Low-educated women have an increased risk of gestational diabetes mellitus: the Generation R Study

Multiple Job Holding, Job Changes, and Associations with Gestational Diabetes and Pregnancy-Related Hypertension in the National Birth Defects Prevention Study

We used National Birth Defects Prevention Study data to investigate associations between working patterns shortly before and during pregnancy and gestational diabetes and pregnancy-related hypertension. We analyzed working patterns (multiple-job holders, job changers, single-job holders) during the three months before and during pregnancy for 8140 participants who delivered a live-born child without a birth defect. "Multiple-job holders" worked more than one job simultaneously, "job changers" worked more than one job with no overlap, and "single-job holders" (referent) worked one job. We used multivariable logistic regression to estimate associations between working pattern and each outcome, adjusting for maternal age and educational attainment at delivery. We explored effect measure modification by household income, peak weekly working hours, and maternal race/ethnicity. Multiple-job holders had higher odds of gestational diabetes (adjusted odds ratio [aOR]: 1.5; 95% confidence interval [CI]: 1.1-2.1) and pregnancy-related hypertension (aOR: 1.5; 95% CI: 1.0-2.2) compared with single-job holders. Multiple-job holders with a household income of more than 30,000 USD per year, 32-44 peak weekly working hours, and from racial/ethnic minority groups had higher odds of gestational diabetes compared with single-job holders in respective categories. Detailed occupational information is important for studies of occupation and maternal health.

Early Gestational Diabetes Screening Based on ACOG Guidelines

OBJECTIVE

 A recent randomized controlled trial suggested that early gestational diabetes mellitus (GDM) screening in patients with obesity (body mass index [BMI] ≥30 kg/m2) does not improve perinatal outcomes. The American College of Obstetrics and Gynecology currently recommends early screening for gestational diabetes in patients who are overweight with one or more additional risk factors. We evaluated the effect of screening based on the number of additional risk factors for development of gestational diabetes.

STUDY DESIGN

 This was a secondary analysis of a multicenter randomized controlled trial of obese patients with singleton nonanomalous fetuses comparing early (14-20 weeks' gestation) with routine (24-28 weeks' gestation) GDM screening. Exclusion criteria were pregestational diabetes, major medical illnesses, bariatric surgery, chronic steroid use, and prior cesarean. Early versus routine GDM screening groups were compared and stratified by the number of additional risk factors for GDM (0, 1, 2, and ≥3). The primary outcome was an adverse perinatal composite outcome composed of: macrosomia, primary cesarean delivery, hypertensive disorders of pregnancy, shoulder dystocia, neonatal hyperbilirubinemia, and neonatal hypoglycemia. Analyses examined effects of early versus routine screening by the number of additional risk factors and their possible interaction on the incidences of the primary outcome and GDM.

RESULTS

 Of 913 patients, 5% had 0, 52% had 1, 33% had 2, and 10% had ≥3 additional risk factors. Baseline characteristics, including the number and type of risk factors, were similar between early and routine screening groups. Breslow-Day test for interaction between early versus routine screening and the number of additional risk factors was not significant for either the primary outcome (p = 0.37) or the diagnosis of GDM (p = 0.28). The incidence of GDM and the adverse perinatal composite outcome increased as the number of risk factors increased (p < 0.001).

CONCLUSION

 In patients with BMI ≥30 kg/m2 and additional risk factors, early GDM screening does not prevent adverse outcomes.

KEY POINTS

· The ACOG currently recommends early screening for gestational diabetes if patients have risk factors.. · Even in patients with multiple risk factors, early screening for GDM does not improve outcomes.. · Patients with three or more risk factors may have worse outcomes if they undergo early screening..

Trends in the prevalence of gestational diabetes in Catalonia from 2010 to 2019

INTRODUCTION

Gestational diabetes mellitus (GDM) is globally increasing due to changes in risk factors such as gestational age, obesity, and socioeconomic status (SES). This study examined trends of GDM prevalence over ten years using a real-world Primary Health Care database from Catalonia (Spain).

METHODS

A retrospective analysis of pregnant women screened for GDM was conducted, using clinical and SES data from the SIDIAP database.

RESULTS

Among 221,806 women studied from 2010 to 2019,17,587 had GDM, equating to a 7.9% prevalence (95% CI 7.8-8.04). GDM subjects were older (33.5 ± 5.1 vs. 31.2 ± 5.6 years; p < 0.001) and had higher BMI (29.2 ± 5.1 vs .27.8 ± 4.8 kg/m²; p < 0.001) than non-GDM individuals. Overall GDM prevalence remained unchanged throughout the study, although an increase was observed in younger women (below 20 years: 1.28% [95% CI 0.59-2.42] in 2010 to 2.22% [95% CI 0.96-4.33] in 2019, p = 0.02; ages 20-25.9 years: 3.62% [95% CI 3.12-4.17] in 2010 to 4.63% [95% CI 3.88-5.48)] in 2019, p = 0.02). Age, BMI ≥ 25 kg/m2, deprived SES, and previous hypertension and dyslipidaemia were positively associated with GDM.

CONCLUSIONS

This study offers insights into GDM prevalence in Catalonia (Spain),showing overall stability except for a rising trend among younger women.

Child rearing or childbearing? Risk of cardiovascular diseases associated to parity and number of children

BACKGROUND

An increased risk of cardiovascular diseases (CVD) has been associated with women's parity, but whether or not this association reflects a direct pregnancy effect, or exposure to factors related to childrearing, still appears unclear. We assessed the CVD risk associated with number of children separately by gender and tested effect modification by socioeconomic position (SEP) and employment status, in order to elucidate the possible mechanisms underlying this association.

METHODS

The study population was composed of 20,904 men and 25,246 women who were interviewed in one of two National Health Surveys conducted in 2000 and 2005 in Italy. These subjects were followed for CVD incidence up to 2014 through record-linkage with national archives of mortality and hospitalisations. CVD risk was estimated by Cox regression models that were adjusted for socio-demographics, perceived health, lifestyles, biological CVD risk factors and for other potential confounders.

RESULTS

CVD incidence was significantly increased among men with 3 or more children (HR = 1.26, 95% CI: 1.02-1.56) and among women with 2 and with 3 or more children (HR = 1.42, 95% CI: 1.10-1.83; and HR = 1.39, 95% CI: 1.03-1.87, respectively) compared to subjects without children and no significant gender differences were observed. Subjects with lower SEP displayed stronger associations with parity and a higher number of children for both genders; by contrast, no modifying effect of employment status was observed.

CONCLUSIONS

Taken together, the significant association between higher parity and CVD risk in both genders, and the higher risk of CVD associated with higher parity among lower SEP parents, suggests that childrearing has a potential effect on the development of CVD that is more pronounced among disadvantaged families, although a concurrent effect of childbearing cannot be completely excluded.

How does high socioeconomic status affect maternal and neonatal pregnancy outcomes? A population-based study among American women

Objectives

The purpose of this study was to evaluate the effect of high SES on multiple pregnancy outcomes, while controlling for confounding factors.

Methods

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS), the largest American medical database including 20 % of annual hospital admissions, we studied the years 2004-2014 inclusively. We conducted a population-based retrospective cohort study consisting of women from different median household income quartiles throughout the United States. Women in the highest household income quartile were compared to those in all other lower income quartiles combined. Chi-square and Fischer exact tests were used to compare demographic and baseline characteristics. Univariate and multivariate regression analyses were carried to adjust for confounding factors, including ethnicity, pre-existing conditions, smoking status, obesity, illicit drug use and insurance type.

Results

Among 5,448,255 deliveries during the study period with income data, 1,218,989 deliveries were to women from the wealthiest median household income. These women were more likely to be older, Caucasian, and have private medical insurance (P < 0.05, all). They were less likely to smoke, have chronic hypertension, pre-gestational diabetes, and use illicit drugs (P < 0.05, all). They were less likely to develop complications including gestational hypertension (aOR 0.87 95 %CI 0.85-0.88), preeclampsia (aOR 0.88 95 %CI 0.86-0.89), eclampsia (aOR 0.81 95 %CI 0.66-0.99), gestational diabetes (aOR 0.91 95 %CI 0.89-0.92), preterm premature rupture of membranes (PPROM) (aOR 0.92 95 %CI 0.88-0.96), preterm birth (aOR 0.90 95 %CI 0.89-0.92), and placental abruption (aOR 0.89 95 %CI 0.85-0.93). They were less likely to have an intra-uterine fetal death (IUFD) (aOR 0.80 95 %CI 0.74-0.86), but more likely to deliver neonates with congenital anomalies (aOR 1.10 95 %CI 1.04-1.20).

Conclusions

Higher SES predisposes to better pregnancy outcomes, even when controlled for confounding factors such as ethnicity and underlying baseline health status. Efforts are required in order to eliminate health disparities in pregnancy.

Health promotion intervention among women with recent gestational diabetes mellitus: penetration, participation, and baseline findings from the Face-it randomized controlled trial

INTRODUCTION

Face-it is a randomized controlled trial for women with recent gestational diabetes mellitus (GDM) and their families designed to evaluate the effect of a health promotion intervention on type 2 diabetes mellitus (T2DM) risk and quality of life. This study examined (1) the penetration and participation rates for the Face-it trial, (2) the characteristics of the participating women and the potential differences in characteristics according to partner participation status, and (3) representativity of the women at baseline.

RESEARCH DESIGN AND METHODS

We identified women with GDM during pregnancy and invited them and their partners to a baseline examination 10-14 weeks after delivery. Representativity was assessed by comparing the baseline participants with non-participating women, the general population of women with GDM delivering in Denmark, and populations from other intervention trials.

RESULTS

The penetration rate was 38.0% (867/2279) and the participation rate was 32.9% (285/867). The 285 women who attended baseline had a mean age of 32.7 (±4.8) years and body mass index (BMI) of 28.1 (±5.4) kg/m2, and 69.8% had a partner who participated. The women participating with a partner were more often primiparous, born in Denmark (82.8% vs 68.2%), were younger, and more often had a BMI ≤24.9 kg/m2 (35.7% vs 21.2%) compared with women without a partner. Compared with the general population of women with GDM in Denmark, these women broadly had similar degree of heterogeneity, but had higher rates of primiparity and singleton deliveries, and lower rates of preterm delivery and prepregnancy obesity.

CONCLUSIONS

The penetration and participation rates were acceptable. We found a high rate of partner participation. Overall, women participating with a partner were comparable with those participating without a partner. Participating women were broadly similar to the general national GDM population, however with prepregnancy obesity, multiparity, preterm delivery, and multiple pregnancy being less represented.

TRIAL REGISTRATION NUMBER

NCT03997773.

Effects of Air Pollution Exposure during Preconception and Pregnancy on Gestational Diabetes Mellitus

This study aimed to investigate the association between air pollution and gestational diabetes mellitus (GDM) in small- and medium-sized cities, identify sensitive periods and major pollutants, and explore the effects of air pollution on different populations. A total of 9820 women who delivered in Handan Maternal and Child Health Hospital in the Hebei Province from February 2018 to July 2020 were included in the study. Logistic regression and principal component logistic regression models were used to assess the effects of air pollution exposure during preconception and pregnancy on GDM risk and the differences in the effects across populations. The results suggested that each 20 μg/m3 increase in PM2.5 and PM10 exposure during preconception and pregnancy significantly increased the risk of GDM, and a 10 μg/m3 increase in NO2 exposure during pregnancy was also associated with the risk of GDM. In a subgroup analysis, pregnant women aged 30-35 years, nulliparous women, and those with less than a bachelor's education were the most sensitive groups. This study provides evidence for an association between air pollution and the prevalence of GDM, with PM2.5, PM10, and NO2 as risk factors for GDM.

Socioeconomic status, maternal risk factors, and gestational diabetes mellitus across reproductive years: a Finnish register-based study

INTRODUCTION

To evaluate the degree to which socioeconomic differences in gestational diabetes mellitus (GDM) are accounted for by differences in maternal risk factors, to assess whether age-related risks of GDM differ across socioeconomic groups, and to identify priority populations for future interventions.

RESEARCH DESIGN AND METHODS

We performed a register-based study using data from the Finnish Medical Birth Register and Statistics Finland on the 474 166 women who gave birth in Finland from 2008 to 2015. We collected information on GDM based on the International Classification of Diseases 10th Revision codes O24.4 and O24.9. We used multivariable models to examine the association between socioeconomic status, maternal risk factors, and GDM. We further tested interaction on multiplicative and additive scales.

RESULTS

The incidence of GDM was 8.7% in 2008-2011 and 12.5% in 2012-2015. Lower socioeconomic levels than upper level employees were associated with an increased risk of GDM. Up to 64.0% of socioeconomic differences in GDM were attributed to body mass index and 5.5% to smoking. There was evidence for effect modification. Relative to women in the upper level category who were aged less than 19 years, GDM adjusted ORs (95% CIs) for women 35 years or older in upper level versus long-term unemployed groups were 3.28 (2.08-5.18) and 5.29 (3.35-8.35), respectively.

CONCLUSIONS

There is a paradox that socioeconomic advantage increases the incidence of GDM at the population level while reducing the incidence of GDM within the population. Nevertheless, socioeconomic differences in GDM persist and widen with increasing maternal age, even after accounting for maternal risk factors.

Analysis of an Association between Preterm Birth and Parental Educational Level in Japan Using National Data

Preterm birth rate depending on parental educational level in recent years has not been surveyed in Japan. In this study, we showed the trend in preterm birth rate depending on parental educational level from 2000 to 2020 by linking data from the Census regarding individuals' educational level and parents in birth data of the vital statistics. Four types of parental educational level, namely junior high school, high school, technical school or junior college, and university or graduate school, were compared. Slope and relative indexes of inequality for preterm birth by educational level were computed by binomial models. Data on 3,148,711 births and 381,129,294 people were used in the analysis, and data on 782,536 singleton births were used after data linkage. The preterm birth rate (%) for junior high school graduate mothers and fathers was 5.09 and 5.20 in 2020, respectively. Contrarily, the preterm birth rate (%) for parents who graduated from a university or graduate school was 4.24 for mothers and 4.39 for fathers, and the rate tended to increase as educational level decreased, irrespective of parental gender. Results of inequality indexes showed that a statistically significant inequality by parental educational level persisted from 2000 to 2020.

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.

Knowledge on postpartum type-2 diabetes mellitus screening among pregnant women with gestational diabetes mellitus in Malaysia

INTRODUCTION

Despite the effectiveness of postpartum type 2 diabetes mellitus (T2DM) screening to detect and manage T2DM among women with a history of gestational diabetes mellitus (GDM), the uptake remains low, indicating the potentially low level of relevant knowledge. This study aims to identify the prevalence of postpartum T2DM screening and its associated factors.

METHODS

A cross-sectional study was conducted involving 116 pregnant women with GDM who attended antenatal care follow-up at government health clinics in Seremban District, Negeri Sembilan. Multistage cluster sampling was performed to recruit the respondents from 6 mukims and 10 public health clinics. The data were collected using a validated and pre-tested questionnaire, with Cronbach's alpha values ranging from 0.81 to 0.95 for each section of the questionnaire. Data were collected through face-to-face interviews during the respondents' routine antenatal follow-ups for blood sugar monitoring.

RESULTS

Poor knowledge on postpartum T2DM screening (55.2%) was observed, which was significantly predicted by low educational level (AOR = 6.898, 95% CI 3.62-9.055) and low selfefficacy (AOR = 17.905, 95% CI 5.470-58.611).

CONCLUSION

Most of the respondents had poor knowledge regarding postpartum T2DM screening, which was predicted by low education and self-efficacy. The findings highlight the need for continuous education and health promotion during antenatal follow-up targeting women with GDM with low self-efficacy and education level in order to ensure better adherence to screening.

Physical Activity during Pregnancy: Comparisons between Objective Measures and Self-Reports in Relation to Blood Glucose Levels

Objective: to quantify pregnant women’s physical activity during pregnancy using wearable accelerometers and a self-reported scale and to examine the variation in these two physical activity measures in relation to fasting plasma glucose (FPG) levels and presence of gestational diabetes mellitus (GDM). Methods: this prospective observational study included 197 pregnant women from one of the largest regional hospitals in South China. Women with singleton pregnancy, absence of pre-existing comorbidities and pre-specified contraindications, wore an accelerometer on their waist for 7 consecutive days to objectively record their physical activity, followed by completing a past-7-day physical activity questionnaire, three times, respectively, in three trimesters. GDM was determined by 2-h 75 g oral glucose tolerance test (OGTT) in 24–28th week’s gestation and FPG was obtained in both 1st and 2nd trimesters following standard practice. Results: pregnant women engaged highest levels of various physical activity types in 2nd trimester, except accelerometer-based moderate-to-vigorous physical activity which gradually decreased in pregnancy. Pregnant women were more likely to walk in 3rd trimester. The relationship between objective total physical activity and self-reported total physical activity was non-linear. Increased trend of FPG from 1st trimester to 2nd trimester disappeared when adjusting for accelerometer-based light physical activity and attenuated when including walking. Self-reported moderate physical activity was surprisingly positively associated with GDM. Conclusions: different patterns in physical activity between objective measure and self-report in relation to gestational glucose levels were observed. Short-term increase in moderate physical activity prior to OGTT may not be necessary for reducing presence of GDM. Future glucose management for pregnant women may be targeted at lower intensity physical activity.

Mediators of socioeconomic inequalities in preterm birth: a systematic review

BACKGROUND

Rates of preterm birth are substantial with significant inequalities. Understanding the role of risk factors on the pathway from maternal socioeconomic status (SES) to preterm birth can help inform interventions and policy. This study therefore aimed to identify mediators of the relationship between maternal SES and preterm birth, assess the strength of evidence, and evaluate the quality of methods used to assess mediation.

METHODS

Using Scopus, Medline OVID, "Medline In Process & Other Non-Indexed Citation", PsycINFO, and Social Science Citation Index (via Web of Science), search terms combined variations on mediation, socioeconomic status, and preterm birth. Citation and advanced Google searches supplemented this. Inclusion criteria guided screening and selection of observational studies Jan-2000 to July-2020. The metric extracted was the proportion of socioeconomic inequality in preterm birth explained by each mediator (e.g. 'proportion eliminated'). Included studies were narratively synthesised.

RESULTS

Of 22 studies included, over one-half used cohort design. Most studies had potential measurement bias for mediators, and only two studies fully adjusted for key confounders. Eighteen studies found significant socioeconomic inequalities in preterm birth. Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions. There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth. Significant residual inequalities frequently remained. Difference-of-coefficients between models was the most common mediation analysis approach, only six studies assessed exposure-mediator interaction, and only two considered causal assumptions.

CONCLUSIONS

The substantial socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators that have been studied, particularly maternal smoking in pregnancy. There is, however, a large residual direct effect of SES evident in most studies. Despite the mediation analysis approaches used limiting our ability to make causal inference, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is probably necessary to address inequalities in preterm birth, alongside action on mediating pathways.

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.

Value of HbA1c in Obese Women with Gestational Diabetes

OBJECTIVE

We sought to assess the association of hemoglobin A1c (HbA1c) with adverse perinatal outcomes in obese women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This was a secondary analysis of a multicenter randomized controlled trial assessing early (14-20 weeks) versus routine (24-28 weeks) screening for GDM in obese women. Women were included if they were diagnosed with GDM at either time during pregnancy and had a HbA1c result available. The primary exposure was HbA1c at 24 to 28 weeks. The primary outcome was a composite of macrosomia, primary cesarean, pregnancy-induced hypertension, shoulder dystocia, neonatal hypoglycemia, or hyperbilirubinemia. Receiver operating characteristics (ROC) curves were used to assess the association of HbA1c with the composite outcome. The Liu method was used to select an optimal HbA1c cutoff, and the incidence of the outcome compared.

RESULTS

Of 125 women with GDM, 93 (74%) had a HbA1c at 24 to 28 weeks and 103 (82.4%) had a HbA1c at 14 to 20 weeks. Baseline characteristics were balanced between groups above and below the cutoff. The area under the ROC curve for HbA1c and its association with the adverse perinatal composite outcome was 0.6 (95% confidence interval [CI]: 0.5-0.7). The frequency of the primary outcome was similar among women with low and high HbA1c at 24 to 28 weeks (adjusted relative risk, 1.12, 95% CI: 0.97-1.29). Compared with women with a decreasing HbA1c during pregnancy, women with a stable or increasing HbA1c did not have a significant increase in the primary adverse perinatal composite outcome. However, the frequency of preterm delivery was higher among women with stable or increasing HbA1c compared with those with a decreasing HbA1c (26.1 vs. 6.7%, p = 0.03).

CONCLUSION

A single HbA1c in women with GDM is not associated with a composite perinatal adverse outcome, but a HbA1c that increases or remains stable between 14 to 20 and 24 to 28 weeks is associated with an increase in preterm delivery.

KEY POINTS

· A single HbA1c in GDM is not associated with a composite perinatal adverse outcome.. · HbA1c that increases or remains stable may be associated with an increase in preterm delivery.. · HbA1c at 24 to 28 weeks was not significantly associated with the adverse perinatal composite outcome..

An explainable machine learning-based clinical decision support system for prediction of gestational diabetes mellitus

Gestational Diabetes Mellitus (GDM), a common pregnancy complication associated with many maternal and neonatal consequences, is increased in mothers with overweight and obesity. Interventions initiated early in pregnancy can reduce the rate of GDM in these women, however, untargeted interventions can be costly and time-consuming. We have developed an explainable machine learning-based clinical decision support system (CDSS) to identify at-risk women in need of targeted pregnancy intervention. Maternal characteristics and blood biomarkers at baseline from the PEARS study were used. After appropriate data preparation, synthetic minority oversampling technique and feature selection, five machine learning algorithms were applied with five-fold cross-validated grid search optimising the balanced accuracy. Our models were explained with Shapley additive explanations to increase the trustworthiness and acceptability of the system. We developed multiple models for different use cases: theoretical (AUC-PR 0.485, AUC-ROC 0.792), GDM screening during a normal antenatal visit (AUC-PR 0.208, AUC-ROC 0.659), and remote GDM risk assessment (AUC-PR 0.199, AUC-ROC 0.656). Our models have been implemented as a web server that is publicly available for academic use. Our explainable CDSS demonstrates the potential to assist clinicians in screening at risk patients who may benefit from early pregnancy GDM prevention strategies.

How does antenatal lifestyle affect the risk for gestational diabetes mellitus? A secondary cohort analysis from the GeliS trial

OBJECTIVES

We aimed to investigate the predictive potential of early pregnancy factors such as lifestyle, gestational weight gain (GWG) and mental well-being on gestational diabetes mellitus (GDM) beyond established risk factors.

METHODS

GDM risk was investigated in the cohort of the German 'Gesund leben in der Schwangerschaft'/healthy living in pregnancy study. Women were recruited up to the 12th week of gestation. GDM was diagnosed with a 75 g oral glucose tolerance test between the 24th and 28th weeks of gestation. Pre-pregnancy age and weight, mental health and lifestyle were assessed via questionnaires. Maternal weight was measured throughout pregnancy. Early excessive GWG was defined based on the guidelines of the Institute of Medicine. The association between several factors and the odds of developing GDM was assessed using multiple logistic regression analyses.

RESULTS

Of 1694 included women, 10.8% developed GDM. The odds increased with pre-pregnancy BMI and age (women with obesity: 4.91, CI 3.35-7.19, p < 0.001; women aged 36-43 years: 2.84, CI 1.45-5.56, p = 0.002). Early excessive GWG, mental health and general lifestyle ratings were no significant risk factors. A 31% reduction in the odds of GDM was observed when <30% of energy was consumed from fat (OR 0.69, CI 0.49-0.96, p = 0.026). Vigorous physical activity tended to lower the odds without evidence of statistical significance (OR 0.59 per 10 MET-h/week, p = 0.076).

CONCLUSIONS

Maternal age and BMI stand out as the most important drivers of GDM. Early pregnancy factors like dietary fat content seem to be associated with GDM risk. Further evaluation is warranted before providing reliable recommendations.

Knowledge of gestational diabetes mellitus at first consultation in a multi-ethnic pregnant population in the Oslo region, Norway - a cross-sectional study

Objectives: Gestational diabetes mellitus (GDM) is an increasing problem among pregnant women globally and is associated with short- and long-term consequences for both mother and newborn. The aim of this study was to investigate knowledge of GDM among a multi-ethnic pregnant population at first consultation for GDM in the Oslo region in Norway.Design: We conducted a cross-sectional study using baseline data from a randomised controlled study performed at five diabetic outpatient clinics (DOC) in the Oslo region. Pregnant women diagnosed with GDM following an Oral Glucose Tolerance test (OGTT) with a 2-hours blood glucose level of ≥ 9 mmol/l were included. Women filled out a questionnaire on an electronic tablet at the study entry, and additional data were collected through a recruiting form. Descriptive statistics were performed and associations were investigated using Chi-square test and multiple logistic regression analysis.Results: Of 238 women included in the study, 108 (45.4%) were native Norwegian speakers and 130 (54.6%) were non-native Norwegian speakers. 39.5% of the non-native Norwegian speakers were Asian, 22.5% were African, and 15.5% were from Eastern European Countries. Non-native Norwegian speakers were significantly more likely to have poor knowledge of GDM compared to native Norwegian speakers, adjusted OR = 4.5, 95% CI 1.61-12.5. Sensitivity analyses showed this was not due to poor language skills.Conclusions: Ethnic background was associated with the level of knowledge of GDM. Health professionals should be aware of the various knowledge levels concerning GDM and tailor their information towards women's knowledge. Linguistically- and culturally adapted information regarding GDM may improve knowledge gaps among women with immigrant backgrounds.

Associations of maternal angiogenic factors during pregnancy with childhood carotid intima-media thickness and blood pressure

Background and aims

Reduced maternal placental growth factor (PlGF) and higher soluble fms-like tyrosine kinase (sFlt-1) concentrations in pregnancy may have persistent effects on offspring vasculature. We hypothesized that suboptimal maternal angiogenic factors in pregnancy may adversely affect fetal vascular development, leading to an increased risk of adverse atheriosclerotic adaptations and higher blood pressure in offspring.

Methods

In a population-based prospective cohort among 4565 women and their offspring, we examined the associations of maternal serum PlGF and sFlt-1 concentrations in the first half of pregnancy with offspring vascular development. We measured childhood blood pressure and obtained childhood carotid intima media thickness and carotid distensibility through ultrasonography at 9 years.

Results

After adjustment for maternal sociodemographic and lifestyle characteristics, no associations were present of maternal first and second trimester angiogenic factors with childhood blood pressure, carotid intima media thickness (IMT) or distensibility in the total population. In preterm born children only, higher maternal second trimester PlGF concentrations, but not sFlt-1 concentrations, were associated with a lower childhood diastolic blood pressure (difference: -0.16 SDS (95% CI -0.30, –0.03) per SDS increase in maternal second trimester PlGF concentration). No associations among children born small-for-gestational age were present.

Conclusions

In a low-risk population, maternal angiogenic factors in the first half of pregnancy are not associated with childhood blood pressure, carotid IMT or carotid distensibility after considering maternal socio-demographic and lifestyle factors. Only in children born preterm, lower maternal second trimester PlGF concentrations are associated with higher childhood diastolic blood pressure, but not with other vascular outcomes.

Sedentary behaviors and gestational diabetes mellitus: A systematic review

AIM

Sedentary behaviors are activities that expend less energy than 1.5 metabolic equivalents, such as watching TV, sitting. We aim to systematically review the evidence to determine the association of sedentary behavior (SB) with the risk of gestational diabetes mellitus, and the associations of SB with health outcomes in pregnant women with gestational diabetes mellitus (GDM) and women at high risk of gestational diabetes mellitus.

METHODS

Two researchers independently performed a literature search using PubMed, Medline, EMBASE, CINAHL, the Cochrane Library, the Rehabilitation and Sports Medicine Source, and the Sedentary Behavior Research Database for studies published up to January 27, 2021. Randomized controlled trials, quasi-experimental studies, and observational studies were screened and selected if SB was assessed in the context of gestational diabetes mellitus. Two reviewers extracted the relevant information and independently assessed the included studies for quality and bias.

RESULTS

Eighteen studies were included, involving 60 804 patients, and the timeline of the original study included was from 2006 to 2021. Our review showed that SB before pregnancy was not associated with the risk of gestational diabetes mellitus, while SB during pregnancy was uncertain about the risk of gestational diabetes mellitus. In addition, there were significant associations between SB time and metabolic outcomes. In addition, SB may cause some adverse maternal and fetal outcomes.

CONCLUSION

SB is likely to be the intermediary variable between occurrence of GDM and adverse maternal and infant outcome, rather than a direct influencing factor. Limited by the quantity and quality of included studies, the above conclusions need to be verified by more high-quality studies.

Relationships Among Neighborhood Poverty, Access to Healthy Food, and Diabetes Self-Management in Women Who Received Perinatal Nurse Home Visits

OBJECTIVE

To examine the relationships among neighborhood poverty, access to healthy food, and diabetes self-management in pregnant women in an urban setting who received perinatal nurse home visits.

DESIGN

Exploratory descriptive secondary analysis of existing individual-level and neighborhood-level data.

SETTING

Philadelphia, Pennsylvania, United States.

PARTICIPANTS

Women who were pregnant, had diabetes, and were enrolled in the citywide perinatal nurse home visiting program because of their diabetes (N = 264).

METHODS

We retrieved neighborhood-level aggregated data on poverty and access to healthy food from PolicyMap, a geographic information system. We retrieved individual-level data from a clinical research database. Access to healthy food was operationalized at the individual level by reported use of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). We operationalized diabetes self-management as good or poor glycemic control. We conducted descriptive and logistic regression analyses.

RESULTS

We found no relationship between neighborhood-level poverty and neighborhood-level access to healthy food with women's glycemic control. However, at the individual level, use of the WIC program was associated with glycemic control (p = .034). Participants who reported not using this program were two times more likely to have poor glycemic control than those who did (OR = 2.045, 95% confidence interval [1.003, 2.045]).

CONCLUSION

It is important to understand how the complex interplay between neighborhoods and individual factors of poverty and access to healthy food influences health outcomes among pregnant women. The WIC program may mediate neighborhood influence on diabetes self-management. Future research is warranted on how this program and nurse home visiting services can optimize maternal health outcomes among women who have diabetes during pregnancy.

Early pregnancy essential and non-essential metal mixtures and gestational glucose concentrations in the 2nd trimester: Results from project viva

Metals are involved in glucose metabolism, and some may alter glycemic regulation. However, joint effects of essential and non-essential metals on glucose concentrations during pregnancy are unclear. This study explored the joint associations of pregnancy exposures to essential (copper, magnesium, manganese, selenium, zinc) and non-essential (arsenic, barium, cadmium, cesium, lead, mercury) metals with gestational glucose concentrations using 1,311 women enrolled 1999-2002 in Project Viva, a Boston, MA-area pregnancy cohort. The study measured erythrocyte metal concentrations from 1st trimester blood samples and used glucose concentrations measured 1 h after non-fasting 50-gram glucose challenge tests (GCT) from clinical gestational diabetes screening at 26-28 weeks gestation. Bayesian Kernel Machine Regression (BKMR) and quantile-based g-computation were applied to model the associations of metal mixtures-including their interactions-with glucose concentrations post-GCT. We tested for reproducibility of BKMR results using generalized additive models. The BKMR model showed an inverse U-shaped association for barium and a linear inverse association for mercury. Specifically, estimated mean glucose concentrations were highest around 75th percentile of barium concentrations [2.1 (95% confidence interval: -0.2, 4.4) mg/dL higher comparing to the 25th percentile], and each interquartile range increase of erythrocyte mercury was associated with 1.9 mg/dL lower mean glucose concentrations (95% credible interval: -4.2, 0.4). Quantile g-computation showed joint associations of all metals, essential-metals, and non-essential metals on gestational glucose concentrations were all null, however, we observed evidences of interaction for barium and lead. Overall, we found early pregnancy barium and mercury erythrocytic concentrations were associated with altered post-load glucose concentrations in later pregnancy, with potential interactions between barium and lead.

Associations between periconceptional lifestyle behaviours and adverse pregnancy outcomes

Background

While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours.

Methods

A secondary analysis took place within a prospective multicentre cohort study in the Netherlands, including 3,684 pregnant women. Baseline characteristics and preconceptional and first trimester lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester. Adverse pregnancy outcomes (hypertensive disorders in pregnancy (HDP), small for gestational age (SGA), gestational diabetes (GDM) and spontaneous preterm birth (sPTB)) were reported by healthcare professionals. Data were collected between 2012 and 2014 and analysed using multivariate logistic regression.

Results

Women who are overweight, and especially obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95 % Confidence Interval (CI) 1.31–1.99) and aOR 2.85 (95 %CI 2.20–3.68), respectively), particularly HDP and GDM. Women who prenatally continued smoking attained higher odds for SGA (aOR 1.91 (95 %CI 1.05–1.15)) compared to the reference group, but these odds decreased when women prenatally quit smoking (aOR 1.14 (95 %CI 0.59–2.21)). Women who did not use folic acid supplements tended to have a higher odds of developing adverse pregnancy outcomes (aOR 1.28 (95 %CI 0.97–1.69)), while women who prenatally started folic acid supplements did not (aOR 1.01 (95 %CI 0.82–1.25)).

Conclusions

Our results indicate that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes. Therefore, intervening as early as the preconception period could benefit the health of future generations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03935-x.

Educational Attainment, Decision-Making Preferences, and Interest in Evidence-Based Diabetes Prevention among Women with a History of Gestational Diabetes Mellitus

Background: The Diabetes Prevention Program (DPP) showed that lifestyle change or metformin is equally efficacious in preventing diabetes in women who have had gestational diabetes mellitus (GDM). Few studies have investigated the relationship between education and willingness to engage in either intervention and between education and preferred decision-making style. Methods: Within a large health system, we surveyed insured women 18-64 years old with a history of GDM, identified through the electronic health record. We estimated preference for decision-making style and interest in DPP lifestyle change and/or metformin by educational level, using multivariate logistic regression models controlling for age, race, and ethnicity. Results: Our sample (n = 264) was 36% Latino, 29% Asian, 28% non-Latino white, and 5% African American, with a mean age of 37 years. In terms of education, 31% had a postgraduate degree, 41% were college graduates, and 29% did not graduate from college. In multivariate analyses, willingness to engage in either intervention did not vary by education. Women who did not graduate from college were more likely to leave medical decisions to their provider (p = 0.004) compared to women with a college or postgraduate degree. However, regardless of education, over 80% of women preferred to make medical decisions themselves or jointly with their provider. Conclusions: Most women prefer to play an active role in their own medical decisions and have an interest in both evidence-based diabetes prevention strategies. This suggests that shared decision-making is appropriate for many women with a history of GDM and different levels of educational attainment.

Educational differences in prenatal anxiety and depressive symptoms and the role of childhood circumstances

Despite interest in unequal maternal and child health, previous research has not focused on educational differences in anxiety and depressive symptoms during pregnancy, although they threaten maternal and child wellbeing. Using the prospective FinnBrain Cohort Study data on 2763 pregnant women over the three pregnancy trimesters and Finnish register data, we estimated multilevel regressions to describe educational differences in prenatal anxiety and depressive symptoms and to analyze whether they can be explained by socioeconomic background, parental mental disorders and adverse experiences during childhood. Prenatal anxiety was measured by the Symptom Checklist (SCL-90-anxiety subscale) and depressive symptoms by the Edinburgh Postnatal Depression Scale (EPDS). The results showed less anxiety and depressive symptoms among more educated pregnant women. In accounting for the educational differences, we found support for both the social selection and the social causation perspectives. Adverse childhood experiences partly explained the educational differences, highlighting the role of an undisturbed childhood environment in prenatal mental health disparities. Results from the regression models as well as sensitivity analyses also suggested that education is likely to buffer against prenatal distress.

•

Higher education predicted lower anxiety and depressive symptoms during pregnancy.

•

Educational differences were not attributable to childhood SES or parental mental health.

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Adverse childhood experiences partly explained the educational differences.

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Sensitivity analysis suggested education to buffer against prenatal distress.

Obesity can offset the cardiometabolic benefits of gestational exercise

Pregnancy exercise can prevent excessive gestational weight gain (EGWG), gestational diabetes mellitus (GDM) and hypertension (GH), but inter-individual variability has not been explored. We aimed to analyze the prevalence--and potential sociodemographic and medical predictors of--non-responsiveness to gestational exercise, and the association of non-responsiveness with adverse pregnancy outcomes. Among 688 women who completed a supervised light-to-moderate intensity exercise program (three ~1-h sessions/week including aerobic, resistance, and pelvic floor muscle training) until near-term, those who showed EGWG, GDM or GH were considered 'non-responders'. A low prevalence of non-responders was observed for GDM (3.6%) and GH (3.4%), but not for EGWG (24.2%). Pre-pregnancy obesity was the strongest predictor of non-responsiveness for GH (odds ratio 8.40 [95% confidence interval 3.10-22.78] and EGWG (5.37 [2.78-10.39]), whereas having a highest education level attenuated the risk of being non-responder for GDM (0.10 [0.02-0.49]). Non-responsiveness for EGWG was associated with a higher risk of prolonged labor length, instrumental/cesarean delivery, and macrosomia, and of lower Apgar scores. No association with negative delivery outcomes was found for GDM/GH. In summary, women with pre-pregnancy obesity might require from additional interventions beyond light-to-moderate intensity gestational exercise (e.g., diet and/or higher exercise loads) to ensure cardiometabolic benefits.

The impact of educational attainment on the occurrence of gestational diabetes mellitus in two successive pregnancies of Finnish primiparous women: a population-based cohort study

AIMS

To assess the impact of educational attainment on the occurrence and recurrence of gestational diabetes mellitus (GDM) in two successive pregnancies in primiparous women.

METHODS

This is a population-based observational cohort study including all 2347 Finnish women without previously diagnosed diabetes, aged ≥ 20 years from the city of Vantaa, Finland, who gave birth to their first and second child between 2009 and 2015. National registries provided data on study participants. We divided the population into four groups according to the presence of GDM in the two pregnancies (GDM-/-, n = 1820; GDM-/+, n = 223; GDM+/-, n = 113; GDM+/+, n = 191).

RESULTS

The occurrence of GDM in the first pregnancy was 13.0% (n = 304) and 17.6% (n = 414) in the second. The recurrence rate of GDM was 62.8%. The four groups did not differ in relation to educational attainment (p = 0.11). In multinomial regression analysis, educational attainment protected from GDM in the second pregnancy [relative risk ratio 0.93 (95% confidence interval (CI) 0.86-0.99) per year of schooling for being GDM-/+ compared with GDM-/-]. In multivariate logistics models, prepregnancy body mass index at the first pregnancy [odds ratio (OR) 1.53 per 1-standard deviation (SD) (95% CI 1.22-1.91)], first-born birth weight z-score [OR 1.30 per 1-SD (95% CI 1.00-1.67)], and inter-pregnancy weight change [OR 1.66 per 1-SD (95% CI 1.27-2.16)], but not educational attainment, predicted recurrence of GDM.

CONCLUSIONS

The recurrence rate of GDM was high. Education protected from novel GDM in the second pregnancy, but was not associated with GDM recurrence.

Adherence to the Norwegian dietary recommendations in a multi-ethnic pregnant population prior to being diagnosed with gestational diabetes mellitus

Maternal diet is a modifiable risk factor for the development of gestational diabetes mellitus (GDM). Even though pregnant women are considered to be motivated to eat healthy, previous research found unhealthy eating patterns among some ethnic and lower socio-economic status groups. This cross-sectional study assessed adherence to national dietary recommendations prior to GDM diagnosis in a multi-ethnic population comprising 237 pregnant women. Participants were diagnosed with GDM after performing a two-hour oral glucose tolerance test ≥ 9 mmol/L. Participants answered a 41-item Food Frequency Questionnaire about dietary habits prior to being diagnosed with GDM from October 2015 to March 2018. Their scores were based on adherence to the recommended intake in each food group and summed into a Healthy Diet Score (HDS). Results showed low adherence to national dietary recommendations. A significantly higher proportion of non-native Norwegian-speaking women had a high HDS compared with native Norwegian-speaking women. Participants with a normal prepregnancy weight were more likely to have a high HDS compared with overweight or obese participants. Participants showed low adherence to the recommendations for whole grains, vegetables, and fruits and berries, and a relatively low proportion adhered to the recommendations for intakes of fish, red/processed meat, and ready-made meals. However, the food group intakes varied by country of birth. Given the increase in women with GDM and the emerging evidence that maternal diet is a modifiable risk factor for GDM, effective nutrition communication strategies in antenatal care are urgently needed.

Prevalence of gestational diabetes mellitus and its determinants among pregnant women in Beijing

Objective: To investigate the prevalence of gestational diabetes mellitus (GDM) and its determinants among pregnant women in the Tongzhou district of Beijing, China.Methods: This study was performed on data collected in the routine work of the prenatal health care system from 27,119 pregnant women in the Tongzhou district of Beijing during 2013-2018. Univariate and multivariate logistic regression analyses were used to assess the factors associated with GDM.Results: The overall prevalence of GDM was 24.24%, and it showed an increasing trend over the 6 years. A univariate analysis showed that the prevalence of GDM increased with age (p < .001). In multivariate analysis, it was found that women with a non-local household registration, as well as those without a local household registration but whose husbands had one, had a lower risk for GDM than both spouses who had local registration. Women who were overweight/obese had a higher risk for GDM than women with a normal pre-pregnancy body mass index. Multipara women had a lower likelihood of developing GDM.Conclusions: We found a slightly higher prevalence of GDM in the Tongzhou district of Beijing than has been found in other studies, and the prevalence rose over the 6 years of the study. Advanced age, pre-pregnancy overweight or obesity, and local household registration were important risk factors for GDM. Multiparity may be a protective factor against developing GDM. Intensive health education on related determinants should be strengthened for the prevention and control of GDM, especially in high-risk women.

Environmental and Socioeconomic Factors Influence the Live-Born Incidence of Congenital Heart Disease: A Population-Based Study in California

BACKGROUND

The development of congenital heart disease (CHD) is multifactorial with genetic and environmental influences. We sought to determine the relationship between socioeconomic and environmental factors with the incidence of CHD among live‐born infants in California and to determine whether maternal comorbidities are in the causal pathway.

METHODS AND RESULTS

This was a population‐based cohort study in California (2007–2012). The primary outcome was having significant CHD. Predictors included socioeconomic status and environmental exposure to pollutants determined by U.S. Census data. A social deprivation index and environmental exposure index was assigned based on neighborhood socioeconomic variables, categorized into 4 quartiles. Quartile 1 was the best with the least exposure to pollutants and social deprivation, and quartile 4 was the worst. Multivariate logistic regression and mediation analyses were performed. Among 2 419 651 live‐born infants, the incidence of CHD was 3.2 per 1000 live births. The incidence of CHD was significantly higher among those in quartile 4 compared with quartile 1 (social deprivation index: 0.35% versus 0.29%; odds ratio [OR], 1.31; 95% CI, 1.21–1.41; environmental exposure index: 0.35% versus 0.29%; OR, 1.23; 95% CI, 1.15–1.31) after adjusting for maternal race/ethnicity and age and accounting for the relationship between the 2 primary predictors. Maternal comorbidities explained 13% (95% CI, 10%–20%) of the relationship between social deprivation index and environmental exposure index with the incidence of CHD.

CONCLUSIONS

Increased social deprivation and exposure to environmental pollutants are associated with the incidence of live‐born CHD in California. Maternal comorbidities explain some, but not all, of this relationship. These findings identify targets for social policy initiatives to minimize health disparities.

Evaluating associations between early pregnancy trace elements mixture and 2nd trimester gestational glucose levels: A comparison of three statistical approaches

OBJECTIVE

Studies have shown that individual trace element levels might be associated with abnormal glycemic status, with implications for diabetes. Few studies have considered these trace elements as a mixture and their impact on gestational glucose levels. Comparing three statistical approaches, we assessed the associations between essential trace elements mixture and gestational glucose levels.

METHODS

We used data from 1720 women enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Fetal Growth Study, for whom trace element concentrations (zinc, selenium, copper, molybdenum) were measured by inductively coupled plasma mass spectrometry (ICP-MS) using plasma collected during the 1st trimester. Non-fasting glucose levels were measured during the gestational diabetes mellitus (GDM) screening test in the 2nd trimester. We applied (1) Bayesian Kernel Machine Regression (BKMR); (2) adaptive Least Absolute Shrinkage and Selection Operator (LASSO) in a mutually adjusted linear regression model; and (3) generalized additive models (GAMs) to evaluate the joint associations between trace elements mixture and glucose levels adjusting for potential confounders.

RESULTS

Using BKMR, we observed a mean 2.7 mg/dL higher glucose level for each interquartile increase of plasma copper (95% credible interval: 0.9, 4.5). The positive association between plasma copper and glucose levels was more pronounced at higher quartiles of zinc. Similar associations were detected using adaptive LASSO and GAM. In addition, results from adaptive LASSO and GAM suggested a super-additive interaction between molybdenum and selenium (both p-values = 0.04).

CONCLUSION

Employing different statistical methods, we found consistent evidence of higher gestational glucose levels associated with higher copper and potential synergism between zinc and copper on glucose levels.

A Prospective Study of Early Pregnancy Essential Metal(loid)s and Glucose Levels Late in the Second Trimester

CONTEXT

Studies suggest many essential trace metal(loid)s are involved in glucose metabolism, but the associations among pregnant women are unclear.

OBJECTIVE

To assess associations between early pregnancy plasma zinc, selenium, copper, and molybdenum levels and blood glucose levels later in the second trimester.

DESIGN

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies‒Singleton Cohort is a prospective cohort study conducted between July 2009 and January 2013.

SETTING

Twelve academic research hospitals in the United States.

PATIENTS

A total of 1857 multiracial, nonobese, healthy women.

MAIN OUTCOME MEASURE

Blood glucose levels from 1-hour 50-g gestational load test (GLT) at 24 to 28 weeks of gestation.

RESULTS

Higher concentrations of first-trimester copper were associated with higher glucose levels from the GLT (i.e., every 50% increase in copper concentration was related to 4.9 mg/dL higher glucose level; 95% CI: 2.2, 7.5 mg/dL) adjusted for maternal sociodemographic characteristics and reproductive history. In contrast, every 50% increase in molybdenum concentration was associated with 1.2 mg/dL lower mean glucose level (95% CI: -2.3, -0.1 mg/dL). The magnitude of these associations was greater at the upper tails of glucose level distribution based on quantile regressions of the 10th, 50th, and 90th percentiles.

CONCLUSIONS

Higher copper and lower molybdenum concentrations could increase the risk of glucose dysregulation during pregnancy, with women at higher risk of gestational diabetes mellitus potentially affected to a greater extent. Further work is needed to understand the mechanisms involved with early pregnancy essential metal(loid)s to inform clinical diagnosis and prevention of glucose intolerance during pregnancy.

ARE THE FACTORS AFFECTING ADVERSE PREGNANCY OUTCOMES DIFFERENT IN OBESE GESTATIONAL DIABETES PREGNANT WOMEN RECEIVING DIET OR INSULIN TREATMENT?

CONTEXT

We aimed to examine the factors affecting adverse gestational outcome in gestational diabetes (GDM) patients, who were grouped as obese and normal- weight, having only-diet, or insulin treatments.

SUBJECTS AND METHODS

The study included 373 patients, treated with diet or insulin. These patients were sub-grouped as obese and non-obese, and examined retrospectively. The variables affecting adverse gestational outcome in obese GDM patients having dietary and/ or insulin treatments were detected with multiple regression analysis.

RESULTS

The weight gained during pregnancy in the GDM group having insulin treatment was more than the one in only-diet treated GDM group (p=0.004). Pre-pregnancy body mass index, the weight gained during pregnancy, hemoglobin A1C levels in the second and third trimesters, caesarian rates were higher in the insulin-treated obese patients than in the other groups (p<0.001). The odds ratio for fasting blood glucose level in insulin-treated obese GDM group was 1.081 (95% CI =1.004 - 1.163) (p=0.039); and it was 0.982 (95% CI =0.924 - 1.002) (p=0.048) for the weight gained during pregnancy, in only-diet treated obese GDM patients.

CONCLUSION

The control of weight gained during pregnancy, and of fasting blood glucose levels in obese patients having GDM, is important to decrease adverse gestational outcome.

Can a Simple Dietary Screening in Early Pregnancy Identify Dietary Habits Associated with Gestational Diabetes?

Gestational diabetes mellitus (GDM) is predominantly a lifestyle disease, with diet being an important modifiable risk factor. A major obstacle for the prevention in clinical practice is the complexity of assessing diet. In a cohort of 1651 Icelandic women, this study examined whether a short 40-item dietary screening questionnaire administered in the 1st trimester could identify dietary habits associated with GDM. The dietary variables were aggregated into predefined binary factors reflecting inadequate or optimal intake and stepwise backward elimination was used to identify a reduced set of factors that best predicted GDM. Those binary factors were then aggregated into a risk score (range: 0–7), that was mostly characterised by frequent consumption of soft drinks, sweets, cookies, ice creams and processed meat. The women with poor dietary habits (score ≥ 5, n = 302), had a higher risk of GDM (RR = 1.38; 95%CI = 3, 85) compared with women with a more optimal diet (score ≤ 2, n = 407). In parallel, a pilot (n = 100) intervention was conducted among overweight and obese women examining the effect of internet-based personalized feedback on diet quality. Simple feedback was given in accordance with the answers provided in the screening questionnaire in 1st trimester. At the endpoint, the improvements in diet quality were observed by, as an example, soft drink consumption being reduced by ~1 L/week on average in the intervention group compared to the controls. Our results suggest that a simple dietary screening tool administered in the 1st trimester could identify dietary habits associated with GMD. This tool should be easy to use in a clinical setting, and with simple individualized feedback, improvements in diet may be achieved.

Association between maternal education level and gestational diabetes mellitus: a meta-analysis

Aims: The association between maternal education and gestational diabetes mellitus (GDM) has been discussed in considerable studies, yet the inconsistent findings still exist. The aim of this study is to investigate whether maternal education level is associated with GDM risk.Material and methods: PubMed, ScienceDirect, and Cochrane Library databases were searched up to October 2018. Observational studies on the association between maternal education level and GDM risk were included. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) for highest versus lowest level of maternal education were estimated using a random-effects model.Results: As compared to lowest education level, the pooled OR for women with highest education level was 0.75 (95% CI: 0.53-1.05). After adjusting for body mass index (BMI) and family history of diabetes, the estimated effect of maternal education on GDM were 0.68 (95% CI: 0.57-0.80) and 0.75 (95% CI: 0.60-0.92), respectively.Conclusions: Our results indicate that there is no significant association between maternal education level and risk of GDM.

Impact of maternal income on the risk of gestational diabetes mellitus in primiparous women

AIMS

Findings concerning the impact of socio-economic status on the risk of gestational diabetes mellitus (GDM) are inconclusive and little is known about the simultaneous impact of income and educational attainment on the risk of GDM. This study aims to assess the impact of maternal prepregnancy income in combination with traditional GDM risk factors on the incidence of GDM in primiparous women.

METHODS

This is an observational cohort study including 5962 Finnish women aged ≥ 20 years from the city of Vantaa, Finland, who delivered for the first time between 2009 and 2015, excluding women with pre-existing diabetes mellitus. The Finnish Medical Birth Register, Finnish Tax Administration, Statistics Finland, Social Insurance Institution of Finland and patient healthcare records provided data for the study. We divided the study population according to five maternal income levels and four educational attainment levels.

RESULTS

Incidence of GDM decreased with increasing income level in primiparous women (P < 0.001 for linearity, adjusted for smoking, age, BMI and cohabiting status). In an adjusted two-way model, the relationship was significant for both income (P = 0.007) and education (P = 0.039), but there was no interaction between income and education (P = 0.52).

CONCLUSIONS

There was an inverse relationship between both maternal prepregnancy taxable income and educational attainment, and the risk of GDM in primiparous Finnish women.

Maternal urinary phthalate metabolites in relation to gestational diabetes and glucose intolerance during pregnancy

BACKGROUND

Phthalates are common plasticizer chemicals that have been linked to glucose intolerance in the general population, but there is only limited research on their association with gestational diabetes (GDM).

OBJECTIVE

We evaluated the association between 11 urinary phthalate metabolites and GDM, impaired glucose tolerance (IGT), and continuous blood glucose concentration during pregnancy in The Infant Development and Environment Study (TIDES). Based on prior study results, our primary analyses focused on monoethyl phthalate (MEP) in relation to our outcomes of interest.

STUDY DESIGN

We used multi-variable logistic regression to examine the odds of GDM and IGT in relation to an interquartile-range (IQR) increase in natural log (ln)-transformed, specific gravity (SG)-adjusted first trimester (T1) and average of T1 and third trimester (T3) ("T1T3avg") phthalate metabolite concentrations. We fit linear regression models to examine the percent change in blood glucose per IQR increase in ln-transformed, SG-adjusted T1 and T1T3avg phthalates. In sensitivity analyses, we examined interactions between exposure and race. We adjusted for maternal age, maternal body mass index, study center, race/ethnicity, parity, and gestational age at glucose testing.

RESULTS

In our sample of 705 pregnant women, we observed 60 cases of GDM, 90 cases of IGT, and an average GLT blood glucose of 113.6 ± 27.7 mg/dL. In our primary analysis, T1T3avg MEP was positively associated with GDM ([OR (95% CI) per IQR increase] T1T3avg MEP: 1.61 (1.10, 2.36)). In secondary analyses, most other phthalates were not found to be related to study outcomes, though some associations were noted. Sensitivity analyses indicated possible strong race-specific associations in Asians, though these results are based on a small sample size (n = 35).

CONCLUSION

In alignment with our a priori selection, we documented an association between T1T3avg MEP and GDM. Additional phthalate metabolites were also found to be linked to glucose intolerance, with possible stronger associations in certain racial/ethnic subgroups. Given the prevalence of phthalate exposures and the growing evidence of associations with metabolic outcomes, future studies should continue to examine this question in diverse cohorts of pregnant women, particularly in those who may be at higher risk for GDM and IGT.

Exploring Fetal Sex Dimorphism in the Risk Factors of Gestational Diabetes Mellitus-A Prospective Cohort Study

Gestational diabetes mellitus (GDM) is a common pregnancy complication. Its etiology remains incompletely understood. Studies in recent years suggest that fetal sex may affect maternal metabolic milieu during pregnancy. We sought to assess whether there is fetal sex dimorphism in the risk factors of GDM. In a prospective pregnancy cohort in Shanghai, China, we studied 2,435 singleton pregnant women without pre-existing diabetes. GDM was diagnosed according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG)' criteria. Log-binomial models were applied to obtain the adjusted relative risk (aRR). A total of 380 (15.6%) women developed GDM. Family history of diabetes was associated with an increased risk of GDM in women bearing a female fetus [aRR 1.74 (1.27-2.40), p < 0.001], but not in women bearing a male fetus (p = 0.68) (test for interaction, p = 0.03). Alcohol drinking was associated with an increased risk of GDM in women bearing a male fetus only (p = 0.023), although the test for interaction did not reach statistical significance (p = 0.055). In conclusion, family history of diabetes was associated with an increased risk of GDM in women bearing a female fetus only in this Chinese pregnancy cohort. There may be a need to consider fetal sex dimorphism in evaluating the risk factors of GDM.

ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. However, debate continues to surround the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purposes of this document are the following: 1) provide a brief overview of the understanding of GDM, 2) review management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed.

Indicators of socio-economic status and risk of gestational diabetes mellitus in pregnant women in urban Tianjin, China

AIMS

To examine associations between the indicators of socio-economic status (SES) and gestational diabetes mellitus (GDM).

METHODS

From 2010 to 2012, 17 659 women underwent glucose challenge test (GCT) and oral glucose tolerance test if GCT ≥ 7.8 mmol/L at 24-28 gestational weeks in 6 urban districts of Tianjin, China. Binary logistic regression was used to obtain adjusted odds ratio (OR) of SES for GDM, as defined by education attainment and family monthly income.

RESULTS

A total of 1264 women (7.2%) were found to have GDM. If the women with low-middle income and high school or below used as the reference group, the middle-high income group and the high income group were associated with decreased risks of GDM (OR: 0.85, 95%CI: 0.71-1.00 & 0.80, 0.65-0.98) while tertiary education attainment was associated with decreased risk of GDM (0.75, 0.58-0.97). Women with higher income and/or higher education attainment tended to have a decreased risk of GDM (P for trend: 0.0105). All these significant ORs were attenuated to be non-significant by adjustment for pre-pregnancy body mass index (BMI), but not by adjustment for gestational weight gain (GWG).

CONCLUSIONS

In urban Tianjin, indicators of high SES were associated with decreased risk of GDM via decreased pre-pregnancy BMI.

Evaluation of neonatal and maternal morbidity in mothers with gestational diabetes: a population-based study

BACKGROUND

Gestational diabetes mellitus (GDM) is the most frequent complication during pregnancy. Untreated GDM is a severe threat to maternal and neonatal health. Based on recent evidence, up to 15% of all pregnancies may be affected by GDM. We hypothesized that in a rural birth cohort, higher maternal BMI and adverse socioeconomic conditions would promote GDM, which in turn would lead to adverse effects on pregnancy outcomes.

METHODS

The current study is a part of a population-based cohort study examining the health and socioeconomic information from 5801 mothers and their children. The study, titled the Survey of Neonates in Pomerania (SNiP), was based in northeastern Pomerania, Germany (2002-2008).

RESULTS

The cumulative incidence of GDM was 5.1%. Multiple logistic regression revealed prepregnancy overweight (OR 1.84 (95% CI 1.27-2.68)), prepregnancy obesity (OR 3.67 (2.48-5.44)) and maternal age (OR 1.06 (1.03-1.08)) as risk factors for GDM (p = 0.001). Alcohol use during pregnancy (OR 0.61 (0.41-0.90), a higher monthly income (OR 0.62 (0.46-0.83)), and the highest level of education (OR 0.44 (0.46-0.83)) decreased the risk of GDM. Newborns of GDM mothers had an increased risk of hypoglycaemia (OR 11.71 (7.49-18.30)) or macrosomia (OR 2.43 (1.41-4.18)) and were more often delivered by primary (OR 1.76 (1.21-2.60)) or secondary C-section (OR 2.00 (1.35-2.97)). Moreover, they were born 0.78 weeks (95% CI -1.09 - -0.48 weeks) earlier than infants of mothers without diabetes, resulting in higher percentage of late preterm infants with a gestational age of 32-36 weeks (11.1% vs. 6.96%).

CONCLUSIONS

Age and BMI before pregnancy were the predominant mediators of the increased risk of GDM, whereas a higher income and educational level were protective. GDM affected relevant perinatal and neonatal outcomes based on its association with an increased risk of delivery by C-section, preterm birth, macrosomia at birth and neonatal hypoglycaemia.

Perfluoroalkyl substances and glycemic status in pregnant Danish women: The Odense Child Cohort

BACKGROUND

Perfluoroalkyl substances (PFASs) are persistent chemicals with suspected endocrine disrupting abilities applied in consumer products. PFASs have potentially modulating effects on glucose homeostasis. Insulin resistance prevails during third trimester of pregnancy, and this challenge of glucose homeostasis may reveal putative effects of PFAS concentrations on glycemic status.

OBJECTIVE

To investigate associations between five serum PFASs and glucose-related outcomes in pregnant Danish women based on their risk of gestational diabetes mellitus (GDM).

METHODS

In the prospective Odense Child Cohort serum concentrations of five PFASs - perfluorohexane sulfonic acid (PFHxS), perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA) and perfluorodecanoic acid (PFDA) - were measured at median gestational week (GW) 11 in pregnant women. An oral glucose tolerance test (OGTT) was performed at GW 28. The statistical analysis was conducted among 158 women with high GDM risk and 160 women with low GDM risk matched by gestational age. Multiple linear regression models were performed to estimate associations between PFAS concentrations and glucose, insulin, C-peptide, homeostatic model of assessment of insulin resistance (HOMA-IR) and beta cell function (HOMA-%β), and insulin sensitivity (Matsuda index) during the 2-h OGTT.

RESULTS

In women with high risk for GDM, a two-fold increase in PFHxS concentration was significantly associated with increased fasting glucose, fasting insulin and HOMA-IR after adjusting for age, parity, educational level and pre-pregnancy BMI. Adjusting for the same confounders, a doubling in PFNA concentration was associated with higher fasting insulin and HOMA-%β. In women with low GDM risk, no associations were found between PFAS concentrations and glucose-related outcomes.

CONCLUSION

PFHxS and PFNA concentrations were associated with impaired glycemic status in metabolically vulnerable pregnant women and might further enhance the risk of developing GDM.

Urinary Bisphenol A Concentration and Gestational Diabetes Mellitus in Chinese Women

BACKGROUND

Bisphenol A (BPA) has been associated with variable metabolic effects in animal models. It is unknown whether BPA exposure affects glucose tolerance in pregnancy. We aimed to investigate whether maternal urinary BPA concentration is associated with gestational diabetes mellitus (GDM).

METHODS

This study included 620 pregnant women from Shanghai, China 2012-2013. Maternal urinary BPA concentration was measured by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). GDM (n = 79) was diagnosed according to the criteria of the International Association of Diabetes and Pregnancy Study Groups (IADPSG). Multivariate regressions were used to explore the relationships of urinary BPA with GDM, plasma glucose levels in the 75-g 2-hour oral glucose tolerance test (OGTT), birth weight, and ponder index.

RESULTS

The geometric mean of BPA was 1.32 μg/L. After adjustment for maternal age, education, husband smoking status, prepregnancy body mass index (BMI), and urinary creatinine concentration, plasma glucose at 2 hours in the 75-g OGTT was 0.36 mmol/L lower (95% confidence index [CI] = -0.73, 0.01) for women with urine BPA in the high versus the low tertile. For each unit increase in natural log-transformed BPA, the odds of GDM was reduced by 27% (odds ratio (OR) = 0.73; 95% CI = 0.56, 0.97), the birth weight decreased by 25.70 g (95% CI = -54.48, 3.07), and ponder index was decreased by 0.02 (100 g/cm) (95% CI = -0.03, 0.00).

CONCLUSIONS

Higher maternal urinary BPA concentrations were associated with reduced risk of GDM and marginally lower birth weight and ponder index.

Socioeconomic, environmental and lifestyle factors associated with gestational diabetes mellitus: A matched case-control study in Beijing, China

Gestational diabetes mellitus (GDM) is a common health problem during pregnancy and its prevalence is increasing globally, especially in China. The aim of this study was to investigate socioeconomic, environmental and lifestyle factors associated with GDM in Chinese women. A matched pair case-control study was conducted with 276 GDM women and 276 non-GDM women in two hospitals in Beijing, China. Matched factors include age and pre-pregnancy body mass index (BMI). GDM subjects were defined based on the International Association of Diabetes Study Group criteria for GDM. A conditional logistic regression model with backward stepwise selection was performed to predict the odds ratio (OR) for associated factors of GDM. The analyses of data show that passive smoking at home (OR = 1.52, p = 0.027), passive smoking in the workplace (OR = 1.71, p = 0.01), and family history of diabetes in first degree relatives (OR = 3.07, p = 0.004), were significant factors associated with GDM in Chinese women. These findings may be utilized as suggestions to decrease the incidence of GDM in Chinese women by improving the national tobacco control policy and introducing public health interventions to focus on the social environment of pregnant women in China.

Pregnancy urinary bisphenol-A concentrations and glucose levels across BMI categories

BACKGROUND

Pregnancy exposure to bisphenol-A (BPA) may be associated with gestational diabetes (GDM), but evidence from human studies is limited. Moreover, adiposity is associated with both higher BPA concentrations and GDM risk, and may act as a confounder or an effect modifier of the association.

METHODS

We included 350 term births from the Lifecodes pregnancy cohort (Boston, MA), who had 1st and 2nd trimester measures of urinary BPA concentrations available. BPA measures were SG-adjusted and categorized into quartiles (Q). Multivariable-adjusted linear regressions were used to determine the association between BPA, at both 1st and 2nd trimester, and glucose, in the overall population and by categories of 1st trimester BMI.

RESULTS

No clear associations were seen between BPA and glucose levels in the overall population. From stratified analyses there was suggestive evidence of effect modification by maternal 1st trimester BMI, with significant associations observed among obese/overweight participants (1st trimester BPA concentrations for Q3 vs Q1: adj.β = 14.1 mg/dL; 95% CI: 1.5, 26.6) (2nd trimester BPA concentrations for Q2 vs Q1: adj. β = 16.9 mg/dL; 95% CI: 2.6, 31.2).

CONCLUSION

No associations were found between BPA and glucose levels in the overall population. However, moderately high BPA concentrations were associated with increased glucose levels among overweight/obese women-a subgroup at high-risk of elevated glucose levels in pregnancy.

The impact of a daily smartphone-based feedback system among women with gestational diabetes on compliance, glycemic control, satisfaction, and pregnancy outcome: a randomized controlled trial

BACKGROUND

Patient compliance and tight glycemic control have been demonstrated to improve outcome in pregnancies complicated by gestational diabetes mellitus. The use of advanced technological tools, including smartphone-based platforms, to improve medical care and outcomes has been demonstrated in various fields of medicine, but only a few small studies were performed with gestational diabetes mellitus patients.

OBJECTIVE

We aimed to study the impact of introducing a smartphone-based daily feedback and communication platform between gestational diabetes mellitus patients and their physicians, on patient compliance, glycemic control, pregnancy outcome, and patient satisfaction.

STUDY DESIGN

This is a prospective, single-center, randomized controlled trial. Newly diagnosed gestational diabetes mellitus patients presenting to our multidisciplinary diabetes-in-pregnancy clinic were randomized to: (1) routine biweekly prenatal clinic care (control group); or (2) additional daily detailed feedback on their compliance and glycemic control from the clinic team via an application installed on their smartphone (smartphone group). The primary outcome was patient compliance defined as the actual blood glucose measurements/instructed measurements ×100. The secondary outcomes included diabetes-control parameters, pregnancy, and neonatal outcomes. The study was adequately powered to detect a 20% difference in patient compliance, based on a preliminary phase that demonstrated 70% baseline compliance to glucose measurements.

RESULTS

A total of 120 newly diagnosed gestational diabetes mellitus patients were analyzed. The 2 groups did not differ in terms of age, parity, education, body mass index, family history, maternal comorbidities, oral glucose tolerance test values, and hemoglobin A1C at randomization. The smartphone group demonstrated higher level of compliance (84 ± 0.16% vs 66 ± 0.28%, P < .001); lower mean blood glucose (105.1 ± 8.6 mg/dL vs 112.6 ± 7.4 mg/dL, P < .001); lower rates of off-target measurements both fasting (4.7 ± 0.4% vs 8.4 ± 0.6%, P < .001) and 1-hour postprandial (7.7 ± 0.8% vs 14.3 ± 0.8%, P < .001); and a lower rate of pregnancies requiring insulin treatment (13.3% vs 30.0%, P = .044). The rates of macrosomia, neonatal hypoglycemia, shoulder dystocia, and other delivery and neonatal complications did not differ between the groups. Patients in the smartphone group reported excellent satisfaction from the use of the application and from their overall prenatal care.

CONCLUSION

Introduction of a smartphone-based daily feedback and communication platform between gestational diabetes mellitus patients and the multidisciplinary diabetes-in-pregnancy clinic team improved patient compliance and glycemic control, and lowered the rate of insulin treatment.

Maternal educational level and the risk of persistent post-partum glucose metabolism disorders in women with gestational diabetes mellitus

AIMS

Gestational diabetes mellitus (GDM) occurs in 5-15% of pregnancies, and lower maternal educational attainment has been associated with higher risk of GDM. We aimed to determine if maternal education level is associated with persistent post-partum glucose metabolism disorders in women with GDM.

METHODS

Retrospective cohort study of women with GDM followed in 25 Portuguese health institutions between 2008 and 2012. Educational attainment was categorised into four levels. Prevalence of post-partum glucose metabolism disorders (type 2 diabetes mellitus, increased fasting plasma glucose or impaired glucose tolerance) was compared and adjusted odds ratios calculated controlling for confounders using logistic regression.

RESULTS

We included 4490 women diagnosed with GDM. Educational level ranged as follows: 6.8% (n = 307) were at level 1 (≤ 6th grade), 34.6% (n = 1554) at level 2 (6-9th grade), 30.4% (n = 1364) at level 3 (10-12th grade) and 28.2% (n = 1265) at level 4 (≥ university degree). At 6 weeks post-partum re-evaluation, 10.9% (n = 491) had persistent glucose metabolism disorders. Educational levels 1 and 2 had a higher probability of persistent post-partum glucose metabolism disorders when compared to level 4 (OR = 2.37 [1.69;3.32], p < 0.001 and OR = 1.39 [1.09;1.76], p = 0.008, for level 1 and 2, respectively), an association that persisted in multivariable logistic regression adjusting for confounders (level 1 OR = 2.25 [1.53;3.33], p < 0.001; level 2 OR = 1.43 [1.09;1.89], p = 0.01).

CONCLUSIONS

Persistent post-partum glucose metabolism disorders are frequent in women with GDM and associated with lower maternal educational level. Interventions aimed at this risk group may contribute towards a decrease in prevalence of post-partum glucose metabolism disorders.