Quantification of the type 2 diabetes risk in women with gestational diabetes: a systematic review and meta-analysis of 95,750 women

One-year postpartum weight retention and glucose intolerance in women with prediabetes after gestational diabetes

AIMS

To determine risk factors for 1-year postpartum weight retention (PPWR) and glucose intolerance (prediabetes + diabetes) in women with a previous history of gestational diabetes (GDM) and prediabetes in early postpartum.

METHODS

In this exploratory analysis of the MELINDA randomized controlled trial, we report data of 167 women with prediabetes at the 6-16 weeks (early) postpartum oral glucose tolerance test after a recent history of GDM.

RESULTS

Of all participants, 45% (75) had PPWR >0 kg at 1-year postpartum. Compared to women without PPWR, women with PPWR had higher gestational weight gain [10.5 ± 6.4 vs. 6.5 ± 4.5 kg, p < 0.001], higher BMI (p < 0.01) and a worse metabolic profile (higher waist circumference, worse lipid profile and more insulin resistance) (all p < 0.05) both in early and late postpartum. Of all women with PPWR, 40.0% developed metabolic syndrome, compared to 18.9% of women without late PPWR (p = 0.003). The only independent predictor for late PPWR was weight retention in early postpartum (p < 0.001). Of all participants, 55.1% (92) had glucose intolerance (84 prediabetes, 8 diabetes) 1-year postpartum. Independent predictors for late postpartum glucose intolerance were lower gestational age at start insulin therapy in pregnancy and delivery by caesarean section (resp. p = 0.044 and 0.014).

CONCLUSIONS

In women with a previous history of GDM and prediabetes in early postpartum, PPWR in early postpartum was a strong independent predictor for late PPWR, while earlier start of insulin therapy during pregnancy and delivery by caesarean section were independent predictors of glucose intolerance in late postpartum.

Development of a risk prediction model for postpartum onset of type 2 diabetes mellitus, following gestational diabetes; the lifestyle InterVention in gestational diabetes (LIVING) study

AIMS

This study aimed to develop a prediction model for identifying a woman with gestational diabetes mellitus (GDM) at high risk of type 2 diabetes (T2DM) post-birth.

METHODS

Utilising data from 1299 women in the Lifestyle Intervention IN Gestational Diabetes (LIVING) study, two models were developed: one for pregnancy and another for postpartum. Key predictors included glucose test results, medical history, and biometric indicators.

RESULTS

Of the initial cohort, 124 women developed T2DM within three years. The study identified seven predictors for the antenatal T2DM risk prediction model and four for the postnatal one. The models demonstrated good to excellent predictive ability, with Area under the ROC Curve (AUC) values of 0.76 (95% CI: 0.72 to 0.80) and 0.85 (95% CI: 0.81 to 0.88) for the antenatal and postnatal models, respectively. Both models underwent rigorous validation, showing minimal optimism in predictive capability. Antenatal model, considering the Youden index optimal cut-off point of 0.096, sensitivity, specificity, and accuracy were measured as 70.97%, 70.81%, and 70.82%, respectively. For the postnatal model, considering the cut-off point 0.086, sensitivity, specificity, and accuracy were measured as 81.40%, 75.60%, and 76.10%, respectively.

CONCLUSIONS

These models are effective for predicting T2DM risk in women with GDM, although external validation is recommended before widespread application.

Postpartum glucose intolerance after gestational diabetes mellitus: tailored prediction according to data-driven clusters and BMI-categories

Objectives

To account for the heterogeneity of gestational diabetes (GDM), this study investigated tailored predictors during pregnancy and at 6-8 weeks postpartum of glucose intolerance (GI) at 1-year postpartum. We identified predictors according to data-driven clusters, analogous to the newly proposed diabetes classification, and for clinical ease also based on BMI-categories.

Methods

This is a secondary analysis of the MySweetheart trial. It included 179 women with GDM who underwent a 75g oral glucose tolerance test and HbA1c measurement at 1-year postpartum. Predictors were determined according to: a) cluster analysis based on age, BMI, HOMA-IR and HOMA-B; and b) BMI-categories (normal weight [NW], and overweight/obesity [OW/OB]).

Results

We identified two clusters during pregnancy and at 6-8 weeks postpartum (for both time points an "insulin-resistant", and an "insulin-deficient" cluster). The "insulin-resistant" cluster was associated with a 2.9-fold (CI: 1.46-5.87; pregnancy) and 3.5-fold (CI: 1.63-7.52; at 6-8 weeks postpartum) increased risk of GI at 1-year postpartum. During pregnancy, the most relevant predictors of GI were history of previous GDM and fasting glucose for the "insulin-deficient" and NW category and HOMA-IR for the "insulin-resistant" and OW/OB category (all p ≤0.035). In the postpartum, predictors were more heterogenous and included the insulin-sensitivity-adjusted-secretion index and 1-h glucose in the "insulin-deficient" and NW women.

Main conclusions

In women with GDM, we identified "insulin-resistant" and "insulin-deficient" clusters with distinct risks of future GI. Predictors varied according to clusters or BMI-categories emphasizing the need for tailored risk assessments.

Gestational diabetes mellitus and development of intergenerational non-alcoholic fatty liver disease (NAFLD) after delivery: a systematic review and meta-analysis

Background

It is known that gestational diabetes mellitus (GDM)-complicated pregnancies could affect maternal cardiometabolic health after delivery, resulting in hepatic dysfunction and a heightened risk of developing non-alcoholic fatty liver disease (NAFLD). Hence, this study aims to summarise existing literature on the impact of GDM on NAFLD in mothers and investigate the intergenerational impact on NAFLD in offspring.

Methods

Using 4 databases (PubMed, Embase, Web of Science and Scopus) between January 1980 and December 2023, randomized controlled trials and observational studies that assessed the effect of maternal GDM on intergenerational liver outcomes were extracted and analysed using random-effects meta-analysis to investigate the effect of GDM on NAFLD in mothers and offspring. Pooled odds ratio (OR) was calculated using hazards ratio (HR), relative risk (RR), or OR reported from each study, with corresponding 95% confidence intervals (CI), and statistical heterogeneity was assessed with the Cochran Q-test and I2 statistic, with two-sided p values. The study protocol was pre-registered on PROSPERO (CRD42023392428).

Findings

Twenty studies pertaining to mothers and offspring met the inclusion criteria and 12 papers were included further for meta-analysis on intergenerational NAFLD development. Compared with mothers without a history of GDM, mothers with a history of GDM had a 50% increased risk of developing NAFLD (OR 1.50; 95% CI: 1.21-1.87, over a follow-up period of 16 months-25 years. Similarly, compared with offspring born to non-GDM-complicated pregnancies, offspring born to GDM-complicated pregnancies displayed an approximately two-fold elevated risk of NAFLD development (2.14; 1.57-2.92), over a follow-up period of 1-17.8 years.

Interpretation

This systematic review and meta-analysis suggests that both mothers and offspring from GDM-complicated pregnancies exhibit a greater risk to develop NAFLD. These findings underline the importance of early monitoring of liver function and prompt intervention of NAFLD in both generations from GDM-complicated pregnancies.

Funding

No funding was available for this research.

The effectiveness of pharmacological and lifestyle interventions to reduce the risk of diabetes and hyperglycaemia following gestational diabetes: A systematic review and meta-analysis

AIMS

To synthesize the available evidence to better understand the effectiveness of interventions to prevent or delay hyperglycaemia and Type 2 diabetes mellitus (T2DM) postnatally in women with current or previous gestational diabetes mellitus (GDM).

METHODS

We searched five databases up to December 2020 for primary peer-reviewed articles reporting postpartum glycaemic outcomes in women with (previous) GDM following pharmacological or lifestyle intervention. Outcomes were relative risk of T2DM or continuous measures of glycaemia, change or at follow-up. A minimum of two studies evaluating the same intervention-outcome combination were needed to conduct meta-analyses, otherwise studies were described narratively. Meta-regression was used to evaluate whether associations varied by additional variables. We assessed risk of bias using the Critical Appraisal Skills Programme checklist. PROSPERO record CRD42018102380.

RESULTS

We included 31 studies in the review with a total sample size of 8624 participants, and 26 studies in meta-analyses. Two-thirds of studies followed up participants at 1 year or less. Pharmacological interventions were associated with reduced risk of T2DM (0.80 [95% CI 0.64-1.00], n = 6 studies), as were lifestyle interventions albeit with a smaller effect size (0.88 [95% CI 0.76-1.01], n = 12 studies). Dietary and physical activity interventions were associated with a small reduction in fasting plasma glucose, particularly in longer interventions, but inconsistent effects were seen for other continuous outcomes.

CONCLUSIONS

Although possibly due to chance, interventions to reduce hyperglycaemia after GDM may be effective. Future research should improve understanding of how interventions affect glucose control and how to optimise interventions for this population.

Predicting Progression from Gestational Diabetes to Impaired Glucose Tolerance Using Peridelivery Data: An Observational Study

OBJECTIVE

This article aimed to develop a predictive model to identify persons with recent gestational diabetes mellitus (GDM) most likely to progress to impaired glucose tolerance postpartum.

STUDY DESIGN

We conducted an observational study among persons with GDM in their most recent pregnancy, defined by Carpenter-Coustan criteria. Participants were followed up from delivery through 1-year postpartum. We used lasso regression with k-fold cross validation to develop a multivariable model to predict progression to impaired glucose tolerance, defined as HbA1c≥5.7%, at 1-year postpartum. Predictive ability was assessed by the area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV).

RESULTS

Of 203 participants, 71 (35%) had impaired glucose tolerance at 1-year postpartum. The final model had an AUC of 0.79 (95% confidence interval [CI]: 0.72, 0.85) and included eight indicators of weight, body mass index, family history of type 2 diabetes, GDM in a prior pregnancy, GDM diagnosis<24 weeks' gestation, and fasting and 2-hour plasma glucose at 2 days postpartum. A cutoff point of ≥ 0.25 predicted probability had sensitivity of 80% (95% CI: 69, 89), specificity of 58% (95% CI: 49, 67), PPV of 51% (95% CI: 41, 61), and NPV of 85% (95% CI: 76, 91) to identify women with impaired glucose tolerance at 1-year postpartum.

CONCLUSION

Our predictive model had reasonable ability to predict impaired glucose tolerance around delivery for persons with recent GDM.

KEY POINTS

· We developed a predictive model to identify persons with GDM most likely to develop IGT postpartum.. · The final model had an AUC of 0.79 (95% CI: 0.72, 0.85) and included eight clinical indicators.. · If validated, our model could help prioritize diabetes prevention efforts among persons with GDM..

Indications for the Postpartum Oral Glucose Tolerance Test

BACKGROUND

Gestational diabetes mellitus (GDM) affects more than 50 000 pregnant women in Germany every year. In postpartum diabetes screening, a 75 g oral glucose tolerance test (OGT) is recommended. This is time-consuming and can have side effects, and only 40% of mothers take it. The determination of pre-test probabilities might obviate the need for OGT except in women who are at particular risk.

METHODS

We analyzed 5444 cases of GDM from the GestDiab registry over the period 2015-2019. The pretest probabilities of a postpartum diagnosis of diabetes mellitus (DM) or prediabetes were calculated on the basis of clinical variables including postpartum venous fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c).

RESULTS

In 0.77% of mothers with a history of GDM in whom DM was not detected by FPG or HbA1c, postpartum DM was diagnosed on the basis of the 2-hour value in the OGT. Individual estimation of the pre-test probability of a diagnosis by OGT of postpartum DM or prediabetes was possible with the aid of the FPG and HbA1c values and clinical predictors including insulin treatment during pregnancy, obesity, GDM diagnosed before 24 weeks of gestation, age over 35, and a 1-hour value in the diagnostic OGT during pregnancy of 180 mg/dL (10.0 mmol/L) or above. The pretest probability of postpartum DM in the study group ranged from 0.11% to 4.17%, and that of postpartum prediabetes from 6.4% to 16.3%.

CONCLUSION

The probability of a diagnosis of postpartum diabetes by OGT after GDM can be estimated in postpartum screening on the basis of various parameters. This enables risk-adapted counseling of the affected women along with a long-term strategy for diabetes prevention and follow-up. The findings of our study should be verified by further research.

Prevalence of gestational diabetes mellitus in Germany: Temporal trend and differences by regional socioeconomic deprivation

Background

Gestational diabetes mellitus (GDM) increases the risk for adverse pregnancy outcomes. In 2012, a general screening for GDM was introduced in Germany.

Methods

The analysis is based on data from the external inpatient quality assurance for obstetrics from the years 2013 to 2021. Women with pregestational diabetes were excluded. GDM was defined either by documentation in the maternity record or by ICD diagnosis O24.4 during hospitalisation. We reported the prevalence stratified by year, maternal age and regional socioeconomic deprivation.

Results

The age-standardized prevalence of GDM continuously rose from 4.7 % in 2013 to 8.5 % in 2021. The increase was observed in all age groups. In 2021, this corresponded to 63,563 women with GDM. The prevalence was higher in highly deprived regions than in low deprived regions.

Conclusion

A steady increase in GDM prevalence and evidence of health inequalities emphasise the need for primary prevention strategies for GDM.

Maternal and neonatal outcomes according to the timing of diagnosis of hyperglycaemia in pregnancy: a nationwide cross-sectional study of 695,912 deliveries in France in 2018

AIMS/HYPOTHESIS

We aimed to assess maternal-fetal outcomes according to various subtypes of hyperglycaemia in pregnancy.

METHODS

We used data from the French National Health Data System (Système National des Données de Santé), which links individual data from the hospital discharge database and the French National Health Insurance information system. We included all deliveries after 22 gestational weeks (GW) in women without pre-existing diabetes recorded in 2018. Women with hyperglycaemia were classified as having overt diabetes in pregnancy or gestational diabetes mellitus (GDM), then categorised into three subgroups according to their gestational age at the time of GDM diagnosis: before 22 GW (GDM<22); between 22 and 30 GW (GDM22-30); and after 30 GW (GDM>30). Adjusted prevalence ratios (95% CI) for the outcomes were estimated after adjusting for maternal age, gestational age and socioeconomic status. Due to the multiple tests, we considered an association to be statistically significant according to the Holm-Bonferroni procedure. To take into account the potential immortal time bias, we performed analyses on deliveries at ≥31 GW and deliveries at ≥37 GW.

RESULTS

The study population of 695,912 women who gave birth in 2018 included 84,705 women (12.2%) with hyperglycaemia in pregnancy: overt diabetes in pregnancy, 0.4%; GDM<22, 36.8%; GDM22-30, 52.4%; and GDM>30, 10.4%. The following outcomes were statistically significant after Holm-Bonferroni adjustment for deliveries at ≥31 GW using GDM22-30 as the reference. Caesarean sections (1.54 [1.39, 1.72]), large-for-gestational-age (LGA) infants (2.00 [1.72, 2.32]), Erb's palsy or clavicle fracture (6.38 [2.42, 16.8]), preterm birth (1.84 [1.41, 2.40]) and neonatal hypoglycaemia (1.98 [1.39, 2.83]) were more frequent in women with overt diabetes. Similarly, LGA infants (1.10 [1.06, 1.14]) and Erb's palsy or clavicle fracture (1.55 [1.22, 1.99]) were more frequent in GDM<22. LGA infants (1.44 [1.37, 1.52]) were more frequent in GDM>30. Finally, women without hyperglycaemia in pregnancy were less likely to have preeclampsia or eclampsia (0.74 [0.69, 0.79]), Caesarean section (0.80 [0.79, 0.82]), pregnancy and postpartum haemorrhage (0.93 [0.89, 0.96]), LGA neonate (0.67 [0.65, 0.69]), premature neonate (0.80 [0.77, 0.83]) and neonate with neonatal hypoglycaemia (0.73 [0.66, 0.82]). Overall, the results were similar for deliveries at ≥37 GW. Although the estimation of the adjusted prevalence ratio of perinatal death was five times higher (5.06 [1.87, 13.7]) for women with overt diabetes, this result was non-significant after Holm-Bonferroni adjustment.

CONCLUSIONS/INTERPRETATION

Compared with GDM22-30, overt diabetes, GDM<22 and, to a lesser extent, GDM>30 were associated with poorer maternal-fetal outcomes.

Determination of the Contributing Factors and HbA1c Cutoff Leading to Glucose Tolerance Abnormalities Following Gestational Diabetes

The prevalence of gestational diabetes mellitus (GDM) has been steadily increasing over the past years. It is a major risk factor for glucose intolerance and type 2 DM (T2DM). The American Diabetes Association recommends that women whose pregnancy was complicated by GDM be screened for persistent glucose abnormalities at six to 12 weeks postpartum with either a fasting plasma glucose test alone or with a fasting 75-g, two-hour oral glucose tolerance test. This study aimed to identify the main predictive factors of glucose tolerance disorders in early postpartum women with a recent history of GDM. In this retrospective descriptive study, we identified 400 women who met the eligibility criteria for the study. The mean age was 34.54 ± 5.51 years. A total of 70% had a family history of DM, 16% had a personal history of GDM, and 23% had fetal macrosomia in previous pregnancies. The overall incidence of postpartum carbohydrate tolerance disorders was 36.4%, including 12% prediabetes and 24.4% DM. The prevalence of prediabetes and T2DM after delivery was higher with older maternal age, multigravidity, a higher BMI, a history of GDM, and fetal macrosomia in previous pregnancies. Furthermore, the persistence of this impaired glucose tolerance in postpartum was associated with a higher term of diagnosis, a higher glycated hemoglobin (HbA1c) percentage (the discriminant cutoff value with the best sensitivity/specificity ratio was 5.25%), the use of insulin therapy, cesarean section delivery, and fetal macrosomia. After adjusting for confounders, only prior GDM, a higher HbA1c level, macrosomia, and gestational term were found to significantly affect postpartum glucose tolerance. Although postpartum screening for T2DM is recommended for all women with GDM, a significant number of patients fail it. A better knowledge of predictive factors for this outcome is therefore needed for a more effective and targeted medical intervention.

Association between pregnancy-related complications and development of type 2 diabetes and hypertension in women: an umbrella review

BACKGROUND

Despite many systematic reviews and meta-analyses examining the associations of pregnancy complications with risk of type 2 diabetes mellitus (T2DM) and hypertension, previous umbrella reviews have only examined a single pregnancy complication. Here we have synthesised evidence from systematic reviews and meta-analyses on the associations of a wide range of pregnancy-related complications with risk of developing T2DM and hypertension.

METHODS

Medline, Embase and Cochrane Database of Systematic Reviews were searched from inception until 26 September 2022 for systematic reviews and meta-analysis examining the association between pregnancy complications and risk of T2DM and hypertension. Screening of articles, data extraction and quality appraisal (AMSTAR2) were conducted independently by two reviewers using Covidence software. Data were extracted for studies that examined the risk of T2DM and hypertension in pregnant women with the pregnancy complication compared to pregnant women without the pregnancy complication. Summary estimates of each review were presented using tables, forest plots and narrative synthesis and reported following Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines.

RESULTS

Ten systematic reviews were included. Two pregnancy complications were identified. Gestational diabetes mellitus (GDM): One review showed GDM was associated with a 10-fold higher risk of T2DM at least 1 year after pregnancy (relative risk (RR) 9.51 (95% confidence interval (CI) 7.14 to 12.67) and although the association differed by ethnicity (white: RR 16.28 (95% CI 15.01 to 17.66), non-white: RR 10.38 (95% CI 4.61 to 23.39), mixed: RR 8.31 (95% CI 5.44 to 12.69)), the between subgroups difference were not statistically significant at 5% significance level. Another review showed GDM was associated with higher mean blood pressure at least 3 months postpartum (mean difference in systolic blood pressure: 2.57 (95% CI 1.74 to 3.40) mmHg and mean difference in diastolic blood pressure: 1.89 (95% CI 1.32 to 2.46) mmHg). Hypertensive disorders of pregnancy (HDP): Three reviews showed women with a history of HDP were 3 to 6 times more likely to develop hypertension at least 6 weeks after pregnancy compared to women without HDP (meta-analysis with largest number of studies: odds ratio (OR) 4.33 (3.51 to 5.33)) and one review reported a higher rate of T2DM after HDP (hazard ratio (HR) 2.24 (1.95 to 2.58)) at least a year after pregnancy. One of the three reviews and five other reviews reported women with a history of preeclampsia were 3 to 7 times more likely to develop hypertension at least 6 weeks postpartum (meta-analysis with the largest number of studies: OR 3.90 (3.16 to 4.82) with one of these reviews reporting the association was greatest in women from Asia (Asia: OR 7.54 (95% CI 2.49 to 22.81), Europe: OR 2.19 (95% CI 0.30 to 16.02), North and South America: OR 3.32 (95% CI 1.26 to 8.74)).

CONCLUSIONS

GDM and HDP are associated with a greater risk of developing T2DM and hypertension. Common confounders adjusted for across the included studies in the reviews were maternal age, body mass index (BMI), socioeconomic status, smoking status, pre-pregnancy and current BMI, parity, family history of T2DM or cardiovascular disease, ethnicity, and time of delivery. Further research is needed to evaluate the value of embedding these pregnancy complications as part of assessment for future risk of T2DM and chronic hypertension.

To Explore the Putative Molecular Targets of Diabetic Nephropathy and their Inhibition Utilizing Potential Phytocompounds

BACKGROUND

This review critically addresses the putative molecular targets of Diabetic Nephropathy (DN) and screens effective phytocompounds that can be therapeutically beneficial, and highlights their mechanistic modalities of action.

INTRODUCTION

DN has become one of the most prevalent complications of clinical hyperglycemia, with individual-specific variations in the disease spectrum that leads to fatal consequences. Diverse etiologies involving oxidative and nitrosative stress, activation of polyol pathway, inflammasome formation, Extracellular Matrix (ECM) modifications, fibrosis, and change in dynamics of podocyte functional and mesangial cell proliferation adds up to the clinical complexity of DN. Current synthetic therapeutics lacks target-specific approach, and is associated with the development of inevitable residual toxicity and drug resistance. Phytocompounds provides a vast diversity of novel compounds that can become an alternative therapeutic approach to combat the DN.

METHODS

Relevant publications were searched and screened from research databases like GOOGLE SCHOLAR, PUBMED and SCISEARCH. Out of 4895 publications, the most relevant publications were selected and included in this article.

RESULT

This study critically reviews over 60 most promising phytochemical and provides with their molecular targets, that can be of pharmacological significance in context to current treatment and concomitant research in DN.

CONCLUSION

This review highlights those most promising phytocompounds that have the potential of becoming new safer naturally-sourced therapeutic candidates and demands further attention at clinical level.

A Simplified Screening Model to Predict the Risk of Gestational Diabetes Mellitus in Pregnant Chinese Women

INTRODUCTION

This study aimed to develop a simplified screening model to identify pregnant Chinese women at risk of gestational diabetes mellitus (GDM) in the first trimester.

METHODS

This prospective study included 1289 pregnant women in their first trimester (6-12 weeks of gestation) with clinical parameters and laboratory data. Logistic regression was performed to extract coefficients and select predictors. The performance of the prediction model was assessed in terms of discrimination and calibration. Internal validation was performed through bootstrapping (1000 random samples).

RESULTS

The prevalence of GDM in our study cohort was 21.1%. Maternal age, prepregnancy body mass index (BMI), a family history of diabetes, fasting blood glucose levels, the alanine transaminase to aspartate aminotransferase ratio (ALT/AST), and the triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) were selected for inclusion in the prediction model. The Hosmer-Lemeshow goodness-of-fit test showed good consistency between prediction and actual observation, and bootstrapping indicated good internal performance. The area under the receiver operating characteristic curve (ROC-AUC) of the multivariate logistic regression model and the simplified clinical screening model was 0.825 (95% confidence interval [CI] 0.797-0.853, P < 0.001) and 0.784 (95% CI 0.750-0.818, P < 0.001), respectively. The performance of our prediction model was superior to that of three other published models.

CONCLUSION

We developed a simplified clinical screening model for predicting the risk of GDM in pregnant Chinese women. The model provides a feasible and convenient protocol to identify women at high risk of GDM in early pregnancy. Further validations are needed to evaluate the performance of the model in other populations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03246295.

Advanced maternal age (AMA) and 75 g oGTT glucose levels are pedictors for insulin therapy in women with gestational diabetes (GDM)

OBJECTIVES

Gestational diabetes (GDM) is a common complication during pregnancy that is strongly associated with adverse fetal and maternal outcomes. Advanced maternal age (≥35 years) is a known risk factor for GDM. Studies advocate that GDM comprises distinctive metabolic entities, suggesting an individualized approach based on early pregnancy characteristics (such as 75 g oGTT values, maternal age, obstetric history).

METHODS

The oGTT blood glucose levels of 1,664 women were categorized into isolated fasting hyperglycemia (GDM-IFH), isolated postprandial hyperglycemia (GDM-IPH) and combined hyperglycemia (GDM-CH), using the levels of the fasting, 1 h and 2 h values after glucose application. These three subtypes were analysed regarding baseline characteristics as well as fetal and maternal outcome in the context of maternal age.

RESULTS

This analysis reveals that the 75 g oGTT levels and maternal age can distinguish metabolic phenotypes in women with GDM. The overall rate of insulin therapy required was higher in women from the GDM-CH group and increased with maternal age (31.7 %, 38.2 %, <35 years, ≥35-39 years respectively, vs. total insulin rate 22.3 %, p-value <0.001). Women ≥35 years displayed a significantly higher caesarean delivery (CD) rate (<35 years 34.6 %, 38.4 %, 41.1 % vs. ≥35 years 54.8 %, 47.6 %, 46.5 %, GDM-IFH, GDM-IPH, GDM-CH respectively, p-value <0.001).

CONCLUSIONS

Women with fasting hyperglycemia, especially those with combined hyperglycemia and advanced maternal age (AMA) display a higher risk for unfavorable perinatal outcome. A categorization based on oGTT values and maternal age, as well as other characteristics can facilitate a basis for clinical risk stratification. Women at risk should receive an individualized and intensified perinatal care as well as interventional therapies.

Epigenetic implications in maternal diabetes and metabolic syndrome-associated risk of orofacial clefts

Orofacial clefts (OFCs) are one of the most common types of structural birth defects. The etiologies are complicated, involving with genetic, epigenetic, and environmental factors. Studies have found that maternal diabetes and metabolic syndrome are associated with a higher risk of OFCs in offspring. Metabolic syndrome is a clustering of several disease risk factors, including hyperglycemia, dyslipidemia, obesity, and hypertension. Metabolic disease during pregnancy can increase risk of adverse outcomes and significantly influence fetal development, including orofacial formation and fusion. An altered metabolic state may contribute to developmental disorders or congenital defects including OFCs, potentially through epigenetic modulations, such as histone modification, DNA methylation, and noncoding RNA expression to alter activities of critical morphogenetic signaling or related developmental genes. This review summarizes the currently available evidence and underlying mechanisms of how the maternal metabolic syndrome is associated with OFCs in mostly human and some animal studies. It may provide a better understanding of the interactions between intrauterine metabolic status and fetal orofacial development which might be applied toward prevention and treatments of OFCs.

Continuous glucose monitoring in individuals undergoing gestational diabetes screening

BACKGROUND

Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus.

OBJECTIVE

This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening.

STUDY DESIGN

This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes.

RESULTS

Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups.

CONCLUSION

In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).

Racial and Ethnic Inequities in Development of Type 2 Diabetes After Gestational Diabetes Mellitus

OBJECTIVE

To estimate racial and ethnic disparities in type 2 diabetes mellitus after gestational diabetes mellitus (GDM) and to investigate baseline pregnancy clinical and social or structural characteristics as mediators.

METHODS

We conducted a retrospective cohort of individuals with GDM using linked 2009-2011 New York City birth and hospital data and 2009-2017 New York City A1c Registry data. We ascertained GDM and pregnancy characteristics from birth and hospital records. We classified type 2 diabetes as two hemoglobin A 1c test results of 6.5% or higher. We grouped pregnancy characteristics into clinical (body mass index [BMI], chronic hypertension, gestational hypertension, preeclampsia, preterm delivery, caesarean, breastfeeding, macrosomia, shoulder dystocia) and social or structural (education, Medicaid insurance, prenatal care, and WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] participation). We used Cox proportional hazards models to estimate associations between race and ethnicity and 8-year type 2 diabetes incidence, and we tested mediation of pregnancy characteristics, additionally adjusting for age and nativity (U.S.-born vs foreign-born).

RESULTS

The analytic data set included 22,338 patients with GDM. The 8-year type 2 diabetes incidence was 11.7% overall and 18.5% in Black, 16.8% in South and Southeast Asian, 14.6% in Hispanic, 5.5% in East and Central Asian, and 5.4% in White individuals with adjusted hazard ratios of 4.0 (95% CI 2.4-3.9), 2.9 (95% CI 2.4-3.3), 3.3 (95% CI 2.7-4.2), and 1.0 (95% CI 0.9-1.4) for each group compared with White individuals. Clinical and social or structural pregnancy characteristics explained 9.3% and 23.8% of Black, 31.2% and 24.7% of Hispanic, and 7.6% and 16.3% of South and Southeast Asian compared with White disparities. Associations between education, Medicaid insurance, WIC participation, and BMI and type 2 diabetes incidence were more pronounced among White than Black, Hispanic, and South and Southeast Asian individuals.

CONCLUSION

Population-based racial and ethnic inequities are substantial in type 2 diabetes after GDM. Characteristics at the time of delivery partially explain disparities, creating an opportunity to intervene on life-course cardiometabolic inequities, whereas weak associations of common social or structural measures and BMI in Black, Hispanic and South and Southeast Asian individuals demonstrate the need for greater understanding of how structural racism influences postpartum cardiometabolic risk in these groups.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A holistic approach to preventing type 2 diabetes in Asian women with a history of gestational diabetes mellitus: a feasibility study and pilot randomized controlled trial

Background

Gestational Diabetes Mellitus (GDM) exposes women to future risk of Type 2 Diabetes. Previous studies focused on diet and physical activity, less emphasis was given to tackle intertwined risk factors such as sleep and stress. Knowledge remains scarce in multi-ethnic Asian communities. This study explored the: (1) feasibility of a holistic digital intervention on improving diet, physical activity (PA), sleep and stress of Asian women with a history of GDM, and (2) preliminary efficacy of the holistic intervention on women's physical and mental well-being via a pilot randomized controlled trial.

Methods

Female volunteers with a history of GDM but without pre-existing diabetes were recruited from multi-ethnic Singaporean community. Each eligible woman was given a self-monitoring opportunity using Oura Ring that provided daily feedback on step counts, PA, sleep and bedtime heart rate. Intervention group additionally received personalized recommendations aimed to reinforce healthy behaviors holistically (diet, PA, sleep and stress). Dietary intake was evaluated by a research dietitian, while step counts, PA, sleep and bedtime heart rate were evaluated by health coaches based on Oura Ring data. Perceived physical and mental health and well-being were self-reported. Clinical outcomes included glycemic status determined by HbA1c and OGTT tests, body mass index, blood pressures and lipid profile.

Results

Of 196 women from the community, 72 women completed diabetes screening, 61 women were eligible and 56 women completed the study. The 56 completers had mean age of 35.8 ± 3.7 years, predominantly Chinese, majority had their first GDM diagnosed at least 2 years ago and had two GDM-affected pregnancies. After intervention period, more women in the Intervention group achieved at least 8,000 steps/day and had at least 6 hours of sleep per night. Noticeable reduction of added sugar in their food and beverages were observed after the dietary intervention. Changes in body weight and mental well-being were observed but group differences were not statistically significant.

Conclusions

The holistic approach appeared feasible for personalizing lifestyle recommendations to promote physical and mental well-being among women with a history of GDM. Larger studies with sufficient assessment timepoints and follow-up duration are warranted to improve the evaluation of intervention effects on clinical outcomes.

Clinical trial registration number

https://clinicaltrials.gov/show/NCT05512871, NCT05512871.

Influence of Gestational Diabetes Mellitus on Diabetes Risk and Glycemic Control in a Retrospective Population-Based Cohort

OBJECTIVE

Racial/ethnic-specific estimates of the influence of gestational diabetes mellitus (GDM) on type 2 diabetes remain underexplored in large population-based cohorts. We estimated racial/ethnic differences in the influence of GDM on diabetes risk and glycemic control in a multiethnic, population-based cohort of postpartum women.

RESEARCH DESIGN AND METHODS

Hospital discharge and vital registry data for New York City (NYC) births between 2009 and 2011 were linked with NYC A1C Registry data between 2009 and 2017. Women with baseline diabetes (n = 2,810) were excluded for a final birth cohort of 336,276. GDM on time to diabetes onset (two A1C tests of ≥6.5% from 12 weeks postpartum onward) or glucose control (first test of A1C <7.0% following diagnosis) was assessed using Cox regression with a time-varying exposure. Models were adjusted for sociodemographic and clinical factors and stratified by race/ethnicity.

RESULTS

The cumulative incidence for diabetes was 11.8% and 0.6% among women with and without GDM, respectively. The adjusted hazard ratio (aHR) of GDM status on diabetes risk was 11.5 (95% CI 10.8, 12.3) overall, with slight differences by race/ethnicity. GDM was associated with a lower likelihood of glycemic control (aHR 0.85; 95% CI 0.79, 0.92), with the largest negative influence among Black (aHR 0.77; 95% CI 0.68, 0.88) and Hispanic (aHR 0.84; 95% CI 0.74, 0.95) women. Adjustment for screening bias and loss to follow-up modestly attenuated racial/ethnic differences in diabetes risk but had little influence on glycemic control.

CONCLUSIONS

Understanding racial/ethnic differences in the influence of GDM on diabetes progression is critical to disrupt life course cardiometabolic disparities.

The joint effect of gestational diabetes mellitus and hypertension contribute to higher risk of diabetes mellitus after delivery: a nationwide population-based study

BACKGROUND

Gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH) are known risk factors for postpartum diabetes mellitus (DM) and hypertension, respectively. This study aimed to examine the association between the co-occurrence of GDM and PIH and the subsequent development of diabetes mellitus (DM), hypertension, and metabolic syndrome.

METHODS

A cohort study was conducted using data from the Taiwan National Health Insurance Research Database (TNHIRD). The study population included 2,297,613 pregnant women with no history of certain medical conditions who gave birth between 2004 and 2015. The women were classified into four cohorts based on their medical history: GDM cohort, PIH cohort, both GDM and PIH cohort, and normal cohort (without GDM and PIH).

RESULTS

The GDM cohort had a higher risk of developing DM, hypertension, and metabolic syndrome than the normal cohort, with hazard ratios of 7.07, 1.54, and 2.51, respectively. The PIH cohort also had an increased risk for these conditions compared with the normal cohort, with hazard ratios of 3.41, 7.26, and 2.68, respectively. The cohort with both GDM and PIH had the highest risk of developing postpartum DM, hypertension, and metabolic syndrome, with hazard ratios of 21.47, 8.02, and 5.04, respectively, compared with the normal cohort.

CONCLUSION

The cohort of patients with both GDM and PIH had the highest impact on developing postpartum DM compared with either condition alone cohort. Furthermore, the co-occurrence of both conditions increases the risk, with a higher likelihood of developing postpartum DM than hypertension or metabolic syndrome.

Diabetes detection in women with gestational diabetes and polycystic ovarian syndrome

Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) represent two of the highest risk factors for development of type 2 diabetes mellitus in young women. As these increasingly common conditions generally affect younger women, early detection of dysglycemia is key if preventative measures are to be effective. While international guidance recommends screening for type 2 diabetes, current screening strategies suffer from significant challenges.First, guidance lacks consensus in defining which tests to use and frequency of monitoring, thereby sending mixed messages to healthcare professionals.Second, conformity to guidance is poor, with only a minority of women having tests at the recommended frequency (where specified). Approaches to improve conformity have focused on healthcare related factors (largely technology driven reminder systems), but patient factors such as convenience and clear messaging around risk have been neglected.Third, and most critically, current screening strategies are too generic and rely on tests that become abnormal far too late in the trajectory towards dysglycemia to offer opportunities for effective preventative measures. Risk factors show wide interindividual variation, and insulin sensitivity and β cell function are often abnormal during pre-diabetes stage, well before frank diabetes.New, consistent, targeted screening strategies are required that incorporate early, prevention focused testing and personalised risk stratification.

Long-term Outcomes Associated With Post-kidney Donation Pregnancy Complications

BACKGROUND

Kidney donors have increased risk of postdonation gestational hypertension (gHTN) and preeclampsia. In the general population, pregnancy complications are associated with long-term maternal risk. However, little data exist on whether donors with postdonation pregnancy-related complications have similar increased long-term risks. We studied whether postdonation gHTN, preeclampsia/eclampsia, or gestational diabetes (gDM) was associated with increased risk of developing hypertension, DM, cardiovascular disease, or estimated glomerular filtration rate <45 mL/min/1.73 m 2 .

METHODS

Postdonation pregnancies with complications were matched to pregnancies without complications based on time from donation. Incidence of outcomes was compared using sequential Cox regression with robust standard errors. Donors with predonation pregnancy complications were excluded. Models were adjusted for age at pregnancy, gravidity, year of donation, and family history of hypertension, DM, and heart disease.

RESULTS

Of the 384 donors with postdonation pregnancies (median [quartiles] follow-up of 27.0 [14.2-36.2] y after donation), 39 experienced preeclampsia/eclampsia, 29 gHTN without preeclampsia, and 17 gDM. Median interval from donation to first pregnancy with preeclampsia was 5.1 (2.9-8.6) y; for gHTN, 3.7 (1.9-7.8) y; and for gDM, 7.3 (3.7-10.3) y. Preeclampsia/eclampsia (hazard ratio [HR] 2.70; 95% confidence interval [CI], 1.53-4.77) and gHTN (HR 2.39; 95% CI, 1.24-4.60) were associated with development of hypertension. Preeclampsia/eclampsia (HR 2.15; 95% CI, 1.11-4.16) and gDM (HR 5.60; 95% CI, 1.41-22.15) were associated with development of DM. Pregnancy-related complications were not associated with increased risk of cardiovascular disease or estimated glomerular filtration rate <45 mL/min/1.73 m 2 .

CONCLUSIONS

In our single-center study, postdonation preeclampsia, gHTN, or gDM was associated with long-term risk of hypertension or DM.

Preventing Adverse Cardiovascular Outcomes in Pregnancy Complicated by Obesity

Purpose of review

Obesity is a chronic disease that is becoming increasingly prevalent, and more individuals of reproductive age have obesity prior to becoming pregnant. Obesity in pregnancy is associated with short- and long-term adverse consequences for both the birthing person and their offspring which have been associated with increased long-term cardiovascular morbidity and mortality. The goal of this review is to discuss what is currently understood about the relationship between maternal obesity and adverse pregnancy outcomes (APOs), the association between APOs and future cardiovascular disease (CVD) risk, and what evidence-based interventions can be implemented to prevent adverse outcomes in this population.

Recent findings

Maternal obesity has been associated with an increased risk of APOs such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth as well as an increased risk of future CVD, such as metabolic syndrome, chronic hypertension, coronary heart disease, and stroke. The impact of maternal obesity also extends beyond the pregnant individual to the offspring, increasing the risk of fetal, neonatal, and infant mortality, as well as of congenital malformations, prematurity, and long-term health problems such as insulin resistance and childhood obesity. Prevention guidelines are incorporating the increased risk of adverse outcomes from maternal obesity into formalized risk assessments to guide both prenatal and postpartum care. It is becoming evident that a multidisciplinary cardio-obstetrics team is an important part of providing comprehensive care for pregnant individuals with obesity and other cardiovascular risk factors, including preexisting CVD and a history of prior APOs. There remains a need for further studies to better understand the mechanisms underlying the relationship between maternal obesity and APOs, as well as the racial and ethnic disparities that have been noted in the prevalence of APOs and associated CVD risk and mortality.

Summary

There is increasing awareness that obesity in pregnancy is associated with various short- and long-term adverse maternal and offspring outcomes. There are multiple screening and prevention strategies that may be implemented before, during, and after pregnancy to prevent these adverse outcomes.

Low Serum Creatinine Levels in Early Pregnancy Are Associated with a Higher Incidence of Postpartum Abnormal Glucose Metabolism among Women with Gestational Diabetes Mellitus: A Retrospective Cohort Study

The predictive factors for the progression from gestational diabetes mellitus (GDM) to type 2 diabetes remain incompletely elucidated. Our objective was to investigate the link between serum creatinine, a proxy for skeletal muscle mass, and the development of postpartum abnormal glucose metabolism (AGM).

METHODS

A retrospective review of the medical records of 501 women with GDM was conducted, all of whom underwent a 75 g oral glucose tolerance test (OGTT) between 4 and 12 weeks postpartum. Women were grouped based on quartiles of serum creatinine at the first antenatal visit to estimate the association between serum creatinine and postpartum AGM incidence.

RESULTS

Compared with the highest quartile of creatinine, lower quartiles were substantially linked to an increased incidence of postpartum AGM (adjusted odds ratios 3.37 [95% CI 1.77-6.42], 2.42 [95% CI 1.29-4.51] and 2.27 [95% CI 1.23-4.18], respectively). The generalized additive model suggested a linear relationship between serum creatinine levels and the risk of postpartum AGM below 68 µmol/L of serum creatinine levels. A decrease of 2 μmol/L in serum creatinine levels was found to be associated with a 10% increase in the odds of developing postpartum AGM. Linear regression revealed that a low serum creatinine level was linked to a higher postpartum 2-h glucose level and a decreased insulinogenic index (p = 0.007 and p = 0.027, respectively).

CONCLUSIONS

An association was observed between lower serum creatinine levels in early pregnancy and an increased risk of postpartum AGM and poorer β-cell function in women with a recent history of GDM. Further research is needed to understand the mechanisms underlying our findings, as well as the role of skeletal muscle mass or nutritional status in early pregnancy on later glucose metabolism.

Thyroid dysfunction during gestation and gestational diabetes mellitus: a complex relationship

PURPOSE

Gestational diabetes mellitus (GDM) and thyroid dysfunction during gestation (GTD) are the two most prevalent endocrinopathies during pregnancy. The aim of the present review is to provide an overview of the peculiar aspects of GDM and GTD, to highlight the potential interactions and clinical consequences of these two frequent clinical conditions.

METHODS

A literature review regarding GDM and GTD was carried out with particular interest on meta-analyses and human studies dealing with the (i) shared risk factors between GDM and GTD, (ii) the epidemiological link between GTD and GDM, (iii) physiopathologic link between GTD and GDM, (iv) clinical consequences of GDM and GTD, and (v) post-partum implications of GDM and GTD.

RESULTS

The association between GDM and GTD is common and may be explained by the insulin-resistance state due to maternal GTD, to alterations in the placentation process or to the many shared risk factors. Discrepant results of epidemiologic studies can be explained, at least in part, by the changes in diagnostic criteria and screening strategies throughout the years for both conditions. GDM and GTD impact pregnancy outcome and have post-partum long-term consequences, but more studies are needed to prove an additional adverse effect.

CONCLUSIONS

Based on the epidemiological and physio-pathological link between GDM and GTD, it could be suggested that a diagnosis of GTD could lead to screen GDM and the other way round.

The Association of Specific Dietary Patterns with Cardiometabolic Outcomes in Women with a History of Gestational Diabetes Mellitus: A Scoping Review

Gestational diabetes mellitus is associated with a significantly increased risk of later type 2 diabetes (T2DM) and cardiovascular disease (CVD). Post-natal interventions aim to reduce this risk by addressing diet and lifestyle factors and frequently focus on restricting energy or macronutrient intake. With increased interest in the role of complete dietary patterns in the prevention of cardiometabolic disease, we sought to evaluate what is known about the role of dietary patterns in reducing cardiometabolic risk in women with previous GDM. A systematic search was conducted to identify studies relating to dietary pattern and cardiometabolic parameters in women with a history of GDM. The search criteria returned 6014 individual studies. In total, 71 full texts were reviewed, with 24 studies included in the final review. Eleven individual dietary patterns were identified, with the Alternative Health Eating Index (AHEI), Mediterranean diet (MD), and low glycaemic index (GI) as the most commonly featured dietary patterns. Relevant reported outcomes included incident T2DM and glucose tolerance parameters, as well as several cardiovascular risk factors. Dietary patterns which have previously been extensively demonstrated to reduce the risk of cardiovascular and metabolic disorders in the general population, including AHEI, MD, and DASH, were found to be associated with a reduction in the incidence of T2DM, hypertension, and additional risk factors for cardiometabolic disease in women with a history of GDM. Notable gaps in the literature were identified, including the relationship between dietary patterns and incident CVD, as well as the relationship between a low GI diet and the development of T2DM in this population.

Pregnancy as an opportunity to prevent type 2 diabetes mellitus: FIGO Best Practice Advice

Gestational diabetes (GDM) impacts approximately 17 million pregnancies worldwide. Women with a history of GDM have an 8-10-fold higher risk of developing type 2 diabetes and a 2-fold higher risk of developing cardiovascular disease (CVD) compared with women without prior GDM. Although it is possible to prevent and/or delay progression of GDM to type 2 diabetes, this is not widely undertaken. Considering the increasing global rates of type 2 diabetes and CVD in women, it is essential to utilize pregnancy as an opportunity to identify women at risk and initiate preventive intervention. This article reviews existing clinical guidelines for postpartum identification and management of women with previous GDM and identifies key recommendations for the prevention and/or delayed progression to type 2 diabetes for global clinical practice.

Predictability of HOMA-IR for Gestational Diabetes Mellitus in Early Pregnancy Based on Different First Trimester BMI Values

Objective: To investigate the ability of homeostasis model assessment of insulin resistance (HOMA-IR) in early pregnancy for predicting gestational diabetes mellitus (GDM) in Chinese women with different first-trimester body mass index (FT-BMI) values. Methods: Baseline characteristics and laboratory tests were collected at the first prenatal visit (6−12 weeks of gestation). GDM was diagnosed by a 75 g oral glucose tolerance test (OGTT) at 24−28 weeks of gestation. Partial correlation analysis and binary logistic regression were applied to identify the association between HOMA-IR and GDM. The cutoff points for predicting GDM were estimated using receiver operating characteristic (ROC) curve analysis. Results: Of the total of 1343 women, 300 (22.34%) were diagnosed with GDM in the 24−28 weeks of gestation. Partial correlation analysis and binary logistic regression verified HOMA-IR as a significant risk factor for GDM in the normal weight subgroup (FT-BMI < 24 kg/m2) (adjusted OR 2.941 [95% CI 2.153, 4.016], P < 0.001), overweight subgroup (24.0 kg/m2 ≤ FT-BMI < 28.0 kg/m2) (adjusted OR 3.188 [95% CI 2.011, 5.055], P < 0.001), and obese subgroup (FT-BMI ≥ 28.0 kg/m2) (adjusted OR 9.415 [95% CI 1.712, 51.770], p = 0.01). The cutoff values of HOMA-IR were 1.52 (area under the curve (AUC) 0.733, 95% CI 0.701−0.765, p < 0.001) for all participants, 1.43 (AUC 0.691, 95% CI 0.651−0.730, p < 0.001) for normal weight women, 2.27 (AUC 0.760, 95% CI 0.703−0.818, p < 0.001) for overweight women, and 2.31 (AUC 0.801, 95% CI 0.696−0.907, p < 0.001) for obese women. Conclusions: Increased HOMA-IR in early pregnancy is a risk factor for GDM, and HOMA-IR can be affected by body weight. The cutoff value of HOMA-IR to predict GDM should be distinguished by different FT-BMI values.

A global view of hypertensive disorders and diabetes mellitus during pregnancy

Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis.

Influence of Maternal Diabetes on the Risk of Neurodevelopmental Disorders in Offspring in the Prenatal and Postnatal Periods

BACKGROUND

This study aimed to evaluate the influence of maternal diabetes in the risk of neurodevelopmental disorders in offspring in the prenatal and postnatal periods.

METHODS

This cohort study included singleton gestational diabetes mellitus (GDM) pregnancies >22 weeks' gestation with live newborns between 1991 and 2008. The control group was randomly selected and matched (1:2) for maternal age, weeks of gestation and birth year. Cox regression models estimated the effect of GDM on the risk of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and maternal type 2 diabetes mellitus (T2DM). Moreover, interaction between maternal T2DM and GDM-ADHD relationship was evaluated.

RESULTS

Children (n=3,123) were included (1,073 GDM; 2,050 control group). The median follow-up was 18.2 years (interquartile range, 14.2 to 22.3) (n=323 with ADHD, n=36 with ASD, and n=275 from women who developed T2DM). GDM exposure was associated with ADHD (hazard ratio [HR]crude, 1.67; 95% confidence interval [CI], 1.33 to 2.07) (HRadjusted, 1.64; 95% CI, 1.31 to 2.05). This association remained significant regardless of the treatment (diet or insulin) and diagnosis after 26 weeks of gestation. Children of mothers who developed T2DM presented higher rates of ADHD (14.2 vs. 10%, P=0.029). However, no interaction was found when T2DM was included in the GDM and ADHD models (P>0.05). GDM was not associated with an increased risk of ASD (HRadjusted, 1.46; 95% CI, 0.74 to 2.84).

CONCLUSION

Prenatal exposure to GDM increases the risk of ADHD in offspring, regardless of GDM treatment complexity. However, postnatal exposure to maternal T2DM was not related to the development of ADHD.

Barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior gestational diabetes: A systematic review and qualitative synthesis applying the theoretical domains framework

AIMS

Racial and ethnic disparities exist in gestational diabetes prevalence and risk of subsequent type 2 diabetes mellitus (T2DM). Postpartum engagement in healthy behaviours is recommended for prevention and early detection of T2DM, yet uptake is low among women from diverse cultural backgrounds. Greater understanding of factors impacting postpartum health behaviours is needed. Applying the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation-Behaviour (COM-B) model, our aim was to synthesise barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior GDM and identify relevant intervention components.

METHODS

Databases, reference lists and grey literature were searched from September 2017 to April 2021. Two reviewers screened articles independently against inclusion criteria and extracted data. Using an inductive-deductive model, themes were mapped to the TDF and COM-B model.

RESULTS

After screening 5148 citations and 139 full texts, we included 35 studies (N = 787 participants). The main ethnicities included Asian (43%), Indigenous (15%) and African (11%). Barriers and enablers focused on Capability (e.g. knowledge), Opportunity (e.g. competing demands, social support from family, friends and healthcare professionals, culturally appropriate education and resources) and Motivation (e.g. negative emotions, perceived consequences and necessity of health behaviours, social/cultural identity). Five relevant intervention functions are identified to link the barriers and enablers to evidence-based recommendations for communications to support behaviour change.

CONCLUSIONS

We provide a conceptual model to inform recommendations regarding the development of messaging and interventions to support women from diverse cultural backgrounds in engaging in healthy behaviours to reduce risk of T2DM.

Pre-kidney Donation Pregnancy Complications and Long-term Outcomes

BACKGROUND

Hypertension and diabetes are contraindications for living kidney donation in young candidates. However, little is known about the long-term outcomes of women who had these pregnancy-related complications and subsequently became donors. In the general population, gestational hypertension (GHtn), preeclampsia/eclampsia, and gestational diabetes (GDM) are associated with long-term risks.

METHODS

Donors with the specified predonation complication were matched to contemporary control donors with pregnancies without the complication using nearest neighbor propensity score matching. Propensity scores were estimated using logistic regression with covariates for gravidity, blood pressure, glucose, body mass index, age, and creatinine at donation, donation year, race, relationship with recipient, and family history of disease. Long-term incidence of hypertension, diabetes, cardiovascular disease, and reduced renal function (estimated glomerular filtration rate [eGFR] <30, eGFR <45 mL/min/1.73 m 2 ) were compared between groups using proportional hazards models.

RESULTS

Of 1862 donors with predonation pregnancies, 48 had preeclampsia/eclampsia, 49 had GHtn without preeclampsia, and 43 had GDM. Donors had a long interval between first pregnancy and donation (median, 18.5 y; interquartile range, 10.6-27.5) and a long postdonation follow-up time (median, 18.0; interquartile range, 9.2-27.7 y). GHtn was associated with the development of hypertension (hazard ratio, 1.89; 95% confidence interval, 1.26-2.83); GDM was associated with diabetes (hazard ratio, 3.04; 95% confidence interval, 1.33-6.99). Pregnancy complications were not associated with eGFR <30 or eGFR <45 mL/min/1.73 m 2 .

CONCLUSIONS

Our data suggest that women with predonation pregnancy-related complications have long-term risks even with a normal donor evaluation. Donor candidates with a history of pregnancy-related complications should be counseled about these risks.

Regulation of Placental Efflux Transporters during Pregnancy Complications

The placenta is essential for regulating the exchange of solutes between the maternal and fetal circulations. As a result, the placenta offers support and protection to the developing fetus by delivering crucial nutrients and removing waste and xenobiotics. ATP-binding cassette transporters, including multidrug resistance protein 1, multidrug resistance-associated proteins, and breast cancer resistance protein, remove chemicals through active efflux and are considered the primary transporters within the placental barrier. Altered transporter expression at the barrier could result in fetal exposure to chemicals and/or accumulation of xenobiotics within trophoblasts. Emerging data demonstrate that expression of these transporters is changed in women with pregnancy complications, suggesting potentially compromised integrity of placental barrier function. The purpose of this review is to summarize the regulation of placental efflux transporters during medical complications of pregnancy, including 1) placental inflammation/infection and chorioamnionitis, 2) hypertensive disorders of pregnancy, 3) metabolic disorders including gestational diabetes and obesity, and 4) fetal growth restriction/altered fetal size for gestational age. For each disorder, we review the basic pathophysiology and consider impacts on the expression and function of placental efflux transporters. Mechanisms of transporter dysregulation and implications for fetal drug and toxicant exposure are discussed. Understanding how transporters are up- or downregulated during pathology is important in assessing possible exposures of the fetus to potentially harmful chemicals in the environment as well as the disposition of novel therapeutics intended to treat placental and fetal diseases. SIGNIFICANCE STATEMENT: Diseases of pregnancy are associated with reduced expression of placental barrier transporters that may impact fetal pharmacotherapy and exposure to dietary and environmental toxicants.

Screening Accuracy of the 50 g-Glucose Challenge Test in Twin Compared With Singleton Pregnancies

CONTEXT

The optimal 50 g-glucose challenge test (GCT) cutoff for the diagnosis of gestational diabetes mellitus (GDM) in twin pregnancies is unknown.

OBJECTIVE

This work aimed to explore the screening accuracy of the 50 g-GCT and its correlation with the risk of large for gestational age (LGA) newborn in twin compared to singleton pregnancies. A population-based retrospective cohort study (2007-2017) was conducted in Ontario, Canada. Participants included patients with a singleton (n = 546 892 [98.4%]) or twin (n = 8832 [1.6%]) birth who underwent screening for GDM using the 50 g-GCT.

METHODS

We compared the screening accuracy, risk of GDM, and risk of LGA between twin and singleton pregnancies using various 50 g-GCT cutoffs.

RESULTS

For any given 50 g-GCT result, the probability of GDM was higher (P = .0.007), whereas the probability of LGA was considerably lower in the twin compared with the singleton group, even when a twin-specific growth chart was used to diagnose LGA in the twin group (P < .001). The estimated false-positive rate (FPR) for GDM was higher in twin compared with singleton pregnancies irrespective of the 50 g-GCT cutoff used. The cutoff of 8.2 mmol/L (148 mg/dL) in twin pregnancies was associated with an estimated FPR (10.7%-11.1%) that was similar to the FPR associated with the cutoff of 7.8 mmol/L (140 mg/dL) in singleton pregnancies (10.8%).

CONCLUSION

The screening performance of the 50 g-GCT for GDM and its correlation with LGA differ between twin and singleton pregnancies.

High prevalence and significant ethnic differences in actionable HbA1C after gestational diabetes mellitus in women living in Norway

BACKGROUND

The type 2 diabetes risk after gestational diabetes mellitus (GDM) is twice as high in South Asian compared to European women. Current guidelines differ regarding which test to use as a screening-tool post-GDM. We aimed to identify ethnic differences in the prevalence rates and early predictors for actionable HbA_1c (defined as prediabetes and diabetes) short time after GDM.

METHODS

This cross-sectional study, enrolling South Asian and Nordic women 1-3 years after a diagnosis of GDM, was undertaken at three hospitals in Norway. We performed a clinical and laboratory evaluation including an oral glucose tolerance test (OGTT). Medical records were used to retrieve data during pregnancy. Prediabetes was classified with HbA_1c alone or combined with OGTT glucose measurements according to the WHO, WHO-IEC, and ADA criteria (fasting plasma glucose (FPG) 6.1-6.9 mmol/L, FPG 6.1-6.9 mmol/L and/or HbA_1c 42-47 mmol/mol (6.0-6.4%), and FPG 5.6-6.9 mmol/L and/or HbA_1c 39-47 mmol/mol (5.7-6.4%)). Ethnic differences in prevalence and predictors of glucose deterioration were assed by χ² (Pearson) tests and logistic regression models.

RESULTS

We included 163 South Asian and 108 Nordic women. Actionable HbA_1c levels were highly prevalent and more so among South Asian than Nordic women (WHO-IEC-HbA_1c: 25.8% vs. 6.5% (p ≤ 0.001), ADA-HbA_1c: 58.3% vs. 22.2% (p ≤ 0.001)). Although adding OGTT-data gave higher combined prevalence rates of prediabetes and diabetes (WHO: 65.6% vs. 47.2% (p ≤ 0.05), WHO-IEC: 70.6% vs. 47.2% (p ≤ 0.001), ADA: 87.8% vs. 65.7% (p ≤ 0.001)), the excess risk in the South Asian women was best captured by the HbA_1c. Important predictors for glucose deterioration after GDM were: South Asian ethnicity, GDM before the index pregnancy, use of glucose-lowering drugs in pregnancy, higher age, and higher in-pregnancy fasting glucose levels.

CONCLUSIONS

In women with GDM 1-3 year previously, we found high prevalence and significant ethnic differences in actionable ADA-HbA_1c levels, with South Asian ethnicity, GDM before the index pregnancy, and the use of glucose-lowering drugs in pregnancy as the most important risk factors. This study reinforces the importance of annual screening-preferably with HbA_1c measurements-to facilitate early intervention after GDM.

The Roles of Probiotics in the Gut Microbiota Composition and Metabolic Outcomes in Asymptomatic Post-Gestational Diabetes Women: A Randomized Controlled Trial

Probiotics are widely used as an adjuvant therapy in various diseases. Nonetheless, it is uncertain how they affect the gut microbiota composition and metabolic and inflammatory outcomes in women who have recently experienced gestational diabetes mellitus (post-GDM). A randomized, double-blind, placebo-controlled clinical trial involving 132 asymptomatic post-GDM women was conducted to close this gap (Clinical Trial Registration: NCT05273073). The intervention (probiotics) group received a cocktail of six probiotic strains from Bifidobacterium and Lactobacillus for 12 weeks, while the placebo group received an identical sachet devoid of living microorganisms. Anthropometric measurements, biochemical analyses, and 16S rRNA gene sequencing results were evaluated pre- and post-intervention. After the 12-week intervention, the probiotics group’s fasting blood glucose level significantly decreased (mean difference −0.20 mmol/L; p = 0.0021). The HbA1c, total cholesterol, triglycerides, and high-sensitivity C-reactive protein levels were significantly different between the two groups (p < 0.05). Sequencing data also demonstrated a large rise in the Bifidobacterium adolescentis following probiotic supplementation. Our findings suggest that multi-strain probiotics are beneficial for improved metabolic and inflammatory outcomes in post-GDM women by modulating gut dysbiosis. This study emphasizes the necessity for a comprehensive strategy for postpartum treatment that includes probiotics to protect post-GDM women from developing glucose intolerance.

A Mobile Phone App for the Prevention of Type 2 Diabetes in Malaysian Women With Gestational Diabetes Mellitus: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Over 50% of women with a history of gestational diabetes mellitus (GDM) will develop type 2 diabetes (T2D) in later life. Asian women experience a disproportionate risk of both GDM and T2D compared to women from other ethnic backgrounds. Lifestyle interventions and behavior change can delay or even prevent the onset of T2D. We have developed a digitalized diabetes prevention intervention for the prevention of T2D in Malaysian women with GDM.

OBJECTIVE

The protocol describes a randomized controlled trial (RCT) to test the feasibility of undertaking a definitive trial of a diabetes prevention intervention, including a smartphone app and group support. Secondary aims are to summarize anthropometric, biomedical, psychological, and lifestyle outcomes overall and by allocation group, and to undertake a process evaluation.

METHODS

This is a two-arm parallel feasibility RCT. A total of 60 Malaysian women with GDM will be randomized in the antenatal period to receive the intervention or standard care until 12 months post partum. The intervention is a diabetes prevention intervention delivered via a smartphone app developed based on the Information-Motivation-Behavioral Skills model of behavior change and group support using motivational interviewing. The intervention provides women with tailored information and support to encourage weight loss through adapted dietary intake and physical activity. Women in the control arm will receive standard care. The Malaysian Ministry of Health's Medical Research and Ethics Committee has approved the trial (NMRR-21-1667-60212).

RESULTS

Recruitment and enrollment began in February 2022. Future outcomes will be published in peer-reviewed health-related research journals and presented at national, regional, or state professional meetings and conferences. This publication is based on protocol version 2, January 19, 2022.

CONCLUSIONS

To our knowledge, this will be the first study in Malaysia that aims to determine the feasibility of a digital intervention in T2D prevention among women with GDM. Findings from this feasibility study will inform the design of a full-scale RCT in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05204706; https://clinicaltrials.gov/ct2/show/NCT05204706.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37288.

Increased Oral Care Needs and Third Molar Symptoms in Women with Gestational Diabetes Mellitus: A Finnish Gestational Diabetes Case-Control Study

(1) Hyperglycemia and oral pathology accelerate each other in diabetes. We evaluated whether gestational diabetes mellitus (GDM) is associated with self-reported increased oral health care needs and oral symptoms, including third molar symptoms, during pregnancy. (2) Pregnant women with (n = 1030) and without GDM (n = 935) were recruited in this multicenter Finnish Gestational Diabetes study in 2009-2012. Of the women with GDM, 196 (19.0%) receiving pharmacological treatment, 797 (77.0%) receiving diet treatment and 233 (23.0%) with recurrent GDM were analyzed separately. Oral health was assessed using structured questionnaires and analyzed by multivariable logistic regression adjusted for background risk factors. (3) Women with GDM were more likely to report a higher need for oral care than controls (31.1% vs. 24.5%; odds ratio (OR) 1.39; 95% confidence interval (CI) 1.14-1.69), particularly women with recurrent GDM (38.1% vs. 24.5%; OR 1.90; 95% CI 1.40-2.58). Women with pharmacologically treated GDM (46.9%) more often had third molar symptoms than controls (36.1%; OR 1.57; 95% CI 1.15-2.15) than women with diet-treated GDM (38.0%; OR 1.47; 95% CI 1.07-2.02). (4) GDM is associated with perceived oral care needs. Third molar symptoms were associated with pharmacologically treated GDM.

Association between the cut-off value of the first trimester fasting plasma glucose level and gestational diabetes mellitus: a retrospective study from southern China

Purpose

Our previous studies have suggested that the first trimester fasting plasma glucose (FPG) level is associated with gestational diabetes mellitus (GDM) and is a predictor of GDM. The aim of the present study was to provide valuable insights into the accuracy of the first trimester FPG level in the screening and diagnosis of GDM in southern China.

Methods

This retrospective study included pregnant women who had their first trimester FPG level recorded at 9–13⁺⁶ weeks and underwent screening for GDM using the 2-h 75 g oral glucose tolerance test (OGTT) between the 24th and 28th gestational weeks. Differences between the GDM and non-GDM groups were assessed by Student’s t test and the chi-squared test according to the nature of the variables. A restricted cubic spine was used to explore the relationship between the first trimester FPG level and the odds ratio (OR) of GDM in pregnant women. Cut-off values of first trimester FPG were determined using receiver operating characteristic (ROC) curves and the area under the curve (AUC), and 95% confidence intervals (CIs), the positive predictive value (PPV) and the negative predictive value (NPV) were calculated.

Results

The medical records of 28,030 pregnant women were analysed, and 4,669 (16.66%) of them were diagnosed with GDM. The average first trimester FPG level was 4.62 ± 0.37 mmol/L. The OR of GDM increased with increasing first trimester FPG levels and with a value of first trimester FPG of approximately 4.6 mmol/L, which was equal to 1 (Chi-Square = 665.79, P < 0.001), and then started to increase rapidly afterwards. The ROC curve for fasting plasma glucose in the first trimester (4.735 mmol/L) for predicting gestational diabetes mellitus in pregnant women was 0.608 (95% CI: 0.598–0.617), with a sensitivity of 0.490 and a specificity of 0.676.

Conclusion

Based on the research, we recommend that all pregnant women undergo FPG testing in the first trimester, particularly at the first antenatal visit. Furthermore, we suggest that the risks of GDM should be given increased attention and management as soon as the first trimester FPG value is more than 4.7 mmol/L. First trimester FPG levels should be considered a screening marker when diagnosing GDM in pregnant women but this needs to be confirmed by more prospective studies. These factors may have a significant impact on the clinical treatment of pregnant women.

Gestational Diabetes Mellitus Among Pregnant Women Attending Ante-natal Clinic at a Secondary Care Health Facility in Haryana, India

Introduction: Gestational diabetes has serious health effects during pregnancy and childbirth. We estimated the occurrence of gestational diabetes mellitus (GDM) among pregnant women in a secondary care hospital in Haryana.

Methods: It was a hospital-based cross-sectional study, done in an ante-natal clinic (ANC) at a sub-district hospital (SDH), Faridabad district of Haryana, India. Eligible pregnant women attending the ANC clinic were recruited. An oral glucose tolerance test (OGTT) with 75 g of glucose was done with a collection of blood for fasting blood sugar (FBS) and two-hour post-OGTT blood glucose. A pre-tested semi-structured interview schedule was administered. Both the modified International Association of the Diabetes and Pregnancy Study Groups criteria (IADPSGC) and the Diabetes in Pregnancy Study Group of India (DIPSI) criteria were used. Data were presented as percentages, means, standard deviation, and 95% confidence interval (CI). Bi-variable and multi-variable logistic regressions were done. The level of significance was set at 0.05.

Results: Of the 623 eligible participants, 66.1% were within the 20-25 age group. The GDM was found in 14.1% (95%CI: 11.5-17.1) participants as per modified IADPSG criteria and 6.7% (95%CI: 4.9-9.0) participants as per DIPSI criteria, respectively. Increasing age [adjusted odds ratio (AOR): 1.24 (95% CI: 1.05-1.47), p=0.008] and increasing years of schooling [AOR: 1.19 (1.01-1.41), p=0.032] were significantly associated with GDM by DIPSI criteria. Family history of DM was also found to have an increased odds with GDM using modified IADPSG criteria [AOR 2.87 (95% CI: 1.09-7.54), p=0.032]. 

Conclusion: Considerable proportion of pregnant women were found to have GDM in a Sub-district hospital at Ballabgarh in north India. The study highlighted the need and generated evidence about the feasibility of GDM screening utilizing routine staff in a secondary care facility.

ENDOCRINOLOGY IN PREGNANCY: Targeting metabolic health promotion to optimise maternal and offspring health

There is an increase in maternal metabolic burden due to the rise in pregnancies complicated by obesity, gestational diabetes, type 2 diabetes and polycystic ovary syndrome. Metabolic dysfunction during pregnancy is associated with increased risks of long-term morbidity and mortality for women and their offspring. Lifestyle interventions in pregnancy in women at risk of metabolic dysfunction have demonstrated short-term improvements such as reduced gestational weight gain and lowered risk of gestational diabetes. It is not known whether these interventions lead to sustained improvements in the metabolic health of the mother and baby. Pharmacological interventions have also shown benefits for the mother and baby in pregnancy, including improvements in glycaemic control, reduction in gestational weight gain and reduction in large for gestational age infants; however, there remains uncertainty over long-term outcomes for mother and child. Existing studies on interventions targeting metabolic health are limited to selected populations in the preconception and postpartum periods and lack follow-up beyond delivery of the intervention. The COVID-19 pandemic has refocused our attention on the effects of maternal metabolic ill-health that play a role in contributing to premature morbidity and mortality. There is an urgent need for strategies to accurately identify the growing number of women and offspring at risk of long-term adverse metabolic health. Strategies which focus on early identification and risk stratification using individualised risk scores in the pre and inter-conception periods must take priority if we are to target and improve the metabolic health of women and their offspring who are at highest risk.

Adverse pregnancy outcomes are associated with an increased risk of postpartum prediabetes and diabetes in Chinese women with gestational diabetes

AIMS

To explore associations between adverse pregnancy outcomes and risk of postpartum diabetes and prediabetes among Chinese women with gestational diabetes mellitus (GDM).

METHODS

A total of 507 women with GDM who participated in a randomized controlled trial were successfully followed up at a median of 9.1  (interquartile range: 7.7-11.3) weeks after delivery and underwent a 75 g 2-h oral glucose tolerance test. GDM was diagnosed according to the International Association of Diabetes and Pregnancy Study Group's criteria. Postpartum diabetes and prediabetes were defined by the World Health Organization's. Generalized logit model was used to obtain odds ratios (OR) and 95% confidence interval (CI) of adverse pregnancy outcomes for postpartum diabetes, prediabetes and abnormal glucose regulation (AGR).

RESULTS

Of 507 women with GDM, 3.7% (19) women developed postpartum diabetes, 35.1% (178) women developed postpartum prediabetes. Preterm birth was associated with increased risk of postpartum prediabetes and AGR (adjusted OR: 3.24, 95%CI: 1.48-7.07 & 3.16, 1.46-6.85). Low birth weight was associated with the risk of postpartum prediabetes, diabetes and AGR (adjusted OR: 2.78, 95%CI: 1.13-6.86; 5.21, 1.13-24.02 & 2.99, 1.24-7.21).

CONCLUSIONS

Preterm birth and low birth weight were predictive of postpartum prediabetes, diabetes or AGR in Chinese women with GDM.

Development of type 2 diabetes in women with comorbid gestational diabetes and common mental disorders in the Born in Bradford cohort

OBJECTIVES

To compare, in a population of women with gestational diabetes mellitus (GDM), the time to diagnosis of Type 2 diabetes in those with and without common mental disorder (CMD) (depression and/or anxiety) during pregnancy.

DESIGN AND SETTING

prospective study of the Born in Bradford cohort in Bradford, UK.

PARTICIPANTS

909 women diagnosed with GDM between 2007 and 2010, with linkage to their primary care records until 2017. The exposed population were women with an indicator of CMD during pregnancy in primary care records. The unexposed were those without an indicator.

OUTCOME MEASURES

Time to diagnosis of type 2 diabetes as indicated by a diagnosis in primary care records.

ANALYSIS

time to event analysis using Cox regression was employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education, preconception CMD and tobacco smoking during pregnancy.

RESULTS

165 women (18%) were diagnosed with type 2 diabetes over a follow-up period of around 10 years. There was no evidence of an effect of antenatal CMD on the development of type 2 diabetes following GDM (adjusted HR 0.95; 95% CI 0.57 to 1.57).

CONCLUSIONS

Women with CMD were not at an increased risk of type 2 diabetes following GDM. This is reassuring for women with these co-morbidities but requires replication in other study populations.

Risk stratification of women with gestational diabetes mellitus using mutually exclusive categories based on the International Association of Diabetes and Pregnancy Study Groups criteria for the development of postpartum dysglycaemia: a retrospective cohort study

OBJECTIVES

Women with gestational diabetes mellitus (GDM) are more predisposed to develop postpartum diabetes mellitus (DM). This study aimed to estimate the relative risk (RR) of postpartum dysglycaemia (prediabetes and DM) using mutually exclusive categories according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria cut-off points in patients with GDM, so as to establish a risk-stratification method for developing GDM management strategies.

DESIGN, SETTING AND PARTICIPANTS

In this retrospective cohort study, 942 women who had been diagnosed with GDM (IADPSG criteria) at 24-28 weeks of gestation from November 2016 to April 2018 underwent a 75 g oral glucose tolerance test (OGTT) at 6-12 weeks postpartum in a tertiary hospital of Singapore. Seven mutually exclusive categories (three one timepoint positive categories (fasting, 1 hour and 2 hours), three two timepoint positive categories (fasting+1 hour, fasting+2 hours and 1 hour+2 hours) and one three timepoint positive category (fasting+1 hour+2 hours)) were derived from the three timepoint antenatal OGTT according to the IADPSG criteria. To calculate the RRs of postpartum dysglyceamia of each mutually exclusive group, logistic regression was applied.

RESULTS

924 mothers with GDM, whose mean age was 32.7±4.7 years, were mainly composed of Chinese (45.4%), Malay (21.7%) and Indian (14.3%) ethnicity. The total prevalence of postnatal dysglycaemia was 16.7% at 6-12 weeks postpartum. Stratifying subjects into seven mutually exclusive categories, the RRs of the one-time, two-time and three-time positive groups of the antenatal OGTT test were 1.0 (Ref.), 2.0 (95% CI=1.3 to 3.1; p=0.001) and 6.7 (95% CI=4.1 to 10.9; p<0.001), respectively, which could be used to categorise patients with GDM into low-risk, intermediate-risk and high-risk group.

CONCLUSIONS

Mutually exclusive categories could be useful for risk stratification and early management of patients with prenatal GDM. It is plausible and can be easily translated into clinical practice.

Risk and Risk Factors for Postpartum Type 2 Diabetes Mellitus in Women with Gestational Diabetes: A Korean Nationwide Cohort Study

BACKGROUND

There are differences in risk and risk factor findings of postpartum type 2 diabetes mellitus (T2DM) after gestational diabetes depending on study design and subjects of previous studies. This study aimed to assess these risk and risk factors more accurately through a population-based study to provide basic data for prevention strategies.

METHODS

This open retrospective cohort included data of 419,101 women with gestational diabetes and matched 1,228,802 control women who delivered between 2004 and 2016 from the South Korea National Health Information Database of the National Health Insurance Service. Following 14 (median 5.9) years of follow-up, the incidence and hazard ratio (HR) of postpartum T2DM were evaluated using Kaplan-Meier curves and Cox proportional regression models.

RESULTS

The incidence and HR of postpartum T2DM in women with gestational diabetes (compared to women without gestational diabetes) after the 14-year follow-up was 21.3% and 2.78 (95% confidence interval [CI], 2.74 to 2.82), respectively. Comorbid obesity (body mass index [BMI] ≥25 kg/m2) increased postpartum T2DM risk 7.59 times (95% CI, 7.33 to 7.86). Significant risk factors for postpartum T2DM were fasting glucose level, BMI, age, family history of diabetes, hypertension, and insulin use during pregnancy.

CONCLUSION

This population-based study showed higher postpartum T2DM risk in women with gestational diabetes than in those without, which was further increased by comorbid obesity. BMI and fasting glucose level were important postpartum risk factors. The management of obesity and glycemic control may be important strategies to prevent the incidence of diabetes after delivery.

"Post-GDM support would be really good for mothers": A qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes

BACKGROUND

Women with a history of gestational diabetes mellitus (GDM) are at high risk of developing type 2 diabetes mellitus (T2DM). They are therefore recommended to follow a healthy diet and be physically active in order to reduce that risk. However, achieving and maintaining these behaviours in the postpartum period is challenging. This study sought to explore women's views on suggested practical approaches to achieve and maintain a healthy diet and physical activity to reduce T2DM risk.

METHODS

Semi-structured interviews with 20 participants in Cambridgeshire, UK were conducted at three to 48 months after GDM. The participants' current diet and physical activity, intentions for any changes, and views on potential interventions to help manage T2DM risk through these behaviours were discussed. Framework analysis was used to analyse the transcripts. The interview schedule, suggested interventions, and thematic framework were based on a recent systematic review.

RESULTS

Most of the participants wanted to eat more healthily and be more active. A third of the participants considered that postpartum support for these behaviours would be transformative, a third thought it would be beneficial, and a third did not want additional support. The majority agreed that more information about the impact of diet and physical activity on diabetes risk, support to exercise with others, and advice about eating healthily, exercising with a busy schedule, monitoring progress and sustaining changes would facilitate a healthy diet and physical activity. Four other suggested interventions received mixed responses. It would be acceptable for this support to be delivered throughout pregnancy and postpartum through a range of formats. Clinicians were seen to have important roles in giving or signposting to support.

CONCLUSIONS

Many women would appreciate more support to reduce their T2DM risk after GDM and believe that a variety of interventions to integrate changes into their daily lives would help them to sustain healthier lifestyles.

Translation and psychometric validation of the Arabic Gestational Diabetes Management Self-Efficacy Scale (GDMSES)

INTRODUCTION

The assessment of self-efficacy for adherence to healthy behaviours among women with gestational diabetes (GDM) is undermined by the unavailability of validated tools. Therefore, this study aimed at translating, culturally adapting and assessing the psychometric properties of the Arabic version of Gestational Diabetes Management Self-Efficacy Scale (GDMSES).

MATERIALS AND METHODS

This methodological study was conducted in the Antenatal Clinic at Sultan Qaboos University Hospital in Oman between October 2016 and January 2017. A total of 90 forms of the Arabic GDMSES tool were completed by Omani pregnant women with gestational diabetes. The study has a multiphase design: (1) cultural and linguistic validation; (2) content and face validity; (3) construct validity; (4) internal validity.

RESULTS

The Arabic GDMSES showed satisfactory content validity (CVI between .8 and 1), acceptable overall scale internal consistency reliability (Cronbach's alpha=0.85) and stability overtime (Pearson correlation coefficient>.6). Four factors emerged for construct validity using exploratory factor analysis: nutrition and body weight, adaptation to healthy eating, physical activity and treatment and blood sugar. Our sample size of 90 was considered adequate in determining these factors (Kaiser-Meyer-Olkin=.78).

CONCLUSIONS

GDMSES is a valid and reliable tool, thus providing a quick and easy self-efficacy assessment tool for antenatal nurses dealing with pregnant women with GDM.