Peri-conception hyperglycaemia and nephropathy are associated with risk of congenital anomaly in women with pre-existing diabetes: a population-based cohort study

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.

Hemoglobin A1c Trajectories During Pregnancy and Adverse Outcomes in Women With Type 2 Diabetes: A Danish National Population-Based Cohort Study

OBJECTIVE

To identify and characterize groups of pregnant women with type 2 diabetes with distinct hemoglobin A1c (HbA1c) trajectories across gestation and to examine the association with adverse obstetric and perinatal outcomes.

RESEARCH DESIGN AND METHODS

This was a retrospective Danish national cohort study including all singleton pregnancies in women with type 2 diabetes, giving birth to a liveborn infant, between 2004 and 2019. HbA1c trajectories were identified using latent class linear mixed-model analysis. Associations with adverse outcomes were examined with logistic regression models.

RESULTS

A total of 1,129 pregnancies were included. Three HbA1c trajectory groups were identified and named according to the glycemic control in early pregnancy (good, 59%; moderate, 32%; and poor, 9%). According to the model, all groups attained an estimated HbA1c <6.5% (48 mmol/mol) during pregnancy, with no differences between groups in the 3rd trimester. Women with poor glycemic control in early pregnancy had lower odds of having an infant with large-for-gestational-age (LGA) birth weight (adjusted odds ratio [aOR] 0.57, 95% CI 0.40-0.83), and higher odds of having an infant with small-for-gestational age (SGA) birth weight (aOR 2.49, 95% CI 2.00-3.10) and congenital malformation (CM) (aOR 4.60 95% CI 3.39-6.26) compared with women with good glycemic control. There was no evidence of a difference in odds of preeclampsia, preterm birth, and caesarean section between groups.

CONCLUSIONS

Women with poor glycemic control in early pregnancy have lower odds of having an infant with LGA birth weight, but higher odds of having an infant with SGA birth weight and CM.

3-generation family histories of mental, neurologic, cardiometabolic, birth defect, asthma, allergy, and autoimmune conditions associated with autism: an open-source catalogue of findings

The relatively few conditions and family members investigated in autism family health history limits etiologic understanding. For more comprehensive understanding and hypothesis-generation we produced an open-source catalogue of autism associations with family histories of mental, neurologic, cardiometabolic, birth defect, asthma, allergy, and autoimmune conditions. All live births in Denmark, 1980-2012, of Denmark-born parents (1,697,231 births), and their 3-generation family members were followed through April 10, 2017 for each of 90 diagnoses (including autism), emigration or death. Adjusted hazard ratios (aHR) were estimated via Cox regression for each diagnosis-family member type combination, adjusting for birth year, sex, birth weight, gestational age, parental ages at birth, and number of family member types of index person; aHRs also calculated for sex-specific co-occurrence of each disorder. We obtained 6,462 individual family history aHRS across autism overall (26,840 autistic persons; 1.6% of births), by sex, and considering intellectual disability (ID); and 350 individual co-occurrence aHRS. Results are catalogued in interactive heat maps and down-loadable data files: https://ncrr-au.shinyapps.io/asd-riskatlas/ and interactive graphic summaries: https://public.tableau.com/views/ASDPlots_16918786403110/e-Figure5. While primarily for reference material or use in other studies (e.g., meta-analyses), results revealed considerable breadth and variation in magnitude of familial health history associations with autism by type of condition, family member type, sex of the family member, side of the family, sex of the index person, and ID status, indicative of diverse genetic, familial, and non-genetic autism etiologic pathways. Careful attention to sources of autism likelihood in family health history, aided by our open data resource, may accelerate understanding of factors underlying neurodiversity.

Use of GLP1 receptor agonists in early pregnancy and reproductive safety: a multicentre, observational, prospective cohort study based on the databases of six Teratology Information Services

OBJECTIVES

Glucagon-like peptide 1 receptor agonists (GLP1-RA) are indicated for the treatment of type 2 diabetes and more recently for weight loss. The aim of this study was to assess the risks associated with GLP1-RA exposure during early pregnancy.

DESIGN

This multicentre, observational prospective cohort study compared pregnancy outcomes in women exposed to GLP1-RA in early pregnancy either for diabetes or obesity treatment with those in two reference groups: (1) women with diabetes exposed to at least one non-GLP1-RA antidiabetic drug during the first trimester and (2) a reference group of overweight/obese women without diabetes, between 2009 and 2022.

SETTING

Data were collected from the databases of six Teratology Information Services.

PARTICIPANTS

This study included 168 pregnancies of women exposed to GLP1-RA during the first trimester, alongside a reference group of 156 pregnancies of women with diabetes and 163 pregnancies of overweight/obese women.

RESULTS

Exposure to GLP1-RA in the first trimester was not associated with a risk of major birth defects when compared with diabetes (2.6% vs 2.3%; adjusted OR, 0.98 (95% CI, 0.16 to 5.82)) or to overweight/obese (2.6% vs 3.9%; adjusted OR 0.54 (0.11 to 2.75)). For the GLP1-RA group, cumulative incidence for live births, pregnancy losses and pregnancy terminations was 59%, 23% and 18%, respectively. In the diabetes reference group, corresponding estimates were 69%, 26% and 6%, while in the overweight/obese reference group, they were 63%, 29% and 8%, respectively. Cox proportional cause-specific hazard models indicated no increased risk of pregnancy losses in the GLP1-RA versus the diabetes and the overweight/obese reference groups, in both crude and adjusted analyses.

CONCLUSIONS

This study offers reassurance in cases of inadvertent exposure to GLP1-RA during the first trimester of pregnancy. Due to the limited sample size, larger studies are required to validate these findings.

Fetal Overgrowth and Preterm Delivery in Women With Type 1 Diabetes Using Insulin Pumps or Multiple Daily Injections: A Post Hoc Analysis of the EVOLVE Study Cohort

OBJECTIVE

To compare the risk of fetal overgrowth and preterm delivery in pregnant women with type 1 diabetes (T1D) treated with insulin pumps versus multiple daily injections (MDI) and examine whether possible differences were mediated through improved glycemic control or gestational weight gain during pregnancy.

RESEARCH DESIGN AND METHODS

The risk of pregnancy and perinatal outcomes were evaluated in a cohort of 2,003 pregnant women with T1D enrolled from 17 countries in a real-world setting during 2013-2018.

RESULTS

In total, 723 women were treated with pumps and 1,280 with MDI. At inclusion (median gestational weeks 8.6 [interquartile range 7-10]), pump users had lower mean HbA1c (mean ± SD 50.6 ± 9.8 mmol/mol [6.8 ± 0.9%] vs. 53.6 ± 13.8 mmol/mol [7.1 ± 1.3%], P < 0.001), longer diabetes duration (18.4 ± 7.8 vs. 14.4 ± 8.2 years, P < 0.001), and higher prevalence of retinopathy (35.3% vs. 24.4%, P < 0.001). Proportions of large for gestational age (LGA) offspring and preterm delivery were 59.0% vs. 52.2% (adjusted odds ratio [OR] 1.36 [95% CI 1.09; 1.70], P = 0.007) and 39.6% vs. 32.1% (adjusted OR 1.46 (95% CI 1.17; 1.82), P < 0.001), respectively. The results did not change after adjustment for HbA1c or gestational weight gain.

CONCLUSIONS

Insulin pump treatment in pregnant women with T1D, prior to the widespread use of continuous glucose monitoring or automated insulin delivery, was associated with a higher risk of LGA offspring and preterm delivery compared with MDI in crude and adjusted analyses. This association did not appear to be mediated by differences in glycemic control as represented by HbA1c or by gestational weight gain.

Universal Fetal Echocardiography for Pregestational Diabetes Mellitus: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost effectiveness of universal fetal echocardiogram for patients with pregestational diabetes mellitus by first-trimester hemoglobin A1c (Hb A1c) level.

METHODS

We developed a cost-effectiveness model comparing two strategies of screening for critical fetal congenital heart disease among patients with diabetes: universal fetal echocardiogram and fetal echocardiogram only after abnormal findings on detailed anatomy ultrasonogram. We excluded ventricular septal defect, atrial septal defects, and bicuspid aortic valve from the definition of critical fetal congenital heart disease. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios: first-trimester Hb A1c lower than 6.5%, Hb A1c 6.5-9.0%, and Hb A1c higher than 9.0%. Primary outcomes included fetal death, neonatal death, and false-positive and false-negative results. A cost-effectiveness threshold was set at $100,000 per quality-adjusted life-year. Univariable sensitivity analyses were performed to investigate the drivers of the model.

RESULTS

Universal fetal echocardiogram is not cost effective except for when first-trimester Hb A1c level is higher than 9.0% (incremental cost-effectiveness ratio $638,100, $223,693, and $67,697 for Hb A1c lower than 6.5%, 6.5-9.0%, and higher than 9.0%, respectively). The models are sensitive to changes in the probability of congenital heart disease at a given Hb A1c level, as well as the cost of neonatal transfer to a higher level of care. Universal fetal echocardiogram became both cost saving and more effective when the probability of congenital heart disease reached 14.48% (15.4 times the baseline risk). In the Monte Carlo simulation, universal fetal echocardiogram is cost effective in 22.7%, 48.6%, and 62.3% of scenarios for each of the three models, respectively.

CONCLUSION

For pregnant patients with first-trimester Hb A1c levels lower than 6.5%, universal fetal echocardiogram was not cost effective, whereas, for those with first-trimester Hb A1c levels higher than 9.0%, universal fetal echocardiogram was cost effective. For those with intermediate Hb A1c levels, universal fetal echocardiogram was cost effective in about 50% of cases; therefore, clinical judgment based on individual patient values, willingness to pay to detect congenital heart disease, and resource availability needs to be considered.

Imaging spectrum of spinal dysraphism: A diagnostic challenge

Spinal dysraphism (SD) is a collective term for congenital malformations of the spine and spinal cord. It includes a wide range of congenital anomalies resulting from aberrations in the stages of gastrulation, primary neurulation and secondary neurulation. Spinal dysraphism may lead to neurological impairment of varying severity including weakness of the extremities, incontinence of bowel and bladder, sexual dysfunction, among others. Diagnosis of SDs is quite challenging because of its wide spectrum and complex cascade of embryologic events. Knowledge of normal embryology and proper understanding of imaging features of SD are important for early accurate diagnosis.

Contribution

This series of five cases describes the imaging spectrum of spinal dysraphism and highlights the embryological basis for their development, which could facilitate early correct diagnosis, surgical planning and reduced morbidity related to these malformations. It also includes an extremely rare case of complex spinal dysraphism (Type II diastematomyelia with right hemimyelomeningocoele and left hemilipomyelomeningocoele) with Chiari II malformation.

Maternal and Infant Outcomes in GCK-MODY Complicated by Pregnancy

CONTEXT

Challenges exist in the management of Glucokinase-maturity-onset diabetes of the young (GCK-MODY), especially during pregnancy.

OBJECTIVE

This work aimed to evaluate the prevalence of congenital anomaly in newborns from GCK-MODY mothers, and the relationship between fetus genotype and the risk of congenital malformation as well as other adverse pregnancy outcomes.

METHODS

Electronic databases including PubMed, EMBASE, and Cochrane database last updated July 16, 2022, were searched. We included observational studies conducted in GCK-MODY complicated by pregnancy, and reporting at least one pregnancy outcome. We extracted data in duplicate, and the risk of bias was evaluated by the Newcastle-Ottawa Quality Assessment Scale (NOS). All statistical analysis was performed by Cochrane Review Manager.

RESULTS

Eight studies were selected in the meta-analysis. Five were of high quality and 3 were of medium quality evaluated by NOS. A total of 257 GCK-MODY mothers and 499 offspring were enrolled. Among them, 370 offspring were divided into 2 groups: GCK-affected offspring (GCK+, n = 238) and GCK-unaffected offspring (GCK-, n = 132). The percentage of congenital malformations in GCK pregnant women's offspring was 2.4%. The risk of congenital malformations was similar between the GCK+ and GCK- group (odds ratio = 0.56; 95% CI, 0.07-4.51; I2 = 0%; P = .59). The risk of macrosomia/large for gestational age, neonatal hypoglycemia, and combined adverse neonatal outcome was significantly lower in offspring with the GCK mutation compared with non-GCK mutation carriers.

CONCLUSION

The percentage of congenital malformations was 2.4% in GCK-MODY pregnant women's offspring, and newborns with the GCK mutation have lower birth complication than non-GCK mutation carriers.

Congenital malformations among offspring of women with type 1 diabetes who use insulin pumps: a prospective cohort study

AIMS/HYPOTHESIS

Continuous subcutaneous insulin infusion by insulin pump is often superior in improving glycaemic control compared with conventional multiple daily insulin injection (MDI). However, whether pump treatment leads to improved pregnancy outcomes in terms of congenital malformations and perinatal death remains unknown. The present aim was to evaluate the risk of malformations and perinatal and neonatal death in pregnant women with type 1 diabetes treated with pump or MDI.

METHODS

We performed a secondary analysis of a prospective multinational cohort of 2088 pregnant women with type 1 diabetes in a real-world setting who were treated by pump (n=750) or MDI (n=1338). ORs for offspring with congenital malformations or perinatal or neonatal death were calculated using crude data and by logistic regression on propensity score-matched data.

RESULTS

At enrolment (gestational week 8; 95% CI 4, 14), pump users had a higher educational level (university degree: 37.3% vs 25.1%; p<0.001) and better glycaemic control (mean HbA1c: 51±10 mmol/mol [6.8±0.9%] vs 54±14 mmol/mol [7.1±1.3%], p<0.001) compared with MDI users. Moreover, a greater proportion of pump users had an HbA1c level below 75 mmol/mol (9%) (97.6% vs 91.9%, p<0.001), and more often reported taking folic acid supplementation (86.3% vs 74.8%; p<0.001) compared with MDI users. All clinically important potential confounders were balanced after propensity score matching, and HbA1c remained lower in pump users. The proportion of fetuses with at least one malformation was 13.5% in pump users vs 11.2% in MDI users (crude OR 1.23; 95% CI 0.94, 1.61; p=0.13; propensity score-matched (adjusted) OR 1.11; 95% CI 0.81, 1.52; p=0.52). The proportion of fetuses with at least one major malformation was 2.8% in pump users vs 3.1% in MDI users (crude OR 0.89; 95% CI 0.52, 1.51; p=0.66; adjusted OR 0.78; 95% CI 0.42, 1.45; p=0.43), and the proportions of fetuses carrying one or more minor malformations (but no major malformations) were 10.7% vs 8.1% (crude OR 1.36; 95% CI 1.00, 1.84; p=0.05; adjusted OR 1.23; 95% CI 0.87, 1.75; p=0.25). The proportions of perinatal and neonatal death were 1.6% vs 1.3% (crude OR 1.23; 95% CI 0.57, 2.67; p=0.59; adjusted OR 2.02; 95% CI 0.69, 5.93; p=0.20) and 0.3% vs 0.3% (n=2 vs n=4, p=not applicable), respectively.

CONCLUSIONS/INTERPRETATIONS

Insulin pump treatment was not associated with a lower risk of congenital malformations, despite better glycaemic control in early pregnancy compared with MDI. Further studies exploring the efficacy and safety of pump treatment during pregnancy are needed.

Alterations in the Gut Microbiota in Pregnant Women with Pregestational Type 2 Diabetes Mellitus

Human gut dysbiosis is associated with type 2 diabetes mellitus (T2DM); however, the gut microbiome in pregnant women with pregestational type 2 diabetes mellitus (PGDM) remains unexplored. We investigated the alterations in the gut microbiota composition in pregnant women with or without PGDM. The gut microbiota was examined using 16S rRNA sequencing data of 234 maternal fecal samples that were collected during the first (T1), second (T2), and third (T3) trimesters. The PGDM group presented a reduction in the number of gut bacteria taxonomies as the pregnancies progressed. Linear discriminant analyses revealed that Megamonas, Bacteroides, and Roseburia intestinalis were enriched in the PGDM group, whereas Bacteroides vulgatus, Faecalibacterium prausnitzii, Eubacterium rectale, Bacteroides uniformis, Eubacterium eligens, Subdoligranulum, Bacteroides fragilis, Dialister, Lachnospiraceae, Christensenellaceae R-7, Roseburia inulinivorans, Streptococcus oralis, Prevotella melaninogenica, Neisseria perflava, Bacteroides ovatus, Bacteroides caccae, Veillonella dispar, and Haemophilus parainfluenzae were overrepresented in the control group. Correlation analyses showed that the PGDM-enriched taxa were correlated with higher blood glucose levels during pregnancy, whereas the taxonomic biomarkers of normoglycemic pregnancies exhibited negative correlations with glycemic traits. The microbial networks in the PGDM group comprised weaker microbial interactions than those in the control group. Our study reveals the distinct characteristics of the gut microbiota composition based on gestational ages between normoglycemic and PGDM pregnancies. Further longitudinal research involving women with T2DM at preconception stages and investigations using shotgun metagenomic sequencing should be performed to elucidate the relationships between specific bacterial functions and PGDM metabolic statuses during pregnancy and to identify potential therapeutic targets. IMPORTANCE The incidence of pregestational type 2 diabetes mellitus (PGDM) is increasing, with high rates of serious adverse maternal and neonatal outcomes that are strongly correlated with hyperglycemia. Recent studies have shown that type 2 diabetes mellitus is associated with gut microbial dysbiosis; however, the gut microbiome composition and its associations with the metabolic features of patients with PGDM remain largely unknown. In this study, we investigated the changes in the gut microbiota composition in pregnant women with and without PGDM. We identified differential taxa that may be correlated with maternal metabolic statuses during pregnancy. Additionally, we observed that the number of taxonomic and microbial networks of gut bacteria were distinctly reduced in women with hyperglycemia as their pregnancies progressed. These results extend our understanding of the associations between the gut microbial composition, PGDM-related metabolic changes, and pregnancy outcomes.

[Clinical practice recommendations for diabetes in pregnancy (Update 2023)]

In 1989 the St. Vincent Declaration aimed to achieve comparable pregnancy outcomes in women with diabetes and those with normal glucose tolerance. However, currently women with pre-gestational diabetes still feature a higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. All women should be experienced in the management of their therapy and on stable glycemic control prior to conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded or treated adequately before pregnancy in order to decrease the risk for a progression of complications during pregnancy as well as maternal and fetal morbidity. Near normoglycaemia and HbA_1c in the normal range are targets for treatment, preferably without the induction of frequent resp. severe hypoglycaemic reactions. Especially in women with type 1 diabetes mellitus the risk of hypoglycemia is high in early pregnancy, but it decreases with the progression of pregnancy due to hormonal changes causing an increase of insulin resistance. In addition, obesity increases worldwide and contributes to higher numbers of women at childbearing age with type 2 diabetes mellitus and adverse pregnancy outcomes. Intensified insulin therapy with multiple daily insulin injections and pump treatment are equally effective in reaching good metabolic control during pregnancy. Insulin is the primary treatment option. Continuous glucose monitoring often adds to achieve targets. Oral glucose lowering drugs (Metformin) may be considered in obese women with type 2 diabetes mellitus to increase insulin sensitivity but need to be prescribed cautiously due to crossing the placenta and lack of long-time follow up data of the offspring (shared decision making). Due to increased risk for preeclampsia in women with diabetes screening needs to be performed. Regular obstetric care as well as an interdisciplinary treatment approach are necessary to improve metabolic control and ensure the healthy development of the offspring.

Missed antenatal diabetes care appointments and neonatal outcomes for pregnancies with Type 1 and Type 2 diabetes

BACKGROUND

There is limited information regarding the association between missed appointments and neonatal outcomes for diabetes in pregnancy.

STUDY METHODS

This retrospective live birth cohort included pregnant women with Type 1 or 2 diabetes who attended specialized clinics from 2008 to 2020. The association between at least one missed antenatal diabetes appointments and outcomes were assessed using logistic regression and reported as adjusted odds ratios (aOR) (95% confidence interval). Mediation analyses were conducted to examine if above target HbA1c mediated these relationships.

RESULTS

The cohort included 407 and 902 women with Type 1 and 2 diabetes, respectively, of whom 25.1% and 34.5% missed at least one appointment. Women with Type 1 diabetes who missed an appointment were more likely to have a caesarean section (aOR 1.95 [1.15, 3.31]) and their babies more likely to be admitted to the neonatal intensive care unit (aOR 2.25 [1.35, 3.75]). Women with Type 2 diabetes who missed an appointment were more likely to have a large-for-gestational-age infant (aOR 1.61 [1.13, 2.28]), and an extreme large-for-gestational-age infant (aOR 1.69 [1.02, 2.81]) compared with women who did not miss appointments. Above target HbA1c mediated the relationship between missed appointments and caesarean delivery in Type 1 diabetes and large-for-gestational age and extreme large-for-gestational age in Type 2 diabetes.

CONCLUSION

In individuals with Type 1 and 2 diabetes, there are differences in neonatal outcomes between those who missed an appointment compared to those who did not. It remains unclear if missed diabetes appointments are causative or a marker of other health behaviours or risk factors leading to neonatal morbidity.

Association Between Maternal Factors and Risk of Congenital Heart Disease in Offspring: A Systematic Review and Meta-Analysis

INTRODUCTION

This study aimed to summarize the evidence describing the relationship between maternal factors during gestation and risk of congenital heart disease (CHD) in offspring.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched for potentially relevant reports from inception to May 2021. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) calculated by the random-effects model were used to evaluate the association between maternal factors and CHD risk.

RESULTS

There was a significant association between CHD risk and obesity in pregnancy (OR 1.29, 95% CI 1.22-1.37; P < 0.001), smoking in pregnancy (OR 1.16, 95% CI 1.07-1.25; P < 0.001), maternal diabetes (OR 2.65, 95% CI 2.20-3.19; P < 0.001), and exposure of pregnant women to organic solvents (OR 1.82, 95% CI 1.23-2.70; P = 0.003). No correlations were revealed between CHD susceptibility and advanced maternal age (OR 1.04, 95% CI 0.96-1.12; P = 0.328), underweight (OR 1.02, 95% CI 0.96-1.08; P = 0.519), alcohol intake in pregnancy (OR 1.08, 95% CI 0.95-1.22; P = 0.251), coffee intake (OR 1.18, 95% CI 0.97-1.44; P = 0.105), and exposure to irradiation (OR 1.80, 95% CI 0.85-3.80; P = 0.125).

DISCUSSION

Maternal factors including maternal obesity, smoking in pregnancy, maternal diabetes and exposure to organic solvents might predispose the offspring to CHD risk.

Major malformations risk following early pregnancy exposure to metformin: a systematic review and meta-analysis

Metformin is considered as first-line treatment for type 2 diabetes and an effective treatment for polycystic ovary syndrome (PCOS). However, evidence regarding its safety in pregnancy is limited. We conducted a systematic review and meta-analysis of major congenital malformations (MCMs) risk after first-trimester exposure to metformin in women with PCOS and pregestational diabetes mellitus (PGDM). Randomized controlled trials (RCTs) and observational cohort studies with a control group investigating risk of MCM after first-trimester pregnancy exposure to metformin were searched until December 2021. ORs and 95% CIs were calculated separately according to indications and study type using Mantel-Haenszel method; outcome data were combined using random-effects model. Eleven studies (two RCTs; nine observational cohorts) met the inclusion criteria: four included pregnant women with PCOS, four included those with PGDM and three evaluated both indications separately and were considered in both indication groups. In PCOS group, there were two RCTs (57 exposed, 52 control infants) and five observational studies (472 exposed, 1892 control infants); point estimates for MCM rates in RCTs and observational studies were OR 0.93 (95% CI 0.09 to 9.21) (I²=0%; Q test=0.31; p value=0.58) and OR 1.35 (95% CI 0.37 to 4.90) (I²=65%; Q test=9.43; p value=0.05), respectively. In PGDM group, all seven studies were observational (1122 exposed, 1851 control infants); the point estimate for MCM rates was OR 1.05 (95% CI 0.50 to 2.18) (I²=59%; Q test=16.34; p value=0.01). Metformin use in first-trimester pregnancy in women with PCOS or PGDM do not meaningfully increase the MCM risk overall. However, further studies are needed to characterize residual safety concerns.

Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding

In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m². Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.

Imaging of Congenital Spine Malformations

Congenital malformations of the spine and spinal cord are a large and diverse group of diagnoses, which are often broadly referred to as spinal dysraphisms (SDs). Derived from the Greek words dys (bad) and raphe (suture), the term dysraphism describes missteps in the process of forming a midline seam during the zipper-like fusion of the neural folds in primary neurulation. As such, the term "spinal dysraphism" is a designation that should technically be reserved for malformations resulting from aberrations in primary neurulation. In medical practice, however, it is a catch-all designation regularly used to describe any of the numerous abnormalities demonstrating incomplete midline closure of mesenchymal, osseous, and nervous tissue, occurring at any point during embryologic development. For the sake of clarity and completeness, this article will also include that breadth in the discussion of congenital abnormalities of the spine.

Risks of specific congenital anomalies in offspring of women with diabetes: A systematic review and meta-analysis of population-based studies including over 80 million births

BACKGROUND

Pre-gestational diabetes mellitus (PGDM) has been known to be a risk factor for congenital heart defects (CHDs) for decades. However, the associations between maternal PGDM and gestational diabetes mellitus (GDM) and the risk of specific types of CHDs and congenital anomalies (CAs) in other systems remain under debate. We aimed to investigate type-specific CAs in offspring of women with diabetes and to examine the extent to which types of maternal diabetes are associated with increased risk of CAs in offspring.

METHODS AND FINDINGS

We searched PubMed and Embase from database inception to 15 October 2021 for population-based studies reporting on type-specific CAs in offspring born to women with PGDM (combined type 1 and 2) or GDM, with no limitation on language. Reviewers extracted data for relevant outcomes and performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. Risk of bias appraisal was performed using the Cochrane Risk of Bias Tool. This study was registered in PROSPERO (CRD42021229217). Primary outcomes were overall CAs and CHDs. Secondary outcomes were type-specific CAs. Overall, 59 population-based studies published from 1990 to 2021 with 80,437,056 participants met the inclusion criteria. Of the participants, 2,407,862 (3.0%) women had PGDM and 2,353,205 (2.9%) women had GDM. The meta-analyses showed increased risks of overall CAs/CHDs in offspring born to women with PGDM (for overall CAs, relative risk [RR] = 1.99, 95% CI 1.82 to 2.17, P < 0.001; for CHDs, RR = 3.46, 95% CI 2.77 to 4.32, P < 0.001) or GDM (for overall CAs, RR = 1.18, 95% CI 1.13 to 1.23, P < 0.001; for CHDs, RR = 1.50, 95% CI 1.38 to 1.64, P < 0.001). The results of the meta-regression analyses showed significant differences in RRs of CAs/CHDs in PGDM versus GDM (all P < 0.001). Of the 23 CA categories, excluding CHD-related categories, in offspring, maternal PGDM was associated with a significantly increased risk of CAs in 21 categories; the corresponding RRs ranged from 1.57 (for hypospadias, 95% CI 1.22 to 2.02) to 18.18 (for holoprosencephaly, 95% CI 4.03 to 82.06). Maternal GDM was associated with a small but significant increase in the risk of CAs in 9 categories; the corresponding RRs ranged from 1.14 (for limb reduction, 95% CI 1.06 to 1.23) to 5.70 (for heterotaxia, 95% CI 1.09 to 29.92). The main limitation of our analysis is that some high significant heterogeneity still persisted in both subgroup and sensitivity analyses.

CONCLUSIONS

In this study, we observed an increased rate of CAs in offspring of women with diabetes and noted the differences for PGDM versus GDM. The RRs of overall CAs and CHDs in offspring of women with PGDM were higher than those in offspring of women with GDM. Screening for diabetes in pregnant women may enable better glycemic control, and may enable identification of offspring at risk for CAs.

Management of cardiovascular risk factors during pregnancy

Cardiovascular (CV) risk factors are rising among women of reproductive age. Obesity, hyperlipidaemia, diabetes, and hypertension are associated with adverse pregnancy outcomes and increased CV disease (CVD) risk following pregnancy. Pre-conception counselling and longitudinal postpartum follow-up with ongoing CV risk factor screening are critical for early CVD prevention, though significant racial/ethnic disparities in access to care result in significant gaps. This review summarises the recommended management of CV risk factors during and after pregnancy. For obesity, prevention of excessive weight gain is critical. Except in rare cases, lipid-lowering therapies for women with hyperlipidaemia should be stopped before pregnancy. Women with diabetes in pregnancy should maintain tight glucose control, with hemolgobin A1c (HbA1c) <6.5% to prevent congenital abnormalities. Hypertensive disorders of pregnancy are associated with high maternal and neonatal morbidity and require long-term follow-up to prevent future CVD. Finally, this review highlights the lack of clinical trials informing optimal treatment strategies of CV risk factors during and after pregnancy. Further research is needed to better understand how to improve long-term CV health among this high-risk population.

Pregnancy in Women With Monogenic Diabetes due to Pathogenic Variants of the Glucokinase Gene: Lessons and Challenges

Heterozygous loss-of-function variants of the glucokinase (GCK) gene are responsible for a subtype of maturity-onset diabetes of the young (MODY). GCK-MODY is characterized by a mild hyperglycemia, mainly due to a higher blood glucose threshold for insulin secretion, and an up-regulated glucose counterregulation. GCK-MODY patients are asymptomatic, are not exposed to diabetes long-term complications, and do not require treatment. The diagnosis of GCK-MODY is made on the discovery of hyperglycemia by systematic screening, or by family screening. The situation is peculiar in GCK-MODY women during pregnancy for three reasons: 1. the degree of maternal hyperglycemia is sufficient to induce pregnancy adverse outcomes, as in pregestational or gestational diabetes; 2. the probability that a fetus inherits the maternal mutation is 50% and; 3. fetal insulin secretion is a major stimulus of fetal growth. Consequently, when the fetus has not inherited the maternal mutation, maternal hyperglycemia will trigger increased fetal insulin secretion and growth, with a high risk of macrosomia. By contrast, when the fetus has inherited the maternal mutation, its insulin secretion is set at the same threshold as the mother's, and no fetal growth excess will occur. Thus, treatment of maternal hyperglycemia is necessary only in the former situation, and will lead to a risk of fetal growth restriction in the latter. It has been recommended that the management of diabetes in GCK-MODY pregnant women should be guided by assessment of fetal growth by serial ultrasounds, and institution of insulin therapy when the abdominal circumference is ≥ 75th percentile, considered as a surrogate for the fetal genotype. This strategy has not been validated in women with in GCK-MODY. Recently, the feasibility of non-invasive fetal genotyping has been demonstrated, that will improve the care of these women. Several challenges persist, including the identification of women with GCK-MODY before or early in pregnancy, and the modalities of insulin therapy. Yet, retrospective observational studies have shown that fetal genotype, not maternal treatment with insulin, is the main determinant of fetal growth and of the risk of macrosomia. Thus, further studies are needed to specify the management of GCK-MODY pregnant women during pregnancy.

Glycaemic control and novel technology management strategies in pregestational diabetes mellitus

INTRODUCTION

Pregestational diabetes (PGDM) is an increasingly common and complex condition that infers risk to both mother and infant. To prevent serious morbidity, strict glycaemic control is essential. The aim of this review is to review the glucose sensing and insulin delivering technologies currently available for women with PGDM.

METHODS

We reviewed online databases for articles relating to technology use in pregnancy using a combination of keywords and MeSH headings. Relevant articles are included below.

RESULTS

A number of technological advancements have improved care and outcomes for women with PGDM. Real time continuous glucose monitoring (rtCGM) offers clear advantages in terms of infants size and neonatal intensive care unit admissions; and further benefits are seen when combined with continuous subcutaneous insulin delivery (insulin pump) and algorithms which continuously adjust insulin levels to glucose targets (hybrid closed loop). Other advancements including flash or intermittent scanning CGM (isCGM) and stand-alone insulin pumps do not confer as many advantages for women and their infants, however they are increasingly used outside of pregnancy and many women enter pregnancy already using these devices.

DISCUSSION

This article offers a discussion of the most commonly used technologies in pregnancy and evaluates their current and future roles.

Trends in hospitalizations and emergency department visits among women with hyperglycemia in pregnancy between 2008 and 2017 in Taiwan

INTRODUCTION

We investigated health service utilization, including hospitalizations and emergency department visits, for women with hyperglycemia in pregnancy between 2008 and 2017 in Taiwan.

METHODS

Data from the Health and Welfare Data Science Center were used to conduct this nationwide population-based study. We identified pregnant women and the date of childbirth according to Birth Certificate Applications from 2007 to 2018. The study population was divided into four groups: known DM, newly diagnosed DM, GDM, and no DM/GDM. To assess quality of healthcare during the gestation period, trends in 30-day readmission rate, number of emergency department visits/hospitalizations per 100 childbirths, and length of hospital stay from 2008 to 2017 were examined.

RESULTS

A total of 1830511 childbirths and 990569 hospitalizations were identified for analyses. Between 2008 and 2017, women with hyperglycemia in pregnancy (known DM, newly diagnosed DM, and GDM) had a higher rate of hospitalization, a longer length of hospital stay, and higher rates of various maternal and fetal outcomes, compared with women with no DM/GDM. Nevertheless, the differences between women with GDM and those with no DM/GDM in the aforementioned outcome measures were modest. Women with GDM had a modest decrease in the 30-day readmission rate (p for trend 0.046) with no significant difference in the number of emergency department visits during the study period.

DISCUSSION

Our findings provide evidence of the quality of healthcare for women with GDM between 2008 and 2017 in Taiwan.

Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis

BACKGROUND

The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population.

METHODS AND FINDINGS

We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes.

CONCLUSIONS

In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.

Congenital malformation and hemoglobin A1c in the first trimester among Japanese women with pregestational diabetes

AIM

To investigate the incidence of major congenital malformations in Japanese women with pregestational diabetes, and to determine the cutoff value of hemoglobin A1c (HbA1c) in the first trimester associated with congenital malformations.

METHODS

This retrospective cohort study included singleton pregnancies in Japanese women with pregestational diabetes, including type 1 and type 2 diabetes, and specific types of diabetes due to other causes. The primary outcome was the incidence of major congenital malformations. The secondary outcome was the incidence of all congenital malformations. The cutoff value of HbA1c for congenital malformations was calculated using receiver operating characteristic curve analysis. The adjusted odds ratios (aOR) of major congenital malformations were calculated using multiple logistic regression analyses.

RESULTS

This study enrolled 292 patients, including 132 (45.2%) with type 1 diabetes, 156 (53.4%) with type 2 diabetes, and 4 (1.4%) with other specific types. The incidence rates of major congenital malformations and all congenital malformations were 7.2% (21/292) and 12.7% (37/292), respectively. The cutoff value of HbA1c in the first trimester for major malformations and for all congenital malformations was 6.5%. HbA1c ≥ 6.5% was significantly associated with major malformations (aOR 3.5; 95% confidence interval: 1.2-12.6; p = 0.018).

CONCLUSION

The incidence of major congenital malformations significantly increased in pregnant Japanese women with HbA1c values of 6.5% or higher. The recommended HbA1c value during the first trimester used in other countries can be applied to pregnant Japanese women.

"Maternal diabetes mellitus and its impact on the risk of delivering a child with congenital heart disease: a systematic review and meta-analysis"

AIM

Maternal pregestational diabetes mellitus (PGDM), type 1 or type 2, has been established as a potential risk factor for congenital heart disease (CHD). At the same time, the correlation between gestational diabetes mellitus (GDM) and increased risk of CHD has not been yet fully elucidated. The objective of this systematic review and meta-analysis (PROSPERO number: CRD42020182390) was to analyze the existing evidence on PGDM and to attempt to fill, to the best of our ability, the remaining knowledge gap in the association of GDM with CHD.

MATERIALS AND METHODS

Two authors have independently searched the Pubmed/Medline, Scopus, Cochrane, Web of Science, and Theses Global databases with keywords and Boolean operators. The search yielded 9333 relevant articles, which were later screened for eligibility. Original peer-reviewed (case-control or cohort) studies were included if they were published in English between 1997 and 2020. Thirteen studies on mothers with PGDM and seven studies on mothers with GDM were finally included in our meta-analysis to investigate the association of maternal diabetes with the risk of delivering a child with CHD. The selected studies were all assessed for their methodological quality using the Newcastle-Ottawa scale. Associations with p < .05 were considered statistically significant.

RESULTS

Our meta-analysis (I² > 75%, total population: n = 12,461,586) of 79,476 women with PGDM and 160,893 with GDM produced an odds ratio of 3.48 (2.36-4.61) and 1.55 (1.48-1.61), respectively. Additionally, we did not find any noticeable difference in the risk for CHD among diabetic women living in the USA and Europe. Nevertheless, it still needs to be clarified, whether or not the gestational diabetic population includes undiagnosed women with preexisting diabetes, which might account for the increased risk of delivering a child with CHD in women classified as suffering from GDM.

CONCLUSION

While both GDM and PGDM seem to significantly increase the risk of CHD in comparison with the general population, PDGM appears to have a greater association with CHD, being correlated with a 3.5-fold increase in the risk of malformation. Preconceptional and gestational diabetes care are, therefore, essential to mitigate the adverse effect of hyperglycemia on fetal heart formation during pregnancy.

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

Purpose

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

Patients and methods

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

Results

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

Conclusions

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

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.

Type 1 Diabetes: Management in Women From Preconception to Postpartum

CONTEXT

This review presents an up-to-date summary on management of type 1 diabetes mellitus (T1DM) among women of reproductive age and covers the following time periods: preconception, gestation, and postpartum.

EVIDENCE ACQUISITION

A systematic search and review of the literature for randomized controlled trials and other studies evaluating management of T1DM before pregnancy, during pregnancy, and postpartum was performed.

EVIDENCE SYNTHESIS

Preconception planning should begin early in the reproductive years for young women with T1DM. Preconception and during pregnancy, it is recommended to have near-normal glucose values to prevent adverse maternal and neonatal outcomes, including fetal demise, congenital anomaly, pre-eclampsia, macrosomia, neonatal respiratory distress, neonatal hyperbilirubinemia, and neonatal hypoglycemia.

CONCLUSION

Women with T1DM can have healthy, safe pregnancies with preconception planning, optimal glycemic control, and multidisciplinary care.

Diabetes care and pregnancy outcomes for women with pregestational diabetes in Ireland

AIMS

Pre-gestational diabetes mellitus (PGDM) is associated with adverse outcomes. We aimed to examine pregnancies affected by PGDM; report on these pregnancy outcomes and compare outcomes for patients with type 1 versus type 2 diabetes mellitus; compare our findings to published Irish and United Kingdom (UK) data and identify potential areas for improvement.

METHODS

Between 2016 and 2018 information on 679 pregnancies from 415 women with type 1 Diabetes Mellitus and 244 women with type 2 diabetes was analysed. Data was collected on maternal characteristics; pregnancy preparation; glycaemic control; pregnancy related complications; foetal and maternal outcomes; unscheduled hospitalisations; congenital anomalies and perinatal deaths.

RESULTS

Only 15.9% of women were adequately prepared for pregnancy. Significant deficits were identified in availability and attendance at pre-pregnancy clinic, use of folic acid, attaining appropriate glycaemic targets and appropriate retinal screening. The majority of pregnancies (n = 567, 83.5%) resulted in a live birth but the large number of infants born large for gestational age (LGA) (n = 280, 49.4%), born prematurely <37 weeks and requiring neonatal intensive care unit (NICU) admission continue to be significant issues.

CONCLUSIONS

This retrospective cohort study identifies multiple targets for improvements in the provision of care to women with pre-gestational DM which are likely to translate into better pregnancy outcomes.

Advances in newer basal and bolus insulins: impact on type 1 diabetes

PURPOSE OF REVIEW

Insulin administration is vitally important to maintain a good glycaemic control in people with type 1 diabetes mellitus (T1DM). The purpose of this review is to give a clinically relevant overview of the newer basal and bolus insulin analogues and to highlight their practicalities of use and advantages in specific categories of patients with T1DM.

RECENT FINDINGS

Second-generation rapid-acting insulin analogues (i.e. faster insulin aspart and ultrarapid-acting lispro) have shown to be safe, efficient and superior in controlling postprandial plasma glucose levels without an increase in hypoglycaemia. The newest basal insulin analogues, insulin glargine U300 and degludec, have proven to be efficient in reducing hypoglycaemic events due to a more stable action profile.

SUMMARY

The second-generation rapid-acting and basal insulin analogues approach better the desired physiological insulin pattern of the beta cell. Due to a faster absorption, it is possible to inject the prandial insulin analogues more closely or even after meals without compromising postprandial glucose control. Due to more stable release patterns, basal insulins now have more reliable and longer profiles, covering basal insulin demands in a superior way, leading to a better glycaemic control with less hypoglycaemia (especially nocturnal events) and an improved quality of life.

A Practical Approach to Diagnosis of Spinal Dysraphism

Spinal dysraphisms (SDs) are congenital malformations of the spinal cord, determined by derangement in the complex cascade of embryologic events involved in spinal development. They represent a heterogeneous group ranging from mild clinical manifestations-going unnoticed or being discovered at clinical examination-to a causal factor of life quality impairment, especially when associated with musculoskeletal, gastrointestinal, genitourinary, or respiratory system malformations. Knowledge of the normal embryologic development of the spinal cord-which encompasses three main steps (gastrulation, primary neurulation, and secondary neurulation)-is crucial for understanding the pathogenesis, neuroradiologic scenarios, and clinical-radiologic classification of congenital malformations of the spinal cord. SDs can be divided with clinical examination or neuroradiologic study into two major groups: open SDs and closed SDs. Congenital malformations of the spinal cord include a wide range of abnormalities that vary considerably in imaging and clinical characteristics and complexity and therefore may represent a diagnostic challenge, even for the experienced radiologist. Online supplemental material is available for this article. ^©RSNA, 2021.

An overview of the management of diabetes from pre-conception, during pregnancy and in the postnatal period

Diabetes is one of the most common medical conditions complicating pregnancy. Both pre-existing diabetes and gestational diabetes are associated with increased risks to the mother and fetus. These risks can be reduced by improving pre-conception and antenatal care. Pre-conception planning and care is important to ensure women are taking high dose folic acid, to optimise glucose control, to review medications and to screen for and manage any complications. All women with either pre-existing diabetes or gestational diabetes should be reviewed by the antenatal team every 1-2 weeks throughout pregnancy. This is to optimise glucose control and to monitor fetal growth and development. Women with diabetes in pregnancy should receive an individualised care plan for delivery. The exact timing of delivery will depend on maternal glucose control, fetal growth and any other complications. Women diagnosed with gestational diabetes in pregnancy are at high risk of developing both gestational diabetes and type 2 diabetes in the future. After delivery, they should be offered a fasting plasma glucose at 6 weeks or a glycated haemoglobin (HbA1c) at 13 weeks to ensure that the gestational diabetes has resolved and an annual HbA1c.

Mechanisms of Congenital Malformations in Pregnancies with Pre-existing Diabetes

PURPOSE OF REVIEW

Fetuses of diabetic mothers are at increased risk for congenital malformations. Research in recent decades using animal and embryonic stem cell models has revealed many embryonic developmental processes that are disturbed by maternal diabetes. The aim of this review is to give clinicians a better understanding of the reasons for rigorous glycemic control in early pregnancy, and to provide background to guide future research.

RECENT FINDINGS

Mouse models of diabetic pregnancy have revealed mechanisms for altered expression of tissue-specific genes that lead to malformations that are more common in diabetic pregnancies, such as neural tube defects (NTDs) and congenital heart defects (CHDs), and how altered gene expression causes apoptosis that leads to malformations. Embryos express the glucose transporter, GLUT2, which confers susceptibility to malformation, due to high rates of glucose uptake during maternal hyperglycemia and subsequent oxidative stress; however, the teleological function of GLUT2 for mammalian embryos may be to transport the amino sugar glucosamine (GlcN) from maternal circulation to be used as substrate for glycosylation reactions and to promote embryo cell growth. Malformations in diabetic pregnancy may be not only due to excess glucose uptake but also due to insufficient GlcN uptake. Avoiding maternal hyperglycemia during early pregnancy should prevent excess glucose uptake via GLUT2 into embryo cells, and also permit sufficient GLUT2-mediated GlcN uptake.

Comprehensive assessment of the associations between maternal diabetes and structural birth defects in offspring: a phenome-wide association study

PURPOSE

Our objective was to comprehensively evaluate the risk of a broad range of birth defects among offspring of women with diabetes, overall and stratified by pregestational versus gestational diagnosis, using the phenome-wide association (PheWAS) methodology.

METHODS

We performed a registry linkage study of all live births (>6,500,000) and birth defects cases (>290,000) in Texas, 1999-2015. We ascertained diabetes from birth and fetal death certificates. We calculated prevalence rate ratios (PRR) for phenotypes with ≥10 cases among exposed offspring (n = 130).

RESULTS

Diabetes was associated with the prevalence of any defect (PRR 1.40, 95% confidence interval [CI] 1.38-1.42), multiple defects (PRR 1.86, 95% CI 1.81-1.91), and 60 specific phenotypes, including novel (hypospadias, mitral stenosis) and previously reported phenotypes (renal a-/dysgenesis, spinal anomalies). Pregestational diabetes was a stronger risk factor for any defect (PRR 2.00, 95% CI 1.93-2.07), multiple defects (PRR 3.27, 95% CI 3.11-3.44), and the 60 specific phenotypes evaluated. Gestational diabetes was associated with any defect (PRR 1.21, 95% CI 1.19-1.23) and 47 specific birth defects phenotypes, although associations were weaker than for pregestational diabetes.

CONCLUSIONS

The PheWAS is an efficient way to identify risk factors for disease using population-based registry data. Pregestational diabetes is associated with a broader range of phenotypes than previously reported. Because diabetes is diagnosed in 1% of women prior to pregnancy and 6%-9% during pregnancy, our results highlight a significant public health concern.

Preconception Counseling, Contraceptive Counseling, and Long-Acting Reversible Contraception Use in Women with Type I Diabetes: A Retrospective Cohort Study

Background: Reproductive-age women with type I diabetes require preconception counseling, contraceptive counseling, and access to long-acting reversible contraception (LARC) to better support peri-conception glycemic control and decrease rates of unplanned pregnancies and adverse pregnancy outcomes. Materials and Methods: This retrospective cohort study identified women (16-49 years old) with an ICD-9/ICD-10 code for type I diabetes and documented hemoglobin A1c (HbA1c) level in a tertiary referral center between January 1, 2010 and October 30, 2017. We abstracted 2 years of data centered on the time of the highest recorded HbA1c. We identified preconception counseling, contraceptive counseling, LARC use, provider type, and the presence of advanced vascular complications or disease >20 years duration. Multivariable logistic regression related disease severity and provider type to counseling and LARC documentation when controlling for patient age and race. Results: Among 541 women, only 5% received preconception counseling, 25% received contraceptive counseling, and 13% used LARC. Younger age and more visits were associated with documented preconception or contraceptive counseling (p < 0.01). Maternal fetal medicine specialists most frequently documented preconception counseling (16%, p = 0.01), whereas gynecologists most frequently documented contraceptive counseling (73%, p < 0.01). Contraceptive counseling was highly associated with LARC use (adjusted odds ratio 9.87, 95% confidence interval 5.09-19.12). Conclusions: Reproductive-age women with type I diabetes have infrequent documentation of preconception counseling and contraceptive counseling. Educating primary care providers and endocrinologists could avoid missed opportunities to improve pregnancy planning and outcomes.

Maternal and infant outcomes in sarcoidosis pregnancy: a Swedish population-based cohort study of first births

Background

It is unclear whether sarcoidosis, a multisystem inflammatory disease, is associated with adverse pregnancy outcomes. We aimed to assess the risk of adverse maternal and infant outcomes in sarcoidosis pregnancies, focused on first births.

Methods

Using a population-based cohort study design and Swedish national registers (2002–2013), we identified 182 singleton first pregnancies in the Medical Birth Register with at least two maternal ICD-coded sarcoidosis visits prior to pregnancy in the National Patient Register. Modified Poisson regression models estimated relative risks (RR) of adverse outcomes in sarcoidosis pregnancies compared to the general population adjusted for maternal age at delivery, calendar year and educational level. Some models were additionally adjusted for maternal body mass index and smoking status.

Results

The prevalence of pre-existing diabetes and hypertension was higher in mothers with sarcoidosis than those without sarcoidosis. Mothers with sarcoidosis had an increased risk of preeclampsia/eclampsia (RR 1.6; 95%CI 1.0, 2.6) and cesarean delivery (RR 1.3; 95%CI 1.0, 1.6). There were < 5 stillbirths and cases of infection and no cases of placental abruption, venous thromboembolism, cardiac arrest or maternal death. Newborns of first-time mothers with sarcoidosis had a 70% increased risk of preterm birth (RR 1.7; 95%CI 1.1, 2.5). There was an increased risk of birth defects (RR 1.6; 95%CI 0.9, 2.8) the majority of which were non-cardiac.

Conclusions

Sarcoidosis is associated with increased risks for preeclampsia/eclampsia, cesarean delivery, preterm birth and some birth defects. Awareness of these conditions may prevent possible pregnancy complications in mothers with sarcoidosis and their newborns.

Identification of MODY among patients screened for gestational diabetes: a clinician's guide

PURPOSE

Screening of gestational diabetes/GDM (although different in different countries) represents a standard procedure allowing to identify women with pregnancy-associated diabetes. Some of the women with GDM (up to 5%) may, however, suffer from previously undiagnosed MODY (Maturity-Onset Diabetes of the Young). Currently, no international or local guidelines focused on the identification of MODY among GDM exist. Thus, the aim of this manuscript is to propose a clear guide for clinicians on how to detect MODY among pregnant women with gestational diabetes.

METHODS

Based on the available literature about diagnosis (in general population) of MODY and management of MODY (both, in general population and in pregnant women), we propose a clear clinical guide on how to diagnose and manage MODY in pregnancy.

RESULTS

The manuscript suggests a feasible clinical approach how to recognize MODY among patients with GDM and how to manage pregnancy of women with three most common MODY subtypes.

CONCLUSION

A correct classification of diabetes is, nonetheless, essential, particularly in case of MODY, as the management of pregnant women with MODY is different and the correct diagnosis of MODY enables individualized treatment with regard to optimal pregnancy outcomes.

Exploratory study of clinician and patient views regarding the use of a preconception care app for women with diabetes

Women with diabetes are at increased risk of adverse maternal and foetal outcomes. Preconception care can minimise risk of complications and improve outcomes, but current provision is inadequate. Electronic health technology, particularly apps, could improve preconception care provision but research is lacking in this area. The aim of this article is to explore the views and experiences of clinicians and women with diabetes regarding the use of a mobile app for preconception care. An exploratory study was conducted. Data were collected using focus group and interviews with 19 participants, comprising 10 clinicians and 9 women with type 1 or 2 diabetes. Data were analysed thematically. Women with diabetes and clinicians highlighted the inadequacy and challenges of current preconception care service provision and expressed a high level of enthusiasm and interest, towards a preconception care app that could support preconception care delivery for women with diabetes and overcome barriers to preconception care service provision and uptake. The acceptability of mobile health technology to both women and clinicians creates an important opportunity to overcome existing barriers to service provision, delivery and uptake, and improve both maternal and foetal outcomes for women with diabetes.

Nutritional Challenges in Pregnant Women with Renal Diseases: Relevance to Fetal Outcomes

Pregnancy in women affected by chronic kidney disease (CKD) has become more common in recent years, probably as a consequence of increased CKD prevalence and improvements in the care provided to these patients. Management of this condition requires careful attention since many clinical aspects have to be taken into consideration, including the reciprocal influence of the renal disease and pregnancy, the need for adjustment of the medical treatments and the high risk of maternal and obstetric complications. Nutrition assessment and management is a crucial step in this process, since nutritional status may affect both maternal and fetal health, with potential effects also on the future development of adult diseases in the offspring. Nevertheless, few data are available on the nutritional management of pregnant women with CKD and the main clinical indications are based on small case series or are extrapolated from the general recommendations for non-pregnant CKD patients. In this review, we discuss the main issues regarding the nutritional management of pregnant women with renal diseases, including CKD patients on conservative treatment, patients on dialysis and kidney transplant patients, focusing on their relevance on fetal outcomes and considering the peculiarities of this population and the approaches that could be implemented into clinical practice.

A Systematic Review and Meta-Analysis of Diabetes During Pregnancy and Congenital Genitourinary Abnormalities

Introduction

This study aimed to assess available epidemiological evidence of the relationship between diabetes during pregnancy and congenital abnormalities of the kidney and the urinary tract (CAKUT).

Methods

POPLINE, MEDLINE, EMBASE, Global Health, CINAHL, and Cochrane Library were searched to retrieve 6962 articles of which 15 case-control and 11 cohort studies met the inclusion criteria. Random-effects meta-analysis was performed to estimate the association between CAKUT and diabetes during pregnancy.

Results

Offspring born to mothers with any form of diabetes in pregnancy had a 50% increased risk of CAKUT compared with offspring of mothers without diabetes (relative risk [RR], 1.51; 95% confidence interval [CI], 1.36–1.67). Compared with offspring with nondiabetic mothers, offspring of mothers with pre-existing diabetes had an almost 2-fold rate of CAKUT (RR, 1.97; 95% CI, 1.52–2.54). Offspring of mothers with gestational diabetes had a 39% increased risk of CAKUT (RR, 1.39; 95% CI, 1.26–1.55) compared with offspring of mothers with no diabetes. The subset of studies that adjusted for body mass index (BMI) before pregnancy showed similar associations. Population attributable risks for gestational diabetes were estimated to be 3.7% of cases of CAKUT in the United States, 4% of CAKUT cases in the United Kingdom, with up to 14.4% CAKUT cases in the South Asian population in the United Kingdom.

Conclusion

This study suggests that 2.0% to 3.7% of cases of CAKUT in the United States, and up to 14% of CAKUT in some populations could be eliminated if gestational diabetes was prevented or eliminated.

Risk of congenital heart defects in offspring exposed to maternal diabetes mellitus: an updated systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis was performed to assess the risk of congenital heart defects (CHDs) and its specific phenotypes associated with maternal diabetes mellitus (DM) including pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM).

METHODS

PubMed, Embase, Medline, Google Scholar, Cochrane Libraries, China National Knowledge Infrastructure, Wanfang Database, Chinese Scientific Journals Fulltext Database and China Biology Medicine disc were searched from the inception dates to 15 December 2018, to identify case-control or cohort studies assessing the association between maternal DM and risk of CHDs. The exposure of interest was maternal DM; the outcomes of interest were CHDs and its specific phenotypes. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. Subgroup analyses were performed to explore potential heterogeneity moderators.

RESULTS

Total 52 studies, which involved 259,917 patients with CHDs among 16,929,835 participants, were included for analysis. Overall, mothers with DM compared with those without DM had a significantly higher risk of CHDs in offspring [odds ratios (OR) = 2.71, 95% confidence intervals (CI) 2.28-3.23]. When data were restricted to different types of DM, a significantly increased risk of CHDs was observed among mothers with PGDM (OR = 3.18, 95% CI 2.77-3.65) and GDM (OR = 1.98, 95% CI 1.66-2.36). Our study suggested the risk of CHDs was significantly higher among mothers with PGDM than those with GDM. Additionally, this study suggested maternal DM was significantly associated with most phenotypes of CHDs; of these, double outlet of the right ventricle (OR = 10.89; 95% CI 8.77-13.53), atrioventricular septal defect (OR = 5.74; 95% CI 3.20-10.27) and truncus arteriosus (OR = 5.06; 95% CI 2.65-9.65) were identified as the first three of the most common phenotypes of CHDs associated with maternal DM.

CONCLUSIONS

The maternal DM including PGDM and GDM are significantly associated with risk of CHDs and its most phenotypes. The PGDM seems to be more likely to cause CHDs in offspring than GDM. Further studies are needed to clarify the underlying mechanisms.

In Utero Exposure to Gestational Diabetes Alters DNA Methylation and Gene Expression of CDKN2A/B in Langerhans Islets of Rat Offspring

Objective

DNA methylation, a major epigenetic reprogramming mechanism, contributes to the increased prevalence of type 2 diabetes mellitus (T2DM). Based on genome-wide association studies, polymorphisms in CDKN2A/B are associated with T2DM. Our previous studies showed that gestational diabetes mellitus (GDM) causes apoptosis in β-cells, leading to a reduction in their number in pancreatic tissue of GDM-exposed adult rat offspring. The aim of this study was to examine the impact of intrauterine exposure to GDM on DNA methylation, mRNA transcription, as well as protein expression of these factors in the pancreatic islets of Wistar rat offspring. Our hypothesis was that the morphological changes seen in our previous study might have been caused by aberrant methylation and expression of CDKN2A/B.

Materials and Methods

In this experimental study, we delineated DNA methylation patterns, mRNA transcription and protein expression level of CDKN2A/B in the pancreatic islets of 15-week-old rat offspring of streptozotocin-induced GDM dams. We performed bisulfite sequencing to determine the DNA methylation patterns of CpGs in candidate promoter regions of CDKN2A/B. Furthermore, we compared the levels of mRNA transcripts as well as the cell cycle inhibitory proteins P15 and P16 in two groups by qPCR and western blotting, respectively.

Results

Our results demonstrated that hypomethylation of CpG sites in the vicinity of CDKN2A and CDKN2B genes is positively related to increased levels of CDKN2A/B mRNA and protein in islets of Langerhans in the GDM offspring. The average percentage of CDKN2A promoter methylation was significantly lower in GDM group compared to the controls (P<0.01).

Conclusion

We postulate that GDM is likely to exert its adverse effects on pancreatic β-cells of offspring through hypomethylation of the CDKN2A/B promoter. Abnormal methylation of these genes may have a link with β-cell dysfunction and diabetes. These data potentially lead to a novel approach to the treatment of T2DM.

Factors associated with stillbirth in women with diabetes

AIMS/HYPOTHESIS

Stillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors.

METHODS

A retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA_1c data and delivery timing were compared between stillborn and liveborn groups.

RESULTS

Stillbirth rates were 16.1 (95% CI 12.4, 20.8) and 22.9 (95% CI 16.4, 31.8) per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA_1c before pregnancy (OR 1.03 [95% CI 1.01, 1.04]; p = 0.0003) and in later pregnancy (OR 1.06 [95% CI 1.04, 1.08]; p < 0.0001) were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI (OR 1.07 [95% CI 1.01, 1.14]; p = 0.02) and pre-pregnancy HbA_1c (OR 1.02 [95% CI 1.00, 1.04]; p = 0.016) were associated with stillbirth. Risk was highest in infants with birthweights <10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th-90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights >95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week (7.0 [95% CI 3.7, 12.9] per 1000 ongoing pregnancies) among mothers with type 1 diabetes and in the 39th week (9.3 [95% CI 2.4, 29.2]) for type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Maternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies.

[Clinical practice recommendations for diabetes in pregnancy (Update 2019)]

In 1989 the St. Vincent Declaration aimed to achieve comparable pregnancy outcomes in diabetic and non-diabetic women. However, currently women with pre-gestational diabetes still feature a higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. All women should be experienced in the management of their therapy and on stable glycemic control prior to the conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded before pregnancy or treated adequately in order to decrease the risk for a progression of complications during pregnancy as well as maternal and fetal morbidity. Especially in women with type 1 diabetes mellitus in early pregnancy the risk of hypoglycemia is highest and decreases with the progression of pregnancy due to hormonal changes causing steady increase of insulin resistance. In addition, obesity increases worldwide and contributes to increasing numbers of women at childbearing age with type 2 diabetes mellitus and further deterioration of pregnancy outcomes in diabetic women. Maternal glycemic control should aim to achieve normoglycemia and normal HbA_1c levels, possibly without hypoglycemia, but is associated with the development of diabetic embryopathy and fetopathy if dysglycemia occurs. Intensified insulin therapy with multiple daily insulin injections and pump treatment are effective in reaching good metabolic control during pregnancy. Oral glucose lowering drugs (Metformin) may be considered in obese women with type 2 diabetes mellitus to increase insulin sensitivity but should be also prescribed cautiously due to crossing the placenta and lack of long-time follow up data of the offspring.

Type 1 Diabetes in Pregnancy

Congenital malformations and perinatal mortality rates remain severalfold higher in pregnant women with type 1 diabetes than in the background population, and still only a minority of women plan their pregnancy. Optimizing glycemic control is the accepted goal, but remains challenging, and must be constantly balanced against the risks of hypoglycemia. Recent advances including Continuous Glucose Monitoring Systems, Continuous Subcutaneous Insulin Infusion, Closed Loop Devices and very Fast Acting Insulin Aspart analogs offer new possibilities to increase glucose time in target in selected, motivated patients, however their relative roles and indication for use require further elucidation. The importance of education cannot be overstated.

Congenital heart defects in West Virginia: Preliminary findings from an ecological study of effects of an industrial watershed on increased incidence

OBJECTIVE

Congenital anomalies are the leading cause of infant death, with congenital heart (CHD) defects the most common type. The study objective was to evaluate the incidence of fetal CHD in a tertiary care medical center's obstetric population in West Virginia and map areas of possible environmental exposure.

METHODS

This was an observational study of patients with positive ultrasound screen for CHD from 1/1/2007-8/31/2016. An Optimized Hot Spot analysis and Ripley's K- Function was constructed to understand the effect of CHD in relation to proximity to chemical and coal extraction sites.

RESULTS

Of the 16,871 obstetric pregnancies, 206 (1.2%) had fetal CHD with ventriculoseptal defects the most common (88; 42.7%). The majority of cases of CHD followed the industrial watershed of the Kanawha River in West Virginia. Direct point source exposure suggests a relationship in cases of CHD within Kanawha River and surrounding areas. The observed K was significantly above the expected K across all 10 distance bands. The fourth distance band exhibited the larger difference at (37914), between the expected verses the observed K function.

CONCLUSION

Through spatial analysis, there appears to be a direct point source exposure for observed cases of f CHD along the industrial watershed of Kanawha County, West Virginia.

Neonatal Near Miss among Newborns of Women with Type 1 Diabetes Mellitus

Objective

To investigate the frequency of neonatal near miss (NNM) and associate it with maternal morbidity in newborns of women with type 1 diabetes mellitus (T1DM).

Methods

This was a cross-sectional retrospective study from a secondary analysis of data retrieved from medical records of pregnant women with T1DM cared at a Brazilian university hospital between 2005 and 2015. Maternal near miss (MNM) and potentially life-threatening conditions (PTLC) were classified according to the World Health Organization criteria. NNM was classified according to the Pan American Health Organization Neonatal Near Miss Working Group criteria. Association of maternal morbidity with NNM was assessed using chi-square test.

Results

There were 122 newborns (NB) among 137 T1DM pregnancies. Thirty-seven NB presented NNM-incidence of 303 NNM per 1000 live births (37/122). NNM was associated with MNM (P < 0.001, OR (95% CI): 17.15 (1.85-159.12)). PLTC did not increase the odds of NNM (P=0.07; OR (95% CI): 2.1281 (0.92-4.91)). Seven newborns died, six of them from pregnancies without severe maternal morbidity. 71% of the neonatal death (5/7) occurred in malformed neonates.

Conclusion

MNM was associated with NNM among women with T1DM, and PLTC, paradoxically, did not increase NNM.