Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States

The impact of CREBRF rs373863828 Pacific-variant on infant body composition

In Māori and Pacific adults, the CREBRF rs373863828 minor (A) allele is associated with increased body mass index (BMI) but reduced incidence of type-2 and gestational diabetes mellitus. In this prospective cohort study of Māori and Pacific infants, nested within a nutritional intervention trial for pregnant women with obesity and without pregestational diabetes, we investigated whether the rs373863828 A allele is associated with differences in growth and body composition from birth to 12-18 months' corrected age. Infants with and without the variant allele were compared using generalised linear models adjusted for potential confounding by gestation length, sex, ethnicity and parity, and in a secondary analysis, additionally adjusted for gestational diabetes. Carriage of the rs373863828 A allele was not associated with altered growth and body composition from birth to 6 months. At 12-18 months, infants with the rs373863828 A allele had lower whole-body fat mass [FM 1.4 (0.7) vs. 1.7 (0.7) kg, aMD -0.4, 95% CI -0.7, 0.0, P = 0.05; FM index 2.2 (1.1) vs. 2.6 (1.0) kg/m2 aMD -0.6, 95% CI -1.2,0.0, P = 0.04]. However, this association was not significant after adjustment for gestational diabetes, suggesting that it may be mediated, at least in part, by the beneficial effect of CREBRF rs373863828 A allele on maternal glycemic status.

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used, and overall rates are increasing globally. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (26 September 2022), and reference lists of the retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs. Trials were eligible for inclusion if women were diagnosed with GDM during pregnancy and the trial compared tighter and less-tight glycaemic targets during management. We defined tighter glycaemic targets as lower numerical glycaemic concentrations, and less-tight glycaemic targets as higher numerical glycaemic concentrations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for carrying out data collection, assessing risk of bias, and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated risk of bias, and extracted data for the four included studies. We assessed the certainty of evidence for selected outcomes using the GRADE approach. Primary maternal outcomes included hypertensive disorders of pregnancy and subsequent development of type 2 diabetes. Primary infant outcomes included perinatal mortality, large-for-gestational-age, composite of mortality or serious morbidity, and neurosensory disability.

MAIN RESULTS

This was an update of a previous review completed in 2016. We included four RCTs (reporting on 1731 women) that compared a tighter glycaemic control with less-tight glycaemic control in women diagnosed with GDM. Three studies were parallel RCTs, and one study was a stepped-wedged cluster-RCT. The trials took place in Canada, New Zealand, Russia, and the USA. We judged the overall risk of bias to be unclear. Two trials were only published in abstract form. Tight glycaemic targets used in the trials ranged between ≤ 5.0 and 5.1 mmol/L for fasting plasma glucose and ≤ 6.7 and 7.4 mmol/L postprandial. Less-tight targets for glycaemic control used in the included trials ranged between < 5.3 and 5.8 mmol/L for fasting plasma glucose and < 7.8 and 8.0 mmol/L postprandial. For the maternal outcomes, compared with less-tight glycaemic control, the evidence suggests a possible increase in hypertensive disorders of pregnancy with tighter glycaemic control (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.80 to 1.69, 2 trials, 1491 women; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. Tighter glycaemic control likely results in little to no difference in caesarean section rates (RR 0.98, 95% CI 0.82 to 1.17, 3 studies, 1662 women; moderate certainty evidence) or induction of labour rates (RR 0.96, 95% CI 0.78 to 1.18, 1 study, 1096 women; moderate certainty evidence) compared with less-tight control. No data were reported for the outcomes of subsequent development of type 2 diabetes, perineal trauma, return to pre-pregnancy weight, and postnatal depression. For the infant outcomes, it was difficult to determine if there was a difference in perinatal mortality (RR not estimable, 2 studies, 1499 infants; low certainty evidence), and there was likely no difference in being large-for-gestational-age (RR 0.96, 95% CI 0.72 to 1.29, 3 studies, 1556 infants; moderate certainty evidence). The evidence suggests a possible reduction in the composite of mortality or serious morbidity with tighter glycaemic control (RR 0.84, 95% CI 0.55 to 1.29, 3 trials, 1559 infants; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. There is probably little difference between groups in infant hypoglycaemia (RR 0.92, 95% CI 0.72 to 1.18, 3 studies, 1556 infants; moderate certainty evidence). Tighter glycaemic control may not reduce adiposity in infants of women with GDM compared with less-tight control (mean difference -0.62%, 95% CI -3.23 to 1.99, 1 study, 60 infants; low certainty evidence), but the wide CI suggests significant uncertainty. We found no data for the long-term outcomes of diabetes or neurosensory disability. Women assigned to tighter glycaemic control experienced an increase in the use of pharmacological therapy compared with women assigned to less-tight glycaemic control (RR 1.37, 95% CI 1.17 to 1.59, 4 trials, 1718 women). Tighter glycaemic control reducedadherence with treatment compared with less-tight glycaemic control (RR 0.41, 95% CI 0.32 to 0.51, 1 trial, 395 women). Overall the certainty of evidence assessed using GRADE ranged from low to moderate, downgraded primarily due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

This review is based on four trials (1731 women) with an overall unclear risk of bias. The trials provided data on most primary outcomes and suggest that tighter glycaemic control may increase the risk of hypertensive disorders of pregnancy. The risk of birth of a large-for-gestational-age infant and perinatal mortality may be similar between groups, and tighter glycaemic targets may result in a possible reduction in composite of death or severe infant morbidity. However, the CIs for these outcomes are wide, suggesting both benefit and harm. There remains limited evidence regarding the benefit of different glycaemic targets for women with GDM to minimise adverse effects on maternal and infant health. Glycaemic target recommendations from international professional organisations vary widely and are currently reliant on consensus given the lack of high-certainty evidence. Further high-quality trials are needed, and these should assess both short- and long-term health outcomes for women and their babies; include women's experiences; and assess health services costs in order to confirm the current findings. Two trials are ongoing.

Progression From Gestational Diabetes Mellitus to Type 2 Diabetes Mellitus Among First Nations Women in Northwest Ontario: A Retrospective Cohort Study

OBJECTIVE

Our aim in this study was to identify the incidence of type 2 diabetes mellitus among First Nations women in northwest Ontario with a history of gestational diabetes mellitus (GDM).

METHODS

This work was a retrospective cohort study of women diagnosed with GDM using a 50-gram oral glucose challenge test or a 75-gram oral glucose tolerance test from January 1, 2010, to December 31, 2017, at the Sioux Lookout Meno Ya Win Health Centre. Outcomes were assessed based on glycated hemoglobin (A1C) measurements performed between January 1, 2010, and December 31, 2019.

RESULTS

The cumulative incidence of T2DM among women with a history of GDM was 18% (42 of 237) at 2 years and 39% (76 of 194) at 6 years. Women with GDM who developed T2DM were of similar age and parity and had equivalent C-section rates (26%) compared to those who did not develop T2DM. They had higher birth weights (3,866 grams vs 3,600 grams, p=0.006) and rates of treatment with insulin (24% vs 5%, p<0.001) and metformin (16% vs 5%, p=0.005).

CONCLUSIONS

GDM confers a significant risk for the development of T2DM in First Nations women. Broad community-based resources, food security, and social programming are required.

Integrating equity, diversity and inclusion throughout the lifecycle of AI within healthcare: a scoping review protocol

INTRODUCTION

Artificial intelligence (AI) has the potential to improve efficiency and quality of care in healthcare settings. The lack of consideration for equity, diversity and inclusion (EDI) in the lifecycle of AI within healthcare settings may intensify social and health inequities, potentially causing harm to under-represented populations. This article describes the protocol for a scoping review of the literature relating to integration of EDI in the AI interventions within healthcare setting. The objective of the review is to evaluate what has been done on integrating EDI concepts, principles and practices in the lifecycles of AI interventions within healthcare settings. It also aims to explore which EDI concepts, principles and practices have been integrated into the design, development and implementation of AI in healthcare settings.

METHOD AND ANALYSIS

The scoping review will be guided by the six-step methodological framework developed by Arksey and O'Malley supplemented by Levac et al, and Joanna Briggs Institute methodological framework for scoping reviews. Relevant literature will be identified by searching seven electronic databases in engineering/computer science and healthcare, and searching the reference lists and citations of studies that meet the inclusion criteria. Studies on AI in any healthcare and geographical settings, that have considered aspects of EDI, published in English and French between 2005 and present will be considered. Two reviewers will independently screen titles, abstracts and full-text articles according to inclusion criteria. We will conduct a thematic analysis and use a narrative description to describe the work. Any disagreements will be resolved through discussion with the third reviewer. Extracted data will be summarised and analysed to address aims of the scoping review. Reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. The study began in April 2022 and is expected to end in September 2023. The database initial searches resulted in 5,745 records when piloted in April 2022.

ETHICS AND DISSEMINATION

Ethical approval is not required. The study will map the available literature on EDI concepts, principles and practices in AI interventions within healthcare settings, highlight the significance of this context, and offer insights into the best practices for incorporating EDI into AI-based solutions in healthcare settings. The results will be disseminated through open-access peer-reviewed publications, conference presentations, social media and 2-day workshops with relevant stakeholders.

Gestational diabetes mellitus and COVID-19: The epidemic during the pandemic

During the global coronavirus disease 2019 (COVID-19) pandemic, people worldwide have experienced an unprecedented rise in psychological distress and anxiety. In addition to this challenging situation, the prevalence of diabetes mellitus (DM), a hidden epidemic, has been steadily increasing in recent years. Lower-middle-income countries have faced significant barriers in providing accessible prenatal care and promoting a healthy diet for pregnant women, and the pandemic has made these challenges even more difficult to overcome. Pregnant women are at a higher risk of developing complications such as hyper-tension, preeclampsia, and gestational diabetes, all of which can have adverse implications for both maternal and fetal health. The occurrence of gestational diabetes has been on the rise, and it is possible that the pandemic has worsened its prevalence. Although data is limited, studies conducted in Italy and Canada suggest that the pandemic has had an impact on gestational diabetes rates, especially among women in their first trimester of pregnancy. The significant disruptions to daily routines caused by the pandemic, such as limited exercise options, indicate a possible link between COVID-19 and an increased likelihood of experiencing higher levels of weight gain during pregnancy. Notably, individuals in the United States with singleton pregnancies are at a significantly higher risk of excessive gestational weight gain, making this association particularly important to consider. Although comprehensive data is currently lacking, it is important for clinical researchers to explore the possibility of establishing correlations between the stress experienced during the pandemic, its consequences such as gestational gain weight, and the increasing incidence of gestational DM. This knowledge would contribute to better preventive measures and support for pregnant individuals during challenging times.

Remnant cholesterol, but not other cholesterol parameters, is associated with gestational diabetes mellitus in pregnant women: a prospective cohort study

OBJECTIVE

No evidence has been found of a relationship between remnant cholesterol (RC) and the likelihood of gestational diabetes mellitus (GDM) in pregnant women. The aim of our study was to investigate the link between serum RC at 12-14 weeks of gestation and the risk of GDM.

METHODS

This was a secondary analysis with data from a prospective cohort study in Korea. A total of 590 single pregnant women attending two hospitals in Korea, up to 14 weeks gestation, from November 2014 to July 2016 were included in the study. The formula used to calculate RC in detail was RC (mg/dL) = TC (mg/dL)-HDL-c (mg/dL)-LDL-c (mg/dL). Logistic regression models were employed to examine the relationship between RC and GDM and explore the association between other lipoprotein cholesterol parameters and the risk of GDM. Furthermore, receiver operating characteristic (ROC) analysis was performed to assess the ability of RC to identify GDM. Additionally, sensitivity and subgroup analyses were conducted.

RESULTS

The mean age of participants was 32.06 ± 3.80 years. The median of RC was 34.66 mg/dL. 37 pregnant women (6.27%) were eventually diagnosed with GDM. Multivariate adjusted logistic regression analysis showed that RC was positively associated with the risk of GDM (OR = 1.458, 95% CI 1.221, 1.741). There was no significant association between other lipoprotein cholesterols (including TC, LDL-c, HDL-c) and the risk of GDM. The area under the ROC curve for RC as a predictor of GDM was 0.8038 (95% CI 0.7338-0.8738), and the optimal RC cut-off was 24.30 mg/dL. Our findings were demonstrated to be robust by performing a series of sensitivity analyses.

CONCLUSION

Serum RC levels at 12-14 weeks of gestation are positively associated with GDM risk in pregnant women. RC in early pregnancy is an early warning indicator of GDM in pregnant women, especially those with normal HDL-c, LDL-c, and TC that are easily overlooked. There is a high risk of developing GDM in pregnant women whose RC is more than 24.30 mg/dL. This study may help optimize GDM prevention in pregnant women and facilitate communication between physicians, pregnant patients, and their families.

Prevalence of abnormal glucose values and gestational diabetes mellitus among pregnant women in Xi'an from 2015 to 2021

BACKGROUND

Pregnant women with gestational diabetes mellitus (GDM) often have an increased risk of adverse pregnancy outcomes. The purpose of this study was to explore the prevalence and characteristics of GDM in Xi'an from 2015 to 2021 since the implementation of China's "Two-Child policy" and to provide a clinical basis for the management of GDM.

METHODS

We analyzed the oral glucose tolerance test (OGTT) results of 152,836 pregnant women who underwent routine prenatal examination at the Northwest Women and Children's Hospital from 2015 to 2021. Additionally, we analyzed the GDM prevalence and characteristics.

RESULTS

The prevalence of GDM in the Xi'an urban area was 24.66% and exhibited an increasing trend annually (χ2 for trend = 43.922, p < 0.001) and with age (χ2 for trend = 2527.000, p < 0.001). Consistent with this, the proportion of pregnant women aged 18-25 and 26-30 years decreased significantly with the annual growth (χ2 for trend = 183.279, p < 0.001 and χ2 for trend = 33.192, p < 0.001, respectively). The proportion of pregnant women aged 31-35 and 36-42 years increased gradually annually (χ2 for trend = 134.436, p < 0.001and χ2 for trend = 44.403, p < 0.001, respectively). Of the pregnant women diagnosed with GDM, 71.15% (65.05-74.95%) had abnormal fasting plasma glucose (FPG) values. The highest percentage of patients had a single abnormal OGTT value (68.31%; 65.77-70.61%), followed by two (20.52%; 18.79-22.55%) and three (11.17%; 10.11-11.85%) abnormal values (FPG and 1-h and 2-h plasma glucose (PG).

CONCLUSION

The prevalence of GDM among pregnant women in Xi'an region was high, and it had a increasing trend over the period from 2015 to 2021. Notably, the proportion of elder pregnant women, aged 31-42 years, presented a significant rise after the implementation of the universal two-child policy. On the basis of the high incidence of GDM among elder pregnant women and the high rate of abnormal OGTT values (numbe ≥ 2) in pregnant women diagnosed with GDM, the management of GDM should be intensified, and relevant departments should pay more attention to pregnant women of advanced age.

Uptake of antepartum care services in a matrilineal-matrilocal society: a study of Garo indigenous women in Bangladesh

BACKGROUND

The indigenous Garo is a close-knit matrilineal-matrilocal community. This community's expectant mothers receive less antepartum biomedical care, making them prone to maternal mortality. This study developed a conceptual framework to explore how the external environment, personal predispositions, enabling components and perceived antepartum care needs influence and generate a gap in antepartum biomedical care uptake.

METHODS

The author used qualitative data from the study area. The data were collected through conducting 24 semi-structured interviews with purposively selected Garo women. After transcribing the data, the author generated the themes, grouped them into two broader domains, and analyzed them using the grounded theory approach.

RESULTS

The emergent themes suggest adding the external environment (i.e., healthcare facilities' availability and services and culturally relevant healthcare services) to Anderson's behavioral model to understand indigenous women's antepartum care uptake disparity. Antepartum care uptake disparities arise when Andersen's behavioral model's other three drivers-personal predisposition, enabling components, and needs components-interact with the external environment. The interplay between enabling resources and the external environment is the conduit by which their predispositions and perceived needs are shaped and, thus, generate a disparity in antepartum care uptake. The data demonstrate that enabling resources include gendered power dynamics in families, home composition and income, men's spousal role, community practices of maternal health, and mother groups' and husbands' knowledge. Birth order, past treatment, late pregnancy, and healthcare knowledge are predispositions. According to data, social support, home-based care, mental health well-being, cultural norms and rituals, doctors' friendliness, affordable care, and transportation costs are perceived needs.

CONCLUSIONS

Garo family members (mothers/in-laws and male husbands) should be included in health intervention initiatives to address the problem with effective health education, highlighting the advantages of biomedical antepartum care. Health policymakers should ensure the availability of nearby and culturally appropriate pregnancy care services.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

A Glimpse at the Size of the Fetal Liver-Is It Connected with the Evolution of Gestational Diabetes?

Gestational diabetes mellitus (GDM) is defined as an impairment of glucose tolerance, manifested by hyperglycemia, which occurs at any stage of pregnancy. GDM is more common in the third trimester of pregnancy and usually disappears after birth. It was hypothesized that the glycemic status of the mother can modulate liver development and growth early during the pregnancy. The simplest modality to monitor the evolution of GDM employs noninvasive techniques. In this category, routinely obstetrical ultrasound (OUS) examinations (simple or 2D/3D) can be employed for specific fetal measurements, such as fetal liver length (FLL) or volume (FLV). FLL and FLV may emerge as possible predictors of GDM as they positively relate to the maternal glycated hemoglobin (HbA1c) levels and to the results of the oral glucose tolerance test. The aim of this review is to offer insight into the relationship between GDM and fetal nutritional status. Risk factors for GDM and the short- and long-term outcomes of GDM pregnancies are also discussed, as well as the significance of different dietary patterns. Moreover, the review aims to fill one gap in the literature, investigating whether fetal liver growth can be used as a predictor of GDM evolution. To conclude, although studies pointed out a connection between fetal indices and GDM as useful tools in the early detection of GDM (before 23 weeks of gestation), additional research is needed to properly manage GDM and offspring health.

Pregnancy outcomes among multi-ethnic women with different degrees of hyperglycaemia during pregnancy in an urban New Zealand population and their association with postnatal HbA1c uptake

BACKGROUND

Adverse pregnancy outcomes are more common in women with hyperglycaemia. Many women have suboptimal uptake of HbA1c testing postdelivery.

AIMS

To compare pregnancy outcomes among multi-ethnic women with different degrees of hyperglycaemia during pregnancy, and their association with postnatal HbA1c uptake after the introduction of email reminders.

MATERIALS AND METHODS

A retrospective and prospective single-centre study was conducted in South Auckland in 2639 women with early gestational diabetes mellitus (GDM) (diagnosed < 20 weeks), late GDM (diagnosed ≥ 20 weeks), overt diabetes in pregnancy, or known type 2 diabetes (T2DM) during pregnancy. Automated email reminders were sent to general practitioners to increase postnatal HbA1c screening.

RESULTS

HbA1c during pregnancy increased across the late GDM (n = 1425), early GDM (n = 148), overt diabetes (n = 573) and T2DM (n = 493) groups (P < 0.001). Stillbirth was least common in the late GDM group (0, 0.7, 0.5, and 1.9%, respectively, P < 0.001), as were caesarean delivery (32.7, 45.1, 39.4, and 53.5%, respectively, P < 0.001), large for gestational age (LGA) (14.7, 18.2, 22.3, and 30.5%, respectively, P < 0.001), small for gestational age (8.8, 16.7, 11.0, and 11.1%, respectively, P = 0.02), and preeclampsia/eclampsia (7.7, 9.2, 13.0, and 14.8%, respectively, P < 0.001). LGA and preeclampsia/eclampsia were more common among Pacific and Māori women than European women (LGA, 30.1, 22.7, 10.3%, respectively, P < 0.001; preeclampsia/eclampsia, 13.5, 14.0, and 8.1%, respectively, P < 0.001). Postpartum HbA1c screening increased among women with GDM/overt diabetes after the introduction of the reminder emails (39.6% vs 34.0%, P = 0.03).

CONCLUSIONS

Women with late GDM are least likely to experience adverse outcomes. Email reminders to improve postpartum HbA1c screening warrant further investigation.

Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention

Background

Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes.

Methods

A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines.

Discussion

This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Pregnancy And Neonatal Diabetes Outcomes in Remote Australia: the PANDORA study-an observational birth cohort

BACKGROUND

In Australia's Northern Territory, 33% of babies are born to Indigenous mothers, who experience high rates of hyperglycemia in pregnancy. We aimed to determine the extent to which pregnancy outcomes for Indigenous Australian women are explained by relative frequencies of diabetes type [type 2 diabetes (T2DM) and gestational diabetes (GDM)].

METHODS

This prospective birth cohort study examined participants recruited from a hyperglycemia in pregnancy register. Baseline data collected were antenatal and perinatal clinical information, cord blood and neonatal anthropometry. Of 1135 women (48% Indigenous), 900 had diabetes: 175 T2DM, 86 newly diagnosed diabetes in pregnancy (DIP) and 639 had GDM. A group of 235 women without hyperglycemia in pregnancy was also recruited.

RESULTS

Diabetes type differed for Indigenous and non-Indigenous women (T2DM, 36 vs 5%; DIP, 15 vs 7%; GDM, 49 vs 88%, p < 0.001). Within each diabetes type, Indigenous women were younger and had higher smoking rates. Among women with GDM/DIP, Indigenous women demonstrated poorer birth outcomes than non-Indigenous women: large for gestational age, 19 vs 11%, p = 0·002; neonatal fat 11.3 vs 10.2%, p < 0.001. In the full cohort, on multivariate regression, T2DM and DIP were independently associated (and Indigenous ethnicity was not) with pregnancy outcomes.

CONCLUSIONS

Higher rates of T2DM among Indigenous women predominantly contribute to absolute poorer pregnancy outcomes among Indigenous women with hyperglycemia. As with Indigenous and minority populations globally, prevention or delay of type 2 diabetes in younger women is vital to improve pregnancy outcomes and possibly to improve the long-term health of their offspring.

Characteristics of Women With Gestational Diabetes From Non-Caucasian Compared With Caucasian Ethnic Groups

OBJECTIVES

Short- and long-term outcomes in women after gestational diabetes mellitus (GDM) vary by ethnicity. Understanding differences in baseline diabetes risk factors is important for informing choice of risk-reducing interventions. We aimed to compare maternal and pregnancy-related characteristics in Caucasian and non-Caucasian women with GDM.

METHODS

Using a large multicentre Canadian cohort of women diagnosed with GDM and recruited between 2009 and 2013, we compared demographic, clinical and behavioural characteristics in women with GDM across 7 ethnic groups. Data were obtained from chart reviews and surveys, and logistic and linear regression models were used to compare binary and continuous variables, respectively, between Caucasian and non-Caucasian ethnic groups.

RESULTS

Of the 1,332 women with GDM, 911 were eligible for inclusion. Of these, 41.4% were white Caucasian, 17.1% were South Asian, 18.4% were East Asian, 5.8% were black, 8.8% were Filipina, 5.2% were Middle Eastern and 3.3% were Hispanic. Non-Caucasian women were diagnosed with GDM at a younger age and were more likely to have a family history of diabetes compared with Caucasian women. With the exception of East Asians, non-Caucasian women were more likely to be overweight using ethnicity-specific body mass index cutoffs and have higher oral glucose tolerance test values than Caucasian women. Prepregnancy smoking and alcohol consumption prevalence were highest in Caucasian women.

CONCLUSIONS

Several important ethnicity-specific differences in clinical and behavioural characteristics of women with GDM were identified. These differences need to be considered when offering interventions for reducing risk of adverse perinatal outcomes and subsequent type 2 diabetes.

Non-pharmacological management of gestational diabetes: The role of myo-inositol

Gestational diabetes mellitus (GDM) is the most common metabolic disorder occurring in pregnancy. GDM plays an important role in the current diabetes epidemic: exposure to a high glycemic environment during the early stages of development increases the risk of the fetus to develop type two diabetes mellitus (T2DM) in adult life. Various cardiometabolic risk factors are linked to GDM. A thorough knowledge of the risk factors and genes involved in the development of GDM, along with an understanding of the underlying pathophysiological mechanisms are crucial to properly identify patients at risk of developing this condition. There is growing evidence showing that myo-inositol, combined with an appropriate therapeutic regimen for GDM, can provide additional benefits to the patient. The aim of this review is to analyze the role of inositol isomers - especially myo-inositol (MYO-INS) - in the treatment of patients with GDM.

Birthweight and early-onset type 2 diabetes in American Indians: differential effects in adolescents and young adults and additive effects of genotype, BMI and maternal diabetes

AIMS/HYPOTHESIS

The aim of this work was to estimate the impact of birthweight on early-onset (age <40 years) type 2 diabetes.

METHODS

A longitudinal study of American Indians, aged ≥5 years, was conducted from 1965 to 2007. Participants who had a recorded birthweight were followed until they developed diabetes or their last examination before the age of 40 years, whichever came first. Age- and sex-adjusted diabetes incidence rates were computed and Poisson regression was used to model the effect of birthweight on diabetes incidence, adjusted for sex, BMI, a type 2 diabetes susceptibility genetic risk score (GRS) and maternal covariates.

RESULTS

Among 3039 participants, there were 652 incident diabetes cases over a median follow-up of 14.3 years. Diabetes incidence increased with age and was greater in the lowest and highest quintiles of birthweight. Adjusted for covariates, the effect of birthweight on diabetes varied over time, with a non-linear effect at 10-19 years (p < 0.001) and a negative linear effect at older age intervals (20-29 years, p < 0.001; 30-39 years, p = 0.003). Higher GRS, greater BMI and maternal diabetes had additive but not interactive effects on the association between birthweight and diabetes incidence.

CONCLUSIONS/INTERPRETATION

In this high-risk population, both low and high birthweights were associated with increased type 2 diabetes risk in adolescence (age 10-19 years) but only low birthweight was associated with increased risk in young adulthood (20-39 years). Higher type 2 diabetes GRS, greater BMI and maternal diabetes added to the risk of early-onset diabetes.

Diabetes care in the dispersed population of Greenland. A new model based on continued monitoring, analysis and adjustment of initiatives taken

Diabetes used to be a rare condition among Inuit in Greenland. However, research in recent decades has shown a high prevalence of undiagnosed diabetes. Addressing diabetes in the geographically dispersed population of Greenland presents a challenge to the health care system. In 2008, a new model of diabetes care was introduced in Greenland that included continual monitoring, analysis, and adjustment of initiatives taken. The overall aim of this review was to review the feasibility of the monitoring of an ongoing national diabetes care programme. After ten years of observation it was clear that monitoring of such a programme based on information in electronic medical records in Greenland was feasible. It was found that the majority of the population in Greenland was in contact with the health care system. Increased diagnostic activity resulted in an increased prevalence of diagnosed diabetes. The quality of diabetes care in Greenland and the testing effectiveness of gestational diabetes were improved. Microvascular complications were frequently observed among Greenlandic diabetic patients, except for retinopathy that was as an exception. In summary, this model may improve diabetes care and potentially care for other chronic conditions in Greenland, and may also be helpful in other remote settings where chronic disease care is difficult.Abbreviations: AD: Anno Domini; ADA: American Diabetes Association; BC: Before Christ; BMI: Body Mass Index; BP: Blood Pressure; CWB: Capillary Whole Blood; EMR: Electronic Medical Record; EASD: European Association for Study of Diabetes; GA: Gestational Age; GDM: Gestational Diabetes Mellitus; FIGO: The International Federation of Gynaecology and Obstetrics; HbA1c: Glycosylated haemoglobin; IDF: International Diabetes Federation; LDL: Low density lipoprotein; NDQIA: National Diabetes Quality Improvement Alliancel; NICE: National Institute for Health and Care Excellence; OECD: Organisation for Economic Co-operation and Development; OGTT: Oral Glucose Tolerance Test; QIH: Queen Ingrid Hospital; RCT: Randomised Controlled Tria;l T1D: Type 1 Diabetes; T2D: Type 2 Diabetes; UACR: Urine Albumin Creatinine Ratio; WHO: World Health Organisation.

The experience of gestational diabetes for indigenous Māori women living in rural New Zealand: qualitative research informing the development of decolonising interventions

Background

Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation.

Method

A qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes.

Results

Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management.

Conclusion

Māori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2103-8) contains supplementary material, which is available to authorized users.

Neonatal outcomes of live-born term singletons in vertex presentation born to mothers with diabetes during pregnancy by mode of birth: a New South Wales population-based retrospective cohort study

OBJECTIVES

To investigate the association between the mode of birth and adverse neonatal outcomes of macrosomic (birth weight ≥4000 g) and non-macrosomic (birth weight <4000 g) live-born term singletons in vertex presentation (TSV) born to mothers with diabetes (pre-existing and gestational diabetes mellitus (GDM)).

DESIGN

A population-based retrospective cohort study.

SETTING

New South Wales, Australia.

PATIENTS

All live-born TSV born to mothers with diabetes from 2002 to 2012.

INTERVENTION

Comparison of neonatal outcomes by mode of birth (prelabour caesarean section (CS) and planned vaginal birth resulted in intrapartum CS, non-instrumental or instrumental vaginal birth).

MAIN OUTCOME MEASURES

Five-minute Apgar score <7, admission to neonatal intensive care unit (NICU) or special care nursery (SCN) and the need for resuscitation.

RESULTS

Among the 48 882 TSV born to mothers with diabetes, prelabour CS was associated with a significant increase in the rate of admission to NICU/SCN compared with planned vaginal birth.For TSV born to mothers with pre-existing diabetes, compared with non-instrumental vaginal birth, instrumental vaginal birth was associated with increased odds of the need for resuscitation in macrosomic (adjusted ORs (AOR) 2.6; 95% CI (1.2 to 7.5)) and non-macrosomic TSV (AOR 3.3; 95% CI (2.2 to 5.0)).For TSV born to mothers with GDM, intrapartum CS was associated with increased odds of the need for resuscitation compared with non-instrumental vaginal birth in non-macrosomic TSV (AOR 2.3; 95% CI (2.1 to 2.7)). Instrumental vaginal birth was associated with increased likelihood of requiring resuscitation compared with non-instrumental vaginal birth for both macrosomic (AOR 2.3; 95% CI (1.7 to 3.1)) and non-macrosomic (AOR 2.5; 95% CI (2.2 to 2.9)) TSV.

CONCLUSION

Pregnant women with diabetes, particularly those with suspected fetal macrosomia, need to be aware of the increased likelihood of adverse neonatal outcomes following instrumental vaginal birth and intrapartum CS when planning mode of birth.

Planned birth at or near term for improving health outcomes for pregnant women with gestational diabetes and their infants

BACKGROUND

Gestational diabetes is a type of diabetes that occurs during pregnancy. Women with gestational diabetes are more likely to experience adverse health outcomes such as pre-eclampsia or polyhydramnios (excess amniotic fluid). Their babies are also more likely to have health complications such as macrosomia (birthweight > 4000 g) and being large-for-gestational age (birthweight above the 90th percentile for gestational age). Current clinical guidelines support elective birth, at or near term in women with gestational diabetes to minimise perinatal complications, especially those related to macrosomia.This review replaces a review previously published in 2001 that included "diabetic pregnant women", which has now been split into two reviews. This current review focuses on pregnant women with gestational diabetes and a sister review focuses on women with pre-existing diabetes (Type 1 or Type 2).

OBJECTIVES

To assess the effect of planned birth (either by induction of labour or caesarean birth), at or near term (37 to 40 weeks' gestation) compared with an expectant approach for improving health outcomes for women with gestational diabetes and their infants. The primary outcomes relate to maternal and perinatal mortality and morbidity.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (15 August 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised trials comparing planned birth, at or near term (37 to 40 weeks' gestation), with an expectant approach, for women with gestational diabetes. Cluster-randomised and non-randomised trials (e.g. quasi-randomised trials using alternate allocation) were also eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included study. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

The findings of this review are based on a single trial involving 425 women with gestational diabetes. The trial compared induction of labour with expectant management (waiting for the spontaneous onset of labour in the absence of any maternal or fetal issues that may necessitate birth) in pregnant women with gestational diabetes at term. We assessed the overall risk of bias as being low for most domains, apart from performance, detection and attrition bias (for outcome perineum intact), which we assessed as being at high risk. It was an open-label trial, and women and healthcare professionals were not blinded.There were no clear differences between women randomised to induction of labour and women randomised to expectant management for maternal mortality or serious maternal morbidity (risk ratio (RR) 1.48, 95% confidence interval (CI) 0.25 to 8.76, one trial, 425 women); caesarean section (RR 1.06, 95% CI 0.64 to 1.77, one trial, 425 women); or instrumental vaginal birth (RR 0.81, 95% CI 0.45 to 1.46, one trial, 425 women). For the primary outcome of maternal mortality or serious maternal morbidity, there were no deaths in either group and serious maternal morbidity related to admissions to intensive care unit. The quality of the evidence contributing to these outcomes was assessed as very low, mainly due to the study having high risk of bias for some domains and because of the imprecision of effect estimates.In relation to primary neonatal outcomes, there were no perinatal deaths in either group. The quality of evidence for this outcome was judged as very low, mainly due to high risk of bias and imprecision of effect estimates. There were no clear differences in infant outcomes between women randomised to induction of labour and women randomised to expectant management: shoulder dystocia (RR 2.96, 95% CI 0.31 to 28.21, one trial, 425 infants, very low-quality evidence); large-for-gestational age (RR 0.53, 95% CI 0.28 to 1.02, one trial, 425 infants, low-quality evidence).There were no clear differences between women randomised to induction of labour and women randomised to expectant management for postpartum haemorrhage (RR 1.17, 95% CI 0.53 to 2.54, one trial, 425 women); admission to intensive care unit (RR 1.48, 95% CI 0.25 to 8.76, one trial, 425 women); and intact perineum (RR 1.02, 95% CI 0.73 to 1.43, one trial, 425 women). No infant experienced a birth trauma, therefore, we could not draw conclusions about the effect of the intervention on the outcomes of brachial plexus injury and bone fracture at birth. Infants of women in the induction-of-labour group had higher incidences of neonatal hyperbilirubinaemia (jaundice) when compared to infants of women in the expectant-management group (RR 2.46, 95% CI 1.11 to 5.46, one trial, 425 women).We found no data on the following prespecified outcomes of this review: postnatal depression, maternal satisfaction, length of postnatal stay (mother), acidaemia, intracranial haemorrhage, hypoxia ischaemic encephalopathy, small-for-gestational age, length of postnatal stay (baby) and cost.The authors of this trial acknowledge that it is underpowered for their primary outcome of caesarean section. The authors of the trial and of this review note that the CIs demonstrate a wide range, therefore making it inappropriate to draw definite conclusions.

AUTHORS' CONCLUSIONS

There is limited evidence to inform implications for practice. The available data are not of high quality and lack power to detect possible important differences in either benefit or harm. There is an urgent need for high-quality trials evaluating the effectiveness of planned birth at or near term gestation for women with gestational diabetes compared with an expectant approach.

Gestational diabetes from A to Z

Gestational diabetes mellitus (GDM) is defined as any degree of hyperglycaemia that is recognized for the first time during pregnancy. This definition includes cases of undiagnosed type 2 diabetes mellitus (T2DM) identified early in pregnancy and true GDM which develops later. GDM constitutes a greater impact on diabetes epidemic as it carries a major risk of developing T2DM to the mother and foetus later in life. In addition, GDM has also been linked with cardiometabolic risk factors such as lipid abnormalities, hypertensive disorders and hyperinsulinemia. These might result in later development of cardiovascular disease and metabolic syndrome. The understanding of the different risk factors, the pathophysiological mechanisms and the genetic factors of GDM, will help us to identify the women at risk, to develop effective preventive measures and to provide adequate management of the disease. Clinical trials have shown that T2DM can be prevented in women with prior GDM, by intensive lifestyle modification and by using pioglitazone and metformin. However, a matter of controversy surrounding both screening and management of GDM continues to emerge, despite several recent well-designed clinical trials tackling these issues. The aim of this manuscript is to critically review GDM in a detailed and comprehensive manner, in order to provide a scientific analysis and updated write-up of different related aspects.

Insulin for the treatment of women with gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with short- and long-term complications for the mother and her infant. Women who are unable to maintain their blood glucose concentration within pre-specified treatment targets with diet and lifestyle interventions will require anti-diabetic pharmacological therapies. This review explores the safety and effectiveness of insulin compared with oral anti-diabetic pharmacological therapies, non-pharmacological interventions and insulin regimens.

OBJECTIVES

To evaluate the effects of insulin in treating women with gestational diabetes.

SEARCH METHODS

We searched Pregnancy and Childbirth's Trials Register (1 May 2017), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (1 May 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (including those published in abstract form) comparing:a) insulin with an oral anti-diabetic pharmacological therapy;b) with a non-pharmacological intervention;c) different insulin analogues;d) different insulin regimens for treating women with diagnosed with GDM.We excluded quasi-randomised and trials including women with pre-existing type 1 or type 2 diabetes. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, risk of bias, and extracted data. Data were checked for accuracy.

MAIN RESULTS

We included 53 relevant studies (103 publications), reporting data for 7381 women. Forty-six of these studies reported data for 6435 infants but our analyses were based on fewer number of studies/participants.Overall, the risk of bias was unclear; 40 of the 53 included trials were not blinded. Overall, the quality of the evidence ranged from moderate to very low quality. The primary reasons for downgrading evidence were imprecision, risk of bias and inconsistency. We report the results for our maternal and infant GRADE outcomes for the main comparison. Insulin versus oral anti-diabetic pharmacological therapyFor the mother, insulin was associated with an increased risk for hypertensive disorders of pregnancy (not defined) compared to oral anti-diabetic pharmacological therapy (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.14 to 3.12; four studies, 1214 women; moderate-quality evidence). There was no clear evidence of a difference between those who had been treated with insulin and those who had been treated with an oral anti-diabetic pharmacological therapy for the risk of pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 studies, 2060 women; moderate-quality evidence); the risk of birth by caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 studies, 1988 women; moderate-quality evidence); or the risk of developing type 2 diabetes (metformin only) (RR 1.39, 95% CI 0.80 to 2.44; two studies, 754 women; moderate-quality evidence). The risk of undergoing induction of labour for those treated with insulin compared with oral anti-diabetic pharmacological therapy may possibly be increased, although the evidence was not clear (average RR 1.30, 95% CI 0.96 to 1.75; three studies, 348 women; I² = 32%; moderate-quality of evidence). There was no clear evidence of difference in postnatal weight retention between women treated with insulin and those treated with oral anti-diabetic pharmacological therapy (metformin) at six to eight weeks postpartum (MD -1.60 kg, 95% CI -6.34 to 3.14; one study, 167 women; low-quality evidence) or one year postpartum (MD -3.70, 95% CI -8.50 to 1.10; one study, 176 women; low-quality evidence). The outcomes of perineal trauma/tearing or postnatal depression were not reported in the included studies.For the infant, there was no evidence of a clear difference between those whose mothers had been treated with insulin and those treated with oral anti-diabetic pharmacological therapies for the risk of being born large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 studies, 2352 infants; moderate-quality evidence); the risk of perinatal (fetal and neonatal death) mortality (RR 0.85; 95% CI 0.29 to 2.49; 10 studies, 1463 infants; low-quality evidence);, for the risk of death or serious morbidity composite (RR 1.03, 95% CI 0.84 to 1.26; two studies, 760 infants; moderate-quality evidence); the risk of neonatal hypoglycaemia (average RR 1.14, 95% CI 0.85 to 1.52; 24 studies, 3892 infants; low-quality evidence); neonatal adiposity at birth (% fat mass) (mean difference (MD) 1.6%, 95% CI -3.77 to 0.57; one study, 82 infants; moderate-quality evidence); neonatal adiposity at birth (skinfold sum/mm) (MD 0.8 mm, 95% CI -2.33 to 0.73; random-effects; one study, 82 infants; very low-quality evidence); or childhood adiposity (total percentage fat mass) (MD 0.5%; 95% CI -0.49 to 1.49; one study, 318 children; low-quality evidence). Low-quality evidence also found no clear differences between groups for rates of neurosensory disabilities in later childhood: hearing impairment (RR 0.31, 95% CI 0.01 to 7.49; one study, 93 children), visual impairment (RR 0.31, 95% CI 0.03 to 2.90; one study, 93 children), or any mild developmental delay (RR 1.07, 95% CI 0.33 to 3.44; one study, 93 children). Later infant mortality, and childhood diabetes were not reported as outcomes in the included studies.We also looked at comparisons for regular human insulin versus other insulin analogues, insulin versus diet/standard care, insulin versus exercise and comparisons of insulin regimens, however there was insufficient evidence to determine any differences for many of the key health outcomes. Please refer to the main results for more information about these comparisons.

AUTHORS' CONCLUSIONS

The main comparison in this review is insulin versus oral anti-diabetic pharmacological therapies. Insulin and oral anti-diabetic pharmacological therapies have similar effects on key health outcomes. The quality of the evidence ranged from very low to moderate, with downgrading decisions due to imprecision, risk of bias and inconsistency.For the other comparisons of this review (insulin compared with non-pharmacological interventions, different insulin analogies or different insulin regimens), there is insufficient volume of high-quality evidence to determine differences for key health outcomes.Long-term maternal and neonatal outcomes were poorly reported for all comparisons.The evidence suggests that there are minimal harms associated with the effects of treatment with either insulin or oral anti-diabetic pharmacological therapies. The choice to use one or the other may be down to physician or maternal preference, availability or severity of GDM. Further research is needed to explore optimal insulin regimens. Further research could aim to report data for standardised GDM outcomes.

Mapping the social determinants of substance use for pregnant-involved young Aboriginal women

There is a dearth of knowledge about the social determinants of substance use among young pregnant-involved Indigenous women in Canada from their perspectives. As part of life history interviews, 17 young pregnant-involved Indigenous women with experiences with substances completed a participant-generated mapping activity CIRCLES (Charting Intersectional Relationships in the Context of Life). As women created their maps, they discussed how different social determinants impacted their experiences with pregnancy and substance use. The social determinants identified and used by women to explain determinants of their substance use were grouped into 10 themes: traumatic life histories; socioeconomic status; culture, identity and spirituality; shame and guilt; mental wellness; family connections; romantic and platonic relationships; strength and hope; mothering; and the intersections of determinants. We conclude that understanding the context and social determinants of substance use from a woman-informed perspective is paramount to informing effective and appropriate programs to support young Indigenous women who use substances.

Paths to improving care of Australian Aboriginal and Torres Strait Islander women following gestational diabetes

Aim

To understand enablers and barriers influencing postpartum screening for type 2 diabetes following gestational diabetes in Australian Indigenous women and how screening might be improved.

Background

Australian Indigenous women with gestational diabetes mellitus (GDM) are less likely than other Australian women to receive postpartum diabetes screening. This is despite a fourfold higher risk of developing type 2 diabetes within eight years postpartum.

Methods

We conducted interviews with seven Indigenous women with previous GDM, focus groups with 20 Indigenous health workers and workshops with 24 other health professionals. Data collection included brainstorming, visualisation, sorting and prioritising activities. Data were analysed thematically using the Theoretical Domains Framework. Barriers are presented under the headings of ‘capability’, ‘motivation’ and ‘opportunity’. Enabling strategies are presented under ‘intervention’ and ‘policy’ headings.

Findings

Participants generated 28 enabling environmental, educational and incentive interventions, and service provision, communication, guideline, persuasive and fiscal policies to address barriers to screening and improve postpartum support for women. The highest priorities included providing holistic social support, culturally appropriate resources, improving Indigenous workforce involvement and establishing structured follow-up systems. Understanding Indigenous women’s perspectives, developing strategies with health workers and action planning with other health professionals can generate context-relevant feasible strategies to improve postpartum care after GDM. Importantly, we need evidence which can demonstrate whether the strategies are effective.

Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with both short- and long-term complications for the mother and her baby. Exercise interventions may be useful in helping with glycaemic control and improve maternal and infant outcomes.The original review on Exercise for diabetic pregnant women has been split into two new review titles reflecting the role of exercise for pregnant women with gestational diabetes and for pregnant women with pre-existing diabetes. Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes (this review) Exercise for pregnant women with pre-existing diabetes for improving maternal and fetal outcomes OBJECTIVES: To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with GDM.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 August 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (18th August 2016), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing an exercise intervention with standard care or another intervention in pregnant women diagnosed with gestational diabetes. Quasi-randomised and cross-over studies, and studies including women with pre-existing type 1 or type 2 diabetes were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All selection of studies, assessment of trial quality and data extraction was conducted independently by two review authors. Data were checked for accuracy.

MAIN RESULTS

We included 11 randomised trials, involving 638 women. The overall risk of bias was judged to be unclear due to lack of methodological detail in the included studies.For the mother, there was no clear evidence of a difference between women in the exercise group and those in the control group for the risk of pre-eclampsia as the measure of hypertensive disorders of pregnancy (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.01 to 7.09; two RCTs, 48 women; low-quality evidence), birth by caesarean section (RR 0.86, 95% CI 0.63 to 1.16; five RCTs, 316 women; I² = 0%; moderate-quality evidence), the risk of induction of labour (RR 1.38, 95% CI 0.71 to 2.68; one RCT, 40 women; low-quality evidence) or maternal body mass index at follow-up (postnatal weight retention or return to pre-pregnancy weight) (mean difference (MD) 0.11 kg/m², 95% CI -1.04 to 1.26; three RCTs, 254 women; I² = 0%; high-quality evidence). Development of type 2 diabetes, perineal trauma/tearing and postnatal depression were not reported as outcomes in the included studies.For the infant/child/adult, a single small (n = 19) trial reported no perinatal mortality (stillbirth and neonatal mortality) events in either the exercise intervention or control group (low-quality evidence). There was no clear evidence of a difference between groups for a mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy) (RR 0.56, 95% CI 0.12 to 2.61; two RCTs, 169 infants; I² = 0%; moderate-quality evidence) or neonatal hypoglycaemia (RR 2.00, 95% CI 0.20 to 20.04; one RCT, 34 infants; low-quality evidence). None of the included trials pre-specified large-for-gestational age, adiposity (neonatal/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonatal/infant) as trial outcomes.Other maternal outcomes of interest: exercise interventions were associated with both reduced fasting blood glucose concentrations (average standardised mean difference (SMD) -0.59, 95% CI -1.07 to -0.11; four RCTs, 363 women; I² = 73%; T² = 0.19) and a reduced postprandial blood glucose concentration compared with control interventions (average SMD -0.85, 95% CI -1.15 to -0.55; three RCTs, 344 women; I² = 34%; T² = 0.03).

AUTHORS' CONCLUSIONS

Short- and long-term outcomes of interest for this review were poorly reported. Current evidence is confounded by the large variety of exercise interventions. There was insufficient high-quality evidence to be able to determine any differences between exercise and control groups for our outcomes of interest. For the woman, both fasting and postprandial blood glucose concentrations were reduced compared with the control groups. There are currently insufficient data for us to determine if there are also benefits for the infant. The quality of the evidence in this review ranged from high to low quality and the main reason for downgrading was for risk of bias and imprecision (wide CIs, low event rates and small sample size). Development of type 2 diabetes, perineal trauma/tearing, postnatal depression, large-for-gestational age, adiposity (neonate/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonate/infant) were not reported as outcomes in the included studies.Further research is required comparing different types of exercise interventions with control groups or with another exercise intervention that reports on both the short- and long-term outcomes (for both the mother and infant/child) as listed in this review.

Lifestyle interventions for the treatment of women with gestational diabetes

BACKGROUND

Gestational diabetes (GDM) is glucose intolerance, first recognised in pregnancy and usually resolving after birth. GDM is associated with both short- and long-term adverse effects for the mother and her infant. Lifestyle interventions are the primary therapeutic strategy for many women with GDM.

OBJECTIVES

To evaluate the effects of combined lifestyle interventions with or without pharmacotherapy in treating women with gestational diabetes.

SEARCH METHODS

We searched the Pregnancy and Childbirth Group's Trials Register (14 May 2016), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (14th May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included only randomised controlled trials comparing a lifestyle intervention with usual care or another intervention for the treatment of pregnant women with GDM. Quasi-randomised trials were excluded. Cross-over trials were not eligible for inclusion. Women with pre-existing type 1 or type 2 diabetes were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. All selection of studies, data extraction was conducted independently by two review authors.

MAIN RESULTS

Fifteen trials (in 45 reports) are included in this review (4501 women, 3768 infants). None of the trials were funded by a conditional grant from a pharmaceutical company. The lifestyle interventions included a wide variety of components such as education, diet, exercise and self-monitoring of blood glucose. The control group included usual antenatal care or diet alone. Using GRADE methodology, the quality of the evidence ranged from high to very low quality. The main reasons for downgrading evidence were inconsistency and risk of bias. We summarised the following data from the important outcomes of this review. Lifestyle intervention versus control groupFor the mother:There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of hypertensive disorders of pregnancy (pre-eclampsia) (average risk ratio (RR) 0.70; 95% confidence interval (CI) 0.40 to 1.22; four trials, 2796 women; I² = 79%, Tau² = 0.23; low-quality evidence); caesarean section (average RR 0.90; 95% CI 0.78 to 1.05; 10 trials, 3545 women; I² = 48%, Tau² = 0.02; low-quality evidence); development of type 2 diabetes (up to a maximum of 10 years follow-up) (RR 0.98, 95% CI 0.54 to 1.76; two trials, 486 women; I² = 16%; low-quality evidence); perineal trauma/tearing (RR 1.04, 95% CI 0.93 to 1.18; one trial, n = 1000 women; moderate-quality evidence) or induction of labour (average RR 1.20, 95% CI 0.99 to 1.46; four trials, n = 2699 women; I² = 37%; high-quality evidence).More women in the lifestyle intervention group had met postpartum weight goals one year after birth than in the control group (RR 1.75, 95% CI 1.05 to 2.90; 156 women; one trial, low-quality evidence). Lifestyle interventions were associated with a decrease in the risk of postnatal depression compared with the control group (RR 0.49, 95% CI 0.31 to 0.78; one trial, n = 573 women; low-quality evidence).For the infant/child/adult:Lifestyle interventions were associated with a reduction in the risk of being born large-for-gestational age (LGA) (RR 0.60, 95% CI 0.50 to 0.71; six trials, 2994 infants; I² = 4%; moderate-quality evidence). Birthweight and the incidence of macrosomia were lower in the lifestyle intervention group.Exposure to the lifestyle intervention was associated with decreased neonatal fat mass compared with the control group (mean difference (MD) -37.30 g, 95% CI -63.97 to -10.63; one trial, 958 infants; low-quality evidence). In childhood, there was no clear evidence of a difference between groups for body mass index (BMI) ≥ 85th percentile (RR 0.91, 95% CI 0.75 to 1.11; three trials, 767 children; I² = 4%; moderate-quality evidence).There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of perinatal death (RR 0.09, 95% CI 0.01 to 1.70; two trials, 1988 infants; low-quality evidence). Of 1988 infants, only five events were reported in total in the control group and there were no events in the lifestyle group. There was no clear evidence of a difference between lifestyle intervention and control groups for a composite of serious infant outcome/s (average RR 0.57, 95% CI 0.21 to 1.55; two trials, 1930 infants; I² = 82%, Tau² = 0.44; very low-quality evidence) or neonatal hypoglycaemia (average RR 0.99, 95% CI 0.65 to 1.52; six trials, 3000 infants; I² = 48%, Tau² = 0.12; moderate-quality evidence). Diabetes and adiposity in adulthood and neurosensory disability in later childhoodwere not prespecified or reported as outcomes for any of the trials included in this review.

AUTHORS' CONCLUSIONS

Lifestyle interventions are the primary therapeutic strategy for women with GDM. Women receiving lifestyle interventions were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born LGA and decreased neonatal adiposity. Long-term maternal and childhood/adulthood outcomes were poorly reported.The value of lifestyle interventions in low-and middle-income countries or for different ethnicities remains unclear. The longer-term benefits or harms of lifestyle interventions remains unclear due to limited reporting.The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy. Lifestyle interventions are useful as the primary therapeutic strategy and most commonly include healthy eating, physical activity and self-monitoring of blood glucose concentrations.Future research could focus on which specific interventions are most useful (as the sole intervention without pharmacological treatment), which health professionals should give them and the optimal format for providing the information. Evaluation of long-term outcomes for the mother and her child should be a priority when planning future trials. There has been no in-depth exploration of the costs 'saved' from reduction in risk of LGA/macrosomia and potential longer-term risks for the infants.

Does Indigenous health research have impact? A systematic review of reviews

Background

Aboriginal and Torres Strait Islander Australians (hereafter respectfully Indigenous Australians) claim that they have been over-researched without corresponding research benefit. This claim raises two questions. The first, which has been covered to some extent in the literature, is about what type(s) of research are likely to achieve benefits for Indigenous people. The second is how researchers report the impact of their research for Indigenous people. This systematic review of Indigenous health reviews addresses the second enquiry.

Methods

Fourteen electronic databases were systematically searched for Indigenous health reviews which met eligibility criteria. Two reviewers assessed their characteristics and methodological rigour using an a priori protocol. Three research hypotheses were stated and tested: (1) reviews address Indigenous health priority needs; (2) reviews adopt best practice guidelines on research conduct and reporting in respect to methodological transparency and rigour, as well as acceptability and appropriateness of research implementation to Indigenous people; and (3) reviews explicitly report the incremental impacts of the included studies and translation of research. We argue that if review authors explicitly address each of these three hypotheses, then the impact of research for Indigenous peoples’ health would be explicated.

Results

Seventy-six reviews were included; comprising 55 journal articles and 21 Australian Government commissioned evidence review reports. While reviews are gaining prominence and recognition in Indigenous health research and increasing in number, breadth and complexity, there is little reporting of the impact of health research for Indigenous people. This finding raises questions about the relevance of these reviews for Indigenous people, their impact on policy and practice and how reviews have been commissioned, reported and evaluated.

Conclusions

The findings of our study serve two main purposes. First, we have identified knowledge and methodological gaps in documenting Indigenous health research impact that can be addressed by researchers and policy makers. Second, the findings provide the justification for developing a framework allowing researchers and funding bodies to structure future Indigenous health research to improve the reporting and assessment of impact over time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-017-0548-4) contains supplementary material, which is available to authorized users.

Effects of maternal age, parity and pre-pregnancy body mass index on the glucose challenge test and gestational diabetes mellitus

Objectives

To study the effects of age, parity and body mass index (BMI) on the incidence of a positive 50 g glucose challenge test (OGCT) and gestational diabetes mellitus (GDM) in healthy pregnant Omani women.

Methods

A 50 g OGCT was performed on 307 healthy pregnant Omani women at 24–28 weeks of gestation. When the venous plasma glucose concentration (VPG) reached >7.8 mmol/l after 1 h, the OGCT was considered to be positive. Women with positive OGCTs had a confirmatory diagnosis of GDM, which was established by performing a 2-h 75 g oral glucose tolerance test (OGTT). When either fasting or post-2-h 75 g OGTT values were >5.5 mmol/l or >8 mmol/l, respectively, women were considered diabetic.

Results

This study screened 307 women and identified 83 (27.03%) OGCT-positive and 23 (7.5%) GDM-positive cases. The incidences of a positive OGCT and GDM increased significantly with increasing maternal age from 20.0% to 2.2%, respectively, in women aged ≤25 years to 37.8% and 14.7%, respectively, in women aged >35 years (p = 0.02 and p = 0.009, respectively). The incidences of a positive OGCT and GDM increased markedly with increasing pre-pregnancy BMI, from 19.8% to 3.8%, respectively, in women with BMIs ≤25 kg/m² to 37.8% and 9.9%, respectively, in women with BMIs >25 kg/m² (p = 0.02 and p = 0.04, respectively).

Conclusion

Maternal age and pre-pregnancy BMI have profound effects on the incidences of a positive OGCT and GDM.

Oral anti-diabetic pharmacological therapies for the treatment of women with gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short- and long-term complications for the mother and her infant. Treatment options can include oral anti-diabetic pharmacological therapies.

OBJECTIVES

To evaluate the effects of oral anti-diabetic pharmacological therapies for treating women with GDM.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov, WHO ICTRP (14 May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials assessing the effects of oral anti-diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti-diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti-diabetic pharmacological therapy, 3) combined oral anti-diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review.Women with pre-existing type 1 or type 2 diabetes were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy.

MAIN RESULTS

We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta-analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality. Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti-diabetic therapy versus placebo for generalisability. Oral anti-diabetic pharmacological therapies versus placebo/standard careThere was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low-quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low-quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low-quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low-quality evidence). No data were reported for development of type 2 diabetes or other pre-specified GRADE maternal outcomes (return to pre-pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large-for-gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low-quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamideThere was no evidence of a difference between metformin- and glibenclamide-treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate-quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I2 = 61%, Tau2 = 0.07 low-quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low-quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low-quality evidence). No data were reported for development of type 2 diabetes or other pre-specified GRADE maternal outcomes (return to pre-pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin- and glibenclamide-exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I2 = 54%, Tau2 = 0.30 low-quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low-quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low-quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarboseThere was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low-quality evidence; perinatal mortality - no events; low-quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low-quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low-quality evidence). There were no data reported for other pre-specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre-pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes).

AUTHORS' CONCLUSIONS

There were insufficient data comparing oral anti-diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high-quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti-diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short- and long-term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti-diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines.The benefits and potential harms of one oral anti-diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long-term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit.

Understanding the Life Histories of Pregnant-Involved Young Aboriginal Women With Substance Use Experiences in Three Canadian Cities

Despite attention paid to substance use during pregnancy, understandings of young Aboriginal women's experiences based on their perspectives have been virtually absent in the published literature. This study's objective was to understand the life experiences of pregnant-involved young Aboriginal women with alcohol and drugs. Semi-structured interviews to gather life histories were conducted with 23 young Aboriginal women who had experiences with pregnancy, and alcohol and drug use. Transcribed interviews were analyzed for themes to describe the social and historical contexts of women's experiences and their self-representations. The findings detail women's strategies for survival, inner strength, and capacities for love, healing, and resilience. Themes included the following: intersectional identities, life histories of trauma (abuse, violence, and neglect; intergenerational trauma; separations and connections), the ever-presence of alcohol and drugs, and the highs and lows of pregnancy and mothering. The findings have implications for guiding policy and interventions for supporting women and their families.

Call to action: A new path for improving diabetes care for Indigenous peoples, a global review

Diabetes has reached epidemic proportions in Indigenous populations around the globe, and there is an urgent need to improve the health and health equity of Indigenous peoples with diabetes through timely and appropriate diabetes prevention and management strategies. This review describes the evolution of the diabetes epidemic in Indigenous populations and associated risk factors, highlighting gestational diabetes and intergenerational risk, lifestyle risk factors and social determinants as having particular importance and impact on Indigenous peoples. This review further describes the impact of chronic disease and diabetes on Indigenous peoples and communities, specifically diabetes-related comorbidities and complications. This review provides continued evidence that dramatic changes are necessary to reduce diabetes-related inequities in Indigenous populations, with a call to action to support programmatic primary healthcare transformation capable of empowering Indigenous peoples and communities and improving chronic disease prevention and management. Promising strategies for transforming health services and care for Indigenous peoples include quality improvement initiatives, facilitating diabetes and chronic disease registry and surveillance systems to identify care gaps, and prioritizing evaluation to build the evidence-base necessary to guide future health policy and planning locally and on a global scale.

Obesity, Diabetes, and Birth Outcomes Among American Indians and Alaska Natives

Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index, with several adverse birth outcomes: preterm delivery (PTB), low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton US first births from 2009-2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child's sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Neither overweight nor obesity predict PTB for AI/AN, in contrast to other groups, while diabetes predicts increased odds of PTB for all groups. Being overweight predicts reduced odds of LBW for all groups, but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Conclusions for Practice Controlling diabetes in pregnancy, as well as prepregnancy weight gain, may help decrease preterm birth and macrosomia among AI/AN.

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used and rates are increasing globally. Risk factors associated with GDM include advanced maternal age, obesity, ethnicity, family history of diabetes, and a previous history of GDM, macrosomia or unexplained stillbirth. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 February 2016) and reference lists of the retrieved studies.

SELECTION CRITERIA

We included one randomised controlled trial. Cluster-randomised and quasi-randomised controlled trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated methodological quality and extracted data for the one included study. We sought additional information from one trial author but had no response. We assessed the quality of evidence for selected outcomes using the GRADE approach.

MAIN RESULTS

We included one Canadian trial of 180 women, recruited between 20 to 32 weeks' gestation, who had been diagnosed with GDM. Data from 171 of the 180 women were published as a conference abstract and no full report has been identified. The overall risk of bias of the single included study was judged to be unclear.The included trial did not report on any of this review's primary outcomes. For the mother, these were hypertension disorders of pregnancy or subsequent development of type 2 diabetes. For the infant, our primary outcomes were (perinatal (fetal and neonatal) mortality; large-for-gestational age; composite of death or severe morbidity or later childhood neurosensory disability).The trial did report data relating to some of this review's secondary outcomes. There was no clear difference in caesarean section rates for women assigned to using strict glycaemic targets (pre-prandial 5.0 mmol/L (90 mg/L) and at one-hour postprandial 6.7 mmol/L (120 mg/dL)) (28/85, 33%) when compared with women assigned to using liberal glycaemic targets (pre-prandial 5.8 mmol/L (103 mg/dL) and at one-hour postprandial 7.8 mmol/L (140 mg/dL)) (21/86, 24%) (risk ratio (RR) 1.35, 95% confidence interval (CI) 0.83 to 2.18, one trial, 171 women; very low quality). Using the GRADE approach, we found the quality of the evidence to bevery low for caesarean section due to poor reporting of risk of bias, imprecision and publication bias. Strict glycaemic targets were associated with an increase in the use of pharmacological therapy (identified as the use of insulin in this study) (33/85; 39%) compared with liberal glycaemic targets (18/86; 21%) (RR 1.85, 95% CI 1.14 to 3.03; one trial, 171 women). CIs are wide suggesting imprecision and caution is required when interpreting the data. No other secondary maternal outcome data relevant to this review were reported. For the infant, there were no clear differences between the groups of women receiving strict and liberal glycaemic targets for macrosomia (birthweight greater than 4000 g) (RR 1.35, 95% CI 0.31 to 5.85, one trial, 171 babies); small-for-gestational age (RR 1.12, 95% CI 0.48 to 2.63, one trial, 171 babies); birthweight (mean difference (MD) -92.00 g, 95% CI -241.97 to 57.97, one trial, 171 babies) or gestational age (MD -0.30 weeks, 95% CI -0.73 to 0.13, one trial, 171 babies). Adverse effects data were not reported. No other secondary neonatal outcomes relevant to this review were reported.

AUTHORS' CONCLUSIONS

This review is based on a single study (involving 180 women) with an unclear risk of bias. The trial (which was only reported in a conference abstract) did not provide data for any of this review's primary outcomes but did provide data for a limited number of our secondary outcomes. There is insufficient evidence to guide clinical practice for targets for glycaemic control for women with GDM to minimise adverse effects on maternal and fetal health. Glycaemic target recommendations from international professional organisations for maternal glycaemic control vary widely and are reliant on consensus given the lack of high-quality evidence.Further high-quality trials are needed, and these should compare different glycaemic targets for guiding treatment of women with GDM, assess both short-term and long-term health outcomes for women and their babies, include women's experiences and assess health services costs. Four studies are ongoing.

Type 2 diabetes after gestational diabetes: greater than fourfold risk among Indigenous compared with non-Indigenous Australian women

BACKGROUND

Gestational diabetes is associated with a high risk of type 2 diabetes. However, progression rates among Indigenous women in Australia who experience high prevalence of gestational diabetes are unknown.

METHODS

This retrospective cohort study includes all births to women at a regional hospital in Far North Queensland, Australia, coded as having 'gestational diabetes' from 1 January 2004 to 31 December 2010 (1098 births) and receiving laboratory postpartum screening from 1 January 2004 to 31 December 2011 (n = 483 births). Women who did not receive postpartum screening were excluded from the denominator. Data were linked between hospital electronic records, routinely collected birth data and laboratories, with sample validation by reviews of medical records. Analysis was conducted using Cox-proportional regression models.

RESULTS

Indigenous women had a greater than fourfold risk of developing type 2 diabetes within 8 years of having gestational diabetes, compared with non-Indigenous women (hazards ratio 4.55, 95% confidence interval 2.63-7.88, p < 0.0001). Among women receiving postpartum screening tests, by 3, 5 and 7 years postpartum, 21.9% (15.8-30.0%), 25.5% (18.6-34.3%) and 42.4% (29.6-58.0%) Indigenous women were diagnosed with type 2 diabetes after gestational diabetes, respectively, compared with 4.2% (2.5-7.2%), 5.7% (3.3-9.5%) and 13.5% (7.3-24.2%) non-Indigenous women. Multivariate analysis showed an increased risk of developing type 2 diabetes among women with an early pregnancy body mass index ≥25 kg/m(2) , only partially breastfeeding at hospital discharge and gestational diabetes diagnosis prior to 17 weeks gestation.

CONCLUSIONS

This study demonstrates that, compared with non-Indigenous women, Indigenous Australian women have a greater than fourfold risk of developing type 2 diabetes after gestational diabetes. Strategies are urgently needed to reduce rates of type 2 diabetes by supporting a healthy weight and breastfeeding and to improve postpartum screening among Indigenous women with gestational diabetes. Copyright © 2015 John Wiley & Sons, Ltd.

The early life origin theory in the development of cardiovascular disease and type 2 diabetes

Life expectancy has been examined from a variety of perspectives in recent history. Epidemiology is one perspective which examines causes of morbidity and mortality at the population level. Over the past few 100 years there have been dramatic shifts in the major causes of death and expected life length. This change has suffered from inconsistency across time and space with vast inequalities observed between population groups. In current focus is the challenge of rising non-communicable diseases (NCD), such as cardiovascular disease and type 2 diabetes mellitus. In the search to discover methods to combat the rising incidence of these diseases, a number of new theories on the development of morbidity have arisen. A pertinent example is the hypothesis published by David Barker in 1995 which postulates the prenatal and early developmental origin of adult onset disease, and highlights the importance of the maternal environment. This theory has been subject to criticism however it has gradually gained acceptance. In addition, the relatively new field of epigenetics is contributing evidence in support of the theory. This review aims to explore the implication and limitations of the developmental origin hypothesis, via an historical perspective, in order to enhance understanding of the increasing incidence of NCDs, and facilitate an improvement in planning public health policy.

The risk factors and incidence of type 2 diabetes mellitus and metabolic syndrome in women with previous gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) affects nearly 5% of pregnancies. Significant proportion of the women with previous GDM develops type 2 diabetes mellitus (T2DM) in the next years, which indicates a higher risk in them than in the general population.

OBJECTIVES

We conducted this study to determine the risk factors and incidence of abnormal glucose level and metabolic syndrome (MetS) in women with a history of GDM in a long period after delivery in our region.

PATIENTS AND METHODS

We extracted the demographic characteristics of 110 women with GDM who had delivered during 2004 - 2010 in three main hospitals of Zanjan City, Iran. The patients were recalled to perform oral glucose tolerance test (OGTT) and other necessary tests for MetS diagnosis. Anthropometric measurements were recorded of all the participants.

RESULTS

In this study, 110 women with a history of GDM were studied at one to six years since delivery. Among these women, 36 (32.7%) developed T2DM and 11 (10%) had impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Moreover, 22 women (20%) had developed MetS. among those with abnormal results in glycemic test, 93.6% had fasting blood sugar (FBS) ≥ 95 mg/dL (≥ 5.27 mmol/L)at the time of GDM diagnosis in the index pregnancy that was significantly higher than the normal glycemic test (NGT) group with 42.9% being affected (OR, 19.55; P < 0.0001). There was a significant difference between those with abnormal results and NGT group in interval between delivery and performing laboratory tests (27 ± 18.8 and 18.5 ± 17.7 months, respectively; OR, 1.02; P = 0.02). No insulin use during pregnancy was discovered as a protective factor in women with a history of GDM (OR, 0.35; P = 0.01). Those with abnormal results were significantly different from NGT group in the number of parities (2.61 ± 1.4 vs. 2.05 ± 1.1, respectively; OR, 1.4; P = 0.03). The most common component of MetS among women with a history of GDM was FBS > 100 mg/dL (> 5.55 mmol/L).

CONCLUSIONS

Regarding the high incidence of the T2DM and MetS among women with a history of GDM, they should be screened at a regular interval for diabetes and other cardiovascular risk factors.

The prevalence of gestational diabetes mellitus among Aboriginal and Torres Strait Islander women in Australia: a systematic review and meta-analysis

INTRODUCTION

Gestational diabetes mellitus (GDM) is an important and increasing health problem. This study aims to investigate and explain the marked variation in reported GDM prevalence among Australian Indigenous women.

MATERIALS AND METHODS

We searched five databases to August 2013 for studies of GDM prevalence; two people independently assessed search results, extracted data, and appraised risk of bias. Meta-analysis was conducted, and between-study heterogeneity examined using subgroup analyses. Within-study findings were synthesized narratively.

RESULTS

The pooled GDM prevalence from 23 of the 25 total studies (5.74%, 4.78-6.71) was similar to that reported in national studies, but heterogeneity was substantial (I(2)  = 97%), making conclusions from between-study comparisons difficult. The greatest reductions in heterogeneity were seen within subgroups using localized diagnostic criteria (I(2)  = 43%, 3 studies), universal screening (I(2)  = 58%) and some jurisdictions, probably reflecting proxy measures of increased consistency in diagnostic and screening methods. Insufficient data were available to assess the effect of factors such as rurality, diagnostic criteria, study design and data sources on prevalence. Synthesis of within-study findings showed: higher age-adjusted prevalences of GDM in Indigenous versus non-Indigenous women; Indigenous women have greater increases in prevalence with maternal age; and non-Indigenous women appear to have a steeper increase in GDM prevalence over time. Prevalence increased almost fourfold in two studies following introduction of universal screening when compared with selective risk-based screening, although numbers were small.

DISCUSSION/CONCLUSIONS

The published GDM prevalence among Indigenous women varies markedly, probably due to variation in diagnostic and screening practices.

Improving health service delivery for women with diabetes in pregnancy in remote Australia: survey of care in the Northern Territory Diabetes in Pregnancy Partnership

BACKGROUND

In the Northern Territory (NT), 38% of 3500 births each year are to Indigenous women, 80% of whom live in regional and remote areas. Compared with the general Australian population, rates of pre-existing type 2 diabetes in pregnancy are 10-fold higher and rates of gestational diabetes are 1.5-fold higher among Indigenous women. Current practices in screening for diabetes in pregnancy in remote Australia are not known.

AIMS

To assess current health service delivery for NT women with diabetes in pregnancy (DIP) by surveying healthcare professionals' views and practices in DIP screening and management.

MATERIALS AND METHODS

A cross-sectional survey of NT healthcare professionals providing clinical care for women with DIP was conducted based on pre-identified themes of communication, care-coordination, education, orientation and guidelines, logistics and access, and information technology.

RESULTS

Of the 116 responders to the survey, 78% were primary healthcare professionals, 32% midwives and 25% general practitioners. High staff turnover was evident: of Central Australian professionals, only 33% (urban) and 18% (regional/remote) had been in their current position over 5 years. DIP screening was conducted at first antenatal visit by 66% and at 24-28-week gestation by 81%. Only 50% of respondents agreed that most women at their health service received appropriate care for DIP, and 41% of primary care practitioners were neutral or not confident in their skills to manage DIP.

CONCLUSIONS

It is promising that many healthcare professionals report following new guidelines in conducting early pregnancy screening for DIP in high risk women. Several challenges were identified in healthcare delivery to a high risk population in remote Australia.

Maternal health issues and cardio-metabolic outcomes in the offspring: a focus on Indigenous populations

Non-communicable diseases (NCDs) including diabetes, obesity and cardiovascular disease are the leading causes of death worldwide. Indigenous populations are disproportionally affected. In an effort to halt the increasing disease burden, the mechanisms underlying the increasing rate of NCDs are an important area of study. Recent evidence has focused on the perinatal period as an influential period impacting the future cardio-metabolic health of the offspring. This concept has been defined as metabolic foetal programming and supports the importance of the developmental origins of health and disease in research and clinical practice, specifically in prevention efforts to protect future generations from NCDs. An understanding of the underlying mechanisms involved is not clear as of yet. However, an understanding of these mechanisms is imperative in order to plan effective intervention strategies. As much of the discussion below is gleaned from large epidemiological studies and animal studies, further research with prospective cohorts is necessary.