Prevalence of gestational diabetes mellitus evaluated by universal screening with a 75-g, 2-hour oral glucose tolerance test and IADPSG criteria

Epidemiology and management of gestational diabetes

Gestational diabetes is defined as hyperglycaemia first detected during pregnancy at glucose concentrations that are less than those of overt diabetes. Around 14% of pregnancies globally are affected by gestational diabetes; its prevalence varies with differences in risk factors and approaches to screening and diagnosis; and it is increasing in parallel with obesity and type 2 diabetes. Gestational diabetes direct costs are US$1·6 billion in the USA alone, largely due to complications including hypertensive disorders, preterm delivery, and neonatal metabolic and respiratory consequences. Between 30% and 70% of gestational diabetes is diagnosed in early pregnancy (ie, early gestational diabetes defined by hyperglycaemia before 20 weeks of gestation). Early gestational diabetes is associated with worse pregnancy outcomes compared with women diagnosed with late gestational diabetes (hyperglycaemia from 24 weeks to 28 weeks of gestation). Randomised controlled trials show benefits of treating gestational diabetes from 24 weeks to 28 weeks of gestation. The WHO 2013 recommendations for diagnosing gestational diabetes (one-step 75 gm 2-h oral glucose tolerance test at 24-28 weeks of gestation) are largely based on the Hyperglycemia and Adverse Pregnancy Outcomes Study, which confirmed the linear association between pregnancy complications and late-pregnancy maternal glycaemia: a phenomenon that has now also been shown in early pregnancy. Recently, the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) trial showed benefit in diagnosis and treatment of early gestational diabetes for women with risk factors. Given the diabesity epidemic, evidence for gestational diabetes heterogeneity by timing and subtype, and advances in technology, a life course precision medicine approach is urgently needed, using evidence-based prevention, diagnostic, and treatment strategies.

Association of Parity with the Risks of Gestational Diabetes and Macrosomia: A Retrospective Cohort Study in Nanjing, China

BACKGROUND

After implementing the two-child policy, more Chinese women who had a previous delivery had their second child. Nevertheless, the impacts of parity on Gestational Diabetes (GDM) and macrosomia have not been fully confirmed. Therefore, we aimed to analyse the characteristics of pregnancy by parity and evaluate the association of parity with risks of GDM/macrosomia in a Chinese population.

METHODS

A total of 193,410 pregnant women (including 148,293 primiparae and 45,117 multiparae) with complete information were included. Univariate and multivariate logistic regression analyses were used to examine the association between parity and risks of GDM/macrosomia.

RESULTS

With the gradual implementation of the two-child policy, the proportion of multiparae increased rapidly and then decreased slightly. Multiparae were more likely to be older and have higher intrapartum BMI, as compared to primiparae (P < 0.001). Univariate regression analyses suggested that parity could increase the risks of GDM and macrosomia; while after adjustment, the association between parity and GDM risk disappeared, and the effects of parity on macrosomia risk and birth weight of babies were also weakened. Further, stratified analysis showed that parity only increased the risk of GDM in women over 30 years, and the effects of parity on macrosomia risk and birth weight were more pronounced among women over 30 years compared to women under 30 years.

CONCLUSION

Parity was not associated with GDM risk, but mildly associated with macrosomia risk. Particular attention should be paid to multiparae with advanced age to reduce the risks of GDM and macrosomia.

Changes in adverse pregnancy outcomes in women with advanced maternal age (AMA) after the enactment of China's universal two-child policy

The universal two-child policy (TCP; 2016) in China has affected many aspects of maternal-neonatal health. A tertiary hospital-based retrospective study (2011–2019) was used to find the association of these policy changes with maternal age and pregnancy outcomes in women with AMA (≥ 35 years) in the Hubei Province, China. The proportion of neonatal births to women with AMA increased by 68.8% from 12.5% in the one-child policy (OCP) period to 21.1% in the universal TCP period [aOR 1.76 (95% CI: 1.60, 1.93)]. In the univariate analysis, the proportion of preterm births (29.4% to 24.1%), low birth weight (LBW) (20.9% to 15.9%), and hypertensive disorders of pregnancy (HDP) (11.5% to 9.2%) significantly (p < 0.05) decreased in women with AMA from the OCP period to universal TCP period. However, the proportion of intrauterine growth restriction (IUGR) (0.2% to 0.7%) and gestational diabetes mellitus (GDM) (1.7% to 15.6%) was significantly (p < 0.05) increased over the policy changes. After adjusting for confounding factors, only the risk of GDM increased [aOR 10.91 (95% CI: 6.05, 19.67)] in women with AMA from the OCP period to the universal TCP period. In conclusion, the risk of GDM increased in women with AMA from the OCP period to the universal TCP period.

Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review

AIMS

Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia.  METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized.

RESULTS

Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed.

CONCLUSIONS

There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.

Increased individual glucose tolerance test values in women with gestational diabetes

BACKGROUND

Individual oral glucose tolerance test (OGTT) values may be of interest to clinicians. We evaluate factors associated with these values.

METHODS

This retrospective study included 225 pregnant women diagnosed with gestational diabetes by abnormal 100-gram oral GTT. Predictor variables were maternal age, race/ethnicity, gravida, parity, pre-pregnancy body mass index (BMI), weight gain in current pregnancy, family history of diabetes, personal history of gestational diabetes, and neonate gender. Outcome variables were continuous OGTT and categorical elevated OGTT for fasting, 1-hour postprandial, 2-hour postprandial, and 3-hour postprandial.

RESULTS

Obese BMI was associated with increased odds for higher fasting level in the continuous OGTT and elevated categorical OGTT; for 1-hour postprandial this significant obese association only occurred for the continuous OGTT. Higher weight gain in pregnancy was associated with a higher fasting level continuous OGTT and elevated categorical OGTT. Higher maternal age at time of delivery was associated with higher 2-hour continuous OGTT and an elevated 1-hour categorical OGTT. Female neonate gender was associated with decreased odds for elevated 2-hour categorical OGTT. Hispanic and Black race/ethnicities were each associated with higher 3-hour continuous OGTT.

CONCLUSIONS

These findings can help clinicians identify the women potentially at risk for having abnormal GTT values diagnostic of GDM to provide preemptive early intervention. Clinicians have the goals to identify these women early so that women can be properly educated and counseled in terms of their nutrition status and as to what negative clinical outcomes may occur should their glucose levels remain poorly controlled in the pregnancy.

Placental exosomes isolated from urine of patients with gestational diabetes exhibit a differential profile expression of microRNAs across gestation

Placenta‑derived exosomes play an important role in cellular communication both in the mother and the fetus. Their concentration and composition are altered in several pregnancy disorders, such as gestational diabetes mellitus (GDM). The isolation and characterization of placental exosomes from serum, plasma and tissues from patients with GDM have been previously described; however, to the best of our knowledge, to date, there is no study available on placental exosomes isolated from urine of patients with GDM. In the present study, placental exosomes were purified from urine the 1st, 2nd and 3rd trimester of gestation. Placental exosomes were characterized by transmission electron microscopy in cryogenic mode and by western blot analysis, confirming the presence of exosomal vesicles. The expression profile of five microRNAs (miR‑516‑5p, miR‑517‑3p, miR‑518‑5p, miR‑222‑3p and miR‑16‑5p) was determined by RT‑qPCR. In healthy pregnant women, the expression of the miRNAs increased across gestation, apart from miR‑516‑5p, which was not expressed at the 2nd trimester. All the miRNAs examined were downregulated in patients with GDM at the 3rd trimester of gestation. The downregulated miRNAs affected several metabolic pathways closely associated with the pathophysiology of GDM. This provides further evidence of the regulatory role of miRNAs in the GDM. This also suggests that the of urinary exosomes may be an excellent source of biomarkers and therapeutic targets.

Projections of the prevalence of hyperglycaemia in pregnancy in 2019 and beyond: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIM

Hyperglycaemia in pregnancy (HIP) is one of the most common complications of pregnancy. This study aims to examine the projected HIP prevalence in 2030 and 2045 using multiple methods.

METHODS

The International Diabetes Federation Diabetes Atlas 2019 prevalence was projected to 2030 and 2045 by: (1) carrying forward the 2019 age-adjusted prevalence rates; (2) applying a linear regression of the past four editions of the IDF Diabetes Atlas; (3) applying a regression of the previous editions with the most consistent trend, followed by extrapolation from the 9th edition HIP estimate.

RESULTS

Respectively, for 2030 and 2045, Method 1 projected a declining HIP rate with prevalences of 14.0% and 13.3%, Method 2 projected an increasing HIP prevalence at 16.5% and 18.3%, Method 3 predicted stabilisation of the rate from 16.0% to 15.8%.

CONCLUSION

Assuming other factors remain unchanged, our best estimation of age-adjusted HIP will show stabilisation between 2019 and 2045 of 15.8% to 16.0%. However, this estimate is confounded by the heterogeneity of studies and the influence of different gestational diabetes mellitus diagnostic criteria. To provide accurate future comparisons we recommend standardising the diagnostic criteria to the International Association of Diabetes in Pregnancy Study Groups.

Clinical importance of the 75-g glucose tolerance test (GTT) in the prediction of large for gestational age (LGA) fetuses in non-diabetic pregnancies

Objective To demonstrate clinical importance of the 75-g glucose tolerance test (GTT) in the prediction of large for gestational age (LGA) fetuses in non-diabetic pregnancies. Methods We retrospectively evaluated 75-g GTT screening results of 356 pregnancies without prompt diagnosis of gestational diabetes mellitus (GDM) between January 2013 and December 2017. Newborns with a birthweight greater than the 90th percentile were evaluated as LGA. Pregnancies with LGA and non-LGA fetuses were compared by demographic and historical factors - maternal age, gravidity, parity, birthweight, birthweek, GTT results and birthweight percentiles - via Student's t-test. Multiple linear regression using the backward elimination method was performed to define the correlation between parameters and LGA (P-value of <0.20 was identified as the threshold). Receiver operator characteristics (ROC) curve analysis was performed for further analysis. Results The cohort was consisted of 45 (12.6%) and 311 (87.4%) pregnancies with LGA and non-LGA fetuses, respectively. Maternal age and 2nd-h GTT results were found to be significantly higher in patients with LGA newborns (P<0.001 and P=0.016, respectively). Fasting glucose levels and GTT 1st-h results were also higher (P=0.112, P=0.065). The coefficient of multiple determination (R2) was 0.055 by multiple linear regression analysis. Accordingly, GTT 2nd-h result and maternal age were statistically significant and contributed to the explanation of LGA, although the R2 value was not that much higher (P=0.016; P=0.001). Maternal age and GTT 2nd-h results were found to be associated with LGA fetuses with area under the curve (AUC) values of 0.662 and 0.608 according to ROC curve analysis. Conclusion Maternal age and 75-g GTT 2nd-h results were significantly higher in gestations with LGA newborns without GDM.

Placental exosomes viewed from an 'omics' perspective: implications for gestational diabetes biomarkers identification

Exosomes are defined as extracellular vesicles that are released from cells upon fusion of an intermediate endocytic compartment - the multivesicular body - with the plasma membrane. Recently, placenta-derived exosomes have gained special attention, since they play a crucial role in the communication between the mother and fetus. It is known that the concentration of placenta-derived exosomes in the maternal bloodstream is higher in patients with preeclampsia or gestational diabetes mellitus. However, their composition in terms of the content of proteins, nucleic acids or lipids is uncertain. In this work, we reviewed the recent advances in placental exosomes characterization through omics-based methods, and their potential to predict gestational diabetes mellitus.

Analysis of the Characteristics of Pregnancy and Delivery before and after Implementation of the Two-child Policy

Background:

After the two-child policy is fully implemented, new challenges regarding pregnancy management and the treatment of pregnancy complications will arise. The aim of this study was to analyze the characteristics of pregnancy and delivery before and after the implementation of the two-child policy to make suggestions on the quality assurance of the new era of obstetrics.

Methods:

In total, 5895 cases of pregnant women who delivered from April 2016 to March 2017 in Peking University Third Hospital served as the study group and 5103 cases of pregnant women who delivered from January to December 2015 served as the control group. The characteristics of pregnancy and delivery were retrospectively analyzed.

Results:

In the study group, the percentage of pregnant women who were older (over 40 years) (3.6% vs. 2.2%), were multipara (30.3% vs. 17.0%), received irregular prenatal care (1.5% vs. 0.9%), were transferred for treatment from a subordinate hospital (4.4% vs. 2.8%), and were not residents of Beijing (3.8% vs. 2.2%), were significantly increased compared with the control group (P < 0.05). In the study group, the rate of a hypertensive disorder complicating pregnancy (6.4% vs. 5.0%), gestational diabetes mellitus (25.3% vs. 23.1%), dangerous placenta previa (3.0% vs. 2.3%), placental implantation (2.4% vs. 1.8%), and severe postpartum hemorrhage (2.8% vs. 1.9%) was significantly increased compared with the control group (P < 0.05). In the study group, the cesarean section rate during primipara was significantly reduced compared with the control group (42.0% vs. 44.2%). However, the rate during multipara was significantly increased compared with the control group (P < 0.05). Indications for cesarean section in the study group as well as the percentages of scared uterus and placenta previa were significantly increased compared with the control group (P < 0.05).

Conclusions:

According to the current situation, better methods are needed to strengthen pregnancy and delivery management, reduce the rate of cesarean section, and ensure a positive outcome for mothers and babies.

Comparing the risk of adverse pregnancy outcomes of Chinese patients with polycystic ovary syndrome with and without antiandrogenic pretreatment

OBJECTIVE

To evaluate the prevalence of adverse pregnancy outcomes in healthy Chinese women and to investigate whether these outcomes could be decreased in patients with polycystic ovary syndrome (PCOS) by ethinylestradiol/cyproterone acetate (EE/CPA) pretreatment.

DESIGN

Retrospective study.

SETTING

Medical university.

PATIENT(S)

Six thousand healthy women (group A) were selected from 24,566 pregnant women by randomized sampling. Four hundred forty-eight patients with PCOS without EE/CPA pretreatment were assigned to group B, and 222 patients with PCOS with 3 months of pretreatment to group C. All patients with PCOS had biochemical and/or clinical hyperandrogenism and conceived within 3 monthly ovulation inductions using clomiphene.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Gestational diabetes mellitus (GDM), pregnancy-induced hypertension (PIH), premature delivery (PD), and neonatal birth weight.

RESULT(S)

The prevalence of GDM, PIH, and PD was higher in group B than in groups A and C (A vs. B vs. C: GDM, 21.2% vs. 35.0% vs. 22.5%; PIH, 6.5% vs. 14.1% vs. 7.7%; PD, 5.4% vs. 8.6% vs. 6.8%). No significant difference was found in neonatal birth weight. After adjusting for age, pregestational body mass index, education level, and employment status, PCOS without pretreatment increased the risk of GDM (adjusted odds ratio [aOR] = 1.666; 95% confidence interval [CI], 1.340-2.072), PIH (aOR = 1.487; 95% CI, 1.093-2.023), and PD (aOR = 1.522; 95% CI 1.051-2.205), compared with healthy women. No increased risk was found in group C.

CONCLUSION(S)

In our highly selected study population, patients with PCOS are more likely to develop GDM, PIH, and PD. Pretreatment with EE/CPA was associated with a lower risk of GDM, PIH, and PD.

Selective Screening Strategies for Gestational Diabetes: A Prospective Cohort Observational Study

AIM

We aimed to develop a prediction model for the diagnosis of gestational diabetes and to evaluate the performance of published prediction tools on our population.

METHODS

We conducted a cohort study on nondiabetic women < 26 weeks gestation at a level 1 clinic in Johannesburg, South Africa. At recruitment, participants completed a questionnaire and random basal glucose and HbA1c were evaluated. A 75 g 2-hour OGTT was scheduled between 24-28 weeks gestation, as per FIGO guidelines. A score was derived using multivariate logistic regression. Published scoring systems were tested by deriving ROC curves.

RESULTS

In 554 women, RBG, BMI, and previous baby ≥ 4000 g were significant risk factors included for GDM, which were used to derive a nomogram-based score. The logistic regression model for prediction of GDM had R2 0.143, Somer's Dxy rank correlation 0.407, and Harrell's c-score 0.703. HbA1c did not improve predictive value of the nomogram at any threshold (e.g,. at probability > 10%, 25.6% of cases were detected without the HbA1c, and 25.8% of cases would have been detected with the HbA1c). The 9 published scoring systems performed poorly.

CONCLUSION

We propose a nomogram-based score that can be used at first antenatal visit to identify women at high risk of GDM.