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

Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2 =82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2 =82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2 =0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2 =0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2 =87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2 =0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

Systematic Review and Meta-analysis of Prenatal Risk Factors for Congenital Heart Disease: Maternal Chronic Diseases and Parental Exposures

BACKGROUND

There is considerable heterogeneity in studies on prenatal risk factors for congenital heart diseases (CHDs). We performed a meta-analysis of all nongenetic factors of CHDs. This report presents results of factors related to maternal chronic diseases and parental exposures.

METHODS

A systematic search encompassing concepts of CHD and risk factors was used, using the following inclusion criteria: (1) original peer-reviewed articles, (2) quantifying the effects of risk factors for CHDs, (3) between 1989 and 2022. Pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated using a random-effect model.

RESULTS

Inclusion criteria were met for 170 studies. There was an association between being overweight or obese and CHDs (OR, 1.26; 95% CI, 1.15-1.37), with a dose-effect relationship. Pregestational diabetes (PGDM) was associated with CHDs (OR, 3.51; 95% CI, 2.86-4.3), without difference between type 1 and type 2 PGDM. The effect size of gestational diabetes was less than that of PGDM (OR, 1.38; 95% CI, 1.18-1.61). There was an association between CHDs and pre-eclampsia (OR, 2.01; 95% CI, 1.32-3.05), paternal smoking (OR, 1.32; 95% CI, 1.03-1.70), and alcohol use (OR, 1.50; 95% CI, 1.08-2.08). A smaller association was found with maternal smoking and advanced maternal age.

CONCLUSIONS

There exists robust evidence for increased risk of CHD in the presence of obesity, maternal diabetes, maternal smoking, and increased maternal age. The effect sizes were relatively modest, except for PGDM. The robustness of the evidence decreased when CHDs were divided into subgroups or when the analyses were restricted to severe CHDs.

The Relationship Between Gestational Diabetes and Postpartum Depression: A Systematic Review

This study aims to examine the relationship between gestational diabetes mellitus (GDM) and the likelihood of postpartum depression (PPD) symptoms. PubMed, Scopus, Web of Science, ScienceDirect, and the Wiley Online Library were systematically searched for relevant literature. Our results included eight studies with a total of 4,209 women diagnosed with GDM and/or PPD. The prevalence of PPD in women diagnosed with GDM ranged from 6.5% to 48.4%. The included studies demonstrated that PPD was more likely to strike women with GDM. One study reported that the most severe type of GDM is more likely to occur in those with a history of depression. Perinatal depression during pregnancy can be strongly predicted by age, BMI, and a personal history of depression. The findings imply that GDM and the likelihood of depression during the postpartum phase are related. It was also found that there was a positive correlation between depression and the chance of having GDM. This emphasizes how the association between GDM and depression appears to be reciprocal. However, the association does not imply causation, and the data at hand do not allow for the establishment of causality. Subsequent studies ought to endeavor to show causative connections between GDM and depression as well as pinpoint shared underlying endocrine variables that may play a role in the genesis of both conditions. The available information that is now available is limited due to the complexity of the etiology of both GD and depression in pregnant women; nonetheless, prevention of both conditions depends on a better understanding of the link between GD and depression. The risk of bias in the included studies was moderate to high.

2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Trends in cardiovascular complications of pregnancy: A nationwide inpatient sample analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. Physiologic stress of pregnancy can induce several hemodynamic changes that contribute to an increased risk of cardiac complications in the peripartum period. There are ongoing efforts to improve cardiovascular mortality in pregnant patients. Understanding trends in cardiovascular complications during pregnancy may provide insight into improving care for high-risk pregnancies.

METHODS

We retrospectively analyzed data from the National Inpatient Sample (NIS) Database and identified all inpatient hospitalizations for pregnancy and delivery. We then analyzed trends in the rates of cardiac complications in the pregnant patient.

RESULTS

There are concerning increases in trends of cardiac complications and comorbidities in pregnant people including: acute coronary syndrome, spontaneous coronary artery dissection, cardiogenic shock, pulmonary hypertension, chronic congestive heart failure, heart transplant, aortic syndromes, stroke, and pulmonary embolism. While the rates of STEMI have decreased, the incidence of peripartum cardiomyopathy has remained stable.

CONCLUSION

There are concerning increases in certain cardiac complications during pregnancy. This is likely due to increasing age at the time of pregnancy and associated comorbidities.

Comparing the detection rate of postpartum diabetes in early and 4-12 week postpartum screening tests in women with gestational diabetes mellitus: A systematic review and meta-analysis

Gestational Diabetes Mellitus (GDM) is one of the critical risk factors for diabetes mellitus (DM). An early postpartum test done in the first few postpartum days can increase the screening rate in women with GDM. Therefore, this systematic review and meta-analysis aimed to combine and analyze data from different studies reporting the detection rate of postpartum diabetes in early and 4-12 week postpartum screening tests in women with GDM. ProQuest, Web of Science, EMBASE, PubMed, Cochrane, and Scopus were searched for English articles from January 1985 to January 2021. Two independent reviewers selected the eligible studies, and the outcomes of interest were extracted. The quality of studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for diagnostic test accuracy studies. Sensitivity and specificity, negative likelihood ratio (NLR), and positive likelihood ratio (PLR) were calculated for the early postpartum oral glucose tolerance test (OGTT). Of 1944 initially identified articles, four studies were included. The sensitivity and specificity of the early test were 74% and 56%, respectively, and the PLR and NLR were calculated as 1.7 and 0.4, respectively. The sensitivity of the early test was higher than the specificity. Based on this sensitivity and specificity, normal cases could be distinguished from abnormal cases, including diabetes and glucose intolerance. Early postpartum OGTT can be advised before hospital discharge. Early testing is a practical option in patients with GDM. Further studies are required to evaluate the early test detection rate for DM and glucose intolerance separately.

The Bidirectional Relationship between Gestational Diabetes and Depression in Pregnant Women: A Systematic Search and Review

This systematic search and review aims to understand the two-way relationship between gestational diabetes and depression. This study assesses gestational diabetes in relation to a history of depression, depression during pregnancy and postpartum depression. Searches were conducted on PubMed and Scopus. Studies were excluded due to being duplicates, not available, published before 2015 or did not include both gestational diabetes and depression. Of the 915 articles initially identified, 22 articles were included for review. Of the included studies, 18 were cohorts, 2 were case-controls, 1 was cross-sectional and 1 was a claims analysis. A meta-ethnography was conducted, and a bidirectional relationship was observed between a history of depression, depression during pregnancy, postpartum depression and gestational diabetes. Differing methodologies between studies were a limiting factor throughout this review. A two-way relationship between gestational diabetes and depression was observed; the diagnosis of gestational diabetes may lead to an increased risk of depression, both during the pregnancy and in the postpartum period, and a history of depression or symptoms of depression during pregnancy may lead to an increased risk of gestational diabetes.

Risk of birth defects by pregestational type 1 or type 2 diabetes: National Birth Defects Prevention Study, 1997-2011

BACKGROUND

Previous studies found consistent associations between pregestational diabetes and birth defects. Given the different biological mechanisms for type 1 (PGD1) and type 2 (PGD2) diabetes, we used National Birth Defects Prevention Study (NBDPS) data to estimate associations by diabetes type.

METHODS

The NBDPS was a study of major birth defects that included pregnancies with estimated delivery dates from October 1997 to December 2011. We compared self-reported PGD1 and PGD2 for 29,024 birth defect cases and 10,898 live-born controls. For case groups with ≥5 exposed cases, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between specific defects and each diabetes type. We calculated crude ORs (cORs) and 95% CIs with Firth's penalized likelihood for case groups with 3-4 exposed cases.

RESULTS

Overall, 252 (0.9%) cases and 24 (0.2%) control mothers reported PGD1, and 357 (1.2%) cases and 34 (0.3%) control mothers reported PGD2. PGD1 was associated with 22/26 defects examined and PGD2 was associated with 29/39 defects examined. Adjusted ORs ranged from 1.6 to 70.4 for PGD1 and from 1.6 to 59.9 for PGD2. We observed the strongest aORs for sacral agenesis (PGD1: 70.4, 32.3-147; PGD2: 59.9, 25.4-135). For both PGD1 and PGD2, we observed elevated aORs in every body system we evaluated, including central nervous system, orofacial, eye, genitourinary, gastrointestinal, musculoskeletal, and cardiac defects.

CONCLUSIONS

We observed positive associations between both PGD1 and PGD2 and birth defects across multiple body systems. Future studies should focus on the role of glycemic control in birth defect risk to inform prevention efforts.

ASSESSMENT OF NEONATAL AND MATERNAL COMPLICATIONS IN PREGNANT WOMEN WITH GESTATIONAL DIABETES IN THE IRANIAN POPULATION

Context

Gestational diabetes mellitus (GDM) is one of the most common complications during pregnancy. It is also a growing problem worldwide and is associated with many maternal and fetal complications during and after pregnancy.

Objective

This study aimed to investigate the neonatal and maternal complications of gestational diabetes in the Iranian population of pregnant women.

Design

This prospective cohort study was carried out on the health assessment data of pregnant women in the age range of 18-45 years who were referred to health centers affiliated with Mashhad University of Medical Sciences, Mashhad, Iran, from March 2019 to September 2020.

Subjects and Methods

Overall, 2,500 pregnant women with GDM and 7,700 healthy pregnant women were enrolled in the GDM and healthy groups, respectively. Individuals' data were recorded in an electronic health record system (SINA System) and were later collected and analyzed.

Results

Significant between-group differences were observed in terms of cesarean delivery risk, hypertension, fetal macrosomia, preeclampsia, preterm birth, fetal birth weight, and neonatal icterus in GDM and non-GDM groups. However, no significant differences were found in terms of stillbirth, and low birth weight between the two groups. Based on the logistic regression model, GDM significantly increased the risk of cesarean delivery, fetal macrosomia, and neonatal icterus.

Conclusions

The fetal macrosomia leading to the cesarean delivery, and neonatal icterus were determined as the significant complications of GDM in the Iranian population. These results can provide valuable insight into healthcare planning.

2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Primary care nurse practitioner practices to lower type 2 diabetes risks in women with a history of gestational diabetes mellitus

BACKGROUND

Women with a gestational diabetes mellitus (GDM) history have increased lifetime type 2 diabetes (T2D) risk, with 16 times greater risk 3 to 6 years after the pregnancy, compared with women without GDM. Offspring from diabetes-complicated pregnancies also face increased health risks.

PURPOSE

The study purpose was to describe the primary care practices of nurse practitioners (NPs) aimed at reducing T2D-related health risks in women with a history of GDM.

METHODOLOGY

Florida-licensed primary care NPs (n = 47) completed a 57-item online survey that included an 8-item scale about recommended practices to reduce T2D risks for women with GDM history. Descriptive statistics, Chi Square test, and Fisher exact test were conducted.

RESULTS

Most (67%) participants "often/always" screened for T2D every 1-3 years per guidelines, but only 31.8% "often/always" advised about pregnancy planning/preconception T2D assessment. Compared with "none" or ≤2 hours of GDM care education, participants with >2 hours were more likely (p < .05) to "often/always" perform five recommended practices: 1) counsel about increased T2D risks; 2) educate about self-advocacy for T2D screening; 3) T2D screening every 1-3 years; 4) counsel about breastfeeding to reduce T2D risk; and 5) discuss postpartum weight loss and increased physical activity to lower T2D risk.

CONCLUSION

Findings indicate inconsistent care practices and suggest that >2 hours of education about care of women with GDM history may increase primary care NPs performing recommended practices to reduce T2D risks and prevent health problems for women and future offspring.

IMPLICATIONS

Nurse practitioner education is needed involving care of women with GDM history to mitigate risks for T2D.

Does the risk of embryo abnormality increase in PCOS women? A secondary analysis of a multi-center randomized controlled trial

CONTEXT

Some studies reported the early miscarriage rate was higher in PCOS women. However, whether the risk of embryo abnormalities increases in PCOS women is lack of evidence.

OBJECTIVE

To evaluate the association between polycystic ovarian syndrome (PCOS) and embryo ploidy.

DESIGN

A secondary analysis of multi-center randomized controlled trial which was conducted from July 2017 to June 2018. The original intent was to identify whether preimplantation genetic test for aneuploidy (PGT-A) improves the live birth rate as compared with in-vitro fertilization (IVF).

SETTING

14 reproductive centers.

PATIENTS

190 patients diagnosed with PCOS and 1:1 age-matched non-PCOS patients were chosen from PGT-A group. A total of 380 patients with 1118 embryos were included in our study.

INTERVENTIONS

Women diagnosed with PCOS.

MAIN OUTCOME MEASURES

Embryonic aneuploidy and embryonic mosaic.

RESULTS

After adjusted for potential confounders, the rate of embryonic aneuploidy and embryonic mosaic in PCOS group were comparable with control group [embryonic aneuploid rate PCOS group: 14.0% vs control group: 18.3%, adjusted OR (95%CI): 0.78(0.54,1.12), P = 0.19; embryonic mosaic rate 10.9% vs 10.1%, adjusted OR (95%CI): 0.91(0.59,1.40), P = 0.66]. We further stratified PCOS women into four groups according to phenotype. The rate of aneuploid and mosaic embryos was comparable between each of PCOS phenotype and control group. There was still no significant difference of embryonic aneuploid and embryo mosaic rates within four phenotypes.

CONCLUSIONS

The risk of aneuploid and mosaic embryos was not increased in PCOS women. Thus, we suggests that the miscarriage rate arising from abnormal embryonic chromosomes could be similar between PCOS and non-PCOS women.

Need for Improved Collection and Harmonization of Rural Maternal Healthcare Data

Representation in data sets is critical to improving healthcare for the largest possible number of people. Unfortunately, pregnancy is a very understudied period of time. Further, the gap in available data is wide between pregnancies in urban areas versus rural areas. There are many limitations in the current data that is available. Herein, we review these limitations and strengths of available data sources. In addition, we propose a new mechanism to enhance the granularity, depth, and speed with which data is made available regarding rural pregnancy.

Societal cost of nine selected maternal morbidities in the United States

OBJECTIVE

To estimate the cost of maternal morbidity for all 2019 pregnancies and births in the United States.

METHODS

Using data from 2010 to 2020, we developed a cost analysis model that calculated the excess cases of outcomes attributed to nine maternal morbidity conditions with evidence of outcomes in the literature. We then modeled the associated medical and nonmedical costs of each outcome incurred by birthing people and their children in 2019, projected through five years postpartum.

RESULTS

We estimated that the total cost of nine maternal morbidity conditions for all pregnancies and births in 2019 was $32.3 billion from conception to five years postpartum, amounting to $8,624 in societal costs per birthing person.

CONCLUSION

We found only nine maternal morbidity conditions with sufficient supporting evidence of linkages to outcomes and costs. The lack of comprehensive data for other conditions suggests that maternal morbidity exacts a higher toll on society than we found.

POLICY IMPLICATIONS

Although this study likely provides lower bound cost estimates, it establishes the substantial adverse societal impact of maternal morbidity and suggests further opportunities to invest in maternal health.

The Fibrinolytic System in Peripartum Depression

The relationship between depression and reduced fibrinolytic activity reflects the role of tissue plasminogen activator and plasmin in brain remodeling underlying resilience, depression remission, and reward processing, rather than the dissolution of fibrin clots. Individuals who experience depression demonstrate hippocampal and prefrontal cortex atrophy, as well as impaired neuronal connectivity. Brain-derived neurotrophic factor (BDNF), synthesized as a precursor that is activated through cleavage by tissue plasminogen activator and plasmin, influences adult neurogenesis and neuronal plasticity in the hippocampus and prefrontal cortex. Depression is associated with decreased brain levels of BDNF, due to reduced activity of tissue plasminogen activator and plasmin. Tissue plasminogen activator and plasmin also mediate the release of dopamine, a neurotransmitter implicated in motivation and reward. Peripartum depression defines a depressive episode that occurs during pregnancy or in the first month after delivery, reinforcing the concept that postpartum depression may be a continuum of antenatal depression. This article describes the fibrinolytic status in the healthy brain, in stress and depression, emphasizing the links between biological markers of depression and defective fibrinolysis. It also discusses the association between hypofibrinolysis and risk factors for perinatal depression, including polycystic ovary syndrome, early miscarriage, preeclampsia, stressful life events, sedentariness, eating habits, gestational and type 2 diabetes, and antithyroid peroxidase antibodies. In addition, it reviews the evidence that antidepressant medications and interventions as diverse as placebo, psychotherapy, massage, video game playing, regular exercise, dietary modifications, omega 3 fatty acid supplementation, neurohormones, and cigarette smoking may reduce depression by restoring the fibrinolytic activity. Last, it suggests new directions for research.

Effect of Maternal Glucose and Triglyceride Levels during Early Pregnancy on Pregnancy Outcomes: A Retrospective Cohort Study

Maternal dysglycemia and lipid metabolic dysfunction have been recognized as risk factors for pregnancy complications and adverse perinatal outcome jointly and separately, but current diagnostic window-period which is at the end of the second trimester might be late to avoid chronic adverse impacts on both mother and fetus. A retrospective cohort study involving 48,973 women with fasting blood glucose (FPG) below diagnostic thresholds and lipid screening in early pregnancy was performed. Data of pregnancy outcomes including gestational diabetes mellitus (GDM), hypertensive disorders in pregnancy (HDP), and neonatal outcomes were obtained for multivariable logistic analysis. As a result, higher FPG (≥75th, 4.68 mM) significantly increased risks of GDM (Adjusted odds ratio (AOR), 2.81; 95% CI, 2.60 to 3.05) and HDP (1.98; 1.81 to 2.16), and slightly increased risks of large for gestational age (LGA), macrosomia births and neonatal intensive care unit (NICU) compared to women with low FPG (≤25th, 4.21 mM). High maternal triglyceride (mTG) level had higher risks of GDM and HDP in all maternal FPG strata. Further analysis showed that women of top quartile of glucose combined with upper 10 percentile triglyceride have higher risks for GDM (AOR, 5.97; 95% CI, 5.26 to 6.78; risk difference 30.8, 95% CI 29.2 to 32.3) and HDP (AOR, 2.56; 95% CI, 2.20 to 2.99, risk difference 11.3, 95% CI 9.9 to 12.7) when compared to those in women of the bottom strata after adjustment. Therefore, both the early-pregnancy FPG and mTG levels should be screened among overall population including the low-risk population to reduce the incidence of pregnancy complications.

Contraceptives, chronic illness, pregnancy and health care costs in one health insurance in Colombia

Objetive Evaluation of the impact of pregnancy on women with a high disease burden, especially with Chronic Non-Communicable Diseases (CNCD) in the costs of a health insurer. Materials and Methods Retrospective costing study conducted at Famisanar EPS between 2016 and 2018. We used multiple linear regression models to evaluate; the overall costs were calculated for each patient. The insurer's perspective was taken into account for the analysis. Results The study universe was made up of 458 249 women of childbearing age affiliated to Famisanar EPS between 15 and 49 years, of which 24 030 (5.2%) women have some relationship with the CNCD, of these, 2 454 (10.2%) went to childbirth and caesarean section. We had determined the costs of pregnancy healthy´s women in U$200.41 and pregnancy CNCD´s women U$519.95 (97.5%) in terms of the costs for the complication’s gestation care. Using multinomial regression, we compared the pregnancy with CNCD with the other groups of women. We did not observe any significant differences in ingress and zone. However, we observe signicant differences in the age. Conclusion Pre-existing CNCD in pregnant women can lead to the use of additional resources in the health system. CNCD in society represent a severe burden for a health system due to high costs and especially when talking about women who have an CNCD and are in pregnant. The study also indicates that female infertility treatments are important for cost containment in health systems.

IDF Diabetes Atlas: The prevalence of pre-existing diabetes in pregnancy - A systematic reviewand meta-analysis of studies published during 2010-2020

OBJECTIVES

To estimate the prevalence of pre-existing diabetes in pregnancy from studies published during 2010-2020.

METHODS

We searched PubMed, CINAHL, Scopus and other sources for relevant data sources. The prevalence of overall pre-existing, type 1 and type 2 diabetes, by country, region and period of study was synthesised from included studies using the inverse-variance heterogeneity model and the Freeman-Tukey transformation. Heterogeneity was assessed using the I² statistic and publication bias using funnel plots.

RESULTS

We identified 2479 records, of which 42 data sources with a total of 78 943 376 women, met the eligibility criteria. The included studies were from 17 countries in North America, Europe, the Middle East and North Africa, Australasia, Asia and Africa. The lowest prevalence was in Europe (0.5%, 95 %CI 0.4-0.7) and the highest in the Middle East and North Africa (2.4%, 95 %CI 1.5-3.1). The prevalence of pre-existing diabetes doubled from 0.5% (95 %CI 0.1-1.0) to 1.0% (95 %CI 0.6-1.5) during the period 1990-2020. The pooled prevalences of pre-existing type 1 and type 2 diabetes were 0.3% (95 %CI 0.2-0.4) and 0.2% (95 %CI 0.0-0.9) respectively.

CONCLUSION

While the prevalence of pre-existing diabetes in pregnancy is low, it has doubled from 1990 to 2020.

The association between gestational diabetes and stillbirth: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Controversy exists over whether gestational diabetes increases the risk of stillbirth. The aim of this review was to examine the association between gestational diabetes and stillbirth.

METHODS

We performed searches of the published literature to May 2021. Study selection and data extraction were performed in duplicate by independent reviewers. Meta-analyses of summary measures were conducted using random-effect models for cohort and case-control studies separately. The study protocol was registered in PROSPERO (registration ID CRD42020166939).

RESULTS

From 9981 citations, 419 were identified for full-text review and 73 met inclusion criteria (n = 70,292,090). There was no significant association between gestational diabetes and stillbirth in cohort studies (pooled OR 1.04 [95% CI 0.90, 1.21]; I² 86.1%) or in case-control studies (pooled OR 1.57 [95% CI 0.83, 2.98]; I² 94.8%). Gestational diabetes was associated with lower odds of stillbirth among cohort studies presenting with an adjusted OR (pooled OR 0.78 [95% CI 0.68, 0.88]; I² 42.7%). Stratified analyses by stillbirth ≥28 weeks' gestation, studies published prior to 2013 and studies identified as low quality demonstrated a significantly higher odds of stillbirth in meta-regression (p = 0.016, 0.023 and 0.005, respectively). Egger's test for all included cohort studies (p = 0.018) suggests publication bias for the main meta-analysis.

CONCLUSIONS/INTERPRETATION

Given the substantial heterogeneity across studies, there are insufficient data to define the relationship between stillbirth and gestational diabetes adequately. In the main analyes, gestational diabetes was not associated with an increased risk of stillbirth. However, heterogeneity across studies means this finding should be interpreted cautiously.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Role of Osteocalcin in Placental Function in Gestational Diabetes Mellitus

Evidence for the role of osteocalcin in glucose metabolism is increasing. The aim of this study was to examine the associations between osteocalcin and gestational diabetes mellitus. Thirteen discovery study subjects and 76 reduplication study subjects were recruited from the Maternal and Child Health Hospital Guangxi Zhuang Autonomous Region from May 2018 to August 2018. Total osteocalcin and biochemical indices of maternal serum and umbilical vein serum were analyzed. Placental tissue samples were used for transcriptome sequencing. For the discovery study subjects, the total osteocalcin concentration in umbilical vein serum was significantly higher than that in maternal serum and umbilical artery serum (55.32 ng/mL ± 17.37 vs. 12.06 ng/mL ± 5.42 [P < 0.001] vs. 38.31 ng/mL ± 11.52 [P < 0.01]), suggesting that trophoblasts may synthesize osteocalcin. In a reduplication subject study, the gestational diabetes mellitus group had lower umbilical vein serum total osteocalcin (51.46 ng/mL ± 24.29 vs. 67.00 ng/mL ± 25.33, P = 0.008), lower adiponectin (1099.72 μg/L ± 102.65 vs. 1235.85 μg/L ± 94.63, P < 0.001). Spearman's correlation analysis showed that umbilical vein serum total osteocalcin levels were closely correlated with leptin (r = -0.456, P = 0.007). A coexpression model of the placental RNA sequence was constructed. Two modules were correlated with osteocalcin, and the Gene ontology pathways of these modules were rich in glucose and lipid metabolism. In conclusion, the placenta may synthesize osteocalcin by itself, and a lower osteocalcin level in umbilical vein serum is associated with gestational diabetes mellitus.

Congenital Malformation Risk According to Hemoglobin A1c Values in a Contemporary Cohort with Pregestational Diabetes

OBJECTIVE

The study aimed to evaluate the association between hemoglobin A1c values and likelihood of fetal anomalies in women with pregestational diabetes.

STUDY DESIGN

Women with pregestational diabetes who delivered at a single institution that serves a nonreferred population from May 1, 2009 to December 31, 2018 were ascertained. Hemoglobin A1c values were obtained at the first prenatal visit. Women who delivered a singleton live- or stillborn infant with a major malformation as defined by European Surveillance of Congenital Anomalies criteria were identified. In infants with multiple system anomalies, each malformation was considered separately. Hemoglobin A1c values were analyzed categorically by using Mantel-Haenszel method and continuously with linear regression for trend for fetal anomalies.

RESULTS

A total of 1,676 deliveries to women with pregestational diabetes were delivered at our institution, and hemoglobin A1c was assessed in 1,573 deliveries (94%). There were 129 deliveries of an infant with at least one major malformation, an overall anomaly rate of approximately 8%. Mean hemoglobin A1c concentration was significantly higher in pregnancies with anomalous infants, 9.3 ± 2.1% versus 8.0 ± 2.1%, and p <0.001. There was no difference in gestational age at the time hemoglobin A1c was obtained, 13 ± 8.3 versus 14 ± 8.7 weeks. Hemoglobin A1c was associated with increased probability of a congenital malformation. This reached 10% with a hemoglobin A1c concentration of 10%, and 20% with a hemoglobin A1c of 13%. Similar trends were seen when examining risk of anomalies by organ system with increasing hemoglobin A1c levels, with the greatest increase in probability for both cardiac and genitourinary anomalies.

CONCLUSION

In women with pregestational diabetes, hemoglobin A1c is strongly associated with fetal anomaly risk. Data from a contemporary cohort may facilitate counseling and also highlight the need for preconceptual care and glycemic optimization prior to entry to obstetric care.

KEY POINTS

· Infants of diabetic mothers had an 8% major anomaly rate.. · HbA1c of 10% in pregnancy associated with 10% anomaly rate.. · HbA1c of 13% in pregnancy associated with 20% anomaly rate.. · Preconceptual care is important to reduce prevalence..

Pregnancy outcomes and maternal characteristics in women with pregestational and gestational diabetes: a retrospective study on 206,917 singleton live births

AIMS

To examine risk of adverse pregnancy outcomes, mothers' characteristics and incidence rate over time of pregestational type 1 (T1D), type 2 (T2D) or gestational diabetes (GDM).

METHODS

The study included all singleton live births born from women aged 15-45 year, in Tuscany, Italy from 2010 to 2018. Pregnancy outcomes were retrieved by certificates of care at delivery compiled by midwives. Pregestational diabetes and GDM were identified by regional administrative databases. Time course of pregestational diabetes and GDM across last decade was assessed by Poisson analysis. Logistic regression analysis was used to calculate adjusted odds ratios (OR; 95% CI) for maternal characteristics or neonatal outcomes.

RESULTS

Among 206,917 singleton live births, GDM was diagnosed in 21,613 pregnancies (10.46%) and pregestational diabetes in 979, being T2D more prevalent than T1D (606; 0.29% vs. 373; 0.18%). Pregestational T2D incidence progressively decreased over last decade, T1D remained stable while GDM progressively rose. Pre-pregnancy obesity, preterm deliveries or cesarean sections were common characteristics of pregestational diabetes and GDM. Risk of neonatal distress and neonatal malformations was higher in pregestational T1D. Risk of prior spontaneous abortions was higher in GDM and in pregestational T2D (OR: 4.19; 3.30-5.33), mostly treated with metformin. Risk of neonatal macrosomia was increased only in pregestational diabetes.

CONCLUSIONS

In our population, pregestational T2D was more prevalent than T1D. Neonatal complications were mostly associated with pregestational T1D. Increased risk of previous spontaneous abortions was the hallmark of pregestational T2D. GDM, even if sharing adverse outcomes with pregestational T2D, was unrelated to rise in risk of neonatal macrosomia.

An integrated pre-pregnancy care programme framework theoretically modelled from the perspectives of women with Type 2 diabetes and healthcare professionals

BACKGROUND

Pregnancies in women with diabetes are associated with significant additional risks for the fetus, infant and mother such as, higher risk of stillbirths or congenital anomalies. Pre-pregnancy care can attenuate these risks. However, while women with Type 2 diabetes account for half of pregnancies in women with pre-existing diabetes, they are much less likely to receive pre-pregnancy care than women with Type 1 diabetes. This discrepancy may be related to the fact that most pre-pregnancy care is located in specialist diabetes centres where women with Type 1 diabetes are managed; whereas women with Type 2 diabetes are managed in primary care and reproductive care is not a routine element of diabetes care. Therefore, to improve pre-pregnancy care among women with Type 2 diabetes strategies need to be tailored to the specific needs of this group and the context of their diabetes care.

OBJECTIVES

This paper seeks to inform the development of an integrated pre-pregnancy care programme by presenting strategies identified by women with Type 2 diabetes and healthcare professionals that address some of the barriers they experience in relation to pre-pregnancy care.

METHODS

A qualitative study using semi-structured in-depth interviews with women of reproductive age with Type 2 diabetes (n=30) and diabetes healthcare professionals (n=22) from both primary and secondary care. Data were transcribed verbatim and analysed thematically using Framework Analysis. The identified themes were then mapped to create a theoretical intervention framework using Normalisation Process Theory and the Capabilities, Opportunity, and Motivation to perform a Behaviour model.

RESULTS

Six themes were identified expressing the need for a multimodal approach for improving the uptake of pre-pregnancy care in women with Type 2 diabetes. These themes were then mapped onto the constructs of Normalisation Process Theory as follows: coherence (enhancing understanding of reproductive needs among women and healthcare professionals); cognitive participation (constructing a positive narrative for pregnancy and Type 2 diabetes); collective action (increasing the visibly of the reproductive needs of women, integrating healthcare systems and utilising supportive technologies); and reflexive monitoring (using multi-modal approaches to support systemised care). The data were also modelled to identify target behaviours for intervention detailing what needs to be done by whom, when and where.

CONCLUSION

Women with Type 2 diabetes account for half of pregnancies in those with pre-existing diabetes; however, they are less likely to receive pre-pregnancy care than women with Type 1 diabetes. Pre-pregnancy care can reduce the maternal and fetal risks associated with Type 2 diabetes. This study presents strategies to improve the current low uptake of pre-pregnancy care for women with Type 2 diabetes. These strategies have been tailored to the specific needs of women and healthcare professionals and support integration within the woman's routine diabetes management.

Risk factors for pregnancy outcomes in Type 1 and Type 2 diabetes

BACKGROUND

Understanding the risk factors and pregnancy outcomes in women affected by Type 1 and Type 2 diabetes is important for pre-pregnancy counselling.

AIM

To explore differences in pregnancy outcomes between women with Type 1 and Type 2 diabetes, and healthy controls, and to examine the relationships between potential adverse risk factors and pregnancy outcomes in this cohort of women.

METHODS

This is a 10-year retrospective study of women with Type 1 diabetes (n = 92), Type 2 diabetes (n = 106) and healthy women without diabetes (controls) (n = 119) from a tertiary obstetric centre. Clinical and biochemical characteristics of women with Type 1 and Type 2 diabetes were determined and related to major obstetric outcomes using univariate analysis.

RESULTS

Women with pre-existing diabetes had higher adverse pregnancy outcomes (preeclampsia, emergency caesarean section, preterm birth <32 and 37 weeks, large for gestational age, neonatal jaundice, Apgar score < 7 at 5 min, neonatal intensive care admission and neonatal hypoglycaemia) compared to controls. A higher birth weight gestational centile (97.4% vs 72.4%, P = 0.001) and large for gestational age rate (63.4% vs 35.8%, P = 0.001) were observed in Type 1 diabetes compared to Type 2 diabetes. There were no differences in other outcomes between women with Type 1 and 2 diabetes.

CONCLUSION

In this exploratory study, risk factors for maternal adverse outcomes differ between Type 1 and Type 2 diabetes. Maternal and foetal adverse outcomes were higher in pregnancies affected by diabetes compared to healthy women but occurred with similar frequency in women with Type 1 and Type 2 diabetes.

Time in Range in Pregnancy: Is There a Role?

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

Trends in Prevalence of Diabetes among Twin Pregnancies and Perinatal Outcomes in Catalonia between 2006 and 2015: The DIAGESTCAT Study

The aims of our study were to evaluate the trends in the prevalence of diabetes among twin pregnancies in Catalonia, Spain between 2006 and 2015, to assess the influence of diabetes on perinatal outcomes of twin gestations and to ascertain the interaction between twin pregnancies and glycaemic status. A population-based study was conducted using the Spanish Minimum Basic Data Set. Cases of gestational diabetes mellitus (GDM) and pre-existing diabetes were identified using ICD-9-CM codes. Data from 743,762 singleton and 15,956 twin deliveries between 2006 and 2015 in Catalonia was analysed. Among twin pregnancies, 1088 (6.82%) were diagnosed with GDM and 83 (0.52%) had pre-existing diabetes. The prevalence of GDM among twin pregnancies increased from 6.01% in 2006 to 8.48% in 2015 (p < 0.001) and the prevalence of pre-existing diabetes remained stable (from 0.46% to 0.27%, p = 0.416). The risk of pre-eclampsia was higher in pre-existing diabetes (15.66%, p = 0.015) and GDM (11.39%, p < 0.001) than in normoglycaemic twin pregnancies (7.55%). Pre-existing diabetes increased the risk of prematurity (69.62% vs. 51.84%, p = 0.002) and large-for-gestational-age (LGA) infants (20.9% vs. 11.6%, p = 0.001) in twin gestations. An attenuating effect on several adverse perinatal outcomes was found between twin pregnancies and the presence of GDM and pre-existing diabetes. As a result, unlike in singleton pregnancies, diabetes did not increase the risk of all perinatal outcomes in twins and the effect of pre-existing diabetes on pre-eclampsia and LGA appeared to be attenuated. In conclusion, prevalence of GDM among twin pregnancies increased over the study period. Diabetes was associated with a higher risk of pre-eclampsia, prematurity and LGA in twin gestations. However, the impact of both, pre-existing diabetes and GDM, on twin pregnancy outcomes was attenuated when compared with its impact on singleton gestations.

Periconception glycemic control and congenital anomalies in women with pregestational diabetes

INTRODUCTION

To assess the relationship between periconception glycemic control and congenital anomalies in a contemporary, diverse population of women with pregestational diabetes.

RESEARCH DESIGN AND METHODS

This is a retrospective cohort study of all pregnant women with pregestational diabetes at a single institution (2003-2017) in the USA. The primary outcome was frequency of major or minor congenital anomalies. Glycemic control was assessed by periconception glycosylated hemoglobin (HbA1c). The association of periconception HbA1c with pregnancy outcomes was assessed using bivariable and multivariable analyses.

RESULTS

Our sample included 351 women, of which 63.8% had type 2 diabetes. Our study cohort is racially and ethnically diverse, with approximately equal numbers of women identifying as white non-Hispanic, black non-Hispanic and Hispanic, with 3.4% identifying as Asian. Of these 351 women, 52 (14.8%) had a fetus with a congenital anomaly, of whom the majority (n=43) had a major anomaly. Over half (51.1%) of all major anomalies were cardiovascular. Compared with the group with the best glycemic control (HbA1c ≤7.4%), which had an anomaly frequency of 10.2%, the frequency of congenital anomalies increased significantly with each category of worsening glycemic control (HbA1c 7.5%-9.4%: 20.6%, adjusted OR (aOR) 2.35, 95% confidence interval (CI) 1.08 to 5.13; HbA1c 9.5% to 11.4%: 25.8%, aOR 2.86, 95% CI 1.08 to 7.59; HbA1c ≥11.5%: 37.5%, aOR 7.66, 95% CI 2.27 to 25.9).

CONCLUSION

In a diverse cohort of women with pregestational diabetes, higher periconception HbA1c, especially HbA1c >9.5, was significantly associated with major congenital fetal anomalies. Our study sample is reflective of the current population of pregnant women with diabetes, including women with type 2 diabetes and from racial and ethnic minorities.

Preconception Evaluation Before In Vitro Fertilization

Importance

Infertility poses a substantial public health problem for women of reproductive age, in the United States and globally. Infertility can be overcome with a variety of emerging assisted reproductive technologies (ARTs). In vitro fertilization (IVF) currently represents the most commonly utilized method of ART and is typically associated with the highest clinical pregnancy rate and live birth rate compared with other infertility treatment options. However, proper preconception evaluation and counseling is paramount for optimizing IVF and pregnancy outcomes.

Objective

This article aims to outline current guidelines and recommendations for comprehensive preconception evaluation before initiation of IVF.

Evidence Acquisition

Articles were obtained from PubMed, ACOG committee opinions 781 and 762, and relevant textbook chapters.

Results

A variety of recommendations and best practices exist for optimally managing patients seeking IVF. Special attention must be paid to the workup of certain patient populations, such as those with age older than 35 years, uterine abnormalities, comorbidities (especially hypertension, diabetes, and thrombophilias), and obesity. In addition, many lifestyle factors must be addressed before IVF initiation, such as smoking, illicit drug use, and inadequate nutrition. Preconception counseling and expectation management is key to optimizing pregnancy outcome.

Conclusion and Relevance

A myriad of patient and environmental factors impact the potential success rates of IVF in treating infertility. Providers must be equipped to provide data-driven, patient-centered counseling before initiation of IVF.

Trends in prevalence of gestational diabetes mellitus in Zhejiang Province, China, 2016-2018

Background

Limited population-based studies have investigated the secular trend of prevalence of gestational diabetes mellitus (GDM) in mainland China. Therefore, this study aimed to estimate the prevalence of GDM and time trends in Chinese female population.

Methods

Based on Diabetes Surveillance System of Zhejiang Province, 97,063 diagnosed GDM cases aged 20–50 years were identified from January 1, 2016 to December 31, 2018. Annual prevalence, prevalence rate ratios (PRRs) and average annual percentage change with their 95% confidence intervals (CIs) were reported.

Results

The age-standardized overall prevalence of GDM was reported to be 7.30% (95% CI 7.27–7.33%); 9.13% (95% CI 9.07–9.19%) in urban areas and 6.24% (95% CI 6.21–6.27%) in rural areas. Compared with 20–24 years age group, women in advanced age groups (25–50 years) were at higher risk for GDM (PRRs ranged from 1.37 to 8.95 and the 95% CIs did not include the null). Compared with rural areas, the risk for GDM was higher in urban areas (PRR: 1.69, 95% CI 1.67–1.72). The standardized annual prevalence increased from 6.02% in 2016 to 7.94% in 2018, with an average annual increase of 5.48%, and grew more rapidly in rural than urban areas (11.28% vs. 0.00%).

Conclusions

This study suggested a significant increase in the prevalence of GDM among Chinese female population in Zhejiang province during 2016–2018, especially in women characterized by advanced age and rural areas.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabesity and Perinatal Mental Health: Evidence-based Recommendations for Screening and Intervention

Perinatal mental illness, obesity, and diabetes mellitus are common complications of the perinatal period that are becoming ever more prevalent and frequently co-occur. This review seeks to examine the prevalence of comorbid obesity/diabetes (termed "diabesity") and mental illness in the perinatal period and current understandings of the psychosocial and pathophysiological relationships between these diseases. We will present current guidelines for screening and make recommendations for adaptations of mental health treatment in patients with this comorbidity. Finally, we present future directions for research and clinical intervention.

Healthcare outcomes for patients with type 2 diabetes with and without comorbid obesity

AIMS

Examine the burden of comorbid obesity associated with type 2 diabetes (T2D).

METHODS

The IBM® MarketScan® Explorys Claims Electronic Medical Records Data were used to identify adults with T2D, two recorded body mass index (BMI) values, and continuous insurance coverage from 1 year prior through 1 year post index date. Patients with index BMI ≥18 kg/m² and <30 kg/m² (normal/overweight) were matched to patients with index BMI ≥ 30 kg/m² (obese) using propensity score matching (PSM). Using the PSM cohort, multivariable analyses examined the association between obesity and patient comorbidities, healthcare costs, and resource utilization.

RESULTS

In the matched cohort (16,006 normal/overweight; 16,006 obese), multivariable analyses showed that obesity, compared to normal/overweight, was associated with increased odds of a diabetes-related comorbidity (Odds Ratio [OR] = 1.29; 95% Confidence Interval [CI] 1.21-1.38) and an obesity-related comorbidity (OR = 1.42; 95% CI 1.29-1.56). Obesity was also associated with significantly higher annual diabetes-related and all-cause total costs and resource utilization.

CONCLUSIONS

This research increases the knowledge of how patients with T2D and obesity should be of greater concern for healthcare providers compared to T2D patients without comorbid obesity, given their worse comorbidity profile, increased resource utilization, and higher healthcare costs.

Metformin Ameliorates Gestational Diabetes Mellitus-Induced Endothelial Dysfunction via Downregulation of p65 and Upregulation of Nrf2

Gestational diabetes mellitus (GDM) causes oxidative stress in mothers and infants and causes vascular endothelial dysfunction, which is a key factor for maternal and fetal cardiovascular diseases in the later stage of GDM, seriously threatening the life and health of mothers and infants. Nowadays, metformin (MET) has been discovered to improve endothelial function, but studies regarding the mechanism of MET improving endothelial cell function and alleviating endothelial function under hyperglycemia are still extremely limited. We aimed to investigate whether MET exerts its protective role against hyperglycemia-induced endothelial dysfunction through p65 and Nrf2. In our studies, applying cell migration assay and tube formation assay, we observed an obvious improvement of endothelial function under MET-treated, as characterized by that MET accelerated GDM-attenuated migration and angiogenesis of HUVECs. And ELISA assay results uncovered that Nrf2 expression level was decreased in GDM placenta, HVUECs and maternal serum comparing with normal group, however activation Nrf2 largely ameliorated tube formation under hyperglycemic condition. Furthermore, MET elevated the Nrf2 expression level and the level of nuclear Nrf2 accumulation in hyperglycemic HUVECs. Besides, preliminary evidence predicted that Nrf2 expression was modulated by transcription factor p65, which was increased in GDM peripheral blood, placenta and HUVECs, and suppression of p65 could recover GDM-induced suppression of angiogenesis. In addition, we also confirmed MET restores the GDM-induced angiogenesis impairment may via downregulation of p65 and upregulation of Nrf2. Taken together, the endothelial protective effect of MET under GDM (HG) conditions could be partly attributed to its role in downregulating p65 and upregulating Nrf2.

Fetal Anomaly Detection in Pregnancies With Pregestational Diabetes

OBJECTIVES

To evaluate fetal anomaly detection in pregnancies with pregestational diabetes, according to the gestational age at the time of specialized sonography, use of follow-up sonography, maternal body mass index, and organ system(s) involved.

METHODS

Women with pregestational diabetes who received prenatal care and delivered a live-born or stillborn neonate at our hospital from October 2011 through April 2017 were ascertained. We included all pregnancies with at least 1 confirmed structural anomaly (EUROCAT classification) who had detailed sonography at 18 weeks' gestation or later. We analyzed detection of anomalous fetuses at the initial detailed sonogram and, if no abnormality was identified, during any follow-up sonograms. Statistical analyses were performed with the χ² test and Mantel-Haenszel χ² test for trend.

RESULTS

Seventy-two anomalous neonates (72 of 1060 [6.8%]) were born. Overall detection was 55 of 72 (76%); 49 of 72 (68%) were detected at the initial detailed sonogram, compared to 6 of 15 (40%) of follow-up examinations (P = .04). Recognition at the initial or follow-up examination was not dependent on gestational age or body mass index category (all P > .05). Of individual organ system anomalies, 67 of 89 (75%) were identified. Detection exceeded 85% for central nervous system, genitourinary, and musculoskeletal abnormalities and 43% for craniofacial anomalies. Sixty-five percent of cardiac anomalies were detected, and 14 of 17 (82%) requiring specialized care in the immediate neonatal period were recognized.

CONCLUSIONS

Approximately three-fourths of anomalous fetuses were identified, with greater detection at the initial detailed examination. Fetuses with central nervous system, genitourinary, musculoskeletal abnormalities and those with cardiac anomalies requiring specialized cardiac care were more likely to come to attention.

Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006-2015

INTRODUCTION

This study aims to assess trends in the prevalence of pre-existing diabetes and whether the risk of adverse perinatal outcomes decreased in women between 2006 and 2015 in Catalonia, Spain.

RESEARCH DESIGN AND METHODS

A population-based study of 743 762 singleton deliveries between 2006 and 2015 in Catalonia, Spain, was conducted using data from the Spanish Minimum Basic Data Set. Cases of type 1 diabetes (T1DM) and 'type 2 diabetes and other pre-existing diabetes' ('T2DM and other PGD') were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Crude and age-adjusted annual prevalences were calculated. Poisson regression model was used to assess trends in prevalence and perinatal outcomes during the study period.

RESULTS

Overall prevalences of pre-existing diabetes, T1DM and 'T2DM and other PGD' were 0.52% (95% CI 0.51 to 0.54), 0.17% (95% CI 0.17 to 0.18) and 0.35% (95% CI 0.33 to 0.36), respectively. From 2006 to 2015, rates increased for pre-existing diabetes (from 0.43 (95% CI 0.39 to 0.48) to 0.56% (0.50 to 0.62), p<0.001), T1DM (from 0.14 (0.11 to 0.17) to 0.20% (0.17 to 0.23), p<0.001) and 'T2DM and other PGD' (from 0.29 (0.25 to 0.33) to 0.36% (0.31 to 0.40), p<0.001). Pre-eclampsia rose in women with pre-existing diabetes (from 4.38% to 8.97%, adjusted p<0.001), T1DM (from 3.85% to 12.88%, p=0.005) and 'T2DM and other PGD' (from 4.63% to 6.78%, adjusted p=0.01). Prevalence of prematurity, cesarean section and small for gestational age remained stable in all diabetes groups. However, the prevalence of macrosomia fell in women with pre-existing diabetes (from 18.18% to 11.9%, adjusted p=0.011) and 'T2DM and other PGD' (from 14.71% to 11.06%, non-adjusted p=0.022, adjusted p=0.305) and large for gestational age decreased in all diabetes groups (from 39.73% to 30.25% in pre-existing diabetes, adjusted p=0.004).

CONCLUSIONS

The prevalence of pre-existing diabetes increased significantly in Catalonia between 2006 and 2015. Despite improvements in outcomes related to excessive birth weight, pre-eclampsia rates are rising and overall perinatal outcomes in women with pre-existing diabetes continue to be markedly worse than in the population without diabetes.

The relationship between HbA1c reduction and healthcare costs among patients with type 2 diabetes: evidence from a U.S. claims database

OBJECTIVE

To examine the relationship between hemoglobin A1c (HbA1c) reduction and healthcare costs among patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

Truven MarketScan databases over the time-period from 2013 through 2017 were utilized. Patients with T2D who had an HbA1c laboratory result from 1 January 2014 through 1 January 2017 were included, first such date identified as the index date. Generalized linear models examined the relationship between HbA1c and one-year post-period all-cause and diabetes-related costs.

RESULTS

For patients with T2D (N = 77,622), multivariable analyses revealed that a 1% reduction in HbA1c was associated with a 2% reduction in all-cause total health care costs and a 13% reduction in diabetes-related total healthcare costs (both p < .0001), and that these reductions resulted in annual cost savings of $429 and $736, respectively. For patients with an index HbA1c ≥7% (N = 33,648), a 1% reduction in HbA1c was associated with a 1.7% reduction in all-cause total healthcare costs and a 6.9% reduction in diabetes-related healthcare costs (both p ≤ .0001), with associated annual cost savings of $545 and $555, respectively. The analyses also found that having an index HbA1c <7% compared to HbA1c ≥7% or having an index HbA1c ≥7% and subsequently reducing HbA1c to below 7%, was associated with significant cost reductions.

CONCLUSION

Results suggest that there are economic benefits associated with HbA1c reduction and that these benefits are seen for all patients with T2D and for patients whose index HbA1c is above the American Diabetes Association recommended target.

A Florida public health-based endocrine clinic for low-income pregnant women with diabetes

OBJECTIVES

To evaluate pregnancy outcomes of low-income women with diabetes-complicated pregnancies who received care from an embedded, public health-based endocrine specialty clinic (ESC) in Florida.

DESIGN

This program evaluation used retrospective chart data to analyze client characteristics, pre-program and during-program glycemic control, and pregnancy outcomes of women enrolled in a prenatal ESC.

SAMPLE

Ninety-two low-income, pregnant women with type 1/type 2 diabetes or gestational diabetes (GDM) comprised this racially/ethnically diverse sample.

VARIABLES/ANALYSIS

Neonatal outcomes included frequencies of prematurity, hypoglycemia, hyperbilirubinemia, and birth weight-for-gestational-age categories. Differences in maternal HbA1C at program entry and mean HbA1C during ESC care were determined by a Wilcoxon and paired sample t test.

RESULTS

HbA1C levels during ESC care (6.9 ± 1.4) were less than program entry HbA1C levels (7.9 ± 1.8) for women with pregestational diabetes (Z = -3.364, p = .001). Among women with GDM, mean HbA1C values during ESC care (5.5 ± 0.4) did not significantly differ (t(51) = -0.532, p > .05) from program entry HbA1C levels (5.5 ± 0.5), suggestive of glycemic goal achievement. No neonatal hypoglycemia or hyperbilirubinemia cases were observed in both groups. Approximately 11% of births were preterm, and 16% of neonates were large-for-gestational-age.

CONCLUSIONS

A public health-based ESC for low-income pregnant women with diabetes may positively affect pregnancy outcomes.

The Relationship Between Timing of Initiation on a Glucagon-like Peptide-1 Receptor Agonist and Glycosylated Hemoglobin Values Among Patients With Type 2 Diabetes

PURPOSE

This study examines the relationship between timing of initiation on a glucagon-like peptide-1 receptor agonist (GLP-1 RA) and glycosylated hemoglobin (HbA_1c) values.

METHODS

The IBM MarketScan databases were used to identify adults with type 2 diabetes mellitus (T2DM) who initiated GLP-1 RA therapy and had multiple recorded HbA_1c results. Time to GLP-1 RA initiation was proxied by the number of classes of glucose-lowering agents prescribed in the 2 years before GLP-1 RA initiation, with fewer glucose-lowering agents indicating initiation of a GLP-1 RA earlier in disease progression. Paired t tests examined differences in HbA_1c values from preperiod to 2-year postperiod. Multivariable analyses examined the relationship between time to GLP-1 RA initiation and postperiod HbA_1c values.

FINDINGS

Initiation on a GLP-1 RA was associated with a 0.6% reduction in HbA_1c values over 2 years (P < 0.0001). Earliest starts were associated with a 1.3% reduction in HbA_1c levels (P < 0.0001) and the highest likelihood of achieving a postperiod HbA_1c level <7% (odds ratio, 4.9; 95% CI, 3.0-8.1).

IMPLICATIONS

Results indicate that although initiation on a GLP-1 RA is generally associated with reduced HbA_1c levels, there may be additional clinical benefits associated with earlier initiation of a GLP-1 RA.

Time trends in pregnancy-related outcomes among women with type 1 diabetes mellitus, 2004-2017

OBJECTIVE

To examine time trends in US pregnant women with type 1 diabetes mellitus for maternal characteristics and pregnancy outcomes.

STUDY DESIGN

We abstracted clinical data from the medical records of 700 pregnant women from 2004 to 2017. For each time period, means and percentages were calculated. P values for trend were calculated using linear and logistic regression.

RESULTS

HbA1c in each trimester was unchanged across the analysis period. The prevalence of nephropathy decreased from 4.8% to 0% (P = 0.002). Excessive gestational weight gain increased (P = 0.01). Gestation length also increased (P = 0.01), as did vaginal deliveries (P = 0.03). There were no change in birthweight over time (P = 0.07) and the percentage of neonates with macrosomia and large for gestational age (LGA) neonates also remained unchanged.

CONCLUSION

Obstetric guideline changes may have improved gestation length and mode of delivery; however, other outcomes need more attention, including excessive gestational weight gain, macrosomia, and LGA.

Pregnancy environment, and not preconception, leads to fetal growth restriction and congenital abnormalities associated with diabetes

Maternal diabetes can lead to pregnancy complications and impaired fetal development. The goal of this study was to use a mouse model of reciprocal embryo transfer to distinguish between the preconception and gestational effects of diabetes. To induce diabetes female mice were injected with a single high dose of streptozotocin and 3 weeks thereafter used as oocyte donors for in vitro fertilization (IVF) and as recipients for embryo transfer. Following IVF embryos were cultured to the blastocyst stage in vitro or transferred to diabetic and non-diabetic recipients. Diabetic and non-diabetic females did not differ in regard to the number of oocytes obtained after ovarian stimulation, oocytes ability to become fertilized, and embryo development in vitro. However, diabetic females displayed impaired responsiveness to superovulation. Reciprocal embryo transfer resulted in similar incidence of live fetuses and abortions, and no changes in placental size. However, fetuses carried by diabetic recipients were smaller compared to those carried by non-diabetic recipients, regardless hyperglycemia status of oocyte donors. Congenital abnormalities were observed only among the fetuses carried by diabetic recipients. The findings support that the diabetic status during pregnancy, and not the preconception effect of diabetes on oogenesis, leads to fetal growth restriction and congenital deformities.

Chronic Medication Burden and Complexity for US Patients with Type 2 Diabetes Treated with Glucose-Lowering Agents

INTRODUCTION

Most adults with type 2 diabetes (T2D) have several chronic conditions treated with complex regimens and multiple medications. The burden and complexity of multiple medication use are associated with worse patient outcomes, including reduced adherence and increased costs, hospitalizations, mortality rates, and HbA1c. This study quantifies the chronic medication burden, regimen complexity, and potential medication interactions in patients with T2D using a nationwide claims database in the USA.

METHODS

Adults with T2D treated for greater than half of the year with at least one glucose-lowering agent (GLA) in 2017 were included in this descriptive study. Chronic medications were defined as all GLAs and non-GLA medications prescribed for at least 90 days in 2017 to at least 2% of the cohort. Medication burden, defined as the number of medications prescribed, was examined. Medication complexity, proxied by the Medication Regimen Complexity Index (MRCI), and potential use of interacting medications were also examined. Results were investigated for all chronic medications and were reported on the basis of the disease treated (diabetes or other condition) and the route of administration (oral or other).

RESULTS

On average, in 2017, the 814,156 patients included in the study filled prescriptions for 4.1 chronic medications (standard deviation [SD] = 2.0), 3.7 oral chronic medications (SD = 1.9), 1.5 GLAs (SD = 0.8), and 1.1 oral GLAs (SD = 0.7). The average MRCI was 14.7 for all chronic medications (SD = 7.4), with a mean of 12.4 for all oral chronic medications (SD = 6.3), 6.6 for all GLAs (SD = 3.8), and 4.9 for oral GLAs (SD = 2.6).

CONCLUSION

On average, patients with T2D used multiple medications, had a complex medication regimen, and were at potential risk of medication interactions. These findings suggest that patients, practitioners, pharmacists, and payers may benefit from interventions which decrease medication burden, complexity, and/or adverse events related to the treatment of T2D.

Association Between Gestational Diabetes and Mental Illness

The rates of both gestational diabetes mellitus (GDM) and mental illness in pregnancy are rising. There is an association between type 2 diabetes and major depressive disorder, anxiety and schizophrenia, thus there is a need for greater understanding of the relationship between GDM and mental illness. This review suggests that there is a bidirectional and complex relationship between antenatal depression, gestational diabetes and postpartum depression. The combined effect of both a history of depression and gestational diabetes significantly increases the risk of postpartum depression. There is an association between severe mental illness and GDM; however, it is strongly mediated by antipsychotic medications and psychosocial factors, in addition to the disease itself. Medication has a major role in treating mental illness during pregnancy and is not directly linked with GDM in either depression or psychosis. Health-care providers should be mindful of the association between GDM and mental illness to appropriately screen and treat both disorders.

16S rRNA Gene-Based Analysis Reveals the Effects of Gestational Diabetes on the Gut Microbiota of Mice During Pregnancy

Hyperglycemia is one of the metabolic characteristics of gestational diabetes mellitus (GDM). Considering that GDM is able to cause changes in the gut bacterial community and function in the mother's intestine compared with healthy pregnant women, we aimed to clarify the correlation between hyperglycemia and gut microbiota in a GDM mouse model. Mice were divided into four groups: CE0, GDME0, CE18, and GDME18. C and GDM represent the control (C) and GDM groups, while E0 and E18 represent early or late trimesters of embryo day 0 or 18, respectively. GDM mouse models were created by injecting streptozocin on embryo day 0. The gut microbiota was characterized using the Illumina MiSeq platform targeting the V3-4 region of the 16S rRNA. Operational taxonomic unit analysis revealed a significant difference between CE18 and CE0, in which Akkermansia and Prevotellaceae were more abundant in the early trimester group, CE0. Moreover, the Clostridiales_vadinBB60 group was more abundant, while Parasutterella was much lower in GDME18 than in CE18. The gut microbiota community structure correlated with the GDM state, and LEfSe and molecular ecological network analysis further confirmed these diversities. Our research shows that changes in the community structure of the gut microbiota from the early to late trimester correlate with the GDM state. Changes in the abundance of the probiotic bacteria Akkermansia, Prevotellaceae, and Parasutterella may be involved in the GDM state.

Impact of Disturbed Glucose Homeostasis Regulated by AMPK in Endometrium on Embryo Implantation in Diabetes Mice

The incidence of diabetes in women of childbearing age has been increasing recently and implantation failure and early abortion are important reasons for infertility in diabetic women. Glycogen synthesis and decomposition are the cores of glucose homeostasis in endometrium and AMPK is activated when cellular energy consumption increases. Embryo implantation is a complex process required huge energy. Yet the changes of glucose metabolism in endometrium and its impact on embryo implantation in diabetic women are still unclear. In this research, we established diabetic pregnancy mice model by intraperitoneal injecting streptozotocin on pregnant day 1. We first tested the changes of endometrial glucose homeostasis and embryo implantation. Next, we demonstrated abnormal activation of AMPK in the endometrium of diabetic mice and its affecting endometrial glucose homeostasis. Finally, we compared the endometrial glucose homeostasis and embryo implantation outcome in diabetic pregnant mice treated with insulin or insulin combined with metformin. The results indicated that there was disturbed glucose homeostasis associated with excessive activation of AMPK in endometrium of diabetic pregnant mice. AMPK inhibitor improved the over-activation of AMPK pathway in the endometrium, meanwhile, partially corrected the abnormal glycogen metabolism and improved the implantation. Insulin improved the disorder of endometrial glucose homeostasis and implantation of diabetic mice. Our research explores the causes of high abortion and infertility rate in diabetic women which is to provide a therapeutic reference for patients with diabetes complicated with infertility and early abortion.

Economic burden of maternal morbidity - A systematic review of cost-of-illness studies

Aim

To estimate the economic burden of common health problems associated with pregnancy and childbirth, such as incontinence, mental health problems, or gestational diabetes, excluding acute complications of labour or birth, or severe acute adverse maternal outcomes.

Methods

Searches for relevant studies were carried out to November 2019 in Medline, Embase, CINAHL, PsycINFO and EconLit databases. After initial screening, all results were reviewed for inclusion by two authors. An adapted version of a previously developed checklist for cost-of-illness studies was used for quality appraisal. All costs were converted to 2018 Euro using national consumer price indices and purchasing power parity conversion factors.

Results

Thirty-eight relevant studies were identified, some of which reported incremental costs for more than one health problem (16 gestational diabetes, 13 overweight/obesity, 8 mental health, 4 hypertensive disorders, 2 nausea and vomiting, 2 epilepsy, 1 intimate partner violence). A high level of heterogeneity was observed in both the methods used, and the incremental cost estimates obtained for each morbidity. Average incremental costs tended to be higher in studies that modelled a hypothetical cohort of women using data from a range of sources (compared to analyses of primary data), and in studies set in the United States. No studies that examined the economic burden of some common pregnancy-related morbidities, such as incontinence, pelvic girdle pain, or sexual health problems, were identified.

Conclusion

Our findings indicate that maternal morbidity is associated with significant costs to health systems and society, but large gaps remain in the evidence base for the economic burden of some common health problems associated with pregnancy and childbirth. More research is needed to examine the economic burden of a range of common maternal health problems, and future research should adopt consistent methodological approaches to ensure comparability of results.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee (https://doi.org/10.2337/dc20-SPPC), a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Plasma concentrations of vitamin A and E and risk of dysglycemia in first-trimester pregnant Saudi women

BACKGROUND

Existing evidence suggest that low concentrations of vitamin A and E may have a contribution to the development of diabetes complications; however, data regarding the status of vitamin A and E among individuals with prediabetes are lacking. This study aimed to examine the association of plasma concentrations of vitamin A and E with the glycemic control status among first trimester pregnant Saudi women.

METHODS

In this cross-sectional study, 1102 first trimester pregnant Saudi women were recruited from antenatal clinics. Sociodemographic and anthropometric information were collected, and laboratory analyses of blood glycated hemoglobin (A1C) and plasma vitamins A and E were performed. Subjects were classified as normoglycemic, prediabetic, or undiagnosed diabetic. Multinomial regression models adjusted for age estimated the adjusted odds ratios (aORs) and [95% confidence intervals (CIs)].

RESULTS

Among the sample, 78.8% (n = 868) had normal glycemic control, while 19.1% (n = 211) had prediabetes and 2.1% (n = 23) had undiagnosed diabetes. Plasma concentrations of vitamin A and E of prediabetic participants were at a level midway between that of normoglycemic and diabetic participants (p < 0.01). Compared to subjects with normoglycemic status, those with higher concentrations of vitamin A and E had lower odds of being prediabetic (aOR = 0.27 [0.21-0.35] and aOR = 0.95 [0.94-0.96], respectively) or diabetic (aOR = 0.18 [0.13-0.24] and aOR = 0.93 [0.92-0.94], respectively).

CONCLUSIONS

Our findings indicate a possible contribution of vitamins A and E to the progression of prediabetes to diabetes. Future longitudinal studies are needed to elucidate the association between the antioxidant status and dysglycemia. Clinicians should monitor the glycemic and the antioxidant status closely and provide dietary guidance where needed.