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Tan Z, Ding M, Shen J, Huang Y, Li J, Sun A, Hong J, Yang Y, He S, Pei C, Luo R. Causal pathways in preeclampsia: a Mendelian randomization study in European populations. Front Endocrinol (Lausanne) 2024; 15:1453277. [PMID: 39286274 PMCID: PMC11402816 DOI: 10.3389/fendo.2024.1453277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 08/15/2024] [Indexed: 09/19/2024] Open
Abstract
Purpose Our study utilizes Mendelian Randomization (MR) to explore the causal relationships between a range of risk factors and preeclampsia, a major contributor to maternal and perinatal morbidity and mortality. Methods Employing the Inverse Variance Weighting (IVW) approach, we conducted a comprehensive multi-exposure MR study analyzing genetic variants linked to 25 risk factors including metabolic disorders, circulating lipid levels, immune and inflammatory responses, lifestyle choices, and bone metabolism. We applied rigorous statistical techniques such as sensitivity analyses, Cochran's Q test, MR Egger regression, funnel plots, and leave-one-out sensitivity analysis to address potential biases like pleiotropy and population stratification. Results Our analysis included 267,242 individuals, focusing on European ancestries and involving 2,355 patients with preeclampsia. We identified strong genetic associations linking increased preeclampsia risk with factors such as hyperthyroidism, BMI, type 2 diabetes, and elevated serum uric acid levels. Conversely, no significant causal links were found with gestational diabetes, total cholesterol, sleep duration, and bone mineral density, suggesting areas for further investigation. A notable finding was the causal relationship between systemic lupus erythematosus and increased preeclampsia risk, highlighting the significant role of immune and inflammatory responses. Conclusion This extensive MR study sheds light on the complex etiology of preeclampsia, underscoring the causal impact of specific metabolic, lipid, immune, lifestyle, and bone metabolism factors. Our findings advocate for a multidimensional approach to better understand and manage preeclampsia, paving the way for future research to develop targeted preventive and therapeutic strategies.
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Affiliation(s)
- Zilong Tan
- Department of Urology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mengdi Ding
- Department of Urology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianwu Shen
- Department of Urology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Department of Urology, Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, China
| | - Yuxiao Huang
- Department of Gynecology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Junru Li
- Department of Internal Medicine, Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, China
| | - Aochuan Sun
- Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jing Hong
- Department of Integration of Chinese and Western Medicine, Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yan Yang
- Department of Critical Care Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, China
| | - Sheng He
- The First Clinical Medical College of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Chao Pei
- Department of Ophthalmology, China Academy of Traditional Chinese Medicine Hospital of Ophthalmology, Beijing, China
| | - Ran Luo
- Department of Gynecology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Tamura RK, Kodani N, Itoh A, Meguro S, Kajio H, Itoh H. A sensor-augmented pump with a predictive low-glucose suspend system could lead to an optimal time in target range during pregnancy in Japanese women with type 1 diabetes. Diabetol Int 2024; 15:447-455. [PMID: 39101163 PMCID: PMC11291783 DOI: 10.1007/s13340-024-00716-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/18/2024] [Indexed: 08/06/2024]
Abstract
Introduction It is challenging for pregnant women with type 1 diabetes to maintain optimum glucose level to attain good neonatal outcomes. This study evaluated the efficacy of sensor-augmented insulin pump (SAP) with a predictive low-glucose suspend (PLGS) system in pregnant Japanese women with type 1 diabetes. Materials and methods SAP with PLGS was used in 11 of the 22 women with type 1 diabetes who delivered between 2011 and 2021 at the two medical institutions in Japan. Glucose management, insulin delivery suspension time (IST) and neonatal outcomes were retrospectively studied. Results In SAP with PLGS cases (n = 11), average glycated hemoglobin levels were < 6.5% throughout the pregnancy, and the time in range (TIR, 63-140 mg/dl) was > 70% in the second and third trimesters. PLGS was safely used without inducing ketoacidosis. Positive correlation was observed between IST and TIR (r = 0.62, p < 0.01). Negative correlation was observed between IST and time below range (TBR) (r = - 0.40, p = 0.02), and IST and time above range (TAR) (r = - 0.45, p = 0.01). Total daily insulin dose was adequately increased without increasing hypoglycemia. There was only one heavy-for-date HFD) infant among the 11 newborns in SAP with PLGS cases. In cases without SAP (n = 11), target glycemic levels were difficult to achieve and there were 5 HFD infants among the 11 newborns. Conclusion SAP with PLGS was safely and effectively used in pregnant women with type 1 diabetes to achieve target glucose levels without increasing the risk of hypoglycemia, which may have led to good neonatal outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s13340-024-00716-7.
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Affiliation(s)
- Rie Kaneshima Tamura
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582 Japan
| | - Noriko Kodani
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku-Ku, Tokyo, 162-8655 Japan
| | - Arata Itoh
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582 Japan
| | - Shu Meguro
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582 Japan
| | - Hiroshi Kajio
- Department of Diabetes, Endocrinology and Metabolism, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku-Ku, Tokyo, 162-8655 Japan
| | - Hiroshi Itoh
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi Shinjuku-Ku, Tokyo, 160-8582 Japan
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Szmuilowicz ED, Barbour L, Brown FM, Durnwald C, Feig DS, O’Malley G, Polsky S, Aleppo G. Continuous Glucose Monitoring Metrics for Pregnancies Complicated by Diabetes: Critical Appraisal of Current Evidence. J Diabetes Sci Technol 2024; 18:819-834. [PMID: 38606830 PMCID: PMC11307229 DOI: 10.1177/19322968241239341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Ascertaining the utility of continuous glucose monitoring (CGM) in pregnancy complicated by diabetes is a rapidly evolving area, as the prevalence of type 1 diabetes (T1D), type 2 diabetes (T2D), and gestational diabetes mellitus (GDM) escalates. The seminal randomized controlled trial (RCT) evaluating CGM use added to standard care in pregnancy in T1D demonstrated significant improvements in maternal glycemia and neonatal health outcomes. Current clinical guidance recommends targets for percentage time in range (TIR), time above range (TAR), and time below range (TBR) during pregnancy complicated by T1D that are widely used in clinical practice. However, the superiority of CGM over blood glucose monitoring (BGM) is still questioned in both T2D and GDM, and whether glucose targets should be different than in T1D is unknown. Questions requiring additional research include which CGM metrics are superior in predicting clinical outcomes, how should pregnancy-specific CGM targets be defined, whether CGM targets should differ according to gestational age, and if CGM metrics during pregnancy should be similar across all types of diabetes. Limiting the potential for CGM to improve pregnancy outcomes may be our inability to maintain TIR > 70% throughout gestation, a goal achieved in the minority of patients studied. Adverse pregnancy outcomes remain high in women with T1D and T2D in pregnancy despite CGM technology, and this review explores the potential reasons and questions yet to be investigated.
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Affiliation(s)
| | - Linda Barbour
- University of Colorado Anschutz Medical
Campus, Aurora, CO, USA
| | | | | | | | | | - Sarit Polsky
- University of Colorado Anschutz Medical
Campus, Aurora, CO, USA
| | - Grazia Aleppo
- Northwestern University Feinberg School
of Medicine, Chicago, IL, USA
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4
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Koefoed AS, Knorr S, Fuglsang J, Leth-Møller M, Hulman A, Jensen DM, Andersen LLT, Rosbach AE, Damm P, Mathiesen ER, Sørensen A, Christensen TT, McIntyre HD, Ovesen P, Kampmann U. Hemoglobin A1c Trajectories During Pregnancy and Adverse Outcomes in Women With Type 2 Diabetes: A Danish National Population-Based Cohort Study. Diabetes Care 2024; 47:1211-1219. [PMID: 38771955 DOI: 10.2337/dc23-2304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/19/2024] [Indexed: 05/23/2024]
Abstract
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.
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Affiliation(s)
- Anna S Koefoed
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sine Knorr
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Fuglsang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Magnus Leth-Møller
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Adam Hulman
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Dorte M Jensen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Lise Lotte T Andersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - A Emilie Rosbach
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne Sørensen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Trine T Christensen
- Steno Diabetes Center Aalborg, Aalborg University Hospital, Aalborg, Denmark
| | - H David McIntyre
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Mater Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Per Ovesen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ulla Kampmann
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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5
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Rathcke SL, Sinding MM, Christensen TT, Uldbjerg N, Christiansen OB, Kornblad J, Søndergaard KH, Krogh S, Sørensen ANW. Prediction of large-for-gestational-age at birth using fetal biometry in type 1 and type 2 diabetes: A retrospective cohort study. Int J Gynaecol Obstet 2024. [PMID: 38831743 DOI: 10.1002/ijgo.15711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/05/2024] [Accepted: 05/11/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE To compare ultrasound-assessed fetal head circumference (HC), abdominal circumference (AC), HC/AC ratio, and estimated fetal weight (EFW) in prediction of large-for-gestational-age (LGA) at birth in pregnancies affected by type 1 (T1DM) and type 2 (T2DM) diabetes. METHODS This retrospective cohort study included all women with T1DM and T2DM giving birth to singletons between 2010 and 2019 at Aalborg University Hospital, Denmark. Ultrasound scans were performed at 16, 20, 28 and 34 weeks of pregnancy. LGA was defined as birth weight deviation of 15% or greater from the expected for gestational age (≥90th centile). Prediction of LGA was assessed by logistic regression adjusted for maternal characteristics and glycated hemoglobin (HbA1c) and area under the receiver operating characteristics curve (AUC). RESULTS Among 180 T1DM pregnancies, 118 (66%) had an LGA neonate at birth. At 28 weeks of pregnancy, they were predicted with AUCHC/AC = 0.67, AUCAC = 0.85, and AUCEFW = 0.86. The multivariate analysis did not improve the predictive performance of the HC/AC ratio or AC. Among 87 T2DM pregnancies, 36 (41%) had an LGA neonate at birth. At 28 weeks, they were predicted with AUCHC/AC = 0.73, AUCAC = 0.83, and AUCEFW = 0.87. In T2DM, the multivariate analysis significantly improved the predictive performance for both HC/AC ratio and AC from 20 weeks of pregnancy. CONCLUSION In T1DM and T2DM pregnancies, LGA is characterized by a general fetal overgrowth including both AC and HC. Therefore, AC and EFW perform better than the HC/AC ratio in the prediction of LGA. In T2DM, as opposed to T1DM, the predictive performance was improved by the inclusion of maternal characteristics and HbA1c in the analysis.
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Affiliation(s)
- Sidsel L Rathcke
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marianne M Sinding
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Trine T Christensen
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Julia Kornblad
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Sofie Krogh
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne N W Sørensen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Ngema M, Xulu ND, Ngubane PS, Khathi A. Pregestational Prediabetes Induces Maternal Hypothalamic-Pituitary-Adrenal (HPA) Axis Dysregulation and Results in Adverse Foetal Outcomes. Int J Mol Sci 2024; 25:5431. [PMID: 38791468 PMCID: PMC11122116 DOI: 10.3390/ijms25105431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
Maternal type 2 diabetes mellitus (T2DM) has been shown to result in foetal programming of the hypothalamic-pituitary-adrenal (HPA) axis, leading to adverse foetal outcomes. T2DM is preceded by prediabetes and shares similar pathophysiological complications. However, no studies have investigated the effects of maternal prediabetes on foetal HPA axis function and postnatal offspring development. Hence, this study investigated the effects of pregestational prediabetes on maternal HPA axis function and postnatal offspring development. Pre-diabetic (PD) and non-pre-diabetic (NPD) female Sprague Dawley rats were mated with non-prediabetic males. After gestation, male pups born from the PD and NPD groups were collected. Markers of HPA axis function, adrenocorticotropin hormone (ACTH) and corticosterone, were measured in all dams and pups. Glucose tolerance, insulin and gene expressions of mineralocorticoid (MR) and glucocorticoid (GR) receptors were further measured in all pups at birth and their developmental milestones. The results demonstrated increased basal concentrations of ACTH and corticosterone in the dams from the PD group by comparison to NPD. Furthermore, the results show an increase basal ACTH and corticosterone concentrations, disturbed MR and GR gene expression, glucose intolerance and insulin resistance assessed via the Homeostasis Model Assessment (HOMA) indices in the pups born from the PD group compared to NPD group at all developmental milestones. These observations reveal that pregestational prediabetes is associated with maternal dysregulation of the HPA axis, impacting offspring HPA axis development along with impaired glucose handling.
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Affiliation(s)
| | | | | | - Andile Khathi
- School of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Westville, Private Bag X54001, Durban 4041, KwaZulu Natal, South Africa; (M.N.); (N.D.X.); (P.S.N.)
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7
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Suzuki T, Yanagisawa K, Kakogawa J, Babazono T. Clinical factors associated with birth weight of infants born to pregnant women with diabetes. Diabetol Int 2024; 15:177-186. [PMID: 38524925 PMCID: PMC10959873 DOI: 10.1007/s13340-023-00667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/22/2023] [Indexed: 03/26/2024]
Abstract
We aimed to examine the clinical factors associated with the birth weight of infants born to Japanese pregnant women with diabetes. This retrospective observational study enrolled 204 Japanese women with singleton pregnancies with type 1 diabetes (n = 135) or type 2 diabetes (n = 69). We used multiple regression analyses to examine factors associated with birth weight standard deviation (SD) scores. In addition, we compared the clinical findings among the groups of mothers who gave birth to appropriate for gestational age infants (AGA group), large for gestational age infants (LGA group), and small for gestational age infants (SGA group). Multiple regression analyses showed that the birth weight SD score was positively associated with type 2 diabetes. In women with type 1 diabetes, the birth weight SD score was positively associated with glycated albumin levels and gestational weight gain and negatively associated with pre-pregnancy underweight. Only gestational weight gain was positively associated with birth weight SD scores in women with type 2 diabetes. Glycated hemoglobin levels, gestational weight gain, and triglyceride levels were significantly higher in the LGA group than in the AGA group. The SGA group showed significantly lower gestational weight gain and triglyceride levels than the AGA group. These results suggest that it is important to manage not only blood glucose levels but also pre-pregnancy body weight and gestational weight gain for appropriate fetal growth. The effects of clinical factors on infant birth weight may differ between patients with type 1 and those with type 2 diabetes.
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Affiliation(s)
- Tomoko Suzuki
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Keiko Yanagisawa
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
| | - Jun Kakogawa
- Maternal and Perinatal Center, Tokyo Women’s Medical University School of Medicine, Tokyo, Japan
| | - Tetsuya Babazono
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666 Japan
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8
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Nørgaard SK, Søholm JC, Mathiesen ER, Nørgaard K, Clausen TD, Holmager P, Do NC, Damm P, Ringholm L. Faster-acting insulin aspart versus insulin aspart in the treatment of type 1 or type 2 diabetes during pregnancy and post-delivery (CopenFast): an open-label, single-centre, randomised controlled trial. Lancet Diabetes Endocrinol 2023; 11:811-821. [PMID: 37804858 DOI: 10.1016/s2213-8587(23)00236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Faster-acting insulin aspart (faster aspart) is considered safe for use during pregnancy and breastfeeding but has not been evaluated in this population. We aimed to evaluate the effect of faster aspart versus insulin aspart on fetal growth, in women with type 1 or type 2 diabetes during pregnancy and post-delivery. METHODS This open-label, single-centre, superiority trial was conducted at Rigshospitalet, Copenhagen, Denmark. Participants aged 18 years or older with type 1 or type 2 diabetes were stratified by diabetes type and insulin treatment modality (multiple daily injections or insulin pump), randomly assigned 1:1 to faster aspart or insulin aspart, from 8 weeks and 0 days (8+0) of gestation to 13+6 weeks of gestation, and followed up until 3 months post-delivery. Primary outcome was infant birthweight SD score. Secondary outcomes included HbA1c as well as maternal and fetal outcomes in all participants during the trial. This trial is registered with ClinicalTrials.gov, NCT03770767. FINDINGS Between Nov 11, 2019 and May 10, 2022, 109 participants were included in the faster aspart group and 107 in the insulin aspart group. Primary outcome data were available in 203 (94%) of 216 participants, and no participants discontinued treatment during the trial. Mean birthweight SD score was 1·0 (SD 1·4) in the faster aspart group versus 1·2 (1·3) in the insulin aspart group; estimated treatment difference -0·22 [-0·58 to 0·14]; p=0·23. At 33 weeks of gestation, mean HbA1c was 42 mmol/mol (SD 6 mmol/mol; 6·0% [SD 0·9%]) versus 43 mmol/mol (SD 7 mmol/mol; 6·1% [SD 1·2%]); estimated treatment difference -1·01 (-2·86 to 0·83), p=0·28. No additional safety issues were observed with faster aspart compared with insulin aspart. INTERPRETATION Treatment with faster aspart resulted in similar fetal growth and HbA1c, relative to insulin aspart, in women with type 1 or type 2 diabetes. Faster aspart can be used in women with type 1 or type 2 diabetes during pregnancy and post-delivery with no additional safety issues. FUNDING Novo Nordisk. TRANSLATION For the Danish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Sidse K Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Julie C Søholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Tine D Clausen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Pernille Holmager
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
| | - Nicoline C Do
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark; Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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9
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Ahmed MA, Bailey HD, Pereira G, White SW, Wong K, McNamara BJ, Rheeder P, Marriott R, Shepherd CCJ. The impact of diabetes during pregnancy on neonatal outcomes among the Aboriginal population in Western Australia: a whole-population study. Int J Epidemiol 2023; 52:1400-1413. [PMID: 37263617 DOI: 10.1093/ije/dyad072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 05/13/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have a high prevalence of diabetes in pregnancy (DIP), which includes pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). We aimed to characterize the impact of DIP in babies born to Aboriginal mothers. METHODS A retrospective cohort study, using routinely collected linked health data that included all singleton births (N = 510 761) in Western Australia between 1998 and 2015. Stratified by Aboriginal status, generalized linear mixed models quantified the impact of DIP on neonatal outcomes, estimating relative risks (RRs) with 95% CIs. Ratio of RRs (RRRs) examined whether RRs differed between Aboriginal and non-Aboriginal populations. RESULTS Exposure to DIP increased the risk of adverse outcomes to a greater extent in Aboriginal babies. PGDM heightened the risk of large for gestational age (LGA) (RR: 4.10, 95% CI: 3.56-4.72; RRR: 1.25, 95% CI: 1.09-1.43), macrosomia (RR: 2.03, 95% CI: 1.67-2.48; RRR: 1.39, 95% CI: 1.14-1.69), shoulder dystocia (RR: 4.51, 95% CI: 3.14-6.49; RRR: 2.19, 95% CI: 1.44-3.33) and major congenital anomalies (RR: 2.14, 95% CI: 1.68-2.74; RRR: 1.62, 95% CI: 1.24-2.10). GDM increased the risk of LGA (RR: 2.63, 95% CI: 2.36-2.94; RRR: 2.00, 95% CI: 1.80-2.22), macrosomia (RR: 1.95, 95% CI: 1.72-2.21; RRR: 2.27, 95% CI: 2.01-2.56) and shoulder dystocia (RR: 2.78, 95% CI: 2.12-3.63; RRR: 2.11, 95% CI: 1.61-2.77). Birthweight mediated about half of the DIP effect on shoulder dystocia only in the Aboriginal babies. CONCLUSIONS DIP differentially increased the risks of fetal overgrowth, shoulder dystocia and congenital anomalies in Aboriginal babies. Improving care for Aboriginal women with diabetes and further research on preventing shoulder dystocia among these women can reduce the disparities.
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Affiliation(s)
- Marwan Awad Ahmed
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen D Bailey
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Gavin Pereira
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Centre for Fertility and Health (CeFH), Norwegian Institute of Public Health, Oslo, Norway
- enAble Institute, Curtin University, Perth, Western Australia, Australia
| | - Scott W White
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
- Maternal Fetal Medicine Service, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Bridgette J McNamara
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Paul Rheeder
- Department of Internal Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Rhonda Marriott
- Ngangk Yira Research Centre, Murdoch University, Perth, Western Australia, Australia
| | - Carrington C J Shepherd
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Ngangk Yira Research Centre, Murdoch University, Perth, Western Australia, Australia
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10
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Benhalima K, Beunen K, Siegelaar SE, Painter R, Murphy HR, Feig DS, Donovan LE, Polsky S, Buschur E, Levy CJ, Kudva YC, Battelino T, Ringholm L, Mathiesen ER, Mathieu C. Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets. Lancet Diabetes Endocrinol 2023; 11:490-508. [PMID: 37290466 DOI: 10.1016/s2213-8587(23)00116-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 06/10/2023]
Abstract
Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.
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Affiliation(s)
- Katrien Benhalima
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Kaat Beunen
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah E Siegelaar
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Rebecca Painter
- Department of Gynaecology and Obstetrics, Amsterdam UMC, Vrije Universiteit, Netherlands; Amsterdam Reproduction and Development, Amsterdam, Netherlands
| | - Helen R Murphy
- Diabetes and Antenatal Care, University of East Anglia, Norwich, UK
| | - Denice S Feig
- Department of Medicine, Obstetrics, and Gynecology and Department of Health Policy, Management, and Evaluation, University of Toronto, Diabetes and Endocrinology in Pregnancy Program, Mt Sinai Hospital, Toronto, ON, Canada
| | - Lois E Donovan
- Division of Endocrinology and Metabolism, Department of Medicine, and Department of Obstetrics and Gynaecology, Cumming School Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarit Polsky
- Medicine and Pediatrics, Barbara Davis Center for Diabetes, Adult Clinic, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Buschur
- Internal Medicine, Endocrinology, Diabetes, and Metabolism, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Carol J Levy
- Department of Medicine, Endocrinology and Obstetrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yogish C Kudva
- Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
| | | | - Chantal Mathieu
- Endocrinology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
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11
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He LR, Yu L, Guo Y. Birth weight and large for gestational age trends in offspring of pregnant women with gestational diabetes mellitus in southern China, 2012-2021. Front Endocrinol (Lausanne) 2023; 14:1166533. [PMID: 37214242 PMCID: PMC10194652 DOI: 10.3389/fendo.2023.1166533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
Background With increasing prevalence of gestational diabetes mellitus (GDM) and changing management of GDM in pregnancy, it is imperative to understand the evolution of its current outcomes. The present study aimed to explore whether birth weight and large for gestational age (LGA) trends in women with GDM have changed over time in southern China. Methods In this hospital-based retrospective study, all singleton live births for the period 2012 to 2021 were collected from the Guangdong Women and Children Hospital, China. GDM was diagnosed following the criteria of the International Association of Diabetes and Pregnancy Study Group. The cutoff points for defining LGA (>90th centile) at birth based on INTERGROWTH-21st gender-specific standards. Linear regression was used to evaluate trends for birth weight over the years. Logistic regression analysis was used to determine the odds ratios (ORs) of LGA between women with GDM and those without GDM. Results Data from 115097 women with singleton live births were included. The total prevalence of GDM was 16.8%. GDM prevalence varied across different years, with the lowest prevalence in 2014 (15.0%) and the highest prevalence in 2021 (19.2%). The mean birth weight displayed decrease in women with GDM from 3.224kg in 2012 to 3.134kg in 2021, and the z score for mean birth weight decreased from 0.230 to -0.037 (P for trend < 0.001). Among women with GDM, the prevalence of macrosomia and LGA reduced significantly during the study period (from 5.1% to 3.0% in macrosomia and from 11.8% to 7.7% in LGA, respectively). Compared to women without GDM, women with GDM had 1.30 (95% CI: 1.23 - 1.38) times odds for LGA, and the ORs remained stable over the study period. Conclusions Among offspring of women with GDM, there are decreased trends of birth weight in parallel with reductions in LGA prevalence between 2012 and 2021. However, the risk of LGA in women with GDM remains stable at relatively high level over the 10-year period, and efforts are still needed to address regarding causes and effective intervention strategies.
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Affiliation(s)
- Li-Rong He
- Department of Obstetrics, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, China
| | - Li Yu
- Department of Children’s Health Care, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yong Guo
- Department of Children’s Health Care, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, China
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12
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Thorius IH, Husemoen LLN, Nordsborg RB, Alibegovic AC, Gall MA, Petersen J, Mathiesen ER. Congenital malformations among offspring of women with type 1 diabetes who use insulin pumps: a prospective cohort study. Diabetologia 2023; 66:826-836. [PMID: 36640191 DOI: 10.1007/s00125-022-05864-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/23/2022] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Ida H Thorius
- Center for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- Novo Nordisk A/S, Søborg, Denmark.
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark.
| | | | | | | | | | - Janne Petersen
- Copenhagen Phase IV Unit, Department of Clinical Pharmacology and Center for Clinical Research and Prevention, Copenhagen University Hospital, Frederiksberg, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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13
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Ren Y, Hao L, Liu J, Wang P, Ding Q, Chen C, Song Y. Alterations in the Gut Microbiota in Pregnant Women with Pregestational Type 2 Diabetes Mellitus. mSystems 2023; 8:e0114622. [PMID: 36853013 PMCID: PMC10134876 DOI: 10.1128/msystems.01146-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/17/2023] [Indexed: 03/01/2023] Open
Abstract
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.
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Affiliation(s)
- Yuan Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | | | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Pei Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | | | | | - Yingna Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
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14
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Hummel M, Füchtenbusch M, Battefeld W, Bührer C, Groten T, Haak T, Kainer F, Kautzky-Willer A, Lechner A, Meissner T, Nagel-Reuper C, Schäfer-Graf U, Siegmund T. Diabetes and Pregnancy. Exp Clin Endocrinol Diabetes 2023; 131:4-12. [PMID: 36626920 DOI: 10.1055/a-1946-3648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Michael Hummel
- Internal Medicine Group Practice and Diabetological Practice, Rosenheim, Germany.,Research Group Diabetes e.V. at Helmholtz Center Munich, Munich, Germany
| | - Martin Füchtenbusch
- Research Group Diabetes e.V. at Helmholtz Center Munich, Munich, Germany.,Diabetes Center am Marienplatz Munich, Munich, Germany
| | - Wilgard Battefeld
- Diabetology and Endocrinology, Medical Care Center Kempten-Allgäu, Kempten, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Medical University of Berlin, Berlin, Germany
| | - Tanja Groten
- Department of Obstetrics and Maternal Health, University Hospital Jena, Jena, Germany
| | - Thomas Haak
- Diabetes Center Mergentheim, Bad Mergentheim, Germany
| | - Franz Kainer
- Department of Obstetrics and Prenatal Medicine, Hallerwiese Hospital, Nuremberg, Germany
| | | | - Andreas Lechner
- Department of Internal Medicine IV, Diabetes Center, Ludwigs-Maximilians-University Munich, Munich, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Ute Schäfer-Graf
- Berlin Diabetes Center for Pregnant Women, St. Joseph Hospital Berlin Tempelhof, Berlin, Germany
| | - Thorsten Siegmund
- Diabetes, Hormone, and Metabolism Center, Private Practice at Isar Clinic, Munich, Germany
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15
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Choo S, de Vrijer B, Regnault TRH, Brown HK, Stitt L, Richardson BS. The impact of maternal diabetes on birth to placental weight ratio and umbilical cord oxygen values with implications for fetal-placental development. Placenta 2023; 136:18-24. [PMID: 37003142 DOI: 10.1016/j.placenta.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION We determined the impact of gestational diabetes (GDM) and pre-existing diabetes (DM) on birth/placental weight and cord oxygen values with implications for placental efficiency and fetal-placental growth and development. METHODS A hospital database was used to obtain birth/placental weight, cord PO2 and other information on patients delivering between Jan 1, 1990 and Jun 15, 2011 with GA >34 weeks (N = 69,854). Oxygen saturation was calculated from the cord PO2 and pH data, while fetal O2 extraction was calculated from the oxygen saturation data. The effect of diabetic status on birth/placental weight and cord oxygen values was examined adjusting for covariates. RESULTS Birth/placental weights were stepwise decreased in GDM and DM compared to non-diabetics with placentas disproportionally larger indicating decreasing placental efficiency. Umbilical vein oxygen was marginally increased in GDM but decreased in DM attributed to the previously reported hyper-vascularization in diabetic placentas with absorbing surface area of capillaries initially increased, but then constrained by increasing distance from maternal blood within the intervillous space. Umbilical artery oxygen was unchanged in GDM and DM, with fetal O2 extraction decreased in DM indicating that fetal O2 delivery must be increased relative to O2 consumption and likely due to increased umbilical blood flow. DISCUSSION Increased villous density/hyper-vascularization in GDM and DM with placentas disproportionately larger and umbilical blood flow increased, are postulated to normalize umbilical artery oxygen despite increased birth weights and growth-related O2 consumption. These findings have implications for mechanisms signaling fetal-placental growth and development in diabetic pregnancies and differ from that reported with maternal obesity.
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16
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Desoye G, Ringholm L, Damm P, Mathiesen ER, van Poppel MNM. Secular trend for increasing birthweight in offspring of pregnant women with type 1 diabetes: is improved placentation the reason? Diabetologia 2023; 66:33-43. [PMID: 36287249 PMCID: PMC9607824 DOI: 10.1007/s00125-022-05820-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 12/13/2022]
Abstract
Despite enormous progress in managing blood glucose levels, pregnancy in women with type 1 diabetes still carries risks for the growing fetus. While, previously, fetal undergrowth was not uncommon in these women, with improved maternal glycaemic control we now see an increased prevalence of fetal overgrowth. Besides short-term implications, offspring of women with type 1 diabetes are more likely to become obese and to develop diabetes and features of the metabolic syndrome. Here, we argue that the increase in birthweight is paradoxically related to improved glycaemic control in the pre- and periconceptional periods. Good glycaemic control reduces the prevalence of microangiopathy and improves placentation in early pregnancy, which may lead to unimpeded fetal nutrition. Even mild maternal hyperglycaemia may then later result in fetal overnutrition. This notion is supported by circumstantial evidence that lower HbA1c levels as well as increases in markers of placental size and function in early pregnancy are associated with large-for-gestational age neonates. We also emphasise that neonates with normal birthweight can have excessive fat deposition. This may occur when poor placentation leads to initial fetal undergrowth, followed by fetal overnutrition due to maternal hyperglycaemia. Thus, the complex interaction of glucose levels during different periods of pregnancy ultimately determines the risk of adiposity, which can occur in fetuses with both normal and elevated birthweight. Prevention of fetal adiposity calls for revised goal setting to enable pregnant women to maintain blood glucose levels that are closer to normal. This could be supported by continuous glucose monitoring throughout pregnancy and appropriate maternal gestational weight gain. Future research should consider the measurement of adiposity in neonates.
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Affiliation(s)
- Gernot Desoye
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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17
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Kiefer MK, Finneran MM, Ware CA, Foy P, Thung SF, Gabbe SG, Landon MB, Grobman WA, Venkatesh KK. Prediction of large-for-gestational-age infant by fetal growth charts and hemoglobin A1c level in pregnancy complicated by pregestational diabetes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:751-758. [PMID: 36099480 PMCID: PMC10107738 DOI: 10.1002/uog.26071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To compare the ability of three fetal growth charts (Fetal Medicine Foundation (FMF), Hadlock and National Institutes of Child Health and Human Development (NICHD) race/ethnicity-specific) to predict large-for-gestational age (LGA) at birth in pregnant individuals with pregestational diabetes, and to determine whether inclusion of hemoglobin A1c (HbA1c) level improves the predictive performance of the growth charts. METHODS This was a retrospective analysis of individuals with Type-1 or Type-2 diabetes with a singleton pregnancy that resulted in a non-anomalous live birth. Fetal biometry was performed between 28 + 0 and 36 + 6 weeks of gestation. The primary exposure was suspected LGA, defined as estimated fetal weight ≥ 90th percentile using the Hadlock (Formula C), FMF and NICHD growth charts. The primary outcome was LGA at birth, defined as birth weight ≥ 90th percentile, using 2017 USA natality reference data. The performance of the three growth charts to predict LGA at birth, alone and in combination with HbA1c as a continuous measure, was assessed using the area under the receiver-operating-characteristics curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. RESULTS Of 358 assessed pregnant individuals with pregestational diabetes (34% with Type 1 and 66% with Type 2), 147 (41%) had a LGA infant at birth. Suspected LGA was identified in 123 (34.4%) by the Hadlock, 152 (42.5%) by the FMF and 152 (42.5%) by the NICHD growth chart. The FMF growth chart had the highest sensitivity (77% vs 69% (NICHD) vs 63% (Hadlock)) and the Hadlock growth chart had the highest specificity (86% vs 76% (NICHD) and 82% (FMF)) for predicting LGA at birth. The FMF growth chart had a significantly higher AUC (0.79 (95% CI, 0.74-0.84)) for LGA at birth compared with the NICHD (AUC, 0.72 (95% CI, 0.68-0.77); P < 0.001) and Hadlock (AUC, 0.75 (95% CI, 0.70-0.79); P < 0.01) growth charts. Prediction of LGA improved for all three growth charts with the inclusion of HbA1c measurement in comparison to each growth chart alone (P < 0.001 for all); the FMF growth chart remained more predictive of LGA at birth (AUC, 0.85 (95% CI, 0.81-0.90)) compared with the NICHD (AUC, 0.79 (95% CI, 0.73-0.84)) and Hadlock (AUC, 0.81 (95% CI, 0.76-0.86)) growth charts. CONCLUSIONS The FMF fetal growth chart had the best predictive performance for LGA at birth in comparison with the Hadlock and NICHD race/ethnicity-specific growth charts in pregnant individuals with pregestational diabetes. Inclusion of HbA1c improved further the prediction of LGA for all three charts. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M. K. Kiefer
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - M. M. Finneran
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineMedical University of South CarolinaCharlestonSCUSA
| | - C. A. Ware
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - P. Foy
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - S. F. Thung
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - S. G. Gabbe
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - M. B. Landon
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - W. A. Grobman
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
| | - K. K. Venkatesh
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineThe Ohio State UniversityColumbusOHUSA
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18
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Ringholm L, Nørgaard SK, Rytter A, Damm P, Mathiesen ER. Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding. Nutrients 2022; 14:4867. [PMID: 36432552 PMCID: PMC9692490 DOI: 10.3390/nu14224867] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Ane Rytter
- The Nutrition Unit, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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19
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Hummel M, Füchtenbusch M, Battefeld W, Bührer C, Groten T, Haak T, Kainer F, Kautzky-Willer A, Lechner A, Meissner T, Nagel-Reuper C, Schäfer-Graf U, Siegmund T. Diabetes und Schwangerschaft. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1901-0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michael Hummel
- Internistische Gemeinschaftspraxis und Diabetologische Schwerpunktpraxis, Rosenheim, Deutschland
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
| | - Martin Füchtenbusch
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
- Diabeteszentrum am Marienplatz München, München, Deutschland
| | - Wilgard Battefeld
- Diabetologie und Endokrinologie, Medizinisches Versorgungszentrum Kempten-Allgäu, Kempten, Deutschland
| | - Christoph Bührer
- Klinik für Neonatologie, Charité -Universitätsmedizin Berlin, Berlin, Deutschland
| | - Tanja Groten
- Geburtsmedizin und maternale Gesundheit, Universitätsklinikum Jena, Jena, Deutschland
| | - Thomas Haak
- Diabetes Zentrum Mergentheim, Bad Mergentheim, Deutschland
| | - Franz Kainer
- Abteilung für Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg, Deutschland
| | | | - Andreas Lechner
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
- Medizinische Klinik und Poliklinik IV, Diabeteszentrum, Ludwigs-Maximilians-Universität München, München, Deutschland
| | - Thomas Meissner
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | | | - Ute Schäfer-Graf
- Berliner Diabetes Zentrum für Schwangere, St. Joseph Krankenhaus Berlin Tempelhof, Berlin, Deutschland
| | - Thorsten Siegmund
- Diabetes-, Hormon-, und Stoffwechselzentrum, Privatpraxis am Isar Klinikum, München, Deutschland
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20
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Lee TTM, Collett C, Man MS, Hammond M, Shepstone L, Hartnell S, Gurnell E, Byrne C, Scott EM, Lindsay RS, Morris D, Brackenridge A, Dover AR, Reynolds RM, Hunt KF, McCance DR, Barnard-Kelly K, Rankin D, Lawton J, Bocchino LE, Sibayan J, Kollman C, Wilinska ME, Hovorka R, Murphy HR. AiDAPT: automated insulin delivery amongst pregnant women with type 1 diabetes: a multicentre randomized controlled trial - study protocol. BMC Pregnancy Childbirth 2022; 22:282. [PMID: 35382796 PMCID: PMC8982306 DOI: 10.1186/s12884-022-04543-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background Pregnant women with type 1 diabetes strive for tight glucose targets (3.5-7.8 mmol/L) to minimise the risks of obstetric and neonatal complications. Despite using diabetes technologies including continuous glucose monitoring (CGM), insulin pumps and contemporary insulin analogues, most women struggle to achieve and maintain the recommended pregnancy glucose targets. This study aims to evaluate whether the use of automated closed-loop insulin delivery improves antenatal glucose levels in pregnant women with type 1 diabetes. Methods/design A multicentre, open label, randomized, controlled trial of pregnant women with type 1 diabetes and a HbA1c of ≥48 mmol/mol (6.5%) at pregnancy confirmation and ≤ 86 mmol/mol (10%) at randomization. Participants who provide written informed consent before 13 weeks 6 days gestation will be entered into a run-in phase to collect 96 h (24 h overnight) of CGM glucose values. Eligible participants will be randomized on a 1:1 basis to CGM (Dexcom G6) with usual insulin delivery (control) or closed-loop (intervention). The closed-loop system includes a model predictive control algorithm (CamAPS FX application), hosted on an android smartphone that communicates wirelessly with the insulin pump (Dana Diabecare RS) and CGM transmitter. Research visits and device training will be provided virtually or face-to-face in conjunction with 4-weekly antenatal clinic visits where possible. Randomization will stratify for clinic site. One hundred twenty-four participants will be recruited. This takes into account 10% attrition and 10% who experience miscarriage or pregnancy loss. Analyses will be performed according to intention to treat. The primary analysis will evaluate the change in the time spent in the target glucose range (3.5-7.8 mmol/l) between the intervention and control group from 16 weeks gestation until delivery. Secondary outcomes include overnight time in target, time above target (> 7.8 mmol/l), standard CGM metrics, HbA1c and psychosocial functioning and health economic measures. Safety outcomes include the number and severity of ketoacidosis, severe hypoglycaemia and adverse device events. Discussion This will be the largest randomized controlled trial to evaluate the impact of closed-loop insulin delivery during type 1 diabetes pregnancy. Trial registration ISRCTN 56898625 Registration Date: 10 April, 2018.
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Affiliation(s)
- Tara T M Lee
- Norwich Medical School, University of East Anglia, Floor 2, Bob Champion Research and Education Building, Rosalind Franklin Road, Norwich Research Park, Norwich, UK
| | - Corinne Collett
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mei-See Man
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Matt Hammond
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lee Shepstone
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Sara Hartnell
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Eleanor Gurnell
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Caroline Byrne
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Eleanor M Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Damian Morris
- Department of Diabetes & Endocrinology, East Suffolk & North Essex Foundation Trust, The Ipswich Hospital, Suffolk, UK
| | - Anna Brackenridge
- Department of Diabetes & Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna R Dover
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rebecca M Reynolds
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - David R McCance
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital Belfast, Belfast, Northern Ireland
| | | | - David Rankin
- The Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Julia Lawton
- The Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | | | - Judy Sibayan
- Jaeb Center For Health Research, Tampa, Florida, USA
| | - Craig Kollman
- Jaeb Center For Health Research, Tampa, Florida, USA
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Floor 2, Bob Champion Research and Education Building, Rosalind Franklin Road, Norwich Research Park, Norwich, UK. .,Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK.
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21
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Timsit J, Ciangura C, Dubois-Laforgue D, Saint-Martin C, Bellanne-Chantelot C. Pregnancy in Women With Monogenic Diabetes due to Pathogenic Variants of the Glucokinase Gene: Lessons and Challenges. Front Endocrinol (Lausanne) 2022; 12:802423. [PMID: 35069449 PMCID: PMC8766338 DOI: 10.3389/fendo.2021.802423] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- José Timsit
- Department of Diabetology, Université de Paris, AP-HP, Cochin-Port-Royal Hospital, DMU ENDROMED, Paris, France
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
| | - Cécile Ciangura
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
- Department of Diabetology, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Danièle Dubois-Laforgue
- Department of Diabetology, Université de Paris, AP-HP, Cochin-Port-Royal Hospital, DMU ENDROMED, Paris, France
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
- INSERM U1016, Cochin Hospital, Paris, France
| | - Cécile Saint-Martin
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Department of Medical Genetics, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, DMU BioGeM, Paris, France
| | - Christine Bellanne-Chantelot
- PRISIS National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity, Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, Paris, France
- Monogenic Diabetes Study Group of the Société Francophone du Diabète, Paris, France
- Department of Medical Genetics, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, DMU BioGeM, Paris, France
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22
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Lepore C, Damaso E, Suazo V, Queiroz R, Junior RL, Moisés E. Molecular Changes in the Glucokinase Gene (GCK) Associated with the Diagnosis of Maturity Onset Diabetes of the Young (MODY) in Pregnant Women and Newborns. Curr Diabetes Rev 2022; 18:e060821195358. [PMID: 34365926 DOI: 10.2174/1573399817666210806110633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetes mellitus is the most common metabolic alteration in gestation. Monogenic diabetes or Maturity-Onset Diabetes of the Young (MODY) is a subtype caused by a primary defect in insulin secretion determined by autosomal dominant inheritance. OBJECTIVES This study aimed to analyze molecular changes of the Glucokinase gene (GCK) in pregnant women with hyperglycemia during gestation and in their neonates. Case Study and Methods: We collected 201 blood samples, 128 from pregnant patients diagnosed with hyperglycemia and 73 from umbilical cord blood from neonates of the respective patients. DNA extraction and polymerase chain reaction (PCR) were performed to identify molecular changes in the GCK gene. RESULTS In a total of 201 samples (128 from mothers and 73 from neonates), we found changes in 21 (10.6%), among which 12 were maternal samples (6.0%) and 9 were neonatal samples (4.5%). DNA sequencing identified two polymorphisms and one deleterious MODY GCK-diagnostic mutation. CONCLUSION The prevalence of molecular changes in the Glucokinase gene (GCK) and the deleterious MODY GCK-diagnostic mutation were 9.3% and 0.7%, respectively, in women with hyperglycemia during gestation and 12.5% and 1.3%, respectively, in their neonates. The deleterious MODY GCK mutation identified is associated with a reduction in GCK activity and hyperglycemia. In the other molecular changes identified, it was impossible to exclude phenotypic change despite not having clinical significance. Therefore, these changes may interfere with the management and clinical outcome of the patients.
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Affiliation(s)
- Carolina Lepore
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Enio Damaso
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Veridiana Suazo
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Rosane Queiroz
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Raphael Liberatore Junior
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Elaine Moisés
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
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23
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Nørgaard SK, Mathiesen ER, Nørgaard K, Ringholm L. Comparison of Glycemic Metrics Measured Simultaneously by Intermittently Scanned Continuous Glucose Monitoring and Real-Time Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:665-672. [PMID: 34086494 DOI: 10.1089/dia.2021.0109] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: We aimed to compare clinically important glycemic metrics with focus on mean sensor glucose and time-below-target range (TBR) during nighttime obtained with intermittently scanned continuous glucose monitoring (isCGM) and real-time CGM (rtCGM) in early pregnancy in women with type 1 diabetes. Materials and Methods: A prospective, observational study including 20 women with type 1 diabetes simultaneously monitored with isCGM (Freestyle Libre; Abbott) and rtCGM (Envision™ Pro; Medtronic) for 7 days in early pregnancy. Time-in-target range (TIR) was defined as 3.5-7.8 mmol/L. Results: Gestational age was median 66 (interquartile range 63-74) days and HbA1c was 48 mmol/mol (43-54). Median difference between isCGM and rtCGM was 0.1 mmol/L (-0.1 to 0.5) (P = 0.50) and -0.1 mmol/L (-0.4 to 0.2) (P = 0.35) for 24 h and during nighttime, respectively. For 24 h, TBR was 3.9% (1.6-7.0) versus 2.0% (0.6-3.7) (P = 0.06) and TIR was 57.2% (50.8-76.5) versus 69.6% (55.4-81.5) (P = 0.001) for isCGM and rtCGM, respectively. During nighttime TBR was 6.5% (0.4-16.7) versus 0% (0.0-0.8) (P = 0.003), TIR was 55.4 (41.1-81.0) versus 68.8 (52.4-80.3) (P = 0.005) and 75% versus 40% of the women had ≥1 glucose reading <3.5 mmol/L. Conclusions: In pregnant women with type 1 diabetes, mean sensor glucose was reported similar when measured by isCGM and rtCGM. However, during nighttime isCGM measured a clinically relevant higher percentage of TBR compared with rtCGM. Thus, the type of CGM device used may influence adjustments of insulin dose based on the concern for nocturnal hypoglycemia. ClinicalTrials.gov (NCT03770767).
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Affiliation(s)
- Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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24
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Swain D, Begum J, Parida SP. Effect of Preconception Care Intervention on Maternal Nutritional Status and Birth Outcome in a Low-Resource Setting: Proposal for a Nonrandomized Controlled Trial. JMIR Res Protoc 2021; 10:e28148. [PMID: 34398798 PMCID: PMC8406098 DOI: 10.2196/28148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/13/2021] [Accepted: 05/28/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The provision of preconception care approaches such as maternal assessments and education on healthy lifestyle (including physical activity, nutrition, and dietary supplements such as folic acid), general and sexual health, avoidance of high-risk behavior, and immunizations has been shown to identify and reduce the risk of adverse birth outcomes through appropriate management and preventive measures. OBJECTIVE The goal of the study is to determine the effect of an integrated preconception care intervention on delivery outcomes, which is a novel challenge for lowering unfavorable birth outcomes in India's low-resource setting. The main objectives are to investigate the relationship of birth outcomes to both maternal and paternal preconception health and determine the effect of preconception care intervention on improvement of maternal nutritional status and reduction of the risk of adverse birth outcomes such as prematurity, low birth weight, and maternal and neonatal complications. METHODS A nonrandomized controlled trial design will be used for comparing 2 groups: preconception care with a standard maternal health care (MHC) program and an integrated MHC program (without preconception care). Two rural field areas of Khordha district, Odisha, will be selected for conducting the study. The study will enroll 782 married women between the ages of 18 and 35 years with their spouses, with 391 women in each group. The couples will receive preconception care based on their health circumstances, and they will be followed up at 3-month intervals before pregnancy. Following pregnancy, they will be followed up for 8 prenatal monitoring and care visits as well as 6 weeks after delivery as part of the standard MCH program. The preconception care intervention package includes couples counseling, contraceptive education and distribution, sex education, lifestyle modification, and nutritional supplementation of iron and folic acid, along with multivitamins if needed. RESULTS The proposal was approved by the institutional ethical committee for conducting the study in June 2020 (Ref No: T/EMF/Nursing/20/6). Participants were enrolled in phase 1 in April 2021, phase 2 of offering preconception services will begin in August 2021, and study outcomes will be measured from 2023 to 2024. CONCLUSIONS Through preconception care and counseling, the eligible couples will recognize, embrace, and implement the actions to improve their preconception health. Finally, it is expected that maternal and paternal health will have a significant impact on enhancing maternal nutritional status and birth outcomes. TRIAL REGISTRATION Clinical Trials Registry-India CTRI/2021/04/032836; http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=48239&EncHid=&userName=CTRI/2021/04/032836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/28148.
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Affiliation(s)
- Dharitri Swain
- College of Nursing, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Jasmina Begum
- Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Swayam Prangnan Parida
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
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Blue NR, Page JM, Silver RM. Recurrence Risk of Fetal Growth Restriction: Management of Subsequent Pregnancies. Obstet Gynecol Clin North Am 2021; 48:419-436. [PMID: 33972075 DOI: 10.1016/j.ogc.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Fetal growth restriction (FGR) is a common obstetric complication that predisposes to mortality across the lifespan. Women with a prior pregnancy affected by FGR have a 20% to 30% risk of recurrence, but effective preventive strategies are lacking. Pharmacologic interventions to prevent FGR are lacking. Low-dose aspirin may be somewhat effective, but low-molecular-weight heparin and sildenafil are not. Surveillance in a subsequent pregnancy may consist of serial ultrasonography with timing and frequency determined by the clinical severity in the index pregnancy. Once FGR is diagnosed, the principal management strategy consists of close surveillance and carefully timed delivery.
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Affiliation(s)
- Nathan R Blue
- Maternal-Fetal Medicine, University of Utah Health, Intermountain Healthcare, 30 North 1900 East, 2A200, Salt Lake City, UT 84132, USA.
| | - Jessica M Page
- Maternal-Fetal Medicine, Intermountain Healthcare, University of Utah Health, 5121 South Cottonwood Street, Suite 100, Murray, UT 84107, USA. https://twitter.com/jess_m_page
| | - Robert M Silver
- Maternal-Fetal Medicine, University of Utah Health, 30 North 1900 East, 2A200, Salt Lake City, UT 84132, USA
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Attique HB, Phachu D, Loza A, Campbell W, Hammer E, Elali I. Diabetic nephropathy in pregnancy: Report of two cases progressing to end-stage renal disease within one year postpartum. Case Rep Womens Health 2021; 31:e00326. [PMID: 34195020 PMCID: PMC8226387 DOI: 10.1016/j.crwh.2021.e00326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background Diabetes mellitus is a leading cause of nephropathy and end-stage renal disease. However, diabetic nephropathy during pregnancy in patients with normal glomerular filtration rate and subsequent progression to end-stage renal disease has not been well studied. Cases This report presents two patients with poorly controlled type 1 diabetes mellitus who had diabetic nephropathy with preserved estimated glomerular filtration rate (Case 1: 117 mL/min/1.73m2; Case 2: 79 mL/min/1.73m2) and shared a similar clinical course, with glomerular filtration rates decreasing by approximately one-half during pregnancy and progression to end-stage renal disease within the first year postpartum. Both women had a long history of type 1 diabetes: 18 years and 24 years for case 1 and case 2 respectively. The first patient's course of pregnancy was complicated by difficult-to-control blood glucose and hypertension with subsequent preeclampsia. The second patient's course of pregnancy was complicated by difficult-to-control blood sugars and preterm labor resulting in classical cesarean delivery at 24 weeks. Both patients had renal biopsies shortly after delivery as their renal function continued to worsen postpartum. Both kidney biopsies demonstrated advanced diabetic nephropathy changes and ultimately required chronic renal replacement therapy within 7–9 months postpartum. Conclusion Comprehensive family planning discussions with women who have diabetic nephropathy should include the risks of renal disease progression, even in those patients with preserved renal function at the time of conception. Diabetic nephropathy carries a high risk for renal disease progression. Diabetics with nephropathy need counseling on risk of kidney disease progression. Diabetic women should be started on kidney-protective medications postpartum.
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Affiliation(s)
- Hassan Bin Attique
- UConn Health Division of Nephrology, 263 Farmington Ave, Farmington, CT 06030, USA
| | - Deep Phachu
- UConn Health Division of Nephrology, 263 Farmington Ave, Farmington, CT 06030, USA
| | - Alexandra Loza
- UConn Health Division of Maternal Fetal Medicine, 263 Farmington Ave, Farmington, CT 06030, USA
| | - Winston Campbell
- UConn Health Division of Maternal Fetal Medicine, 263 Farmington Ave, Farmington, CT 06030, USA
| | - Erica Hammer
- Hartford Hospital Division of Maternal Fetal Medicine, 80 Seymour St, Hartford, CT 06106, USA
| | - Ibrahim Elali
- UConn Health Division of Nephrology, 263 Farmington Ave, Farmington, CT 06030, USA
- Corresponding author at: University of Connecticut Health Center, Division of Nephrology, 263 Farmington Avenue, CT 06032, USA.
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Nørgaard SK, Mathiesen ER, Nørgaard K, Clausen TD, Damm P, Ringholm L. CopenFast trial: Faster-acting insulin Fiasp versus insulin NovoRapid in the treatment of women with type 1 or type 2 diabetes during pregnancy and lactation - a randomised controlled trial. BMJ Open 2021; 11:e045650. [PMID: 33837106 PMCID: PMC8043014 DOI: 10.1136/bmjopen-2020-045650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Faster-acting insulin aspart (Fiasp) is approved for use in pregnancy and lactation, but no clinical study has evaluated its effects during this life stage in women with pre-existing diabetes. The aim of the CopenFast trial is to evaluate the effect of Fiasp compared with insulin aspart (NovoRapid) on maternal glycaemic control during pregnancy, delivery and lactation and on fetal growth and infant health. METHODS AND ANALYSIS An open-label randomised controlled trial of pregnant women with type 1 or type 2 diabetes including women on multiple daily injection (MDI) therapy or insulin pump therapy. During a 2-year inclusion period, approximately 220 women will be randomised 1:1 to Fiasp or NovoRapid in early pregnancy and followed until 3 months after delivery. At 9, 21 and 33 gestational weeks and during planned induction of labour or caesarean section, women are offered blinded continuous glucose monitoring (CGM) for 7 days. Randomisation will stratify for type of diabetes and insulin treatment modality (MDI or insulin pump therapy, respectively). Health status of the infants will be followed until 3 months of age. The primary outcome is birth weight SD score adjusted for gestational age and gender. Secondary outcomes include maternal glycaemic control including glycated haemoglobin, preprandial and postprandial self-monitored plasma glucose levels, episodes of mild and severe hypoglycaemia, maternal gestational weight gain and weight retention, CGM time spent in, above and below target ranges as well as pregnancy outcomes including pre-eclampsia, preterm delivery, perinatal mortality and neonatal morbidity. Data analysis will be performed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The trial has been approved by the Regional Ethics Committee (H-19029966) on 7 August 2019. Results will be sought disseminated in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION NUMBER NCT03770767.
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Affiliation(s)
- Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | | | - Tine Dalsgaard Clausen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Gynaecology and Obstetrics, Nordsjaellands Hospital, Hillerod, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
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Skajaa GO, Kampmann U, Fuglsang J, Ovesen PG. "High prepregnancy HbA1c is challenging to improve and affects insulin requirements, gestational length, and birthweight". J Diabetes 2020; 12:798-806. [PMID: 32462784 DOI: 10.1111/1753-0407.13070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The aim of this study was to explore how prepregnancy glycosylated hemoglobin (HbA1c) affects the course of HbA1c and insulin requirements during pregnancy, the gestational length, and birthweight. METHODS An observational cohort study was conducted consisting of 380 women with type 1 diabetes who gave birth 530 times from 2004 to 2014. The participants were divided into four groups according to prepregnancy HbA1c. RESULTS HbA1c was significantly different between the groups at all time intervals from week 5 to 10 to week 33 to 36 (P ≤ .01). In group 1, with the lowest prepregnancy HbA1c (<6.5% [48 mmol/mol]), HbA1c stayed at the same level throughout pregnancy. In the other groups (group 2: 6.5% [48 mmol/mol]-7.9% [63 mmol/mol], group 3: 8% [64 mmol/mol]-9.9% [86 mmol/mol], and group 4: > 10% [86 mmol/mol]) a decrease in HbA1c was seen in early pregnancy but stabilized from midpregnancy onward. Group 1 had the lowest daily insulin requirements throughout pregnancy among the four groups (P = .001). The relationship between birthweight and prepregnancy HbA1c was found to be inversely U-shaped. Mean gestational length in group 4 was significantly shorter than in group 1 (P = .001). CONCLUSIONS In this very large cohort, we found that a poor prepregnancy HbA1c is a predictor for poor glycemic control during pregnancy and that HbA1c decreases until midpregnancy and then plateaus. A very poor prepregnancy HbA1c is associated with shorter gestational length and lower birthweight, which is contrary to the common assumption that poor glycemic control leads to higher birthweight.
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Affiliation(s)
- Gitte Oeskov Skajaa
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus N, Denmark
| | - Ulla Kampmann
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus N, Denmark
| | - Jens Fuglsang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus N, Denmark
| | - Per Glud Ovesen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus N, Denmark
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Xu Q, Lu J, Hu J, Ge Z, Zhu D, Bi Y. Perinatal outcomes in pregnancies complicated by type 1 diabetes mellitus. Gynecol Endocrinol 2020; 36:879-884. [PMID: 32075454 DOI: 10.1080/09513590.2020.1727432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The aim of this study was to explore the risk of perinatal outcomes in pre-gestational type 1 diabetes mellitus (T1DM) compared to gestational diabetes mellitus (GDM) and pregnancy without diabetes and to examine the association of glycemic level of third-trimester gestation with perinatal outcomes in T1DM. We included 69 pre-gestational T1DM, 1398 cases of GDM, and 1304 control pregnancies and collected data regarding demographics, obstetric, and perinatal outcomes from the hospital discharge database. Relative to the pregnancies without diabetes, women with T1DM encountered increasing risk of polyhydramnios, preterm delivery, and cesarean section. These adverse outcomes were also common in GDM, although with relatively lower adjusted ORs. The weights of babies delivered by women with T1DM were more intend to be large for gestational age, as well as to be less than 2.5 kg relative to those without diabetes. Poorly controlled hemoglobin A1c in late pregnancy was significantly associated with an increased risk of preterm birth in T1DM (adjusted odds ratio 2.01, 95%confidence interval 1.1-3.6). Women with T1DM have considerably increased risks of adverse perinatal outcomes, which appear more prevalent than the perinatal outcomes in women with GDM. Thus, a specific routine is required for pregnancy in T1DM to improve the glycemic control and obstetric care.
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Affiliation(s)
- Qianyue Xu
- Department of Endocrinology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Jing Lu
- Department of Endocrinology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Jun Hu
- Department of Endocrinology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Zhijuan Ge
- Department of Endocrinology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Dalong Zhu
- Department of Endocrinology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Yan Bi
- Department of Endocrinology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
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Hauffe F, Fauzan R, Schohe AL, Scholle D, Sedlacek L, Scherer KA, Klapp C, Ramsauer B, Henrich W, Schlembach D, Abou-Dakn M, Schaefer-Graf UM. Need for less tight glucose control in early pregnancy after embryogenesis due to high risk of maternal hypoglycaemia in women with pre-existing diabetes can be compensated by good control in late pregnancy. Diabet Med 2020; 37:1490-1498. [PMID: 32583455 DOI: 10.1111/dme.14350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/18/2020] [Accepted: 06/18/2020] [Indexed: 11/29/2022]
Abstract
AIM Poor glucose control is associated with adverse outcomes in pregnancies with pre-existing diabetes. However, strict glucose control increases the risk of severe hypoglycaemia, particularly in the first trimester. Therefore, we aimed to investigate whether less tight glucose control in the first trimester determines adverse outcomes or can be compensated for by good control in late pregnancy. METHODS Retrospective data were collected from 517 singleton pregnancies complicated by pre-existing diabetes delivering between 2010 and 2017. Three hundred and thirty-six pregnancies fulfilled the inclusion criteria of having available HbA1c values either pre-conception or in the first trimester (65% type 1 diabetes, 35% type 2 diabetes). RESULTS Higher HbA1c values in the first trimester were associated with increasing rates of large for gestational age (LGA) neonates, preterm delivery or neonatal intensive care unit admissions. Multiple regression analysis demonstrated third trimester HbA1c , type 1 diabetes, multiparity and excess weight gain, but not first trimester HbA1c , to be independently predictive for LGA. Pre-eclampsia and third trimester HbA1c increased the risk for preterm delivery. If HbA1c was ≤ 42 mmol/mol (6.0%) in the third trimester, rates of adverse outcomes were not significantly higher even if HbA1c targets of ≤ 48 mmol/mol (6.5%) had not been met in the first trimester. Good first trimester glucose control did not modify the rates of adverse outcomes if HbA1c was > 42 mmol/mol (6.0%) in the third trimester. CONCLUSIONS Less tight glycaemic control, for example due to high frequency of severe hypoglycaemia in the first trimester, does not lead to increased adverse neonatal events if followed by tight control in the third trimester. Besides glycaemic control, excess weight gain is a modifiable predictor of adverse outcome.
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Affiliation(s)
- F Hauffe
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
| | - R Fauzan
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
| | - A L Schohe
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
| | - D Scholle
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
| | - L Sedlacek
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
| | - K A Scherer
- Department of Obstetrics, Campus Rudolf-Virchow, Charité, Humboldt-University, Berlin, Germany
| | - C Klapp
- Department of Obstetrics, Campus Rudolf-Virchow, Charité, Humboldt-University, Berlin, Germany
| | - B Ramsauer
- Clinic of Obstetrics, Clinicum Vivantes Neukoelln, Berlin, Germany
| | - W Henrich
- Department of Obstetrics, Campus Rudolf-Virchow, Charité, Humboldt-University, Berlin, Germany
| | - D Schlembach
- Clinic of Obstetrics, Clinicum Vivantes Neukoelln, Berlin, Germany
| | - M Abou-Dakn
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
| | - U M Schaefer-Graf
- Berlin Center for Diabetes and Pregnancy, Department of Obstetrics and Gynaecology, St. Joseph Hospital, Berlin, Germany
- Department of Obstetrics, Campus Rudolf-Virchow, Charité, Humboldt-University, Berlin, Germany
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Talton OO, Bates K, Salazar SR, Ji T, Schulz LC. Lean maternal hyperglycemia alters offspring lipid metabolism and susceptibility to diet-induced obesity in mice†. Biol Reprod 2020; 100:1356-1369. [PMID: 30698664 DOI: 10.1093/biolre/ioz009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 12/20/2018] [Accepted: 01/28/2019] [Indexed: 01/06/2023] Open
Abstract
We previously developed a model of gestational diabetes mellitus (GDM) in which dams exhibit glucose intolerance, insulin resistance, and reduced insulin response to glucose challenge only during pregnancy, without accompanying obesity. Here, we aimed to determine how lean gestational glucose intolerance affects offspring risk of metabolic dysfunction. One cohort of offspring was sacrificed at 19 weeks, and one at 31 weeks, with half of the second cohort placed on a high-fat, high-sucrose diet (HFHS) at 23 weeks. Exposure to maternal glucose intolerance increased weights of HFHS-fed offspring. Chow-fed offspring of GDM dams exhibited higher body fat percentages at 4, 12, and 20 weeks of age. At 28 weeks, offspring of GDM dams fed the HFHS but not the chow diet (CD) also had higher body fat percentages than offspring of controls (CON). Exposure to GDM increased the respiratory quotient (Vol CO2/Vol O2) in offspring. Maternal GDM increased adipose mRNA levels of peroxisome proliferator-activated receptor gamma (Pparg) and adiponectin (Adipoq) in 31-week-old CD-fed male offspring, and increased mRNA levels of insulin receptor (Insr) and lipoprotein lipase (Lpl) in 31-week-old male offspring on both diets. In liver at 31 weeks, mRNA levels of peroxisome proliferator-activated receptor alpha (Ppara) were elevated in CD-fed male offspring of GDM dams, and male offspring of GDM dams exhibited higher mRNA levels of Insr on both diets. Neither fasting insulin nor glucose tolerance was affected by exposure to GDM. Our findings show that GDM comprising glucose intolerance only during pregnancy programs increased adiposity in offspring, and suggests increased insulin sensitivity of subcutaneous adipose tissue.
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Affiliation(s)
- Omonseigho O Talton
- Department of Obstetrics, Gynecology, and Women's Health, University of Missouri, Columbia, Missouri, USA.,Division of Biological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Keenan Bates
- Department of Obstetrics, Gynecology, and Women's Health, University of Missouri, Columbia, Missouri, USA.,Division of Biological Sciences, University of Missouri, Columbia, Missouri, USA
| | | | - Tieming Ji
- Department of Statistics, University of Missouri, Columbia, Missouri, USA
| | - Laura Clamon Schulz
- Department of Obstetrics, Gynecology, and Women's Health, University of Missouri, Columbia, Missouri, USA.,Division of Biological Sciences, University of Missouri, Columbia, Missouri, USA
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García-Patterson A, Ovejero D, Miñambres I, Chico A, Gil PA, Martínez MJ, Adelantado JM, de Leiva A, Gich I, Desoye G, de Mouzon SH, Corcoy R. Both glycaemic control and insulin dose during pregnancy in women with type 1 diabetes are associated with neonatal anthropometric measures and placental weight. Diabetes Metab Res Rev 2020; 36:e3300. [PMID: 32048800 DOI: 10.1002/dmrr.3300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/27/2019] [Accepted: 01/16/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND To investigate longitudinal associations of maternal glucose/HbA1c and insulin dose with birthweight-related outcomes in women with type 1 diabetes. METHODS We performed a cohort study including 473 pregnant women with type 1 diabetes with singleton pregnancies. We investigated maternal self-monitored blood glucose (SMBG, mmol/L), HbA1c (%, mmol/mol) and insulin dose (IU/kg/day) in the three trimesters as potential independent variables, while adjusting for potential confounders. Outcomes of interest were birthweight, birthweight SD score, neonatal length, weight/length index, ponderal index and placental weight. Multiple linear regression analysis was performed with separate analyses for SMBG and HbA1c . RESULTS Maternal glucose and insulin dose were independently associated with birthweight-related outcomes. In the main analysis, in the first trimester most associations were positive for insulin dose, in the second the associations were positive for glucose and inverse for insulin while in the third there were no associations. Most sensitivity analyses produced consistent results. In a sensitivity analysis splitting the first trimester in two periods, positive associations of maternal insulin with birthweight-related outcomes were observed in weeks 0+ to 6+. CONCLUSIONS Early in pregnancy in women with type 1 diabetes, maternal insulin dose is positively associated with birthweight-related outcomes, whereas in the second trimester, a positive association with SMBG emerges and the association with maternal insulin becomes inverse. If confirmed in other cohorts, these results would have implications in the management of women with type 1 diabetes.
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Affiliation(s)
| | - Diana Ovejero
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Inka Miñambres
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ana Chico
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER Bioengineering, Biomaterials and Nanotechnology (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Pedro Alejandro Gil
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - María-José Martínez
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Juan María Adelantado
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto de Leiva
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignasi Gich
- Department of Clinic Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Gernot Desoye
- Department of Obstetrics and Gynecology, Medizinische Universitaet Graz, Graz, Austria
| | | | - Rosa Corcoy
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER Bioengineering, Biomaterials and Nanotechnology (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
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Thong EP, Codner E, Laven JSE, Teede H. Diabetes: a metabolic and reproductive disorder in women. Lancet Diabetes Endocrinol 2020; 8:134-149. [PMID: 31635966 DOI: 10.1016/s2213-8587(19)30345-6] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023]
Abstract
Reproductive dysfunction is a common but little studied complication of diabetes. The spectrum of reproductive health problems in diabetes is broad, and encompasses delayed puberty and menarche, menstrual cycle abnormalities, subfertility, adverse pregnancy outcomes, and potentially early menopause. Depending on the age at diagnosis of diabetes, reproductive problems can manifest early on in puberty, emerge later when fertility is desired, or occur during the climacteric period. Historically, women with type 1 diabetes have frequently had amenorrhoea and infertility, due to central hypogonadism. With the intensification of insulin therapy and improved metabolic control, these problems have declined, but do persist. Additional reproductive implications of contemporary diabetes management are now emerging, including polycystic ovary syndrome and hyperandrogenism, which are underpinned by insulin action on the ovary. The sharp rise in type 2 diabetes incidence in youth suggests that more women of reproductive age will encounter diabetes-related reproductive problems in their lifetimes. With an ever increasing number of young women living with diabetes, clinicians need to be aware of and equipped for the challenges of navigating reproductive health concerns across the lifespan.
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Affiliation(s)
- Eleanor P Thong
- Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, Monash Health, Clayton, VIC, Australia
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Helena Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia; Department of Endocrinology and Diabetes, Monash Health, Clayton, VIC, Australia.
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Finneran MM, Kiefer MK, Ware CA, Buschur EO, Thung SF, Landon MB, Gabbe SG. The use of longitudinal hemoglobin A1c values to predict adverse obstetric and neonatal outcomes in pregnancies complicated by pregestational diabetes. Am J Obstet Gynecol MFM 2019; 2:100069. [PMID: 33345983 DOI: 10.1016/j.ajogmf.2019.100069] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although an elevated early pregnancy hemoglobin A1c has been associated with both spontaneous abortion and congenital anomalies, it is unclear whether A1c assessment is of value beyond the first trimester in pregnancies complicated by pregestational diabetes. OBJECTIVE We sought to investigate the prognostic ability of longitudinal A1c assessment to predict obstetric and neonatal adverse outcomes based on degree of glycemic control in early and late pregnancy. MATERIALS AND METHODS This was a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016 at The Ohio State University Wexner Medical Center with both an early A1c (<20 weeks' gestation) and late A1c (>26 weeks' gestation) available for analysis. Patients were categorized by good (early and late A1c <6.5%), improved (early A1c >6.5% and late A1c <6.5%) and poor (late A1c >6.5%) glycemic control. A multivariate regression model was used to calculate adjusted odds ratios (aOR) for each identified obstetric and neonatal outcome, controlling for maternal age, body mass index, race/ethnicity, type of diabetes, and gestational age at delivery compared to good control as the referent group. RESULTS A total of 341 patients met inclusion criteria during the study period. The median A1c values improved from early to late gestation in the good (5.7% [interquartile range [IQR], 5.4-6.1%] versus 5.4%; [IQR 5.2-5.7%]), improved (7.5% [IQR, 6.7-8.5] versus 5.9% [IQR, 5.6-6.1%]) and poor (8.3% [IQR, 7.1-9.6%] versus 7.3% [IQR, 6.8-7.9%]) glycemic control groups. There were no statistically significant differences in the rate of adverse outcomes between the good and improved groups except for an increased rate of neonatal intensive care unit admissions in the improved group (aOR, 3.7; confidence interval [CI], 1.9-7.3). In contrast, the poor control group had an increased rate of shoulder dystocia (aOR, 6.8; CI, 1.4-34.0), preterm delivery (aOR, 3.9; CI, 2.1-7.3), neonatal intensive care unit admission (aOR, 2.8; CI, 1.4-5.3), respiratory distress syndrome (aOR, 3.0; CI, 1.1-8.0), hypoglycemia (aOR, 3.2; CI, 1.5-6.9), large for gestational age weight at birth (aOR, 2.7; CI, 1.5-4.9), neonatal length of stay >4 days (aOR, 3.1; CI, 1.6-6.0) and preeclampsia (aOR, 2.4; CI, 1.2-4.6). There were no differences in rates of cesarean delivery, umbilical artery pH <7.1, or Apgar score <7 at 5 minutes after regression analysis. CONCLUSION Antenatal hemoglobin A1c values are useful for objective risk stratification of patients with pregestational diabetes. Strict glycemic control throughout pregnancy with a late pregnancy A1c target of <6.5% leads to reduced rates of obstetric and neonatal adverse outcomes independent of early pregnancy glucose control.
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Affiliation(s)
- Matthew M Finneran
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.
| | - Miranda K Kiefer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - Courtney A Ware
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - Elizabeth O Buschur
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Stephen F Thung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - Mark B Landon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - Steven G Gabbe
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
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Foussard N, Cougnard-Grégoire A, Rajaobelina K, Delcourt C, Helmer C, Lamireau T, Gonzalez C, Grouthier V, Haissaguerre M, Blanco L, Alexandre L, Mohammedi K, Rigalleau V. Skin Autofluorescence of Pregnant Women With Diabetes Predicts the Macrosomia of Their Children. Diabetes 2019; 68:1663-1669. [PMID: 31127055 DOI: 10.2337/db18-0906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 05/18/2019] [Indexed: 11/13/2022]
Abstract
Advanced glycation end products (AGEs) accumulated during long-term hyperglycemia are involved in diabetes complications and can be estimated by skin autofluorescence (sAF). During pregnancy, hyperglycemia exposes women to the risk of having a macrosomic newborn. The aim of this study was to determine whether sAF of women with diabetes during a singleton pregnancy could predict macrosomia in their newborns. Using an AGE Reader, we measured the sAF at the first visit of 343 women who were referred to our diabetology department during years 2011-2015. Thirty-nine women had pregestational diabetes, 95 early gestational diabetes mellitus (GDM), and 209 late GDM. Macrosomia was defined as birth weight ≥4,000 g and/or large for gestational age ≥90th percentile. Forty-six newborns were macrosomic. Their mothers had 11% higher sAF compared with other mothers: 2.03 ± 0.30 arbitrary units (AUs) vs. 1.80 ± 0.34 (P < 0.0001). Using multivariate logistic regression, the relation between sAF and macrosomia was significant (odds ratio 4.13 for 1-AU increase of sAF [95% CI 1.46-11.71]) after adjusting for several potential confounders. This relation remained significant after further adjustment for HbA1c (among 263 women with available HbA1c) and for women with GDM only. sAF of pregnant women with diabetes, a marker of long-term hyperglycemic exposure, predicts macrosomia in their newborns.
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Affiliation(s)
- Ninon Foussard
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Audrey Cougnard-Grégoire
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team Lifelong Exposures Health and Aging, UMR 1219, Bordeaux, France
| | - Kalina Rajaobelina
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team Lifelong Exposures Health and Aging, UMR 1219, Bordeaux, France
| | - Cécile Delcourt
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team Lifelong Exposures Health and Aging, UMR 1219, Bordeaux, France
| | - Catherine Helmer
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team Lifelong Exposures Health and Aging, UMR 1219, Bordeaux, France
| | - Thierry Lamireau
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team Lifelong Exposures Health and Aging, UMR 1219, Bordeaux, France
| | - Concepcion Gonzalez
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Virginie Grouthier
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | | | - Laurence Blanco
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Laure Alexandre
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Kamel Mohammedi
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - Vincent Rigalleau
- Nutrition-Diabetology, CHU de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, Team Lifelong Exposures Health and Aging, UMR 1219, Bordeaux, France
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Kristensen K, Ögge LE, Sengpiel V, Kjölhede K, Dotevall A, Elfvin A, Knop FK, Wiberg N, Katsarou A, Shaat N, Kristensen L, Berntorp K. Continuous glucose monitoring in pregnant women with type 1 diabetes: an observational cohort study of 186 pregnancies. Diabetologia 2019; 62:1143-1153. [PMID: 30904938 PMCID: PMC6560021 DOI: 10.1007/s00125-019-4850-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 02/25/2019] [Indexed: 01/12/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to analyse patterns of continuous glucose monitoring (CGM) data for associations with large for gestational age (LGA) infants and an adverse neonatal composite outcome (NCO) in pregnancies in women with type 1 diabetes. METHODS This was an observational cohort study of 186 pregnant women with type 1 diabetes in Sweden. The interstitial glucose readings from 92 real-time (rt) CGM and 94 intermittently viewed (i) CGM devices were used to calculate mean glucose, SD, CV%, time spent in target range (3.5-7.8 mmol/l), mean amplitude of glucose excursions and also high and low blood glucose indices (HBGI and LBGI, respectively). Electronic records provided information on maternal demographics and neonatal outcomes. Associations between CGM indices and neonatal outcomes were analysed by stepwise logistic regression analysis adjusted for confounders. RESULTS The number of infants born LGA was similar in rtCGM and iCGM users (52% vs 53%). In the combined group, elevated mean glucose levels in the second and the third trimester were significantly associated with LGA (OR 1.53, 95% CI 1.12, 2.08, and OR 1.57, 95% CI 1.12, 2.19, respectively). Furthermore, a high percentage of time in target in the second and the third trimester was associated with lower risk of LGA (OR 0.96, 95% CI 0.94, 0.99 and OR 0.97, 95% CI 0.95, 1.00, respectively). The same associations were found for mean glucose and for time in target and the risk of NCO in all trimesters. SD was significantly associated with LGA in the second trimester and with NCO in the third trimester. Glucose patterns did not differ between rtCGM and iCGM users except that rtCGM users had lower LBGI and spent less time below target. CONCLUSIONS/INTERPRETATION Higher mean glucose levels, higher SD and less time in target range were associated with increased risk of LGA and NCO. Despite the use of CGM throughout pregnancy, the day-to-day glucose control was not optimal and the incidence of LGA remained high.
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Affiliation(s)
- Karl Kristensen
- Department of Clinical Sciences Lund, Lund University, Sölvegatan 19, 221 84, Lund, Sweden.
- The Parker Institute, Copenhagen University Hospital, Copenhagen, Denmark.
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden.
| | - Linda E Ögge
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Verena Sengpiel
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Kjölhede
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Dotevall
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Östra/Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Elfvin
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Filip K Knop
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nana Wiberg
- Department of Clinical Sciences Lund, Lund University, Sölvegatan 19, 221 84, Lund, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
| | - Anastasia Katsarou
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Nael Shaat
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Lars Kristensen
- The Parker Institute, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kerstin Berntorp
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
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Ringholm L, Damm P, Mathiesen ER. Improving pregnancy outcomes in women with diabetes mellitus: modern management. Nat Rev Endocrinol 2019; 15:406-416. [PMID: 30948803 DOI: 10.1038/s41574-019-0197-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Ludvigsson JF, Neovius M, Söderling J, Gudbjörnsdottir S, Svensson AM, Franzén S, Stephansson O, Pasternak B. Maternal Glycemic Control in Type 1 Diabetes and the Risk for Preterm Birth: A Population-Based Cohort Study. Ann Intern Med 2019; 170:691-701. [PMID: 31009941 DOI: 10.7326/m18-1974] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Maternal type 1 diabetes (T1D) has been linked to preterm birth and other adverse pregnancy outcomes. How these risks vary with glycated hemoglobin (or hemoglobin A1c [HbA1c]) levels is unclear. OBJECTIVE To examine preterm birth risk according to periconceptional HbA1c levels in women with T1D. DESIGN Population-based cohort study. SETTING Sweden, 2003 to 2014. PATIENTS 2474 singletons born to women with T1D and 1 165 216 reference infants born to women without diabetes. MEASUREMENTS Risk for preterm birth (<37 gestational weeks). Secondary outcomes were neonatal death, large for gestational age, macrosomia, infant birth injury, hypoglycemia, respiratory distress, 5-minute Apgar score less than 7, and stillbirth. RESULTS Preterm birth occurred in 552 (22.3%) of 2474 infants born to mothers with T1D versus 54 287 (4.7%) in 1 165 216 infants born to mothers without diabetes. The incidence of preterm birth was 13.2% in women with a periconceptional HbA1c level below 6.5% (adjusted risk ratio [aRR] vs. women without T1D, 2.83 [95% CI, 2.28 to 3.52]), 20.6% in those with a level from 6.5% to less than 7.8% (aRR, 4.22 [CI, 3.74 to 4.75]), 28.3% in those with a level from 7.8% to less than 9.1% (aRR, 5.56 [CI, 4.84 to 6.38]), and 37.5% in those with a level of 9.1% or higher (aRR, 6.91 [CI, 5.85 to 8.17]). The corresponding aRRs for medically indicated preterm birth (n = 320) were 5.26 (CI, 3.83 to 7.22), 7.42 (CI, 6.21 to 8.86), 11.75 (CI, 9.72 to 14.20), and 17.51 (CI, 14.14 to 21.69), respectively. The corresponding aRRs for spontaneous preterm birth (n = 223) were 1.81 (CI, 1.31 to 2.52), 2.86 (CI, 2.38 to 3.44), 2.88 (CI, 2.23 to 3.71), and 2.80 (CI, 1.94 to 4.03), respectively. Increasing HbA1c levels were associated with the study's secondary outcomes: large for gestational age, hypoglycemia, respiratory distress, low Apgar score, neonatal death, and stillbirth. LIMITATION Because HbA1c levels were registered annually at routine visits, they were not available for all pregnant women with T1D. CONCLUSION The risk for preterm birth was strongly linked to periconceptional HbA1c levels. Women with HbA1c levels consistent with recommended target levels also were at increased risk. PRIMARY FUNDING SOURCE Swedish Diabetes Foundation.
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Affiliation(s)
- Jonas F Ludvigsson
- Karolinska Institutet, Stockholm, Sweden, Örebro University Hospital, Örebro, Sweden, University of Nottingham, Nottingham, United Kingdom, and Columbia University College of Physicians and Surgeons, New York, New York (J.F.L.)
| | - Martin Neovius
- Karolinska Institutet, Stockholm, Sweden (M.N., J.S., O.S.)
| | | | - Soffia Gudbjörnsdottir
- Karolinska Institutet, Stockholm, Sweden; Centre of Registers Västra Götaland and University of Gothenburg, Gothenburg, Sweden (S.G., S.F.)
| | | | - Stefan Franzén
- Karolinska Institutet, Stockholm, Sweden; Centre of Registers Västra Götaland and University of Gothenburg, Gothenburg, Sweden (S.G., S.F.)
| | | | - Björn Pasternak
- Karolinska Institutet, Stockholm, Sweden, and Statens Serum Institut, Copenhagen, Denmark (B.P.)
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Bashir M, Naem E, Taha F, Konje JC, Abou-Samra AB. Outcomes of type 1 diabetes mellitus in pregnancy; effect of excessive gestational weight gain and hyperglycaemia on fetal growth. Diabetes Metab Syndr 2019; 13:84-88. [PMID: 30641818 DOI: 10.1016/j.dsx.2018.08.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/27/2018] [Indexed: 01/01/2023]
Abstract
AIMS To study pregnancy outcomes in patients with type 1 diabetes mellitus (T1DM) and the factors associated with poor outcomes. METHODS A retrospective study of 110 patients with T2DM who attended our diabetes in pregnancy clinic at the Women's Wellness and Research centre, Doha, between March 2015 and December 2016 and 1419 normoglycaemic controls. RESULTS There was no difference in age, weight, and BMI between the two groups. The incidence of macrosomia, shoulder dystocia and stillbirth were similar in the two groups while that of pre-term labour, pre-eclampsia, Caesarean section (CS), large for gestational age (LGA), neonatal ICU (NICU) admission and neonatal hypoglycaemia were significantly higher in the T1DM than in the control group. From a multivariate regression analysis, excessive gestational weight gain was associated with increased risk of LGA (OR 4.53; 95% CI [1.42-14.25]). Last trimester HBA1c was associated with increased risk for macrosomia [OR 2.46, 95% CI [1.03-5.86)]; LGA [ OR 3.25, 95% CI [1.65-6.40)]; increased risk for C-section (OR 1.96, 95% CI [1.12-3.45]), and increased risk of NICU admission (OR 2.46, 95% CI [1.04-5.86]). The changes in HBA1C between the first and last trimester HBA1c was associated with a reduction in the risk of LGA [OR 0.46, 95% CI [(0.28-0.75)] CONCLUSION: T1DM in pregnancy is associated with adverse pregnancy outcomes compared to the general population. Reducing gestational weight gain and improving glycaemic control might improve pregnancy outcomes.
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Affiliation(s)
- Mohammed Bashir
- Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar.
| | - Emad Naem
- Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faten Taha
- Department of Obstetrics and Gynaecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Justin C Konje
- Women's Clinical Services Management Group (WCMG), Sidra Medicine, Doha, Qatar
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Strand-Holm KM, Fuglsang J, Ovesen PG, Maimburg RD. Diabetes Mellitus and lower genital tract tears after vaginal birth: A cohort study. Midwifery 2018; 69:121-127. [PMID: 30500727 DOI: 10.1016/j.midw.2018.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/29/2018] [Accepted: 11/20/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Diabetes Mellitus in pregnancy is increasing. No existing studies have examined Diabetes Mellitus as the primary exposure for lower genital tract tears after vaginal birth. The objective was to study the association between Diabetes Mellitus (all types combined), Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus and Gestational Diabetes Mellitus and lower genital tract tears after vaginal birth. MATERIAL AND METHODS A register-based cohort study of women with singleton pregnancy and without a previous cesarean section at near-term (≥ 35 + 0 weeks) and term (≥ 37 + 0 weeks) gestational age, n = 31,297 at Aarhus University Hospital, Denmark from 1 January 2004 to 31 December 2012. The associations between Diabetes Mellitus and lower genital tract tears were analysed using a fixed multiple logistic regression analyses. RESULTS Approximately 32,000 women were eligible for the study; 796 women had diabetes (2.5%) and 1318 experienced anal sphincter injury (4.3%). The overall risk of lower genital tract tears was similar among women with a diagnosis of diabetes (Type1 Diabetes Mellitus, Type 2 Diabetes Mellitus, and Gestational Diabetes Mellitus) compared to women without diabetes, except for nulliparous women with Type1 Diabetes Mellitus who experienced a higher risk of episiotomies, crude and adjusted odds ratios (OR 2.13, 95% CI 1.14-3.97) and (OR 2.48, 95% CI 1.21-5.10), respectively. CONCLUSIONS Women with Diabetes Mellitus without a previous cesarean section who gave birth vaginally to a single child at term or near term did not experienced an increased risk of lower genital tract tears. However, nulliparous women with Type 1 Diabetes Mellitus experienced a higher risk of episiotomy. These results may be used to individualised counselling of women with Diabetes Mellitus regarding mode of birth and may reduce worries about genital tract tears in women with Diabetes Mellitus considering vaginal birth.
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Affiliation(s)
- Karen M Strand-Holm
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Denmark.
| | - Jens Fuglsang
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Denmark; Department of Clinical Medicine, Aarhus University, Incuba / Skejby Building 2 Palle Juul-Jensens Boulevard 82, Aarhus DK-8200, Denmark.
| | - Per G Ovesen
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Denmark; Department of Clinical Medicine, Aarhus University, Incuba / Skejby Building 2 Palle Juul-Jensens Boulevard 82, Aarhus DK-8200, Denmark.
| | - Rikke D Maimburg
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Denmark; Department of Clinical Medicine, Aarhus University, Incuba / Skejby Building 2 Palle Juul-Jensens Boulevard 82, Aarhus DK-8200, Denmark.
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McCarthy EA, Williamson R, Shub A. Pregnancy outcomes for women with pre‐pregnancy diabetes mellitus in Australian populations, rural and metropolitan: A review. Aust N Z J Obstet Gynaecol 2018; 59:183-194. [DOI: 10.1111/ajo.12913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 09/22/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Elizabeth A. McCarthy
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
- Department of Perinatal MedicineMercy Hospital for Women Melbourne Victoria Australia
| | - Rebecca Williamson
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
| | - Alexis Shub
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
- Mercy Hospital for Women Melbourne Victoria Australia
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Gomes D, von Kries R, Delius M, Mansmann U, Nast M, Stubert M, Langhammer L, Haas NA, Netz H, Obermeier V, Kuhle S, Holdt LM, Teupser D, Hasbargen U, Roscher AA, Ensenauer R. Late-pregnancy dysglycemia in obese pregnancies after negative testing for gestational diabetes and risk of future childhood overweight: An interim analysis from a longitudinal mother-child cohort study. PLoS Med 2018; 15:e1002681. [PMID: 30372451 PMCID: PMC6205663 DOI: 10.1371/journal.pmed.1002681] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Maternal pre-conception obesity is a strong risk factor for childhood overweight. However, prenatal mechanisms and their effects in susceptible gestational periods that contribute to this risk are not well understood. We aimed to assess the impact of late-pregnancy dysglycemia in obese pregnancies with negative testing for gestational diabetes mellitus (GDM) on long-term mother-child outcomes. METHODS AND FINDINGS The prospective cohort study Programming of Enhanced Adiposity Risk in Childhood-Early Screening (PEACHES) (n = 1,671) enrolled obese and normal weight mothers from August 2010 to December 2015 with trimester-specific data on glucose metabolism including GDM status at the end of the second trimester and maternal glycated hemoglobin (HbA1c) at delivery as a marker for late-pregnancy dysglycemia (HbA1c ≥ 5.7% [39 mmol/mol]). We assessed offspring short- and long-term outcomes up to 4 years, and maternal glucose metabolism 3.5 years postpartum. Multivariable linear and log-binomial regression with effects presented as mean increments (Δ) or relative risks (RRs) with 95% confidence intervals (CIs) were used to examine the association between late-pregnancy dysglycemia and outcomes. Linear mixed-effects models were used to study the longitudinal development of offspring body mass index (BMI) z-scores. The contribution of late-pregnancy dysglycemia to the association between maternal pre-conception obesity and offspring BMI was estimated using mediation analysis. In all, 898 mother-child pairs were included in this unplanned interim analysis. Among obese mothers with negative testing for GDM (n = 448), those with late-pregnancy dysglycemia (n = 135, 30.1%) had higher proportions of excessive total gestational weight gain (GWG), excessive third-trimester GWG, and offspring with large-for-gestational-age birth weight than those without. Besides higher birth weight (Δ 192 g, 95% CI 100-284) and cord-blood C-peptide concentration (Δ 0.10 ng/ml, 95% CI 0.02-0.17), offspring of these women had greater weight gain during early childhood (Δ BMI z-score per year 0.18, 95% CI 0.06-0.30, n = 262) and higher BMI z-score at 4 years (Δ 0.58, 95% CI 0.18-0.99, n = 43) than offspring of the obese, GDM-negative mothers with normal HbA1c values at delivery. Late-pregnancy dysglycemia in GDM-negative mothers accounted for about one-quarter of the association of maternal obesity with offspring BMI at age 4 years (n = 151). In contrast, childhood BMI z-scores were not affected by a diagnosis of GDM in obese pregnancies (GDM-positive: 0.58, 95% CI 0.36-0.79, versus GDM-negative: 0.62, 95% CI 0.44-0.79). One mechanism triggering late-pregnancy dysglycemia in obese, GDM-negative mothers was related to excessive third-trimester weight gain (RR 1.72, 95% CI 1.12-2.65). Furthermore, in the maternal population, we found a 4-fold (RR 4.01, 95% CI 1.97-8.17) increased risk of future prediabetes or diabetes if obese, GDM-negative women had a high versus normal HbA1c at delivery (absolute risk: 43.2% versus 10.5%). There is a potential for misclassification bias as the predominantly used GDM test procedure changed over the enrollment period. Further studies are required to validate the findings and elucidate the possible third-trimester factors contributing to future mother-child health status. CONCLUSIONS Findings from this interim analysis suggest that offspring of obese mothers treated because of a diagnosis of GDM appeared to have a better BMI outcome in childhood than those of obese mothers who-following negative GDM testing-remained untreated in the last trimester and developed dysglycemia. Late-pregnancy dysglycemia related to uncontrolled weight gain may contribute to the development of child overweight and maternal diabetes. Our data suggest that negative GDM testing in obese pregnancies is not an "all-clear signal" and should not lead to reduced attention and risk awareness of physicians and obese women. Effective strategies are needed to maintain third-trimester glycemic and weight gain control among otherwise healthy obese pregnant women.
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Affiliation(s)
- Delphina Gomes
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Division of Experimental Pediatrics and Metabolism, University Children's Hospital, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Rüdiger von Kries
- Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Maria Delius
- Department of Obstetrics and Gynecology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martha Nast
- Department of Obstetrics and Gynecology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Division of Pediatric Cardiology and Intensive Care, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martina Stubert
- Department of Obstetrics and Gynecology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Division of Pediatric Cardiology and Intensive Care, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Lena Langhammer
- Division of Pediatric Cardiology and Intensive Care, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nikolaus A. Haas
- Division of Pediatric Cardiology and Intensive Care, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Heinrich Netz
- Division of Pediatric Cardiology and Intensive Care, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Viola Obermeier
- Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stefan Kuhle
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Division of Experimental Pediatrics and Metabolism, University Children's Hospital, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Lesca M. Holdt
- Institute of Laboratory Medicine, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Daniel Teupser
- Institute of Laboratory Medicine, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Uwe Hasbargen
- Department of Obstetrics and Gynecology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Adelbert A. Roscher
- Department of Pediatrics, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Regina Ensenauer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Division of Experimental Pediatrics and Metabolism, University Children's Hospital, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Faculty of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
- Division of Pediatric Cardiology and Intensive Care, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- * E-mail:
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Nahavandi S, Seah JM, Shub A, Houlihan C, Ekinci EI. Biomarkers for Macrosomia Prediction in Pregnancies Affected by Diabetes. Front Endocrinol (Lausanne) 2018; 9:407. [PMID: 30108547 PMCID: PMC6079223 DOI: 10.3389/fendo.2018.00407] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/29/2018] [Indexed: 12/16/2022] Open
Abstract
Large birthweight, or macrosomia, is one of the commonest complications for pregnancies affected by diabetes. As macrosomia is associated with an increased risk of a number of adverse outcomes for both the mother and offspring, accurate antenatal prediction of fetal macrosomia could be beneficial in guiding appropriate models of care and interventions that may avoid or reduce these associated risks. However, current prediction strategies which include physical examination and ultrasound assessment, are imprecise. Biomarkers are proving useful in various specialties and may offer a new avenue for improved prediction of macrosomia. Prime biomarker candidates in pregnancies with diabetes include maternal glycaemic markers (glucose, 1,5-anhydroglucitol, glycosylated hemoglobin) and hormones proposed implicated in placental nutrient transfer (adiponectin and insulin-like growth factor-1). There is some support for an association of these biomarkers with birthweight and/or macrosomia, although current evidence in this emerging field is still limited. Thus, although biomarkers hold promise, further investigation is needed to elucidate the potential clinical utility of biomarkers for macrosomia prediction for pregnancies affected by diabetes.
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Affiliation(s)
- Sofia Nahavandi
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Jas-mine Seah
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Alexis Shub
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Mercy Hospital for Women, Mercy Health, Melbourne, VIC, Australia
| | - Christine Houlihan
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Mercy Hospital for Women, Mercy Health, Melbourne, VIC, Australia
| | - Elif I. Ekinci
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
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Lepercq J, Le Ray C, Godefroy C, Pelage L, Dubois-Laforgue D, Timsit J. Determinants of a good perinatal outcome in 588 pregnancies in women with type 1 diabetes. DIABETES & METABOLISM 2018; 45:191-196. [PMID: 29776801 DOI: 10.1016/j.diabet.2018.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 04/13/2018] [Accepted: 04/18/2018] [Indexed: 11/28/2022]
Abstract
AIM This study assessed pregnancy outcomes in women with type 1 diabetes (T1D) over the last 15 years and identified modifiable factors associated with good perinatal outcomes. METHODS Pregnancy outcomes were prospectively assessed in this cohort study of 588 singleton pregnancies (441 women) managed by standardized care from 2000 to 2014. A good perinatal outcome was defined as the uncomplicated delivery of a normally formed, non-macrosomic, full-term infant with no neonatal morbidity. Factors associated with good perinatal outcomes were identified by logistic regression. RESULTS The rate of severe congenital malformations was 1.5%, and 0.7% for perinatal mortality. The most frequent perinatal complications were macrosomia (41%), preterm delivery (16%) and neonatal hypoglycaemia (11%). Shoulder dystocia occurred in 2.6% of cases, but without sequelae. Perinatal outcomes were good in 254 (44%) pregnancies, and were associated with lower maternal HbA1c values at delivery [adjusted odds ratio (aOR): 2.78, 95% CI: 2.04-3.70, for each 1% (11mmol/mol) absolute decrease], lower gestational weight gains (aOR: 1.06, 95% CI: 1.02-1.10) and absence of preeclampsia (aOR: 2.63, 95% CI: 1.09-6.25). The relationship between HbA1c at delivery and a good perinatal outcome was continuous, with no discrimination threshold. CONCLUSION In our study, rates of severe congenital malformations and perinatal mortality were similar to those of the general population. Less severe complications, mainly macrosomia and late preterm delivery, persisted. Also, our study identified modifiable risk factors that could be targeted to further improve the prognosis of pregnancy in T1D.
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Affiliation(s)
- J Lepercq
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France.
| | - C Le Ray
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France; Inserm UMR 1153, obstetrical, perinatal and pediatric epidemiology research team (EPOPe), centre for epidemiology and statistics Sorbonne Paris Cité (CRESS), 75014 Paris, France
| | - C Godefroy
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - L Pelage
- Port-Royal maternity unit, DHU risks in pregnancy, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - D Dubois-Laforgue
- Department of diabetology, DHU AUTHORS, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France; Inserm U1016, Cochin hospital, 75014 Paris, France
| | - J Timsit
- Department of diabetology, DHU AUTHORS, Paris Descartes university, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
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Ladfors L, Shaat N, Wiberg N, Katasarou A, Berntorp K, Kristensen K. Fetal overgrowth in women with type 1 and type 2 diabetes mellitus. PLoS One 2017; 12:e0187917. [PMID: 29121112 PMCID: PMC5679529 DOI: 10.1371/journal.pone.0187917] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 10/27/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Despite improved glycemic control, the rate of large-for-gestational-age (LGA) infants remains high in pregnancies complicated by diabetes mellitus type 1 (T1DM) and type 2 (T2DM). Poor glycemic control, obesity, and excessive gestational weight gain are the main risk factors. The aim of this study was to determine the relative contribution of these risk factors for LGA in women with T1DM and T2DM, after controlling for important confounders such as age, smoking, and parity. METHODS In this retrospective chart review study, we analyzed the medical files of pregnant women with T1DM and T2DM who attended the antenatal care program at Skåne University Hospital during the years 2006 to 2016. HbA1c was used as a measure of glycemic control. Maternal weight in early pregnancy and at term was registered. LGA was defined as birth weight > 2 standard deviations of the mean. Univariable and multivariable logistic regression analysis was used to calculate odds ratios (OR's) and 95% confidence intervals (CIs) for LGA. RESULTS Over the 11-year period, we identified 308 singleton pregnancies in 221 women with T1DM and in 87 women with T2DM. The rate of LGA was 50% in women with T1DM and 23% in women with T2DM. The multivariable regression model identified gestational weight gain and second-trimester HbA1c as risk factors for LGA in T1DM pregnancies (OR = 1.107, 95% CI: 1.044-1.17, and OR = 1.047, 95% CI: 1.015-1.080, respectively) and gestational weight gain as a risk factor in T2DM pregnancies (OR = 1.175, 95% CI: 1.048-1.318), independent of body mass index. CONCLUSIONS Gestational weight gain was associated with LGA in women with T1DM and T2DM, independent of maternal body mass index. The findings suggest that monitoring and regulation of gestational weight gain is important in the clinical care of these women, to minimize the risk of fetal overgrowth.
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Affiliation(s)
- Linnea Ladfors
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
| | - Nael Shaat
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Nana Wiberg
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Anastasia Katasarou
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Kerstin Berntorp
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Karl Kristensen
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Egan AM, Galjaard S, Maresh MJA, Loeken MR, Napoli A, Anastasiou E, Noctor E, de Valk HW, van Poppel M, Todd M, Smith V, Devane D, Dunne FP. A core outcome set for studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes. Diabetologia 2017; 60:1190-1196. [PMID: 28409213 PMCID: PMC5487596 DOI: 10.1007/s00125-017-4277-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/13/2017] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to develop a core outcome set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational (pre-existing) diabetes mellitus. METHODS A systematic literature review was completed to identify all outcomes reported in prior studies in this area. Key stakeholders then prioritised these outcomes using a Delphi study. The list of outcomes included in the final COS were finalised at a face-to-face consensus meeting. RESULTS In total, 17 outcomes were selected and agreed on for inclusion in the final COS. These outcomes were grouped under three domains: measures of pregnancy preparation (n = 9), neonatal outcomes (n = 6) and maternal outcomes (n = 2). CONCLUSIONS/INTERPRETATION This study identified a COS essential for studies evaluating prepregnancy care for women with pregestational diabetes. It is advocated that all trials and other non-randomised studies and audits in this area use this COS with the aim of improving transparency and the ability to compare and combine future studies with greater ease.
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Affiliation(s)
- Aoife M Egan
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland.
| | - Sander Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands.
| | - Michael J A Maresh
- Department of Obstetrics, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Angela Napoli
- Department of Clinical and Molecular Medicine, S. Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - Eleni Anastasiou
- Department of Endocrinology & Diabetes Center Alexandra Hospital, Athens, Greece
| | - Eoin Noctor
- Department of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mireille van Poppel
- Institute of Sport Science, University of Graz, Graz, Austria
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, the Netherlands
| | - Marie Todd
- Department of Medicine, Mayo University Hospital, Castlebar, Ireland
| | - Valerie Smith
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
- Health Research Board - Trials Methodology Research Network (HRB-TMRN), Galway, Ireland
| | - Fidelma P Dunne
- Galway Diabetes Research Centre, Department of Medicine, National University of Ireland Galway, Galway, Ireland
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Gutaj P, Wender-Ożegowska E, Brązert J. Maternal lipids associated with large-for-gestational-age birth weight in women with type 1 diabetes: results from a prospective single-center study. Arch Med Sci 2017; 13:753-759. [PMID: 28721142 PMCID: PMC5510499 DOI: 10.5114/aoms.2016.58619] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/15/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite improvement in diabetes care over the years, the incidence of macrosomia in type 1 diabetic mothers is still very high and even shows an increasing tendency. It is suggested that other factors that maternal hyperglycemia might be associated with excessive fetal growth in diabetic mothers. The aim of this study was to determine whether maternal lipids might contribute to high rates of large-for-gestational-age (LGA) newborns in women with type 1 diabetes (T1DM). MATERIAL AND METHODS This prospective, single-center study was performed in a population of women with T1DM admitted to the perinatal center for women with diabetes. Data were collected in the first trimester (< 12th week), in mid-pregnancy (20th-24th weeks), and before delivery (34th-39th weeks). RESULTS Among 114 women included in the analysis, 30 (26.3%) delivered LGA newborns. The remaining 84 (73.7%) newborns were appropriate for gestational age (AGA). Lower high-density lipoprotein (HDL) HDL concentration in the first trimester was significantly associated with LGA (p = 0.01). Similar associations were observed for the HDL concentrations in mid-pregnancy (p = 0.04) and before delivery (p = 0.03). Higher triglyceride concentrations in the first trimester (p = 0.02) and before delivery (p = 0.008) were associated with LGA. Higher glycated haemoglobin (HbA1c) levels in mid-pregnancy and before delivery were associated with LGA. The associations between maternal lipids and LGA were independent of maternal body mass index at onset of the study, gestational weight gain and HbA1c concentrations. CONCLUSIONS Decreased HDL and increased triglycerides during pregnancy might contribute to the development of LGA in women with type 1 diabetes.
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Affiliation(s)
- Paweł Gutaj
- Department of Obstetrics and Women's Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Ewa Wender-Ożegowska
- Department of Obstetrics and Women's Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Brązert
- Department of Obstetrics and Women's Diseases, Poznan University of Medical Sciences, Poznan, Poland
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Cyganek K, Skupien J, Katra B, Hebda-Szydlo A, Janas I, Trznadel-Morawska I, Witek P, Kozek E, Malecki MT. Risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control. Endocrine 2017; 55:447-455. [PMID: 27726091 PMCID: PMC5272887 DOI: 10.1007/s12020-016-1134-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/22/2016] [Indexed: 11/24/2022]
Abstract
Macrosomia risk remains high in type 1 diabetes (T1DM) complicated pregnancies. A linear relationship between macrosomia risk and glycated hemoglobin A1c (HbA1c) was described; however, low range of HbA1c has not been studied. We aimed to identify risk factors and examine the impact of HbA1c on the occurrence of macrosomia in newborns of T1DM women from a cohort with good glycemic control. In this observational retrospective one-center study we analyzed records of 510 consecutive T1DM pregnancies (1998-2012). The analyzed group consisted of 375 term singleton pregnancies. We used multiple regression models to examine the impact of HbA1c and self-monitored glucose in each trimester on the risk of macrosomia and birth weight. The median age of T1DM women was 28 years, median T1DM duration-11 years, median pregestational BMI-23.3 kg/m2. Median birth weight reached 3520 g (1st and 3rd quartiles 3150 and 3960, respectively) at median 39 weeks of gestation. There were 85 (22.7 %) macrosomic (>4000 g) newborns. Median HbA1c levels in the 1st, 2nd, and 3rd trimester were 6.4, 5.7, and 5.6 %. Third trimester HbA1c, mean fasting self-monitored glucose and maternal age were independent predictors of birth weight and macrosomia. There was a linear relationship between 3rd trimester HbA1c and macrosomia risk in HbA1c range from 4.5 to 7.0 %. Macrosomia in children of T1DM mothers was common despite excellent metabolic control. Glycemia during the 3rd trimester was predominantly responsible for this condition.
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Affiliation(s)
- Katarzyna Cyganek
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Jan Skupien
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Barbara Katra
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Alicja Hebda-Szydlo
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Izabela Janas
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - Iwona Trznadel-Morawska
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Przemysław Witek
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Kozek
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T Malecki
- Department of Metabolic Diseases, University Hospital, Krakow, Poland.
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland.
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Growth and BMI during the first 14 y of life in offspring from women with type 1 or type 2 diabetes mellitus. Pediatr Res 2017; 81:342-348. [PMID: 27828938 DOI: 10.1038/pr.2016.236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/30/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Infants of women with pregestational diabetes are at risk for developing obesity in later life. This study aimed to identify subgroups at highest risk, by studying growth profiles of offspring from women with type 1 or 2 diabetes mellitus (ODM1, ODM2) until the age of 14 y. METHODS Information from infant welfare centers was received for 78 ODM1 and 44 ODM2. Mean BMI SD scores (SDS) (based on 1980 nation-wide references) and height SDS (based on 2009 references) were calculated and included in a random-effects model. Values were compared to the 2009 Dutch growth study. RESULTS BMI SDS profiles differed between ODM1 and ODM2, with the highest mean BMI SDS profiles in ODM2. Other factors that affected growth profiles in these infants included the presence of maternal obesity, large for gestational age (LGA) at birth and in ODM2 a Dutch-Mediterranean origin. CONCLUSION Offspring of women with diabetes have higher BMI SDS profiles than observed in the 2009 Dutch growth study, with the highest BMI SDS in ODM2 who are LGA at birth and have obese mothers. Preventive strategies for offspring adiposity may include pursuing lower prepregnancy maternal BMI, prevention of LGA at birth, and prevention of increased weight gain during childhood.
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Yamamoto JM, Kallas-Koeman MM, Butalia S, Lodha AK, Donovan LE. Large-for-gestational-age (LGA) neonate predicts a 2.5-fold increased odds of neonatal hypoglycaemia in women with type 1 diabetes. Diabetes Metab Res Rev 2017; 33. [PMID: 27184133 DOI: 10.1002/dmrr.2824] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 04/22/2016] [Accepted: 05/09/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective of the study is to assess the impact of maternal glycaemic control and large-for-gestational-age (LGA) infant size on the risk of developing neonatal hypoglycaemia in offspring of women with type 1 diabetes and to determine possible predictors of neonatal hypoglycaemia and LGA. RESEARCH METHODS AND DESIGN This retrospective cohort study evaluated pregnancies in 161 women with type 1 diabetes mellitus at a large urban centre between 2006 and 2010. Mean trimester A1c values were categorized into five groups. Multiple logistic regression analyses were used to examine predictors of neonatal hypoglycaemia and large-for-gestational-age (LGA). RESULTS Hypoglycaemia occurred in 36.6% of neonates. There was not a linear association between trimester specific A1c and LGA. After adjusting for maternal age, body mass index (BMI), smoking and premature delivery, neonatal hypoglycaemia was not linearly associated with A1c in the first, second or third trimesters. LGA was the only significant predictor for neonatal hypoglycaemia (OR, 95% CI 2.51 [1.10, 5.70]) in logistic regression analysis that adjusted for glycaemic control, maternal age, smoking, prematurity and BMI. An elevated third trimester A1c increased the odds of LGA (1.81 [1.03, 3.18]) after adjustment for smoking, parity and maternal BMI. CONCLUSIONS Large-for-gestational-age imparts a 2.5-fold increased odds of hypoglycaemia in neonates of women with type 1 diabetes and may be a better predictor of neonatal hypoglycaemia than maternal glycaemic control. Our data suggest that LGA neonates of women with type 1 diabetes should prompt increased surveillance for neonatal hypoglycaemia and that the presence of optimum maternal glycaemic control should not reduce this surveillance. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jennifer M Yamamoto
- Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - Melissa M Kallas-Koeman
- Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - Sonia Butalia
- Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - Abhay K Lodha
- Section of Neonatology, Department of Pediatrics & Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Lois E Donovan
- Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
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