Screening for gestational diabetes mellitus based on different risk profiles and settings for improving maternal and infant health

To neutrally offer or strongly recommend? General practitioners' perspectives on screening for gestational diabetes according to the national guideline in Norway

OBJECTIVE

To explore general practitioners' experiences and reflections on how the current Norwegian guideline for screening for gestational diabetes affects their clinical practice.

DESIGN

A qualitive study in which data were collected through semi-structured focus group interviews and analyzed thematically.

SETTING AND SUBJECTS

Five focus groups conducted in 2020 among GPs in Norway; three interviews took place face-to-face and two were held digitally. The total number of participants was 31.

RESULTS

GPs acknowledged the potential benefits of more extensive screening, but had concerns about the medicalization of pregnancy, stating that some women experienced considerable anxiety. The GPs expressed doubts about the guideline's evidence base but differed in how they interpreted what the guideline was asking them to do. Some offered eligible women the opportunity to be screened, while other set up a screening appointment without consulting the women first. For some, fear of incrimination made them recommend screening without being convinced that it was the right thing for the patient.

CONCLUSIONS

It is unclear whether the guideline for gestational diabetes requires GPs to recommend screening to pregnant women or if they should provide neutral information about the availability of screening. This ambiguity should be addressed, and the guideline evaluated against the core principles of general practice.

Exploring Structural Uncertainty in Cost-Effectiveness Modeling of Gestational Diabetes Screening: An Application Example from Norway

BACKGROUND

Screening pregnant women for gestational diabetes mellitus (GDM) has recently been expanded in Norway, although screening eligibility criteria continue to be debated. We aimed to compare the cost-effectiveness of alternative GDM screening strategies and explored structural uncertainty and the value of future research in determining the most cost-effective eligibility criteria for GDM screening in Norway.

DESIGN

We developed a probabilistic decision tree to estimate the total costs and health benefits (i.e., quality-adjusted life-years; QALYs) associated with 4 GDM screening strategies (universal, current guidelines, high-risk, and no screening). We identified the most cost-effective strategy as the strategy with the highest incremental cost-effectiveness ratio below a Norwegian benchmark for cost-effectiveness ($28,400/QALY). We excluded inconclusive evidence on the effects of screening on later maternal type 2 diabetes mellitus (T2DM) in the primary analysis but included this outcome in a secondary analysis using 2 different sources of evidence (i.e., Cochrane or US Preventive Services Task Force). To quantify decision uncertainty, we conducted scenario analysis and value-of-information analyses.

RESULTS

Current screening recommendations were considered inefficient in all analyses, while universal screening was most cost-effective in our primary analysis ($26,014/QALY gained) and remained most cost-effective when we assumed a preventive effect of GDM treatment on T2DM. When we assumed no preventive effect, high-risk screening was preferred ($19,115/QALY gained). When we assumed GDM screening does not prevent perinatal death in scenario analysis, all strategies except no screening exceeded the cost-effectiveness benchmark. In most analyses, decision uncertainty was high.

CONCLUSIONS

The most cost-effective screening strategy, ranging from no screening to universal screening, depended on the source and inclusion of GDM treatment effects on perinatal death and T2DM. Further research on these long-term outcomes could reduce decision uncertainty.

HIGHLIGHTS

This article analyses the cost-effectiveness of 4 alternative gestational diabetes mellitus (GDM) screening strategies in Norway: universal screening, current (broad) screening, high-risk screening, and no screening.The current Norwegian screening recommendations were considered inefficient under all analyses.The most cost-effective screening strategy ranged from no screening to universal screening depending on the source and inclusion of GDM treatment effects on later maternal diabetes and perinatal death.The parameters related to later maternal diabetes and perinatal death accounted for most of the decision uncertainty.

Relationships Between Exposure to Gestational Diabetes Treatment and Neonatal Anthropometry: Evidence from the Born in Bradford (BiB) Cohort

OBJECTIVES

To examine the relationships between gestational diabetes mellitus (GDM) treatment and neonatal anthropometry.

METHODS

Covariate-adjusted multivariable linear regression analyses were used in 9907 offspring of the Born in Bradford cohort. GDM treatment type (lifestyle changes advice only, lifestyle changes and insulin or lifestyle changes and metformin) was the exposure, offspring born to mothers without GDM the control, and birth weight, head, mid-arm and abdominal circumference, and subscapular and triceps skinfold thickness the outcomes.

RESULTS

Lower birth weight in offspring exposed to insulin (- 117.2 g (95% CI - 173.8, - 60.7)) and metformin (- 200.3 g (- 328.5, - 72.1)) compared to offspring not exposed to GDM was partly attributed to lower gestational age at birth and greater proportion of Pakistani mothers in the treatment groups. Higher subscapular skinfolds in offspring exposed to treatment compared to those not exposed to GDM was partly attributed to higher maternal glucose concentrations at diagnosis. In fully adjusted analyses, offspring exposed to GDM treatment had lower weight, smaller abdominal circumference and skinfolds at birth than those not exposed to GDM. Metformin exposure was associated with smaller offspring mid-arm circumference (- 0.3 cm (- 0.6, - 0.07)) than insulin exposure in fully adjusted models with no other differences found.

CONCLUSIONS FOR PRACTICE

Offspring exposed to GDM treatment were lighter and smaller at birth than those not exposed to GDM. Metformin-exposed offspring had largely comparable birth anthropometric characteristics to those exposed to insulin.

Promoting breastfeeding in women with gestational diabetes mellitus in high-income settings: an integrative review

BACKGROUND

Breastfeeding provides many short- and long-term health benefits for mothers and their infants and is a particularly relevant strategy for women who experience Gestational Diabetes Mellitus (GDM) during pregnancy. However, breastfeeding rates are generally lower amongst this group of women than the general population. This review's objective is to identify the factors that influence breastfeeding by exploring the experiences and outcomes of women in in high-income health care contexts when there is a history of GDM in the corresponding pregnancy.

METHODS

A comprehensive search strategy explored the electronic databases Medline, CINAHL, Web of Science and Scopus for primary studies exploring breastfeeding practices for papers published between January 2011 and June 2023. All papers were screened independently by two researchers with included papers assessed using the Crowe Critical Appraisal tool. Findings were analysed using a narrative synthesis framework.

RESULTS

From an initial search result of 1037 papers, 16 papers representing five high-income nations were included in this review for analysis - the United States of America (n = 10), Australia (n = 3), Finland (n = 1), Norway (n = 1), and Israel (n = 1). Fifteen papers used a quantitative design, and one used a qualitative design. The total number of participants represented in the papers is 963,718 of which 812,052 had GDM and 151,666 did not. Women with an immediate history of GDM were as likely to initiate breastfeeding as those without it. However, they were more likely to have the first feed delayed, be offered supplementation, experience delayed lactogenesis II and or a perception of low supply. Women were less likely to exclusively breastfeed and more likely to completely wean earlier than the general population. Maternity care practices, maternal factors, family influences, and determinants of health were contextual and acted as either a facilitator or barrier for this group.

CONCLUSION

Breastfeeding education and support need to be tailored to recognise the individual needs and challenges of women with a history of GDM. Interventions, including the introduction of commercial milk formula (CMF) may have an even greater impact and needs to be very carefully considered. Supportive strategies should encompass the immediate and extended family who are major sources of influence.

Postpartum lifestyle behaviour among women with prior gestational diabetes mellitus: evidence from the HUNT study

Introduction

Women with a history of gestational diabetes mellitus (GDM) are at increased risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Recommendations for postpartum follow-up include targeted lifestyle advice to lower the risk.The aim of this study was to compare postpartum lifestyle behaviours and perceptions among women with and without a history of GDM. In addition, we examined whether lifestyle behaviours of women with a history of GDM participating in a lifestyle intervention study differed from lifestyle behaviours of women with a history of GDM in the general population.

Research design and methods

We linked data from the fourth survey of the population-based Trøndelag Health Study (HUNT4) to information from the Medical Birth Registry of Norway for women with registered births between 2000 and 2019. Using logistic regression, we compared lifestyle behaviours in women with and without GDM. In secondary analyses, lifestyle behaviours in women with GDM participating in a postpartum lifestyle intervention study were compared with HUNT participants with GDM using Fisher's exact tests/t-tests.

Results

A high proportion of the women in our population, regardless of GDM history, reported several unhealthy lifestyle behaviours. We found no significant association between history of GDM and lifestyle behaviours. The lifestyle intervention study for women with a history of GDM appeared to recruit women with more favourable lifestyle behaviours.

Conclusions

Women, regardless of GDM history, could potentially benefit from further support for lifestyle improvement, but it may be especially important in women with a history of GDM given their increased risk of T2DM and CVD. Interventions targeting women with GDM might not reach the women with the unhealthiest lifestyle behaviours, and measures to reach out to all women should be further investigated.

The Role of Diet during Pregnancy in Protecting against Gestational Diabetes Mellitus in a Population with Mediterranean Dietary Habits: A Cross-Sectional Study

Gestational diabetes mellitus (GDM) is a common metabolic disorder among pregnant women. Dietary habits during pregnancy might alter the risk of GDM development, and populations following the Mediterranean diet are relatively understudied. This was a cross-sectional, observational study of 193 low-risk women admitted to a private maternity hospital in Greece to give birth. Food frequency data on specific food categories, selected based on previous research, were analyzed. Logistic regression models, both crude and adjusted for maternal age, body mass index before pregnancy, and gestational weight gain, were fitted. We observed no association of carbohydrate-rich meals, sweets, soft drinks, coffee, rice, pasta, bread and crackers, potatoes, lentils, and juices with GDM diagnosis. Cereals (crude p = 0.045, adjusted p = 0.095) and fruits and vegetables (crude p = 0.07, adjusted p = 0.04) appeared to have a protective effect against GDM, while frequent tea consumption was linked to higher risk of GDM development (crude p = 0.067, adjusted p = 0.035). These results strengthen previously identified associations and underline the importance and potential impact of changing dietary habits even during pregnancy in adjusting one's risk of metabolic pregnancy complications, such as GDM. The importance of healthy dietary habits is highlighted, with the goal of raising awareness amongst obstetric care specialists regarding the provision of systematic nutrition recommendations to pregnant women.

ANTENATAL FACTORS AFFECTING THE DECISION TO HAVE AN ORAL GLUCOSE TOLERANCE TEST

Aim We aimed to investigate the factors that may affect the pregnant’s decision to have an oral glucose tolerance test (OGTT) between 24-28 gestational weeks. Material and Methods This descriptive and cross-sectional study was conducted prospectively with 307 pregnant women. Demographic characteristics of the pregnant women, pregnancy follow-up findings, antenatal tests, and their decision for having an OGTT were questioned and recorded. All the factors were analyzed that may have a possible effect on the OGTT decision. Results Fifty-three percent of the participants had OGTT during pregnancy. The rate of positive OGTT was found to be 8.5%. Body mass index, gravida, history of abortion, miscarriage risk, weight gain during pregnancy, the rate of using antenatal folic acid and iron supplementation were similar between the groups that had and did not have OGTT (p >0.05). In the univariate model, age, parity, planned pregnancy, regular follow-up, educational status and physical activity were found to have a significant effect on predicting patients who will have OGTT (p <0.05). Also, antenatal screening tests and level 2 obstetrics ultrasonography were shown to have a significant independent effect in predicting patients who will have OGTT (p <0.05). Conclusion By evaluating the factors that may affect the decision of pregnant about OGTT during pregnancy follow-up, we can predict the patients who tend not to have GDM screening and we can increase the screening rate by giving these pregnant women more detailed information. Thus, we have a chance to diagnose and treat more GDM and reduce related mortality and morbidity.

Prevalence of gestational diabetes in Eastern Democratic Republic of Congo

OBJECTIVE

To determine the prevalence of gestational diabetes and associated risk factors in the eastern region of the Democratic Republic of Congo (DRC).

METHODS

A cross-sectional study was conducted in Goma city, Idjwi, Ngungu and Rutshuru districts between April 2019 and February 2021. Pregnant women between 24-28 weeks of amenorrhea who consented to participate in the study were included. Blood sugar, anthropometric parameters and obstetrical and family history were studied. Gestational diabetes was defined as blood glucose level between 92 and 125 mg/dL.

RESULTS

The overall prevalence was 21.2% (n = 391) and was higher in Rutshuru [27.2% (n = 92)] and Goma [26.9% (n = 134)] compared to Ngungu [10.0% (n = 110)] (p = 0.005). An increased risk was associated with a history of a newborn weighing ≥ 4000 g [OR 2.4 95% CI (1.3 - 4.4)] or family diabetes [OR 2.9 95% CI (2.0 - 4.9)]. Median age in the pathological group was not different from that with normal blood glucose [25.0 (16.0 - 44.0) Vs 26.0 (16.0 - 44.0)] (p = 0.67). The prevalence tended to increase for pregnant women with a mid-upper arm circumference ≥ 280 mm [28.1% (n = 57)] Vs [19.3% (n = 322)] if < 280 mm, [OR (95% CI)] [1.5 (0.9-2.3)] (p = 0.13).

CONCLUSION

Gestational diabetes was found in one out of five pregnant women regardless their age. A history of macrosomia birth and diabetes in the family were the main risk factors.

Exercise-Diet Therapy Combined with Insulin Aspart Injection for the Treatment of Gestational Diabetes Mellitus: A Study on Clinical Effect and Its Impact

Objective

To explore the clinical effect and impact of exercise-diet therapy combined with Insulin Aspart Injection on gestational diabetes mellitus (GDM).

Methods

The objects of study were patients with pregestational diabetes mellitus (PGDM) and 62 patients with GDM who were diagnosed by oral glucose tolerance test (OGTT) and insulin release test from February 2017 to February 2019. According to the severity of the disease, enrolled patients were informed to have appropriate exercise and diet control or Insulin Aspart Injection on this basis until the completion of delivery. By using 50 pregnant women with normal glucose as the control, the fasting plasma glucose (FPG), 1-hour postprandial glucose (1hPG), 2-hour postprandial glucose (2hPG), nocturnal glucose, and glycosylated hemoglobin (HbA1c) levels were compared between the PGDM group and the GDM group before and after treatment; besides, further comparison was made in terms of glucose compliance rate, islet B-cell secretory function, and insulin resistance after treatment. The pregnant women were examined by B-ultrasound at 24 and 26 weeks of gestation to check if the fetus had abnormalities in the central nervous system and the heart. Further B-ultrasound examination was performed at 32 and 37 weeks of gestation to check the problems such as polyhydramnios and stillbirth. In addition, a comparative analysis was carried out in terms of the adverse pregnancy outcomes and complications, associated with the comparison of the results after treatment with control group.

Results

After treatment, the levels of FPG, 1hPG, 2hPG, nocturnal glucose, and HbA1c were decreased in the PGDM group and GDM group than those before treatment, especially in the GDM group, with significant difference still when compared with the control group (P < 0.05). Statistical analysis revealed that the blood glucose compliance rate in the GDM group was higher than that in the PGDM group, showing a better therapeutic effect. Fasting insulin (FINS) and homeostasis model assessment index for insulin resistance (HOMA-IR) in the GDM group were significantly higher than those in control group, but lower than those in the PGDM group (P < 0.01), while the level of HOMA-β was lower in the GDM group than that in the control group and higher than that in PGDM (P < 0.01). Further ultrasound examination revealed the presence of fetal cardiac abnormality, polyhydramnios, stillbirth, and problems, showing a higher incidence in the PGDM group but almost nonexistence in the control group. In addition, the incidence of hypertension, macrosomia, premature rupture of membranes, postpartum hemorrhage, and infection were obviously higher in the PGDM group than those in the GDM group and control group (P < 0.05).

Conclusion

Exercise-diet therapy combined with Insulin Aspart Injection can effectively control the blood glucose level of pregnant patients with GDM, improve the pregnancy outcome to a certain extent, and ensure the health of pregnant women and fetus, which is worthy of clinical application.

Recurrent gestational diabetes : Breaking the transgenerational cycle with lifestyle modification

PURPOSE

This literature review is aimed at examining the benefits of lifestyle modifications in preventing recurrent gestational diabetes (GDM). Worldwide GDM affects approximately 16.2% of all pregnancies with significant maternal, fetal and neonatal complications. Almost two thirds of pregnant women with GDM will develop type 2 diabetes mellitus (T2DM) in the years following pregnancy. The proportion of women affected by GDM is on the rise and reflects increasing trends in T2DM as well as adult and childhood obesity.

METHODS

Using predefined subject headings, we searched for relevant articles from the PubMed, Scopus, and Cochrane databases.

RESULTS

For high-risk women lifestyle modifications, such as dietary and exercise changes, are the mainstay of treatment to reduce negative outcomes for both women and their pregnancies. This includes reducing the incidence of recurrent GDM and future T2DM by intervening during pregnancy and in the postnatal period.

CONCLUSION

This review provides an overview of the literature to date, discusses different targeted approaches and how these interventions can optimise their benefits, and where further research is required.

Risk factor-based screening compared to universal screening for gestational diabetes mellitus in marginalized Burman and Karen populations on the Thailand-Myanmar border: An observational cohort

Background: Gestational diabetes mellitus (GDM) contributes to maternal and neonatal morbidity. As data from marginalized populations remains scarce, this study compares risk-factor-based to universal GDM screening in a low resource setting. Methods: This is a secondary analysis of data from a prospective preterm birth cohort. Pregnant women were enrolled in the first trimester and completed a 75g oral glucose tolerance test (OGTT) at 24-32 weeks' gestation. To define GDM cases, Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO trial) criteria were used. All GDM positive cases were treated. Sensitivity and specificity of risk-factor-based selection for screening (criteria: age ≥30y, obesity (Body mass index (BMI) ≥27.5kg/m ²), previous GDM, 1 ^st degree relative with diabetes, previous macrosomia (≥4kg), previous stillbirth, or symphysis-fundal height ≥90th percentile) was compared to universal screening using the OGTT as the gold standard. Adverse maternal and neonatal outcomes were compared by GDM status. Results: GDM prevalence was 13.4% (50/374) (95% CI: 10.3-17.2). Three quarters of women had at least one risk factor (n=271 women), with 37/50 OGTT positive cases correctly identified: sensitivity 74.0% (59.7-85.4) and specificity 27.8% (3.0-33.0). Burman women (self-identified) accounted for 29.1% of the cohort population, but 38.0% of GDM cases. Percentiles for birthweight (p=0.004), head circumference (p=0.002), and weight-length ratio (p=0.030) were higher in newborns of GDM positive compared with non-GDM mothers. 21.7% (75/346) of newborns in the cohort were small-for-gestational age (≤10 ^th percentile). In Burman women, overweight/obese BMI was associated with a significantly increased adjusted odds ratio 5.03 (95% CI: 1.43-17.64) for GDM compared with normal weight, whereas in Karen women, the trend in association was similar but not significant (OR 2.36; 95% CI 0.95-5.89). Conclusions: Risk-factor-based screening missed one in four GDM positive women. Considering the benefits of early detection of GDM and the limited additional cost of universal screening, a two-step screening program was implemented.

Risk factor-based screening compared to universal screening for gestational diabetes mellitus in marginalized Burman and Karen populations on the Thailand-Myanmar border: An observational cohort

Background: Gestational diabetes mellitus (GDM) contributes significantly to maternal and neonatal morbidity, but data from marginalized populations remains scarce. This study aims to compare risk-factor-based screening to universal testing for GDM among migrants along the Thailand-Myanmar border. Methods: From the prospective cohort (September 2016, February 2019), 374 healthy pregnant women completed a 75g oral glucose tolerance test (OGTT) at 24-32 weeks gestation. Fasting, one hour and two hour cut-offs were based on Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO trial) criteria and cases were treated. The sensitivity and specificity of risk-factor-based screening criteria was calculated using OGTT as the gold standard. Risk factors included at least one positive finding among 10 criteria, e.g., obesity (body mass index (BMI) ≥27.5kg/m ²), 1 ^st degree relative with diabetes etc. Adverse maternal and neonatal outcomes were compared by GDM status, and risk factors for GDM were explored. Results: GDM prevalence was 13.4% (50/374) (95% CI: 10.3-17.2). Risk-factors alone correctly identified 74.0% (37/50) OGTT positive cases: sensitivity 74.0% (59.7-85.4) and specificity 27.8% (3.0-33.0). Burman women accounted for 29.1% of the cohort population, but 38.0% of GDM cases. Percentiles for birthweight (p=0.004), head circumference (p=0.005), and weight-length ratio (p=0.010) were higher in newborns of GDM mothers compared with non-GDM, yet 21.7% (75/346) of newborns in the cohort were small-for-gestational age. In Burman women, overweight/obese BMI was associated with a significantly increased adjusted odds ratio 5.03 (95% CI: 1.43-17.64) for GDM compared to normal weight, whereas underweight and overweight/obese in Karen women were both associated with similarly elevated adjusted odds, approximately 2.4-fold (non-significant) for GDM. GDM diagnosis by OGTT was highest prior to peak rainfall. Conclusions: Risk-factor-based screening was not sufficiently sensitive or specific to be useful to diagnose GDM in this setting among a cohort of low-risk pregnant women. A two-step universal screening program has thus been implemented.

Behaviors of Turkish pregnant women towards gestational diabetes screening

OBJECTIVES

Although gestational diabetes is the most common metabolic disease in pregnancy some pregnant women still refuse to undergo oral glucose tolerance test (OGTT). The purpose of this study was to evaluate the behavior of pregnant women undergoing OGTT, and to compare perinatal results between women who undergo and refuse OGTT.

METHODS

This retrospective cohort study was performed by evaluating the data of Izmir Katip Celebi University Gynecology and Obstetrics outpatient clinic between 2012-2017. Data of 2079 pregnant were evaluated retrospectively. Among 373 women who refused OGTT were evaluated as the study group, while remaining 1706 women who underwent OGTT were considered as the control group. The groups were compared with regard to perinatal results.

RESULTS

Sixty-two point four percent of the group who refused OGTT had a C-section, while 56.3% of the control group had a C-section (p<0.05). Intrauterine growth retardation, fetal distress, amniotic fluid pathologies, macrosomia, gestational hypertension and perinatal death were slightly higher in pregnant women who did not undergo OGTT compared to the control group, however, the difference was not statistically significant.

CONCLUSION

Maternal complications and poor pregnancy results were found slightly higher in pregnant women who refused OGTT. These results might be explained by assuring glycemic control in pregnant women who refused OGTT by a series of fasting and postprandial blood sugar measurements in our center.

Integrated bioinformatics analysis reveals novel key biomarkers and potential candidate small molecule drugs in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is the metabolic disorder that appears during pregnancy. The current investigation aimed to identify central differentially expressed genes (DEGs) in GDM. The transcription profiling by array data (E-MTAB-6418) was obtained from the ArrayExpress database. The DEGs between GDM samples and non-GDM samples were analyzed. Functional enrichment analysis were performed using ToppGene. Then we constructed the protein–protein interaction (PPI) network of DEGs by the Search Tool for the Retrieval of Interacting Genes database (STRING) and module analysis was performed. Subsequently, we constructed the miRNA–hub gene network and TF–hub gene regulatory network. The validation of hub genes was performed through receiver operating characteristic curve (ROC). Finally, the candidate small molecules as potential drugs to treat GDM were predicted by using molecular docking. Through transcription profiling by array data, a total of 869 DEGs were detected including 439 up-regulated and 430 down-regulated genes. Functional enrichment analysis showed these DEGs were mainly enriched in reproduction, cell adhesion, cell surface interactions at the vascular wall and extracellular matrix organization. Ten genes, HSP90AA1, EGFR, RPS13, RBX1, PAK1, FYN, ABL1, SMAD3, STAT3 and PRKCA were associated with GDM, according to ROC analysis. Finally, the most significant small molecules were predicted based on molecular docking. This investigation identified hub genes, signal pathways and therapeutic agents, which might help us, enhance our understanding of the mechanisms of GDM and find some novel therapeutic agents for GDM.

Adherence rates to a prediction tool identifying women with an increased gestational diabetes risk: An implementation study

OBJECTIVE

The best screening strategy for gestational diabetes mellitus (GDM) remains a topic of debate. Several organizations made a statement in favor of universal screening, but the volume of oral glucose tolerance tests (OGTT) required may burden healthcare systems. As a result, many countries still rely on selective screening using a checklist of risk factors, but reported diagnostic characteristics vary. Moreover, women's discomfort due to an OGTT is often neglected. Since 2017, obstetric healthcare professionals in a Dutch region assessed women's GDM risk with a prediction model and counseled those with an increased risk regarding an OGTT.

METHODS

From 2017 to 2018, 865 women were recruited in a multicenter prospective cohort.

RESULTS

In total, 385 women (48%) had an increased predicted GDM risk. Of all women, 78% reported that their healthcare professional discussed their GDM risk. Predicted GDM risks were positively correlated with conducting an OGTT.

CONCLUSION

Implementation of a GDM prediction model resulted in moderate rates of OGTTs performed in general, but high rates in high-risk women. As 25% of women experienced discomfort from the OGTT, a selective screening strategy based on a prediction model with a high detection rate may be an interesting alternative to universal screening.

STUDY COHORT REGISTRATION

Netherlands Trial Register: NTR4143; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4143.

Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews

BACKGROUND

Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections.

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women.

METHODS

We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence.

MAIN RESULTS

We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined.

AUTHORS' CONCLUSIONS

While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.

Gestational Diabetes Mellitus-Innovative Approach to Prediction, Diagnosis, Management, and Prevention of Future NCD-Mother and Offspring

Gestational diabetes mellitus (GDM) is the commonest medical complication of pregnancy. The association of GDM with immediate pregnancy complications including excess fetal growth and adiposity with subsequent risk of birth trauma and with hypertensive disorders of pregnancy is well recognized. However, the associations with wide ranges of longer-term health outcomes for mother and baby, including the lifetime risks of obesity, pre-diabetes, and diabetes and cardiovascular disease have received less attention and few health systems address these important issues in a systematic way. This article reviews historical and recent data regarding prediction of GDM using demographic, clinical, and biochemical parameters. We evaluate current and potential future diagnostic approaches designed to most effectively identify GDM and extend this analysis into a critical evaluation of lifestyle and nutritional/pharmacologic interventions designed to prevent the development of GDM. The general approach to management of GDM during pregnancy is then discussed and the major final focus of the article revolves around the importance of a GDM diagnosis as a future marker of the risk of non-communicable disease (NCD), in particular pre-diabetes, diabetes, and cardiovascular disease, both in mother and offspring.

First trimester secreted Frizzled-Related Protein 4 and other adipokine serum concentrations in women developing gestational diabetes mellitus

Background

The aim of this study was to evaluate whether soluble frizzled-related protein 4 (sFRP4) concentration in the first trimester of pregnancy is individually, or in combination with Leptin, Chemerin and/or Adiponectin, associated with the development of gestational diabetes (GDM).

Methods

In a nested case-control study, 50 women with GDM who spontaneously conceived and delivered a live-born infant were matched with a total of 100 uncomplicated singleton control pregnancies based on body mass index (± 2 kg/m²), gestational age at sampling (exact day) and maternal age (± 2 years). In serum samples, obtained between 70–90 days gestational age, sFRP4, Chemerin, Leptin and Adiponectin concentrations were determined by ELISA. Statistical comparisons were performed using univariate and multi-variate logistic regression analysis after logarithmic transformation of the concentrations. Discrimination of the models was assessed by the area under the curve (AUC).

Results

First trimester sFRP4 concentrations were significantly increased in GDM cases (2.04 vs 1.93 ng/ml; p<0.05), just as Chemerin (3.19 vs 3.15 ng/ml; p<0.05) and Leptin (1.44 vs 1.32 ng/ml; p<0.01). Adiponectin concentrations were significantly decreased (2.83 vs 2.94 ng/ml; p<0.01) in GDM cases. Further analysis only showed a weak, though significant, correlation of sFRP4 with Chemerin (R² = 0.124; p<0.001) and Leptin (R² = 0.145; p<0.001), and Chemerin with Leptin (R² = 0.282; p<0.001) in the control group. In a multivariate logistic regression model of these four markers, only Adiponectin showed to be significantly associated with GDM (odds ratio 0.12, 95%CI 0.02–0.68). The AUC of this model was 0.699 (95%CI 0.605–0.793).

Conclusion

In the first trimester of pregnancy, a multi-marker model with sFRP4, Leptin, Chemerin and Adiponectin is associated with the development of GDM. Therefore, this panel seems to be an interesting candidate to further evaluate for prediction of GDM in a prospective study.

What is known and what remains unresolved regarding gestational diabetes mellitus (GDM)

Gestational diabetes mellitus (GDM) has become a major public health issue and one of the most discussed topics in contemporary obstetrics. Due to rising prevalence of GDM worldwide impact and importance of this medical condition in good quality antenatal care is growing. GDM is associated with serious adverse perinatal outcomes and unfavorable long-term health consequences for both, mother and her child. Despite a great amount of knowledge accumulated regarding GDM, medical community remains indecisive and still debates the most appropriate diagnostic strategy, screening policy, and treatment options for pregnancies complicated with GDM. These unresolved issues generate controversies, motivate further research and contribute to the growing interest surrounding GDM. In this review we will discuss and try to explain some of them.

Diagnosing and providing initial management for patients with Gestational Diabetes: What is the General Practitioner's experience?

AIM

This study explores the General Practice (GP) experience of Gestational Diabetes Mellitus (GDM). Much has been written about patient perspectives, yet little is known about the GP perspective at initial diagnosis and management. GDM is increasingly managed in the secondary and tertiary sector, the confidence of GPs and their role in ongoing care has not been examined. Given GDM's poor follow up rates, all aspects of the patient journey warrant close examination.

METHODS

Through purposive and snowball sampling, we conducted semi-structured interviews with GPs in Brisbane, Australia between April and October 2018. Data collection, until saturation, and analysis were concurrent, and the Leximancer analysis tool assisted with content analysis and suggestion of themes.

RESULTS

Dominant themes include uncertainty/urgency and feeling under-utilised. GPs have a pragmatic approach in the face of uncertainty, and adopt one of several strategies to meet patient needs. A key issue that may impact on long term follow up and high quality GP-patient relationships is concern about the patient being 'taken away' by the hospital. Communication with the hospital is generally perceived as poor.

CONCLUSIONS

The experience of GPs in the initial diagnosis and management of GDM may assist in improving GDM follow up.

External validation and clinical utility of prognostic prediction models for gestational diabetes mellitus: A prospective cohort study

Introduction

We performed an independent validation study of all published first trimester prediction models, containing non‐invasive predictors, for the risk of gestational diabetes mellitus. Furthermore, the clinical potential of the best performing models was evaluated.

Material and methods

Systemically selected prediction models from the literature were validated in a Dutch prospective cohort using data from Expect Study I and PRIDE Study. The predictive performance of the models was evaluated by discrimination and calibration. Clinical utility was assessed using decision curve analysis. Screening performance measures were calculated at different risk thresholds for the best model and compared with current selective screening strategies.

Results

The validation cohort included 5260 women. Gestational diabetes mellitus was diagnosed in 127 women (2.4%). The discriminative performance of the 12 included models ranged from 68% to 75%. Nearly all models overestimated the risk. After recalibration, agreement between the observed outcomes and predicted probabilities improved for most models.

Conclusions

The best performing prediction models showed acceptable performance measures and may enable more personalized medicine‐based antenatal care for women at risk of developing gestational diabetes mellitus compared with current applied strategies.

Is there a connection between gestational diabetes mellitus, human immunodeficiency virus infection, and tuberculosis?

Pregnancy is associated with insulin resistance similar to that found in type 2 diabetes mellitus (DM). The prevalence of gestational diabetes mellitus (GDM) in key tuberculosis (TB) endemic countries, such as India and China, has been increasing rapidly in the last decade and may be higher in human immunodeficiency virus (HIV) infected women. Pregnancy is also an independent risk factor for developing active TB; however, little is known about the interaction of GDM, HIV and TB. We review the epidemiology and immunology of GDM, and significant research gaps in understanding the interactions between GDM, pregnancy, and TB in women living with and those without HIV.

Expression of mitofusin 2 in placentae of women with gestational diabetes mellitus

Gestational diabetes mellitus (GDM) represents a common carbohydrate metabolism disorder during pregnancy. The objective of this study was to evaluate the expression levels of mitofusin 2 (MFN2) expression in placentae of GDM patients compared to that in the placental tissues from normal uncomplicated pregnancies. A total of 70 subjects were enrolled from September 2014 to June 2016, including 42 patients with GDM (the GDM group) and 28 normal uncomplicated pregnancies (the control group). Immunohistochemical staining and qRT-PCR were used for the detection of the expression levels and distribution of MFN2 in the placentae of GDM patients and normal controls. Kolmogorov-Smirnov test was used for statistical analysis. P < 0.05 and P < 0.01 were used for assessing statistical significance. The baseline characteristics were comparable in both groups. The 1-h and 2-h postprandial glucose levels (PPG) were 7.94±1.26 versus 6.88±0.51 mmol/L and 7.01±1.34 versus 6.14±0.63 mmol/L, respectively,for the GDM group and the control group (P < 0.05). The relative expression levels of MFN2 mRNA were 0.982±1.242 for GDM and 1.257 ± 0.815 for control, respectively, with significant between group difference (P < 0.01). Immunohistochemical staining analysis showed that MFN2 was mostly distributed in the cytoplasm of syncytiotrophoblasts under optical microscopy. Additionally,about 50% of samples of the GDM group were within the intensity of moderate staining of MFN2 and more than 50% of patients in the control group were within the intensity of strong staining of MFN2. The expression levels of MFN2 in GDM placentae was significantly lower compared to that of placentae from normal uncomplicated pregnancies.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews

BACKGROUND

Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB.

OBJECTIVES

We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update.

METHODS

We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI.

MAIN RESULTS

We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB.

OUTCOME

preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions.

OUTCOME

perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources.

OUTCOMES

preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm.

AUTHORS' CONCLUSIONS

Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

Gestational Diabetes - Major New Clinically Relevant Aspects

The implementation of screening for gestational diabetes (GDM) in the German Prenatal Care guidelines of 2012 and the publication of numerous new studies have led to clinically relevant changes in the care of pregnant women with GDM to whom consideration was given in the new S3 Guideline on the Diagnosis, Management and Follow-up of Gestational Diabetes (AWMF 057/008) published in March this year. Certain aspects are addressed and discussed on the basis of additional background information.

Identification of urinary biomarkers for the prediction of gestational diabetes mellitus in early second trimester of young gravidae based on iTRAQ quantitative proteomics

Gestational Diabetes Mellitus (GDM) has brought great harm to maternal and fetus. Up to now, only a few plasma biomarkers for its early diagnosis have been reported; nevertheless, there is no report about identification of urinary biomarkers for prediction of GDM. Thus, it is necessary to correct this deficiency. In our study, urine samples were collected from 889 healthy young gravidae at the early second trimester (15 to 20 weeks), 69 of whom were subsequently diagnosed with GDM at 24 to 28 weeks. iTRAQ (the isobaric tags for relative and absolute quantification) quantitative proteomics was conducted on sixteen GDM (trial group) and an equal number of matched healthy young gravidae (control group). Validation was performed in 40 cases of each group by ELISA. A total of 1,901 proteins were identified in this study, including 119 significantly differential proteins (fold change ≧1.2 or ≦0.83 and p < 0.05). Compared with control group, 83 differential proteins were increased and 36 proteins were decreased in GDM group. The validation for expression of CD59 and IL1RA showed significant difference and the area under the receiver operating characteristic curve was 0.729 and 0.899, respectively (p < 0.05). The two candidate protein biomarkers (CD59 and IL1RA) in urine could be an early, noninvasive diagnostic predictors of young pravidae with GDM, and IL1RA is stronger diagnostic power than CD59.

Treatments for gestational diabetes

BACKGROUND

Gestational diabetes (GDM) affects 3% to 6% of all pregnancies. Women are often intensively managed with increased obstetric monitoring, dietary regulation, and insulin. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of GDM improves perinatal outcome.

OBJECTIVES

To compare the effect of alternative treatment policies for GDM on both maternal and infant outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials comparing alternative management strategies for women with GDM and impaired glucose tolerance in pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors and a member of the Cochrane Pregnancy and Childbirth Group's editorial team extracted and checked data independently. Disagreements were resolved through discussion with the third author.

MAIN RESULTS

Eight randomised controlled trials (1418 women) were included.Caesarean section rate was not significantly different when comparing any specific treatment with routine antenatal care (ANC) including data from five trials with 1255 participants (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.80 to 1.12). However, when comparing oral hypoglycaemics with insulin as treatment for GDM, there was a significant reduction (RR 0.46, 95% CI 0.27 to 0.77, two trials, 90 participants). There was a reduction in the risk of pre-eclampsia with intensive treatment (including dietary advice and insulin) compared to routine ANC (RR 0.65, 95% CI 0.48 to 0.88, one trial, 1000 participants). More women had their labours induced when given specific treatment compared to routine ANC (RR 1.33, 95% CI 1.13 to 1.57, two trials, 1068 participants). The composite outcome of perinatal morbidity (death, shoulder dystocia, bone fracture and nerve palsy) was significantly reduced for those receiving intensive treatment for mild GDM compared to routine ANC (RR 0.32, 95% CI 0.14 to 0.73, one trial, 1030 infants).There was a reduction in the proportion of infants weighing more than 4000 grams (RR 0.46, 95% CI 0.34 to 0.63, one trial, 1030 infants) and the proportion of infants weighing greater than the 90th birth centile (RR 0.55, 95% CI 0.30 to 0.99, three trials, 223 infants) of mothers receiving specific treatment for GDM compared to routine ANC. However, there was no statistically significant difference in this proportion between infants of mothers receiving oral drugs compared to insulin as treatment for GDM.

AUTHORS' CONCLUSIONS

Specific treatment including dietary advice and insulin for mild GDM reduces the risk of maternal and perinatal morbidity. However, it is associated with higher risk of labour induction. More research is needed to assess the impact of different types of intensive treatment, including oral drugs and insulin, on individual short- and long-term infant outcomes.