WC of less than 65 cm. High FPG, high income, smoking, and drinking were associated with an elevated risk of GDM.

CONCLUSION

The prevalence of GDM in Korean women increased up to 12.70% during 2011 to 2015. These data suggest the importance of GDM screening and prevention in high-risk groups in Korea.

Protein glycation - biomarkers of metabolic dysfunction and early-stage decline in health in the era of precision medicine

Protein glycation provides a biomarker in widespread clinical use, glycated hemoglobin HbA1c (A1C). It is a biomarker for diagnosis of diabetes and prediabetes and of medium-term glycemic control in patients with established diabetes. A1C is an early-stage glycation adduct of hemoglobin with glucose; a fructosamine derivative. Glucose is an amino group-directed glycating agent, modifying N-terminal and lysine sidechain amino groups. A similar fructosamine derivative of serum albumin, glycated albumin (GA), finds use as a biomarker of glycemic control, particularly where there is interference in use of A1C. Later stage adducts, advanced glycation endproducts (AGEs), are formed by the degradation of fructosamines and by the reaction of reactive dicarbonyl metabolites, such as methylglyoxal. Dicarbonyls are arginine-directed glycating agents forming mainly hydroimidazolone AGEs. Glucosepane and pentosidine, an intense fluorophore, are AGE covalent crosslinks. Cellular proteolysis of glycated proteins forms glycated amino acids, which are released into plasma and excreted in urine. Development of diagnostic algorithms by artificial intelligence machine learning is enhancing the applications of glycation biomarkers. Investigational glycation biomarkers are in development for: (i) healthy aging; (ii) risk prediction of vascular complications of diabetes; (iii) diagnosis of autism; and (iv) diagnosis and classification of early-stage arthritis. Protein glycation biomarkers are influenced by heritability, aging, decline in metabolic, vascular, renal and skeletal health, and other factors. They are applicable to populations of differing ethnicities, bridging the gap between genotype and phenotype. They are thereby likely to find continued and expanding clinical use, including in the current era of developing precision medicine, reporting on multiple pathogenic processes and supporting a precision medicine approach.

Stopping Gestational Diabetes in American Indian and Alaska Native Girls: Nutrition as a Key Component to Gestational Diabetes Risk Reduction

BACKGROUND

American Indian and Alaska Native (AI/AN) women have a higher risk of gestational diabetes mellitus (GDM) and subsequent diagnosis of diabetes than do non-Hispanic White women. Healthy eating is key to weight management both prior to pregnancy and between pregnancies and can reduce the risk of developing GDM. Our research team developed an innovative preconception counseling and diabetes risk-reduction program, which includes nutrition and weight-management principles and is culturally tailored for adolescent AI/AN women. The program is entitled Stopping Gestational Diabetes Mellitus (SGDM).

OBJECTIVE

The purpose of this article is to examine nutrition-related information collected as a part of the formative qualitative research conducted for the development of a preconception counseling and gestational diabetes risk-reduction program, SGDM.

METHODS

This in-depth secondary analysis explored the original qualitative data from the needs assessment for SGDM program development. Participants included AI/AN women with a history of GDM (n = 5); AI/AN girls at risk of GDM (n = 14), and their mothers (n = 11), health care providers, and health administrators who care for AI/AN girls (n = 16); AI/AN elected leaders; and Indian health system administrators (n = 12). All focus groups and interviews were reanalyzed utilizing the following research question: "How do key stakeholders discuss food and/or nutrition in terms of gestational diabetes risk reduction for AI/AN adolescent girls?"

RESULTS

Three primary nutrition themes emerged: 1) AI/AN women were aware of healthy nutrition, healthy weight gainduring pregnancy, and healthy nutrition for people with type 2 diabetes, but these principles were not linked to reducing the risk of GDM; 2) participants expressed the need for education on the role of nutrition and weight management in GDM risk reduction; 3) participants shared challenges of healthful eating during and before pregnancy for AI/AN women.

CONCLUSIONS

These stakeholders' comments informed the development of the nutrition components of SGDM.

[Treatment of diabetes mellitus in perioperative medicine-an update]

Patients with diabetes who undergo a surgical intervention have an increased risk of metabolic derailment, anesthesiological complications, postoperative infections and cardiovascular events. The treatment of diabetes mellitus is subject to a continuous further development due to pharmaceutical and technical innovations. This article presents the implications of the current concepts of diabetes treatment for perioperative medicine, particularly the changes due to new oral antidiabetic agents and insulin pump treatment. Some of the currently available guidelines are discussed with respect to the care of diabetes patients in childhood and adulthood in connection with an operation. Finally, possible perspectives in the field of monitoring and treatment of diabetes patients are discussed.

Comparing the Efficacies of Telemedicine and Standard Prenatal Care on Blood Glucose Control in Women With Gestational Diabetes Mellitus: Randomized Controlled Trial

BACKGROUND

Gestational diabetes mellitus (GDM) can usually be well controlled by health education and lifestyle management, resulting in better pregnancy outcomes. However, standard clinical prenatal care, which consists of clinic visits every 2 weeks, may not provide sufficient management for women with GDM. Telemedicine demonstrates a potential to fill this gap.

OBJECTIVE

The objective of this study was to investigate whether health education and lifestyle management delivered through a WeChat group chat was more effective in controlling blood glucose (BG) than standard clinical prenatal care among women with GDM.

METHODS

In this multicenter randomized controlled trial, women with GDM diagnosed by an oral glucose tolerance test between 23 and 30 (+6) gestational weeks were randomized to a WeChat group chat-based BG management group or a routine clinical prenatal care group. The primary outcome was the change in the glycemic qualification rate during the follow-up period in both groups. The secondary outcomes were pregnancy outcomes.

RESULTS

A total of 309 women with GDM participated in the trial, with 162 women randomized to the control group and 147 to the intervention group. No significant differences in baseline characteristics were found between the control and intervention groups. Participants were further divided into 4 groups according to gestational weeks at enrollment for further analysis. The glycemic qualification rate of the intervention group was higher than that of the control group at nearly all time points in Groups 1 to 3, among which 3 time points reached statistical significance: Group 1 at T3 (54.8% vs 83.3%) and Group 2 at T3 (62.5% vs 80.0%) and T7 (75.0% vs 100%). The glycemic qualification rate gradually increased as gestational weeks progressed in both groups, regardless of the intervention method. None of the pregnancy outcomes measured, including delivery mode, premature rupture of the membranes, preterm birth, infant's birth weight, and postpartum hemorrhage, were significantly different between the control and intervention groups.

CONCLUSIONS

This multicenter randomized controlled trial that assessed women with noninsulin-dependent GDM demonstrated that additional instant messaging platforms, such as WeChat, used for health education and lifestyle intervention in China tend to be more effective for BG control than standard clinical prenatal care alone.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03748576; https://clinicaltrials.gov/ct2/show/NCT03748576.

A pathway level analysis of PFAS exposure and risk of gestational diabetes mellitus

Per- and polyfluoroalkyl substances (PFAS) have been found to be associated with gestational diabetes mellitus (GDM) development, a maternal health disorder in pregnancy with negative effects that can extend beyond pregnancy. Studies that report on this association are difficult to summarize due to weak associations and wide confidence intervals. One way to advance this field is to sharpen the biologic theory on a causal pathway behind this association, and to measure it directly by way of molecular biomarkers. The aim of this review is to summarize the literature that supports a novel pathway between PFAS exposure and GDM development. Epidemiological studies demonstrate a clear association of biomarkers of thyroid hormones and glucose metabolism with GDM development. We report biologic plausibility and epidemiologic evidence that PFAS dysregulation of maternal thyroid hormones and thyrotropin (TSH) may disrupt glucose homeostasis, increasing the risk of GDM. Overall, epidemiological studies demonstrate that PFAS were positively associated with TSH and negatively with triiodothyronine (T3) and thyroxine (T4). PFAS were generally positively associated with glucose and insulin levels in pregnancy. We propose dysregulation of thyroid function and glucose metabolism may be a critical and missing component in the accurate estimation of PFAS on the risk of GDM.

Time in Range in Pregnancy: Is There a Role?

Continuous glucose monitoring (CGM) is being used with increasing frequency as an adjunct to self-monitoring of blood glucose in pregnancy, and novel targets based on CGM data are becoming standardized. This adoption of CGM is the result of its improving accuracy, patient preference, and evolving data demonstrating associations of novel targets such as time in range (TIR) with pregnancy and neonatal outcomes. A greater understanding of the relationship of various CGM metrics to outcomes in pregnancy complicated by diabetes is needed. It is clear that TIR parameters need to be uniquely lower for pregnant women than for nonpregnant individuals. CGM technology is also an integral part of hybrid closed-loop insulin delivery systems. These insulin delivery systems will be a significant advance in the management of diabetes during pregnancy if they can achieve the pre- and postprandial targets required for pregnancy and optimize TIR.

Impact of metformin treatment during pregnancy on maternal outcomes: a systematic review/meta-analysis

We systematically assessed the impact of metformin treatment on maternal pregnancy outcomes. PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov and Cochrane databases were systematically searched (inception-1st February 2021). Randomised controlled trials reporting pregnancy outcomes in women randomised to metformin versus any other treatment for any indication were included. Outcomes included gestational weight gain (GWG), pre-eclampsia, gestational hypertension, preterm birth, gestational age at delivery, caesarean section, gestational diabetes, glycaemic control, and gastrointestinal side-effects. Two independent reviewers conducted screening, with a third available to evaluate disagreements. Risk-of-bias and GRADE assessments were conducted using Cochrane Risk-of-Bias and GRADE-pro software. Thirty-five studies (n = 8033 pregnancies) met eligibility criteria. GWG was lower in pregnancies randomised to metformin versus other treatments (1.57 kg ± 0.60 kg; I₂ = 86%, p < 0.0001), as was likelihood of pre-eclampsia (OR 0.69, 95% CI 0.50-0.95; I₂ = 55%, p = 0.02). The risk of gastrointestinal side-effects was greater in metformin-exposed versus other treatment groups (OR 2.43, 95% CI 1.53-3.84; I₂ = 76%, p = 0.0002). The risk of other maternal outcomes assessed was not significantly different between metformin-exposed versus other treatment groups. Metformin for any indication during pregnancy is associated with lower GWG and a modest reduced risk of pre-eclampsia, but increased gastrointestinal side-effects compared to other treatments.

Gender Differences and Their Influences on T2DM Self-Management Among Spanish-Speaking Latinx Immigrants

INTRODUCTION

Evidence suggests that gender may influence many aspects of type 2 diabetes (T2DM) self-management (SM) and we posit that limited English language-proficient Latinx immigrants face additional challenges.

METHODS

Instruments and semi-structured interviews were used to examine gender differences on health literacy, diabetes knowledge, health-promoting behaviors, diabetes, eating and exercise self-efficacy (SE), and T2DM SM practices among a cohort of limited English language-proficient Latinx immigrants. Statistical and qualitative analysis procedures were performed comparing males and females.

RESULTS

Thirty persons participated. Males tended to be older, have higher educational achievement, and more financial security than females. Physiologic measures tended worse among female participants. Health literacy and exercise SE scores were similar, but females scored lower on Eating and Diabetes SE. Forty-seven percent (n= 9) of the women reported a history of gestational diabetes mellitus and a majority of men (n = 7) cited difficulty with excessive alcohol.

CONSUMPTION

Males appeared to receive more SM support compared to females. Females more frequently noted how family obligations and a lack of support impeded their SM. Work environments negatively influenced SM practices.

CONCLUSION

Men and women have unique SM challenges and as such require individualized strategies and support to improve T2DM management.

Preconception Care to Reduce the Risks of Overweight and Obesity in Women of Reproductive Age: An Integrative Review

Despite adverse pregnancy outcomes for women with overweight or obesity, preconception guidelines for achieving optimal wellness for women contemplating pregnancy regarding the risks of overweight or obesity are varied based upon national affiliation. The aim of this study was to synthesize the best evidence related to preconception counseling and care focused on overweight or obesity provided to women of reproductive age. An integrative review of original studies was conducted. PubMed, Cumulative Index in Nursing and Allied Health Literature, Ovid, Scopus, Web of Science, and Embase were included. Full-text, data-based articles were searched from 2009 to 2018, with reviews and synthesis completed in 2019 and 2020. Of 8703 initial articles, 31 articles remained in the review. Quality assessment and level of evidence were evaluated based upon criteria from the Joanna Briggs Institute and the Johns Hopkins Nursing Evidence-Based Practice Quality Guide. The level of evidence for the majority of studies was non-experimental but they were of good quality with appropriate methods, samples and relevant results. Limited attention and interest in preconception counseling regarding risks of overweight or obesity by health care professionals were noted, which may contribute to women’s unawareness of these risks on preconception health.

Physical activity for blood glucose control in gestational diabetes mellitus: rationale and recommendations for translational behavioral interventions

Gestational Diabetes Mellitus (GDM) is associated with adverse health outcomes during pregnancy and beyond. Previous randomized controlled trials of exercise interventions have demonstrated that exercise, conducted primarily during supervised sessions, improves maternal glycemic control in women with GDM. However, additional research is needed to develop physical activity interventions that are easily implemented in healthcare settings (e.g., recommendations and strategies to increase non-supervised physical activity). This narrative review presents: current physical activity recommendations for pregnancy and women with GDM; the scientific literature to date on physical activity, particularly walking, and blood glucose control in GDM; rationale for physical activity interventions targeting women with GDM that are appropriate for translation to the clinical setting (e.g., lifestyle interventions that include behavioral counseling with a health coach); and the strategies employed by previous, successful lifestyle interventions for pregnant and postpartum women that were based in clinical settings.Most previous exercise interventions for blood glucose control in women with GDM have included supervised exercise sessions, and will thus be difficult to translate to the health care system. However, lifestyle interventions for weight maintenance (i.e., healthy diet and physical activity) set in the health care system and delivered by health coaches have been successfully implemented in pregnant and postpartum populations. Therefore, we suggest that future trials examine lifestyle interventions that promote unsupervised walking with evidence-based behavioral strategies (e.g., goal setting, monitoring, and feedback) and consider incorporating the use of physical activity tracking devices to support these strategies.

Improvement in A1c Levels in Early Adulthood in the T1D Exchange: Impact of Racial, Socioeconomic, and Clinical Factors

CONTEXT

Glycemic control in adolescents with type 1 diabetes is poor; yet, it typically improves during early adulthood. Factors related to improvement of glycemic control are unclear.

OBJECTIVE

This work examines how demographic and clinical variables may affect trajectories of glycemic control over time.

METHODS

This retrospective, observational study comprised 1775 participants ages 18 to 30 years at enrollment in the T1D Exchange clinic registry. Latent class trajectory modeling was used to determine subgroups following a similar glycated hemoglobin A1c (HbA1c) trajectory over time.

RESULTS

Five distinct trajectories of HbA1c classes were identified: "low-decline" and "moderate-decline" groups had low or moderate HbA1c with a gradual decline, the "high-stable" group had high HbA1c and remained stable, and the "very high-rapid decline" and "very high-slow decline" groups had very high HbA1c with rapid or gradual decline. Compared with the "high-stable" group, the "low-decline" and "moderate-decline" groups were more likely to be male (P = .009), White non-Hispanic (P = .02), nonsmokers (P < .001), check self-monitoring blood glucose (SMBG) more frequently (P < .001), and have higher education (P < .001), lower body mass index (P = .02), and lower daily insulin dose (P < .001). Compared with the "very high-rapid decline" and "very high-slow decline" groups, the "low-decline" and "moderate-decline" groups were more likely to be male (P = .02), have higher education (P < .001), use insulin pumps (P = .01), be nonsmokers (P < .001), and have a higher number of SMBG checks per day at enrollment (P < .001).

CONCLUSION

We determined 5 distinct patterns of glycemic control from early adulthood into adulthood. Further evaluation into the modifiable factors associated with a declining HbA1c trajectory would aid in the development of targeted interventions.

Metformin for Preventing Type 2 Diabetes Mellitus in Women with a Previous Diagnosis of Gestational Diabetes: A Narrative Review

Women with a history of gestational diabetes mellitus (GDM) are at greater risk of developing type 2 diabetes mellitus (T2DM) when compared with women who have not had GDM. To delay or prevent T2DM, guidelines recommend regular screening in the primary care setting and lifestyle interventions that are largely focused on dietary and physical activity modifications. As the postpartum period can be challenging for women, uptake and engagement in screening and lifestyle interventions have been poor. Poor uptake and engagement places women with a history of GDM at heightened risk for future morbidity and development of T2DM. Metformin has been a longstanding and safe treatment for the control of blood glucose in people with T2DM. Research has supported the efficacy of metformin, used as an adjunct to a lifestyle intervention or as a stand-alone treatment, in preventing T2DM in people at high risk of T2DM. Findings from longitudinal studies have demonstrated the potential for metformin to reduce conversion to T2DM when used by women with a previous diagnosis of GDM. This review examines the potential effectiveness of metformin to reduce the incidence of T2DM among women with a previous diagnosis of GDM in the "real-world" setting.

Women with type 1 diabetes and women with type 2 diabetes differ in knowledge and beliefs about contraception and pregnancy

AIMS

To assess differences in knowledge and beliefs about pregnancy in women with diabetes.

METHODS

Questions were from the Australian 'Contraception, Pregnancy & Women's Health' survey. Women (18-50 years) were eligible if pregnant or planning pregnancy. Knowledge and beliefs items were adapted from the Reproductive Health and Behaviours Questionnaire.

RESULTS

Compared to women with type 2 diabetes (n = 103), women with type 1 diabetes (n = 526) had higher scores for knowledge about pregnancy in diabetes (type 1 diabetes 9.8 ± 2.4 vs. type 2 diabetes 7.7 ± 3.1), beliefs about benefits (type 1 diabetes 18.4 ± 2.2 vs. type 2 diabetes 17.2 ± 3.3), cues-to-action (type 1 diabetes 2.7 ± 1.4 vs. type 2 diabetes 1.5 ± 1.3) and self-efficacy (type 1 diabetes 22.6 ± 5.5 vs. type 2 diabetes 20.2 ± 6.1 (all p < 0.001) regarding preparing for pregnancy. Major knowledge gaps were the need for higher dose folate compared to women without diabetes and uncertainty about breastfeeding recommendations. Women with type 1 diabetes believed more strongly in the benefits of 'close to target' glucose levels prior to pregnancy and using contraception to prevent unplanned pregnancy; they also felt more confident to access pre-pregnancy care and to wait for optimal glycaemia before pregnancy. Women with type 2 diabetes were less aware of contraceptive choices, and risks associated with hyperglycaemia before or early in pregnancy.

CONCLUSIONS

The findings highlighted main gaps in knowledge and beliefs about planning for pregnancy. Especially in type 2 diabetes, there is a need for evidence-based messaging and strategies addressing these gaps, to raise understanding to prepare for future pregnancies.

Efficacy and safety of the pregnancy-IVI, an intravenous insulin protocol for pregnancy, following antenatal betamethasone in type 1 and type 2 diabetes

AIMS

Hyperglycaemia following antenatal corticosteroids is common in women with diabetes in pregnancy, and validated algorithms to maintain pregnancy-specific glucose targets are lacking. The Pregnancy-IVI, an intravenous-insulin (IVI) algorithm, has been validated in gestational diabetes; however, its performance in pre-existing diabetes (Type 1 and Type 2 diabetes) is not known. We hypothesised that Pregnancy-IVI would be superior to a generic Adult-IVI protocol (prior standard of care) following betamethasone in women with pre-existing diabetes.

METHODS

A retrospective cohort study enrolled all women with pre-existing diabetes at a tertiary centre receiving betamethasone and treated with IVI according to one of two protocols: Adult-IVI (n = 73, 2014-2017) or Pregnancy-IVI (n = 62, 2017-2020). The primary outcome was on-IVI glycaemic time-in-range (capillary blood glucose (BGL) 3.8-7.0 mmol/L). Secondary outcomes included time with critical hyperglycaemia (BGL > 10 mmol/L); occurrence of maternal hypoglycaemia (BGL < 3.8 mmol/l) and incidence of neonatal hypoglycaemia (BGL ≤ 2.5 mmol/L). Analysis was stratified by diabetes type.

RESULTS

Overall, Pregnancy-IVI achieved a higher proportion of on-IVI time-in-range (70%, IQR 56-78%) compared to Adult-IVI (52%, IQR 41-69%, p < 0.0001). The duration of critical hyperglycaemia with Pregnancy-IVI was also reduced (2% [IQR 0-7] vs 8% [IQR 4-17], p < 0.0001), without an increase in hypoglycaemia. Glycaemic variability was significantly reduced with Pregnancy-IVI. No difference in the rate of neonatal hypoglycaemia was observed. The Pregnancy-IVI was most effective in women with Type 1 diabetes.

CONCLUSION

The Pregnancy-IVI algorithm is safe and effective when used following betamethasone in type 1 diabetes in pregnancy. Further study of women with type 2 diabetes is required.

Impact of dietary counseling on the perception of diet in patients with gestational diabetes mellitus

AIMS/INTRODUCTION

Medical nutrition therapy is the cornerstone of gestational diabetes mellitus (GDM) treatment. Patients with GDM should receive dietary counseling regarding diet and exercise.

MATERIALS AND METHODS

To study patients' perception level of diet and their level of understanding after dietary counseling, we analyzed 225 reports of dietary counseling of patients with GDM prepared by dieticians. We also assessed the patients' level of understanding after dietary counseling by asking questions regarding the counseling content. The answers to the questions were aggregated, and substantially similar answers were grouped and categorized.

RESULTS

The dieticians' suggestions were well understood by the patients. Moreover, the patients also identified their previous incorrect eating habits, such as excessive carbohydrate restriction or inappropriate fruit intake. Although distributed frequent meals were recommended by the dieticians, few patients actually practiced this for various reasons. Some patients were apparently influenced by dietary information from the mass media.

CONCLUSION

Dietary counseling was regarded as helpful and acceptable to most patients with GDM in our hospital, and many suggestions were recognized as informative for modification of previous dietary habits. By providing the results of the questionnaire survey to the dieticians, they can improve the quality of their counseling, which is expected to result in better individual care of the patients.

Risk factors associated with postpartum impaired glucose regulation in women with previous gestational diabetes

AIMS

For women with previous gestational diabetes (GDM), international guidelines recommend 75 g oral glucose tolerance test (OGTT) at 4-12 weeks after delivery to assess glucose tolerance, considering their increased risk of type 2 diabetes. We evaluated prevalence of postpartum impaired glucose regulation (IGR) and identified associated risk factors.

METHODS

We retrospectively collected data from 749 women with previous GDM (IADPSG criteria) who underwent postpartum OGTT for type 2 diabetes screening between 2011 and 2019. IGR was identified according to ADA criteria.

RESULTS

Prevalence of IGR was 12.7%, lower in women with pre-pregnancy normal weight, higher in women with family history of type 2 diabetes and in those treated with insulin during pregnancy. Prevalence of IGR raised with increasing number of altered glucose values at OGTT performed during pregnancy for GDM screening. HbA1c and triglycerides measured during the third trimester of pregnancy were higher in women with postpartum IGR. At postpartum screening, women with IGR had higher BMI, waist, blood pressure. At multivariate logistic regression analysis, family history of diabetes (OR 2.21; 95% CI: 1.33-3.69; p < 0.01) and presence of all three glucose values exceeding threshold at OGTT during pregnancy (OR 2.89; 95% CI: 1.42-5.86; p < 0.01) were independently associated with IGR.

CONCLUSIONS

In women with GDM, persistence of IGR in the immediate postpartum period is associated with family history of diabetes and the presence of all three glucose values exceeding diagnostic threshold for GDM at OGTT in pregnancy, suggesting that these women should undergo specific diabetes monitoring and prevention programs.