First-trimester fasting glycemia as a predictor of gestational diabetes (GDM) and adverse pregnancy outcomes

Maternal modifiable factors and risk of congenital heart defects: systematic review and causality assessment

OBJECTIVE

Primary prevention strategies are critical to reduce the global burden of congenital heart defects (CHDs); this requires robust knowledge of causal agents. We aimed to review associations between CHDs and maternal advanced age, obesity, diabetes, hypertension, smoking and alcohol consumption and assess the causal nature of the associations.

DESIGN

Systematic review of reviews with application of a Bradford Hill criteria score-based causal assessment system.

DATA SOURCES

We searched PubMed, Embase and Episteminokos (January 1990-April 2023).

ELIGIBILITY CRITERIA

Systematic reviews of original epidemiological studies reporting association (relative risk) between one or more of the above maternal factors and CHDs overall (any type) in subsequent offspring.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers selected eligible reviews, assessed the risk of bias and assigned the strength of evidence for causality.

RESULTS

There was strong evidence of a causal relationship between CHDs and maternal obesity (prepregnancy and early pregnancy) and pre-existing diabetes (six of seven Bradford Hill criteria met). For pre-existing hypertension (strength and biological gradient not met), and advanced age (strength, consistency and biological gradient not met), causal evidence was moderate. Evidence for the causal contribution of gestational diabetes, gestational hypertension, smoking and alcohol consumption was weak (strength, consistency, temporality and biological gradient not met).

CONCLUSIONS

CHDs can be reduced with stronger action to reduce maternal obesity and pre-existing diabetes prevalence. Investigating environmental exposures that have received limited attention, such as air pollutants and chemical exposures, is important to further inform prevention.

First-trimester fasting plasma glucose as a predictor of subsequent gestational diabetes mellitus and adverse fetomaternal outcomes: A systematic review and meta-analysis

BACKGROUND

The implication of intermediately elevated fasting plasma glucose (FPG) in the first trimester of pregnancy is uncertain.

PURPOSE

The primary outcome of the meta-analysis was to analyze if intermediately elevated first-trimester FPG could predict development of GDM at 24-28 weeks. The secondary outcomes were to determine if the commonly used FPG cut-offs 5.1 mmol/L (92 mg/dL), 5.6 mmol/L (100 mg/dL), and 6.1 mmol/L (110 mg/dL) correlated with adverse pregnancy events.

DATA SOURCES

Databases were searched for articles published from 2010 onwards for studies examining the relationship between first-trimester FPG and adverse fetomaternal outcomes.

STUDY SELECTION

A total of sixteen studies involving 115,899 pregnancies satisfied the inclusion criteria.

DATA EXTRACTION AND DATA SYNTHESIS

Women who developed GDM had a significantly higher first-trimester FPG than those who did not [MD 0.29 mmoL/l (5 mg/dL); 95 % CI: 0.21-0.38; P < 0.00001]. First-trimester FPG ≥5.1 mmol/L (92 mg/dL) predicted the development of GDM at 24-28 weeks [RR 3.93 (95 % CI: 2.67-5.77); P < 0.0000], pre-eclampsia [RR 1.55 (95%CI:1.14-2.12); P = 0.006], gestational hypertension [RR1.47 (95%CI:1.20-1.79); P = 0.0001], large-for-gestational-age (LGA) [RR 1.32 (95%CI:1.13-1.54); P = 0.0004], and macrosomia [RR1.29 (95%CI:1.15-1.44); P < 0.001]. However, at the above threshold, the rates of preterm delivery, lower-segment cesarean section (LSCS), small-for gestational age (SGA), and neonatal hypoglycemia were not significantly higher. First-trimester FPG ≥5.6 mmol/L (100 mg/dL) correlated with occurrence of macrosomia [RR1.47 (95 % CI:1.22-1.79); P < 0.0001], LGA [RR 1.43 (95%CI:1.24-1.65); P < 0.00001], and preterm delivery [RR1.51 (95%CI:1.15-1.98); P = 0.003], but not SGA and LSCS.

LIMITATIONS

Only one study reported outcomes at first-trimester FPG of 6.1 mmol/L (110 mg/dL), and hence was not analyzed.

CONCLUSION

The risk of development of GDM at 24-28 weeks increased linearly with higher first-trimester FPG. First trimester FPG cut-offs of 5.1 mmol/L (92 mg/dL) and 5.6 mmol/L (100 mg/dL) predicted several adverse pregnancy outcomes.

Establishment and validation of a prediction model for gestational diabetes

AIM

To develop a visual prediction model for gestational diabetes (GD) in pregnant women and to establish an effective and practical tool for clinical application.

METHODS

To establish a prediction model, the modelling set included 1756 women enrolled in the Zunyi birth cohort, the internal validation set included 1234 enrolled women, and pregnant women in the Wuhan cohort were included in the external validation set. We established a demographic-lifestyle factor model (DLFM) and a demographic-lifestyle-environmental pollution factor model (DLEFM) based on whether the women were exposed to environmental pollutants. The least absolute shrinkage and selection lasso-logistic regression analyses were used to identify the independent predictors of GD and construct a nomogram for predicting its occurrence.

RESULTS

The DLEFM regression analysis showed that a family history of diabetes (odd ratio [OR] 2.28; 95% confidence interval [CI] 1.05-4.71), a history of GD in pregnant women (OR 4.22; 95% CI 1.89-9.41), being overweight or obese before pregnancy (OR 1.71; 95% CI 1.27-2.29), a history of hypertension (OR 2.61; 95% CI 1.41-4.72), sedentary time (h/day) (OR 1.16; 95% CI 1.08-1.24), monobenzyl phthalate (OR 1.95; 95% CI 1.45-2.67) and Q4 mono-ethyl phthalate concentration (OR 1.85; 95% CI 1.26-2.73) were independent predictors. The area under the receiver operating curves for the internal validation of the DLEFM and the DLFM constructed using these seven factors was 0.827 and 0.783, respectively. The calibration curve of the DLEFM was close to the diagonal line. The DLEFM was thus the more optimal model, and the one which we chose.

CONCLUSIONS

A nomogram based on preconception factors was constructed to predict the occurrence of GD in the second and third trimesters. It provided an effective tool for the early prediction and timely management of GD.

The effect of gestational diabetes mellitus on carotid artery intima-media thickness in and after pregnancy: a systematic review and meta-analysis

AIMS

The association between gestational diabetes mellitus (GDM) and common carotid artery (CCA) intima-media thickness (IMT) is still controversial. This systematic review and meta-analysis was performed to assess the correlation between GDM and CCA-IMT in and after pregnancy.

METHODS

PubMed and EMBASE databases were systematically reviewed on April 2023. Studies measuring CCA-IMT in both pregnant women with GDM and women with previous history of GDM (pGDM) vs. healthy controls were included. The subtotal and overall standardized mean differences (SMDs) of CCA-IMT were calculated using the random-effect model.

RESULTS

Nineteen studies with a total of 302 GDM and 861 pGDM women were analyzed. The average value of CCA-IMT measured in GDM/pGDM (0.59 ± 0.12 mm) was slightly increased in comparison to the accepted reference limits of IMT according to age classes. Substantial heterogeneity was detected for the studies involving both GDM and pGDM women, with an overall statistic I2 of 86.0% (p < 0.001). Large SMDs were obtained for the studies conducted on both GDM and pGDM women, with an overall SMD of 0.89 (95%CI 0.63-1.15, p < 0.001). Egger's test for a regression intercept gave a p-value of 0.37, indicating no publication bias. On meta-regression analysis, all potential confounders (number of patients, age at pregnancy, body mass index, measuring time, follow-up duration and GDM criteria) were not significantly associated with effect modification.

CONCLUSIONS

GDM in and after pregnancy is independently associated with subclinical atherosclerosis. The association between GDM and carotid remodeling is potentially mediated by the longstanding underlying risk.

The Association of the Triglyceride and Muscle to Fat Ratio During Early Pregnancy with the Development of Gestational Diabetes Mellitus

Objective

This study explored the association between metabolic factors and body composition during the first trimester of gestational diabetes mellitus (GDM).

Methods

This prospective study recruited pregnant women in their first trimester. Clinical information and glucose and lipid measurements were collected, and body composition was assessed using multifrequency bioelectrical impedance analysis. GDM was diagnosed on the basis of an oral glucose tolerance test at 24-28 gestational week. Factors related to GDM were investigated using correlation, and risk ratios (RRs) and 95% CIs of potential risk factors with GDM were estimated using Poisson regression. The area under the receiver operating characteristic (ROC) curve was used to determine predictive effects.

Results

59/302 women (19.5%) developed GDM. Older (RR 1.076, 95% CI 1.005-1.152), higher body mass index (BMI) before pregnancy (pre-BMI) (RR 1.012, 95% CI 1.005-1.063), triglycerides (RR 4.052, 95% CI 1.641-6.741), and lower skeletal muscle mass (SMM) to fat mass (FM) ratio (SMM/FM) (RR 0.213, 95% CI 0.051-0890) in the first trimester, and family history of type 2 diabetes (RR 1.496, 95% CI 1.014-2.667) significantly associated with the risk of GDM, but neither fasting plasma glucose nor glycated albumin was associated with GDM. The combined multivariate prediction model achieved good discrimination with an AUC of 0.806 (95% CI 0.737-0.895, P<0.001). According to ROC curve, the cut-off values of TG and SMM/FM were 0.925 mmol/L and 1.305.

Conclusion

Reduced SMM/FM and elevated triglyceride (TG) levels in the first trimester are associated with GDM development, and should be screened in early pregnancy to identify high-risk subjects for GDM.

Prepregnancy Glucose Levels Within Normal Range and Its Impact on Obstetric Complications in Subsequent Pregnancy: A Population Cohort Study

BACKGROUND

We sought to identify the influence of prepregnancy glucose levels on obstetric complications in subsequent pregnancy.

METHODS

Women in Republic of Korea who had given birth between January 1st, 2007 and December 31st, 2010 were enrolled. The database of the Health Insurance Review and Assessment Service and data from a national health screening program for infants and children were used. Subjects were divided into seven groups according to their fasting glucose levels.

RESULTS

59,619 women were included for analysis, and 10.4%, 13.7%, 19.1%, 21.5%, 16.0%, 11.6%, and 7.5% women had glucose levels of < 75, 75-79, 80-84, 85-89, 90-94, 95-100 and > 100 mg/dL. Each 5 mg/dL increase in prepregnancy fasting glucose levels was associated with increased risk of gestational diabetes and macrosomia in subsequent pregnancy. Adjusted risk ratio for gestational diabetes per standard deviation prepregnancy glucose > 100 mg/dL was 2.015 (95% confidence interval, 1.649-2.462) and for macrosomia an adjusted risk ratio 1.389 (95% confidence interval, 1.147-1.682).

CONCLUSION

Higher prepregnancy glucose level within normal range was related to gestational diabetes and macrosomia in following pregnancy. Our results may aid in the identification of women at future risk of obstetric complications and may guide to stratify women into normal and intensified care.

TWEETABLE ABSTRACT

Higher prepregnancy glucose in normal range is associated with gestational diabetes and macrosomia.

Prediction of adverse pregnancy outcomes by first-trimester components of metabolic syndrome: a prospective longitudinal study

PURPOSE

This study aimed to identify the optimal cutoff values of each component of metabolic syndrome (MetS) in the first trimester of pregnancy for predicting adverse pregnancy outcomes.

METHODS

A total of 1076 pregnant women in the first trimester of gestation were recruited in this prospective longitudinal cohort study. Specifically, 993 pregnant women at 11-13 weeks of gestation who were followed up until the end of pregnancy were included in the final analysis. The cutoff values of each component of MetS in the occurrence of adverse pregnancy outcomes including gestational diabetes (GDM), gestational hypertensive disorders, and preterm birth were obtained via receiver operating characteristic (ROC) curve analysis using the Youden's index.

RESULTS

Among the 993 pregnant women studied, the significant associations between the first trimester MetS components and adverse pregnancy outcomes were as follows: triglyceride (TG) and body mass index (BMI) with preterm birth; mean arterial pressure (MAP), TG, and high-density lipoprotein cholesterol (HDL-C) with gestational hypertensive disorders; BMI, fasting plasma glucose (FPG), and TG with GDM (all p values < 0.05). The cutoff point values for the above-mentioned MetS components were: TG > 138 mg/dl and BMI < 21 kg/m² for the occurrence of preterm birth; TG > 148 mg/dL, MAP > 84, and HDL-C < 84 mg/dl for gestational hypertensive disorders; BMI > 25 kg/m², FPG > 84 mg/dl, and TG > 161 mg/dl for GDM.

CONCLUSION

The study findings imply the importance of early management of metabolic syndrome in pregnancy to improve maternal-fetal outcomes.

Maternal fasting glucose levels throughout the pregnancy and risk of adverse birth outcomes in newborns: a birth cohort study in Foshan city, Southern China

OBJECTIVE

We aimed to investigate the associations between maternal fasting plasma glucose (FPG) levels and glycemic fluctuations during different trimesters and adverse birth outcomes among newborns.

METHODS

This cohort study used data from 63 213 pregnant women and their offspring in Foshan city from November 2015 to January 2019. Associations between maternal FPG and glycemic fluctuations during different trimesters and adverse birth outcomes [congenital heart defect (CHD), macrosomia, small/large for gestational age (SGA/LGA), and preterm birth (PTB)] in newborns were estimated using mixed-effects logistic regression models.

RESULTS

A total of 45 516 participants accepted at least one FPG test throughout pregnancy, and 7852 of whom had glycemic trajectory data. In the adjusted model, higher maternal FPG throughout the pregnancy was associated with an increased risk of adverse birth outcomes (except for SGA). Each 1 mmol/L increase in maternal FPG during trimester 1 was associated with higher odds of CHD (OR = 1.14 (95% CI: 1.02, 1.26)). The same increase in maternal FPG during trimester 3 was associated with a higher risk of PTB (OR = 1.05 (95% CI: 1.01, 1.10)). Increment of maternal FPG during trimester 2 and trimester 3 was associated with a higher risk of macrosomia and LGA. Increase in FPG throughout the pregnancy was associated with slightly lower odds of SGA. Similar results were observed when analyzing the associations between glycemic fluctuations during different trimesters and adverse birth outcomes.

CONCLUSIONS

Our findings indicate higher maternal FPG levels during different trimesters were associated with different adverse birth outcomes, which suggests the importance of glycemic management throughout the pregnancy.

Evolution of Gestational Diabetes Mellitus across Continents in 21st Century

Over the last few decades, several definitions of gestational diabetes mellitus (GDM) have been described. There is currently not enough research to show which way is the best to diagnose GDM. Opinions differ in terms of the optimal screening and diagnostic measures, in part due to the differences in the population risks, the cost-effectiveness considerations, and the lack of an evidence base to support large national screening programs. The basic method for identifying the disease is the measurement of glucose plasma levels which may be determined when fasting, two hours after a meal, or simply at any random time. The currently increasing incidence of diabetes in the whole population, the altering demographics and the presence of lifestyle changes still require better methods of screening for hyperglycemia, especially during pregnancy. The main aim of this review is to focus on the prevalence and modifications to the screening criteria for GDM across all continents in the 21st century. We would like to show the differences in the above issues and correlate them with the geographical situation. Looking at the history of diabetes, we are sure that more than one evolution in GDM diagnosis will occur, due to the development of medicine, appearance of modern technologies, and the dynamic continuation of research.

Hyperglycemia First Detected in Pregnancy in South Africa: Facts, Gaps, and Opportunities

This review contextualizes hyperglycemia in pregnancy from a South-African perspective. It aims to create awareness of the importance of hyperglycemia in pregnancy in low-middle-income countries. We address unanswered questions to guide future research on sub-Saharan African women with hyperglycemia first detected in pregnancy (HFDP). South African women of childbearing age have the highest prevalence of obesity in sub-Saharan Africa. They are predisposed to Type 2 diabetes (T2DM), the leading cause of death in South African women. T2DM remains undiagnosed in many African countries, with two-thirds of people living with diabetes unaware. With the South African health policy's increased focus on improving antenatal care, women often gain access to screening for non-communicable diseases for the first time in pregnancy. While screening practices and diagnostic criteria for gestational diabetes mellitus (GDM) differ amongst geographical areas in South Africa (SA), hyperglycemia of varying degrees is often first detected in pregnancy. This is often erroneously ascribed to GDM, irrespective of the degree of hyperglycemia and not overt diabetes. T2DM and GDM convey a graded increased risk for the mother and fetus during and after pregnancy, with cardiometabolic risk accumulating across the lifespan. Resource limitations and high patient burden have hampered the opportunity to implement accessible preventative care in young women at increased risk of developing T2DM in the broader public health system in SA. All women with HFDP, including those with true GDM, should be followed and undergo glucose assessment postpartum. In SA, studies conducted early postpartum have noted persistent hyperglycemia in a third of women after GDM. Interpregnancy care is advantageous and may attain a favourable metabolic legacy in these young women, but the yield of return following delivery is suboptimal. We review the current best evidence regarding HFDP and contextualize the applicability in SA and other African or low-middle-income countries. The review identifies gaps and shares pragmatic solutions regarding clinical factors that may improve awareness, identification, diagnosis, and management of women with HFDP.

Can the First Fasting Plasma Glucose Test in Pregnancy Predict Subsequent Gestational Complications?

Objective

To determine the best cut-off level of pregnant women's first fasting plasma glucose (FFPG) test results for the prediction of subsequent onset of gestational diabetes mellitus (GDM) and to examine the association between FFPG and maternal and neonatal outcomes in a large Caucasian population.

Methods

1437 medical records of women with singleton pregnancies followed up between 2015 and 2018 were retrospectively analyzed. Data on FFPG tested in the first trimester and 75 g oral glucose tolerance test (OGTT) findings performed according to IADPSG criteria and Italian guidelines were collected and evaluated. The women's clinical and metabolic characteristics (age, prepregnancy body mass index (BMI), previous pregnancies complicated by GDM, timing of delivery, and gestational hypertension) were also recorded. The fetal variables considered were being large for gestational age (LGA) or small for gestational age (SGA), macrosomia, and hypoglycemia.

Results

Among the 1437 pregnant women studied, 684 had a normal glucose tolerance (NGT) and 753 developed GDM. In a univariate analysis FFPG ≥92 mg/dl predicts the risk of GDM with an OR = 2.36 (95% CI 1.930-3.186; p < 0.001). In multivariate analysis, after adjusting for principal risk factors of GDM (BMI, previous GDM, age >35 years, family history of diabetes) FFPG ≥92 mg/dl was associated with the risk of GDM (OR = 1.92; 95% CI 1.488-2.492; p < 0.001). In univariate analysis, FFPG ≥92 mg/dl predict the risk of insulin therapy in GDM women with a OR = 1.88 (95% CI 1.230-2.066; p < 0.001). As regards LGA, in a multivariate analysis, after adjusting for BMI, FFPG ≥92 mg/dl was associated with the risk of LGA only in NGT women (OR = 2.34; 95% CI 1.173-4.574; p=0.014), but not in GDM women. FFPG was not associated with other maternal or neonatal outcomes.

Conclusions

FFPG ≥92 mg/dl is related to GDM diagnosis and to the need of insulin therapy if GDM is diagnosed. An early diagnosis and a prompt start of insulin therapy are essential to prevent maternal and fetal complications.

Application Value of Predictive Model Based on Maternal Coagulation Function and Glycolipid Metabolism Indicators in Early Diagnosis of Gestational Diabetes Mellitus

Objective

To investigate whether first-trimester fasting plasma glucose (FPG), blood coagulation function and lipid metabolism could predict gestational diabetes mellitus (GDM) risk.

Methods

From October 2020 to May 2021, a total of 584 pregnant women who took prenatal care in Shanghai Jiaotong University Affiliated Sixth People's Hospital were chosen as the observation subjects. The clinical information and serum samples of all pregnant women were collected at 10–13 weeks of gestation and the blood coagulation function, fasting blood glucose and lipid profiles of the pregnant women were detected. A 75 g oral glucose tolerance test was performed up to 24–28 weeks of gestation. One hundred forty-two pregnant women with GDM and 442 pregnant women without GDM were detected. Data were expressed by x ± s or median (interquartile range) and were analyzed using student's t-test, Wilcoxon rank sum test and Logistic regression analysis. The area under the curve (AUC) was calculated by receiver operating characteristic curve (ROC) to analyze the predictive values.

Results

Compared with non-GDM group, age, pre-pregnancy BMI, FPG, FIB, D-Dimer, FDP, FPG, TC, TG, LDL-C, sdLDL-C, APOB and APOE in GDM group were significantly higher than those in non-GDM group, while PT, INR, APTT and TT were significantly lower than those in non-GDM group. Univariate logistic regression analysis was used to explore the risk factors of GDM. Gestational age, pre-pregnancy BMI, FPG, PT, INR, APTT, FIB, TT, D-Dimer, TC, TG, LDL-C, sdLDL-C, APOB and APOE were all independent predictors of GDM. Multivariatelogistic regression showed that pre-pregnancy BMI, FPG, APTT, TT, TG, LDL-C, sdLDL-C and APOB were risk factors for GDM. The AUC of the established GDM risk prediction model was 0.892 (0.858–0.927), and the sensitivity and specificity were 80.71 and 86.85%, respectively; which were greater than that of pre-pregnancy BMI, FPG, APTT, TT,TG, LDL-C, sdLDL-C, APOB alone, and the difffference was statistically signifificant (P < 0.05).

Conclusions

FPG, APTT, TT, TG, LDL-C, sdLDL-C, APOB and pre-pregnancy BMI in early pregnancy has important clinical value for the prediction of GDM, We combined these laboratory indicators and established a GDM risk prediction model, which is conducive to the early identification, intervention and treatment of GDM, so as to reduce the morbidity of maternal and infant complications.

Early pregnancy hyperglycaemia as a significant predictor of large for gestational age neonates

AIMS

We aimed to determine the effect of early pregnancy hyperglycaemia on having a large for gestational age (LGA) neonate.

METHODS

A prospective cohort study was conducted among pregnant women in their first trimester. One-step plasma glucose (PG) evaluation procedure was performed to assess gestational diabetes mellitus (GDM) and diabetes mellitus (DM) in pregnancy as defined by the World Health Organization (WHO) criteria with International Association of Diabetes in Pregnancy Study Group (IADPSG) thresholds. The main outcome studied was large for gestational age neonates (LGA).

RESULTS

A total of 2,709 participants were recruited with a mean age of 28 years (SD = 5.4) and a median gestational age (GA) of eight weeks (interquartile range [IQR] = 2). The prevalence of GDM in first trimester (T1) was 15.0% (95% confidence interval [CI] = 13.7-16.4). Previously undiagnosed DM was detected among 2.5% of the participants. Out of 2,285 live births with a median delivery GA of 38 weeks (IQR = 3), 7.0% were LGA neonates. The cumulative incidence of LGA neonates in women with GDM and DM was 11.1 and 15.5 per 100 women, respectively. The relative risk of having an LGA neonate among women with DM and GDM was 2.30 (95% CI = 1.23-4.28) and 1.80 (95% CI = 1.27-2.53), respectively. The attributable risk percentage of a LGA neonate for hyperglycaemia was 15.01%. T1 fasting PG was significantly correlated with both neonatal birth weight and birth weight centile.

CONCLUSIONS

The proposed WHO criteria for hyperglycaemia in pregnancy are valid, even in T1, for predicting LGA neonates. The use of IADPSG threshold for Fasting PG, for risk assessment in early pregnancy in high-risk populations is recommended.

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

AIMS

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

RESULTS

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

CONCLUSIONS

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

Elevated serum triglyceride levels at first prenatal visit is associated with the development of gestational diabetes mellitus

AIMS

While several studies have indicated that maternal serum lipid profiles are associated with the development of gestational diabetes mellitus (GDM), the results have been inconsistent. This study aimed to explore the relationship between maternal lipids profiles at first prenatal visit and GDM and determine the optimal cut-off values of possible trimester-specific variables in predicting GDM.

MATERIALS AND METHODS

Clinical data of women with singleton pregnancies who delivered in Xinhua Hospital between January 2016 and January 2017 were collected from electronic databases. Multivariate logistic regression was used to determine the potential risk factors of GDM (specific to the trimester at first prenatal visit), including age, body mass index (BMI), and serum lipid profile and fasting plasma glucose (FPG) levels. The receiver operating characteristic (ROC) curve analysis was performed to determine the cut-off values of significant variables.

RESULTS

Among the 2191 pregnant women included, 315 (14.38%) were diagnosed with GDM. Of these, 880 (40.16%) had their first prenatal visit before 14 gestational weeks. Univariate and multivariate analyses showed that both FPG and triglyceride (TG) levels in the first and second trimesters were associated with a high risk of GDM (p < 0.05). The ROC curve showed that serum TG levels >1.235 mmol/L and >1.525 mmol/L in the first and second trimesters, respectively, were significantly associated with the development of GDM (p < 0.05).

CONCLUSIONS

TG levels at first prenatal visit is associated with GDM risk. Different TG cut-off values should be applied in the different trimesters of pregnancy for GDM screening.

Fasting plasma glucose in the first trimester is related to gestational diabetes mellitus and adverse pregnancy outcomes

PURPOSE

To investigate and identify first-trimester fasting plasma glucose (FPG) is related to gestational diabetes mellitus (GDM) and other adverse pregnancy outcomes in Shenzhen population.

METHODS

We used data of 48,444 pregnant women that had been retrospectively collected between 2017 and 2019. Logistic regression analysis was used to evaluated the associations between first-trimester FPG and GDM and adverse pregnancy outcomes, and used to construct a nomogram model for predicting the risk of GDM. The performance of the nomogram was evaluated by using ROC and calibration curves. Decision curve analysis (DCA) was used to determine the clinical usefulness of the first-trimester FPG by quantifying the net benefits at different threshold probabilities.

RESULTS

The mean first-trimester FPG was 4.62 ± 0.42 mmol/L. A total of 6998 (14.4%) pregnancies developed GDM.489(1.01%) pregnancies developed polyhydramnios, the prevalence rates of gestational hypertensive disorder (GHD), cesarean section, primary cesarean section, preterm delivery before 37 weeks (PD) and dystocia was 1130 (2.33%), 20,426 (42.16%), 7237 (14.94%), 2386 (4.93%), and 1865 (3.85%), respectively. 4233 (8.74%) of the newborns were LGA, and the number of macrosomia was 2272 (4.69%), LBW was 1701 (3.51%) and 5084 (10.49%) newborns had admission to the ICU, which all showed significances between GDM and non-GDM groups (all P < 0.05). The univariate analysis showed that first-trimester FPG was strongly associated with risks of outcomes including GDM, cesarean section, macrosomia, GHD, primary cesarean section, and LGA (all OR > 1, all P < 0.05), furthermore, the risks of GDM, primary cesarean section, and LGA was increasing with first-trimester FPG as early as it was at 4.19-4.63 mmol/L. The multivariable analysis showed that the risks of GDM (ORs for FPG 4.19-4.63, 4.63-5.11 and 5.11-7.0 mmol/L were 1.137, 1.592, and 4.031, respectively, all P < 0.05) increased as early as first-trimester FPG was at 4.19-4.63 mmol/L, and first-trimester FPG which was also associated with the risks of cesarean section, macrosomia and LGA (OR for FPG 5.11-7.0 mmol/L of cesarean section: 1.128; OR for FPG 5.11-7.0 mmol/L of macrosomia: 1.561; OR for FPG 4.63-5.11 and 5.11-7.0 mmol/L of LGA: 1.149 and 1.426, respectively, all P < 0.05) and with its increasing, the risks of LGA increased. Furthermore, the nomogram had a C-indices 0.771(95% CI: 0.763~0.779) and 0.770(95% CI:0.758~0.781) in training and testing validation respectively, which showed an acceptable consistency between the observed, validation and nomogram-predicted probabilities, the DAC curve analysis indicated that the nomogram had important clinical application value for GDM risk prediction.

CONCLUSIONS

FPG in the first trimester was an independent risk factor for GDM which can be used as a screening test for identifying pregnancies at risk of GDM and adverse pregnancy outcomes.

Early Gestational Diabetes Mellitus: Diagnostic Strategies and Clinical Implications

Preexisting diabetes mellitus (DM) should be ruled out early in pregnancy in those at risk. During screening, a significant proportion of women do not reach the threshold for overt DM but fulfill the criteria used for diagnosing conventional gestational DM (cGDM). There is no consensus on the management of pregnancies with intermediate levels of hyperglycemia thus diagnosed. We have used the term early gestational DM (eGDM) for this condition and reviewed the currently available literature. Fasting plasma glucose (FPG), oral glucose tolerance test, and glycated hemoglobin (HbA1c) are the commonly employed screening tools in early pregnancy. Observational studies suggest that early pregnancy FPG and Hba1c correlate with the risk of cGDM and adverse perinatal outcomes. However, specific cut-offs, including those proposed by the International Association of the Diabetes and Pregnancy Study Group, do not reliably predict the development of cGDM. Emerging data, though indicate that FPG ≥ 92 mg/dL (5.1 mmol/L), even in the absence of cGDM, signals the risk for perinatal complication. Elevated HbA1c, especially a level ≥ 5.9%, also correlates with the risk of cGDM and worsened outcome. HbA1c as a diagnostic test is however besieged with the usual caveats that occur in pregnancy. The studies that explored the effects of intervention present conflicting results, including a possibility of fetal malnutrition and small-for-date baby in the early treatment group. Diagnostic thresholds and glycemic targets in eGDM may differ, and large multicenter randomized controlled trials are necessary to define the appropriate strategy.

Circadian rhythm and gestational diabetes: working conditions, sleeping habits and lifestyle influence insulin dependency during pregnancy

OBJECTIVE

Management of gestational diabetes (GDM) is currently changing toward a more personalized approach. There  is a growing number of GDM patients requiring only a single dose of basal insulin at night to achieve glucose control. Well-known risk factors like obesity, parity and family history have been associated with GDM treatment requirements. Sleep quality and lifestyle factors interfering with the circadian rhythm are known to affect glucose metabolism. The aim of this study was to investigate the impact of such lifestyle factors on insulin requirement in GDM patients, in particular on long-acting insulin to control fasting glucose levels.

RESEARCH DESIGN AND METHODS

A total of 805 patients treated for GDM between 2012 and 2016 received a study questionnaire on lifestyle conditions. Sleep quality and work condition categories were used for subgroup analysis. Independent effects on treatment approaches were evaluated using multivariate regression.

RESULTS

In total, 235 (29.2%) questionnaires returned. Women reporting poor sleep conditions had higher pre-pregnancy weight and BMI, heavier newborns, more large for gestational age newborns and higher rates of hyperbilirubinemia. Treatment requirements were related to sleep and work condition categories. Multivariate regression for 'Basal' insulin-only treatment revealed an adjOR 3.4 (CI 1.23-9.40, p  <  0.05) for unfavorable work conditions and adjOR 4.3 (CI 1.28-14.50, p  <  0.05) for living with children.

CONCLUSIONS

Our findings suggest that external stressors like unfavorable work conditions and living with children are independently associated with the necessity of long-acting insulin at night in GDM patients. Thus, fasting glucose levels of pregnant women presenting with such lifestyle conditions may be subject to close monitoring.

Screening of postpartum diabetes in women with gestational diabetes: high-risk subgroups and areas for improvements-the STRONG observational study

AIMS

To assess the proportion of women with gestational diabetes (GDM) by performing postpartum Oral Glucose Tolerance Test (OGTT) and to identify GDM phenotypes at high-risk of postpartum dysglycemia (PPD).

METHODS

Observational, retrospective, multicenter study involving consecutive GDM women. Recursive partitioning (RECPAM) analysis was used to identify distinct and homogeneous subgroups of women at different PPD risk.

RESULTS

From a sample of 2,736 women, OGTT was performed in 941 (34.4%) women, of whom 217 (23.0%) developed PPD. Insulin-treated women having family history of diabetes represented the subgroup with the highest PPD risk (OR 5.57, 95% CI 3.60-8.63) compared to the reference class (women on diet with pre-pregnancy BMI <  = 28.1 kg/m2). Insulin-treated women without family diabetes history and women on diet with pre-pregnancy BMI > 28.1 kg/m2 showed a two-fold PPD risk. Previous GDM and socioeconomic status represent additional predictors. Fasting more than post-prandial glycemia plays a predictive role, with values of 81-87 mg/dl (4.5-4.8 mmol/l) (lower than the current diagnostic GDM threshold) being associated with PPD risk.

CONCLUSIONS

Increasing compliance to postpartum OGTT to prevent/delay PPD is a priority. Easily available characteristics identify subgroups of women more likely to benefit from preventive strategies. Fasting BG values during pregnancy lower than those usually considered deserve attention.

Whey protein preloading can alleviate stress adaptation disorder and improve hyperglycemia in women with gestational diabetes mellitus

AIMS

To investigate the change of stress hormones, oxidative stress and insulin resistance (IR) in women with gestational diabetes mellitus (GDM) after supplement whey protein, in an attempt to gain insights into the prevention and treatment of GDM.

MATERIALS AND METHODS

60 GDM women were recruited in this study, and 30 women received a preload drink containing 20 g whey protein as group GDM-W, and the other 30 women received control flavoring drink as group GDM, and the trial lasted for 14 days. Plasma epinephrine (E), noradrenaline (NE), and cortisol were detected; we also determined levels of malondialdehyde (MDA), superoxide dismutase (SOD), and glutathione (GSH). Homeostasis model assessment of insulin resistance (HOMA-IR) was used to assess IR.

RESULTS

In the GDM-W group, postprandial blood glucose was decreased significantly on 3, 5, 7, and 14 days (all p < .05), plasma 2 h insulin was increased by 7.2, 8.6, and 20.5% on days 5, 7, and 14 (p < .05, .05, .01). HOMA-IR was decreased significantly on day 14 (p < .05). MDA was decreased by 20.7% on day 14 (p < .01), and anti-oxidative enzymes' SOD was decreased by 13.4% on day 14 (p < .05) and GSH was decreased by 16.7 and 29.1% on days 7 and 14 (both p < .05). Stress hormones E and cortisol were decreased by 10.8 and 19.8%, respectively, on day 14 (p < .05). There was no significant difference in NE between the two groups within 14 days.

CONCLUSIONS

Whey protein supplementation may improve hyperglycemia by alleviating stress disorder and oxidative stress injury in GDM women. This trial was registered at chictr.org.cn/as ChiCTR1800020413.

Association of higher HbA1c within the normal range with adverse pregnancy outcomes: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate the association between a relatively high HbA1c level within the normal range and the risk of adverse pregnancy outcomes.

METHODS

This retrospective cohort study was conducted between March 2018 and March 2019 at Women's Hospital, School of Medicine, Zhejiang University. Multiple logistic regression models after adjusting for plausible confounders were implemented to assess the relationships between the level of HbA1c and adverse pregnancy outcomes.

RESULTS

A total of 8585 women were included in our study. The rates of preterm birth, macrosomia and preeclampsia were 4.4% (380/8585), 5.3% (457/8585) and 1.7% (149/8585), respectively. After adjusting for potential confounding variables, an HbA1c range of 5.5-5.9% (37-41 mmol/mol) remained significantly associated with an increased risk of preterm delivery (a-OR 2.27; 95% CI, 1.50-3.43), macrosomia (a-OR 1.97; 95% CI, 1.32-2.94) and preeclampsia (a-OR 3.70; 95% CI, 2.07-6.60). GDM-negative pregnant women with an HbA1c level in the range of 5.5-5.9% (37-41 mmol/mol) had an increased risk of preterm delivery (a-OR 2.84; 95% CI, 1.71-4.71) and preeclampsia (a-OR 3.82; 95% CI, 1.81-8.04). However, GDM-positive pregnant women had an increased risk of macrosomia (a-OR 2.12; 95% CI, 1.13-3.97) and preeclampsia (a-OR 2.62; 95% CI, 1.01-6.81).

CONCLUSION

A higher HbA1c level within the normal range is an independent risk factor for preterm delivery and preeclampsia, especially among GDM-negative women. Therefore, relevant medical staff should enhance the awareness of risk and prevention to strengthen pregnancy monitoring.

Characteristics of pregnant women with diabetes using injectable glucose-lowering drugs in the EVOLVE study

AIMS

To examine clinical parameters, glycemic control, folic acid supplementation, and the presence of other chronic diseases during early pregnancy in the EVOLVE study population (women with pre-existing diabetes treated with injectable glucose-lowering drugs).

METHODS

Cross-sectional baseline evaluation of EVOLVE: an international, multicenter, non-interventional study investigating the safety of injectable glucose-lowering drugs in pregnant women with pre-existing type 1 (T1D) or type 2 diabetes (T2D). Data were collected at enrollment visit interviews before gestational week 16.

RESULTS

In total, 2383 women from 17 mainly European countries were enrolled in the study: 2122 with T1D and 261 with T2D; mean age was 31 and 33 years, and duration of diabetes was 15 and 6 years, respectively. For women with T1D or T2D, 63% and 75%, respectively, received basal and rapid-acting insulin, 36% and 3% rapid-acting insulin only, 0.7% and 14.0% basal insulin only, 0.2% and 5.4% premix insulin, 0.0% and 1.2% injectable glucagon-like peptide-1 receptor agonist treatment without insulin. In women with T1D or T2D, respectively, during early pregnancy, 59% and 62% had HbA_1c <7.0% (53 mmol/mol); 16% and 36% reported not taking folic acid before or during early pregnancy. Overall, >40% of women had ≥1 chronic concomitant condition (predominantly thyroid disease or hypertension). Retinopathy was the most commonly reported diabetic complication. The most commonly reported previous pregnancy complication was miscarriage.

CONCLUSIONS

Baseline data from this large multinational population of women with pre-existing diabetes indicate that sub-optimal glycemic control, poor pregnancy planning, and chronic concomitant conditions were common in early pregnancy.

Screening for Gestational Diabetes Mellitus in Early Pregnancy: What Is the Evidence?

The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. This has a significant effect on the health of the mother and offspring. There is no doubt that screening for GDM between 24 and 28 weeks is important to reduce the risk of adverse pregnancy outcomes. However, there is no consensus about diagnosis and treatment of GDM in early pregnancy. In this narrative review on the current evidence on screening for GDM in early pregnancy, we included 37 cohort studies and eight randomized controlled trials (RCTs). Observational studies have shown that a high proportion (15–70%) of women with GDM can be detected early in pregnancy depending on the setting, criteria used and screening strategy. Data from observational studies on the potential benefit of screening and treatment of GDM in early pregnancy show conflicting results. In addition, there is substantial heterogeneity in age and BMI across the different study populations. Smaller RCTs could not show benefit but several large RCTs are ongoing. RCTs are also necessary to determine the appropriate cut-off for HbA1c in pregnancy as there is limited evidence showing that an HbA1c ≥6.5% has a low sensitivity to detect overt diabetes in early pregnancy.

Observations of the Effects of Maternal Fasting Plasma Glucose Changes in Early Pregnancy on Fetal Growth Profiles and Birth Outcomes

INTRODUCTION

Although the role of maternal hyperglycemia on birth outcomes is clear, literature regarding fetal growth is scarce. We examined the possible associations between maternal fasting plasma glucose (FPG) and fetal growth.

MATERIALS AND METHODS

A total of 35,981 singleton-pregnant women with FPG in the first trimester were included. Fetal growth parameters were measured during pregnancy by ultrasound at mid and late pregnancy. Information on birth characteristics was retrieved from medical records. We used multivariable linear and logistic regression to determine the associations between FPG and z-scores of fetal parameters and risks of birth outcomes and to assess effect modification by maternal characteristics.

RESULTS

A per-unit increase in FPG levels was negatively associated with fetal parameters in mid pregnancy but positively correlated with those in late pregnancy and with birth characteristics. The effect estimates in late pregnancy were attenuated by maternal pre-pregnancy body mass index (BMI). A significant relationship between FPG and abdominal circumference (AC), an indicator of fetal adiposity, was sustained in subgroups of women with advanced age, positive family history of diabetes, and multiparity in fully adjusted models. After stratification by BMI, high FPG was associated with accelerated AC only in normal controls (0.044 SD; 95% CI: 0.010, 0.079) and overweight/obese women (0.069 SD; 95% CI: -0.002, 0.140) but not in underweight women. High FPG was an independent risk factor for large-for-gestational age in the whole group and stratified subgroups.

CONCLUSIONS

Increased FPG in early pregnancy is closely related to fetal growth. Maternal characteristics may modify the associations between FPG and fetal adiposity in late pregnancy.

Significance of hyperglycaemia in first trimester pregnancy (SHIFT): A pilot study and literature review

International guidelines recommend screening for overt diabetes in early pregnancy. Women in their first trimester with fasting plasma glucose (FPG) levels that would be diagnostic of gestational diabetes mellitus (GDM) in later pregnancy are being identified and treated despite uncertainty regarding the risks and benefits. The evidence for the current diagnostic criteria and management recommendations in early GDM are reviewed. The results of a prospective observational study assessing the progression to GDM and prespecified maternal-fetal outcomes in women with mild fasting hyperglycaemia in the first trimester suggest that women with FPG 5.1-5.6 mmol/L may warrant proactive management in early pregnancy.

Associations of Maternal Glycemia in the First Half of Pregnancy With Alterations in Cardiac Structure and Function in Childhood

OBJECTIVE

Gestational diabetes mellitus has been associated with offspring cardiac congenital malformations, ventricular hypertrophy, and diastolic dysfunction in large observational cohort studies and experimental animal models. We assessed the associations of maternal random glucose concentrations across the full range with childhood cardiac ventricular structure and function.

RESEARCH DESIGN AND METHODS

In a population-based prospective cohort among 1,959 women and their offspring, maternal random glucose concentrations were measured at a median 13.1 weeks' gestation (95% range 10.5-16.8 weeks). We obtained offspring cardiac outcomes, relative to body size, through cardiac MRI at 10 years.

RESULTS

The mean maternal random glucose concentration was 4.4 mmol/L (SD 0.8). The highest quintile of maternal glucose concentrations, compared with the lowest quintile, was associated with a lower childhood left ventricular mass (-0.19 SD score [SDS]; 95% CI -0.31, -0.07) and left ventricular end-diastolic volume (-0.17 SDS; 95% -0.28, -0.05). Also, higher maternal glucose concentrations across the full range per 1 mmol/L increase were associated with a lower childhood left ventricular mass and left ventricular end-diastolic volume (P values ≤0.05). Adjustment for maternal prepregnancy BMI, gestational age, and weight at birth or childhood BMI and blood pressure did not influence the effect estimates. Maternal glucose concentrations were not significantly associated with childhood right ventricular end-diastolic volume or left and right ventricular ejection fraction.

CONCLUSIONS

Higher maternal random glucose concentrations in the first half of pregnancy are associated with a lower childhood left ventricular mass and left ventricular end-diastolic volume, with the strongest associations for childhood left ventricular mass. These associations were not explained by maternal, birth, or childhood characteristics. Further studies are needed to replicate these findings using repeated maternal glucose measurements throughout pregnancy and offspring cardiac outcomes throughout childhood and adulthood.

Placental Regulation of Energy Homeostasis During Human Pregnancy

Successful pregnancies rely on sufficient energy and nutrient supply, which require the mother to metabolically adapt to support fetal needs. The placenta has a critical role in this process, as this specialized organ produces hormones and peptides that regulate fetal and maternal metabolism. The ability for the mother to metabolically adapt to support the fetus depends on maternal prepregnancy health. Two-thirds of pregnancies in the United States involve obese or overweight women at the time of conception. This poses significant risks for the infant and mother by disrupting metabolic changes that would normally occur during pregnancy. Despite well characterized functions of placental hormones, there is scarce knowledge surrounding placental endocrine regulation of maternal metabolic trends in pathological pregnancies. In this review, we discuss current efforts to close this gap of knowledge and highlight areas where more research is needed. As the intrauterine environment predetermines the health and wellbeing of the offspring in later life, adequate metabolic control is essential for a successful pregnancy outcome. Understanding how placental hormones contribute to aberrant metabolic adaptations in pathological pregnancies may unveil disease mechanisms and provide methods for better identification and treatment. Studies discussed in this review were identified through PubMed searches between the years of 1966 to the present. We investigated studies of normal pregnancy and metabolic disorders in pregnancy that focused on energy requirements during pregnancy, endocrine regulation of glucose metabolism and insulin resistance, cholesterol and lipid metabolism, and placental hormone regulation.

Association of Serum Uric Acid, Urea Nitrogen, and Urine Specific Gravity Levels at 16-18 Weeks of Gestation with the Risk of Gestational Diabetes Mellitus

OBJECTIVE

To evaluate the associations of serum uric acid (UA), urea nitrogen (UN), and urine specific gravity (USG) levels in the first trimester of pregnancy with the risk of gestational diabetes mellitus (GDM).

PATIENTS AND METHODS

A retrospective cohort study was conducted in 1,769 pregnant women aged 31.55 ± 3.91 years. UA, UN, and USG levels were measured during the 16-18th week of gestation. GDM was diagnosed by an oral 75 g glucose tolerance test during the 24-28th week of gestation.

RESULTS

A multivariate adjusted logistic regression analysis showed that UA levels in the highest quartile increased the risk of GDM by 55.7% (odds ratio [OR]: 1.557, 95% confidence interval [CI]: 1.055-2.298; p = 0.026) compared to those in the lowest quartile. USG levels in the second, third, and fourth quartiles increased the risk of GDM by 67.6% (95% CI: 1.090-2.421), 112.4% (95% CI: 1.446-3.119), and 94.5% (95% CI: 1.314-2.880), respectively, compared to those in the first quartile (p trend = 0.001). No significant association between UN levels and the GDM risk was observed. When the extreme composite biomarker score quartiles were compared, the adjusted OR (95% CI) for GDM was 1.909 (95% CI: 1.332-2.736). Age-stratified analyses revealed similar results in women aged ≤35 years only, but not in those aged >35 years.

CONCLUSION

Higher levels of UA and USG and a higher composite kidney function biomarker score during the 16-18th week of gestation were positively and independently associated with an increased risk of GDM.