Prediction of gestational diabetes mellitus in the first trimester, comparison of fasting plasma glucose, two-step and one-step methods: a prospective randomized controlled trial

Association of serum folic acid levels in response to fasting blood glucose in early pregnancy with the risk of gestational diabetes mellitus: A retrospective cohort study

OBJECTIVE

With increasingly prevalent folic acid consumption in early pregnancy, concerns about its potentially negative effect on maternal metabolism have been raised. Recent findings regarding folic acid levels in the first trimester and the risk of gestational diabetes mellitus have been inconclusive. The aim of this study was to investigate the association of folic acid status in early pregnancy with gestational diabetes mellitus as well as examine whether glucose levels can be modulated by folic acid status during the same first trimester.

METHODS

This was a retrospective cohort study based on 27 128 Chinese pregnant women who registered during their first prenatal visit from January 2015 to December 2019. Serum folic acid and fasting blood glucose concentrations were measured during the 9th to 13th gestational weeks. Binary logistic regression was applied to estimate the odds ratios of gestational diabetes mellitus by using the serum folic acid levels quartiles with adjustment for major confounders. To investigate the potential effect of modifying key risk factors for gestational diabetes mellitus, we established subgroups, in which analyses were stratified by age (<25, 25-29, 30-34, and ≥35 y), parity (nulliparous and parous), prepregnancy body mass index (< 18.5, 18.5-23.9, and ≥ 24 kg/m2), and family history of diabetes (yes and no).

RESULTS

The positive association between maternal folate concentrations and fasting blood glucose was observed: the risk for hyperglycemia was higher in those in the middle (Q3) and higher (Q4) quartiles compared with those in Q1 and Q2. A higher risk for gestational diabetes mellitus was found in hyperglycemia of early pregnant women with high folate concentrations (Q3: odds ratio = 5.63; 95% CI, 4.56-6.95, and Q4: odds ratio = 5.57; 95% CI, 4.68-6.64) compared with normal fasting glucose mothers with folate concentrations in Q1 and Q2 after accounting for multiple covariables. Similar patterns were observed for different subgroups. Restricted cubic spline plots had a positive correlation of serum folic acid level with fasting blood glucose concentration as well as risk of gestational diabetes mellitus in a nonlinear pattern, with 32.5 nmol/L as the cutoff point for folic acid level.

CONCLUSIONS

Our findings underscore the importance of maintaining an appropriate folic acid concentration for preserving a lower risk of gestational diabetes mellitus, especially in women with relatively higher blood glucose in early pregnancy. Additionally, folic acid concentration > 32.5 nmol/L may be considered a risk factor for gestational diabetes mellitus. This research suggested that folic acid levels should be monitored during the first trimester from the first prenatal checkup to prevent adverse effects of excessive folic acid intake.

A Prediction Model of Gestational Diabetes Mellitus Based on OGTT in Early Pregnancy: A Prospective Cohort Study

CONTEXT

Gestational diabetes mellitus (GDM) is a common obstetric complication. Although early intervention could prevent the development of GDM, there was no consensus on early identification for women at high risk of GDM.

OBJECTIVE

To develop a reliable prediction model of GDM in early pregnancy.

METHODS

In this prospective cohort study, between May 30, 2021, and August 13, 2022, a total of 721 women were included from Women's Hospital, Zhejiang University School of Medicine. Participants were asked to complete an oral glucose tolerance test (OGTT) during gestational weeks 7 through 14 for early prediction of GDM, and at weeks 24 through 28 for GDM diagnosis. Using OGTT results and baseline characteristics, logistic regression analysis was used to construct the prediction model. Receiver operating characteristic (ROC) curve, Hosmer-Lemeshow test, decision clinical analysis, and a nomogram were used for model performances assessment and visualization. Internal and external validation was performed to testify the stability of this model.

RESULTS

According to the International Association of Diabetes and Pregnancy Study Groups criteria in early OGTT, the mean (SD) age was 30.5 ± 3.7 years in low-risk participants and 31.0 ± 3.9 years in high-risk participants. The area under ROC curve (AUC) of the existing criteria at weeks 7 through 14 varied from 0.705 to 0.724. Based on maternal age, prepregnancy body mass index, and results of early OGTT, the AUC of our prediction model was 0.8720, which was validated by both internal (AUC 0.8541) and external (AUC 0.8241) confirmation.

CONCLUSIONS

The existing diagnostic criteria were unsatisfactory for early prediction of GDM. By combining early OGTT, we provided an effective prediction model of GDM in the first trimester.

Impact of inflammatory factors, hemoglobin A1c, and platelet parameters in gestational diabetes mellitus

PURPOSE

The aim of this study was to evaluate the relationship among inflammatory cytokines including hypersensitive C-reactive protein (hs-CRP) and interleukin-6 (IL-6), glycated hemoglobin A1c (HbA1c), and platelet distribution width (PDW) in women with gestational diabetes mellitus (GDM).

METHODS

Data on 191 pregnant women (96 women with GDM; 95 healthy controls) were extracted from routine prenatal examination records in Nanjing, China. Fasting concentrations of hs-CRP, IL-6, HbA1c, blood cell indices, and glucose at 24-28th gestational weeks were determined.

RESULTS

The levels of hs-CRP, IL-6, FPG, PG1h, PG2h, HbA1c, RBC, and PDW significantly were increased (P < 0.05) in GDM group. hs-CRP had a positive correlation with HbA1c and PLT (P < 0.05). The odds ratios of HbA1c and PDW were 7.817 (95% CI 1.921-31.816, P = 0.004) and 1.523 (95% CI 1.158-2.002, P = 0.003), respectively. Furthermore, AUC of the combined diagnosis of GDM including HbA1c, FPG, and PDW reached 0.754, with specificity of 80.0% and sensitivity of 60.4%.

CONCLUSION

Our findings support that elevated levels of hs-CRP, IL-6, HbA1c, and PDW at 24-28th gestational weeks even within the conventional normal range, may be implicated in the pathogenesis of GDM and their evaluation should be part of prenatal care routine.

Predictive and Prognostic Value of Plasma Zonulin for Gestational Diabetes Mellitus in Women at 24-28 Weeks of Gestation

OBJECTIVE

We aimed to examine the predictive and prognostic value of plasma zonulin for gestational diabetes mellitus (GDM) in women at 24-28 weeks of gestation.

METHODS

This retrospective study was carried out with pregnant women with GDM (n=98) and normal glucose tolerance (control group) (n=132). GDM was diagnosed according to American Diabetes Association (ADA) criteria with a one-step 75-g OGTT at 24-28 gestational weeks. Their serum zonulin levels measured during one-step 75-g OGTT and perinatal outcomes were compared, and the cut-off value of plasma zonulin for the prediction of GDM was calculated with receiver operating characteristic curve analysis.

RESULTS

Plasma zonulin level was significantly higher in women with GDM compared to controls (28.8±24.9 and 7.3±11.3 ng/mL, respectively). According to logistic regression analysis, plasma zonulin levels and GDM were statistically significant. The plasma zonulin cut-off value was>45.2 ng/mL. The rate of cesarean section, the rate of meconium in the amniotic fluid, and the need for admission to the neonatal intensive care unit significantly differed between women with GDM and controls.

CONCLUSION

In pregnant women with GDM, plasma zonulin increases, and with the cut-off level of>45.2 ng/mL, it can predict GDM with values of sensitivity and specificity levels significantly higher in pregnant women with GDM, suggesting that it can be used as a tool for its screening and early diagnosis.

Weighted entropy deep features on hybrid RNN with LSTM for glucose level and diabetes prediction

Glucose level regulation with essential advice regarding diabetes must be provided to the patients to maintain their diet for diabetes treatment. Therefore, the academic community has focused on implementing novel glucose prediction techniques for decision support systems. Recent computational techniques for diagnosing diabetes have certain limitations, and also they are not evaluated under various datasets obtained from the different people of various countries. This generates inefficiency in the prediction systems to apply it in real-time applications. This paper plans to suggest a hybrid deep learning model for diabetes prediction and glucose level classification. Two benchmark datasets are used in the data collection process for experimenting. Initially, the deep selected features were extracted by the Convolutional Neural Network (CNN). Further, weighted entropy deep features are extracted, where the tuning of weight is taken place by the Modified Escaping Energy-based Harris Hawks Optimization. These features are processed in the glucose level classification using the modified Fuzzy classifier for classifying the high-level and low-level glucose. Further, glucose prediction is done by the Hybrid Recurrent Neural Network (RNN), and Long Short Term Memory (LSTM) termed R-LSTM with parameter optimization. From the experimental result, In the dataset 2 analyses on SMAPE, the MEE-HHO-R-LSTM is 12.5%, 87.5%, 50%, 12.5%, and 2.5% better than SVM, LSTM, DNN, RNN, and RNN-LSTM, at the learning percentage of 75%. The analytical results enforce that the suggested methods attain enhanced prediction performance concerning the evaluation metrics compared to conventional prediction models.

One-Step Compared With Two-Step Gestational Diabetes Screening and Pregnancy Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate short-term maternal and neonatal outcomes with one-compared with two-step testing for gestational diabetes mellitus (GDM).

DATA SOURCES

A systematic review of randomized controlled trials (RCTs) and observational studies comparing one-step and two-step GDM testing strategies before September 2021 was conducted. We searched Ovid Medline (1946-), EMBASE (1947-), Scopus (1960-), Cochrane Central, and ClinicalTrials.gov . The primary outcome was rate of large-for-gestational age (LGA) neonates. Secondary outcomes were clinically relevant outcomes for GDM that were selected a priori.

METHODS OF STUDY SELECTION

Titles, abstracts, and manuscripts were screened, selected, and reviewed by the first two authors. Four RCTs (24,966 patients) and 13 observational studies (710,677 patients) were analyzed.

TABULATION, INTEGRATION, AND RESULTS

Pooled relative risks (RRs) were calculated with 95% CIs using random-effects models and were plotted graphically with forest plots. Study heterogeneity was evaluated using Cochran Q and Higgins I 2 tests. The quality of studies that met the inclusion criteria was evaluated with the Downs and Black checklist. Publication bias was assessed by using asymmetry of funnel plots and Harbord's test. There was no difference in the rate of LGA neonates (pooled RR 0.95; 95% CI 0.88-1.04) by testing strategy among RCTs, but patients who underwent one-step testing were more likely to be diagnosed with GDM (pooled RR 2.13; 95% CI 1.61-2.82) and treated with diabetes medications (pooled RR 2.24; 95% CI 1.21-4.15). One-step testing was associated with higher rates of neonatal intensive care unit (NICU) admission (pooled RR 1.12; 95% CI 1.00-1.26) and neonatal hypoglycemia (pooled RR 1.23; 95% CI 1.13-1.34). In analysis of high-quality RCTs and observational studies, one-step testing was associated with a lower rate of LGA neonates (pooled RR 0.97; 95% CI 0.95-0.98), but higher rates of GDM diagnosis, treatment, NICU admission, and neonatal hypoglycemia.

CONCLUSION

Despite a significant increase in GDM diagnosis and treatment with one-step testing, there is no difference in rate of LGA neonates compared with two-step testing among RCTs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021252703.

FGF4, A New Potential Regulator in Gestational Diabetes Mellitus

Background: Gestational diabetes mellitus (GDM) is associated with adverse maternal and neonatal outcomes, however the underlying mechanisms remain elusive. The aim of this study was to find efficient regulator of FGFs in response to the pathogenesis of GDM and explore the role of the FGFs in GDM.

Methods: We performed a systematic screening of placental FGFs in GDM patients and further in two different GDM mouse models to investigate their expression changes. Significant changed FGF4 was selected, engineered, purified, and used to treat GDM mice in order to examine whether it can regulate the adverse metabolic phenotypes of the diabetic mice and protect their fetus.

Results: We found FGF4 expression was elevated in GDM patients and its level was positively correlated to blood glucose, indicating a physiological relevance of FGF4 with respect to the development of GDM. Recombinant FGF4 (rFGF4) treatment could effectively normalize the adverse metabolic phenotypes in high fat diet induced GDM mice but not in STZ induced GDM mice. However, rFGF4 was highly effective in reduce of neural tube defects (NTDs) of embryos in both the two GDM models. Mechanistically, rFGF4 treatment inhibits pro-inflammatory signaling cascades and neuroepithelial cell apoptosis of both GDM models, which was independent of glucose regulation.

Conclusions/interpretation: Our study provides novel insight into the important roles of placental FGF4 and suggests that it may serve as a promising diagnostic factor and therapeutic target for GDM.

Prediction of gestational diabetes mellitus in the first trimester by fasting plasma glucose which cutoff is better?

OBJECTIVE

We aimed to predict subsequent gestational diabetes mellitus (GDM) by fasting plasma glucose (FPG) in the first trimester.

METHODS

Healthy pregnant women who were screened for GDM at 24-28 gestational weeks and had FPG levels calculated during their first antenatal visit and less than 14 gestational weeks were included in this study.

RESULTS

Of the 2605 women who were recruited for the study, 245 (9.4%) were diagnosed with GDM at weeks 24-28. The diagnostic accuracy for FPG predicting GDM was 66.5, 78.4, and 88.2 for the cutoff values of 87.5 mg/dl, 92 mg/dl, and 99.5 mg/dl, respectively.

CONCLUSIONS

FPG values which are within the normoglycaemic range constitute an independent risk factor for the development of GDM. The threshold for gestational diabetes diagnosis must be revised.

Differing risk factors for new onset and recurrent gestational diabetes mellitus in multipara women: a cohort study

OBJECTIVES

To assess whether recurrent gestational diabetes mellitus (GDM) and newly diagnosed GDM share similar risk factors.

METHODS

The study recruited a cohort of 10,151 multipara women with singleton pregnancy who delivered between 2016 and 2019 in Beijing, China. The prevalence of recurrent GDM and associated risk factors were analyzed between women with and without prior GDM history.

RESULTS

Eight hundred and seventy-five (8.6%) multipara women had a diagnosis of GDM during previous pregnancies. The prevalence of GDM and pre-gestational diabetes mellitus were 48.34% (423/875) and 7.89% (69/875) if the women were diagnosed with GDM during previous pregnancies, as compared to 16.00% (1484/9276) and 0.50% (46/9276) if the women were never diagnosed with GDM before. In women without a history of GDM, a variety of factors including older maternal age, higher pre-pregnancy body mass index (PPBMI), prolonged interval between the two pregnancies, higher early pregnancy weight gain, family history of type 2 diabetes mellitus (T2DM), maternal low birth weight, and higher early pregnancy glycemic and lipid indexes were generally associated with an increased risk of GDM at subsequent pregnancy. In women with a history of GDM, higher PPBMI, higher fasting glucose level and maternal birthweight ≥4000 g were independent risk factors for recurrent GDM.

CONCLUSIONS

GDM reoccurred in nearly half of women with a history of GDM. Risk factors for recurrent GDM and newly diagnosed GDM were different. Identifying additional factors for GDM recurrence can help guide clinical management for future pregnancies to prevent GDM recurrence.

Early Identification of the Maternal, Placental and Fetal Dialog in Gestational Diabetes and Its Prevention

Gestational diabetes mellitus (GDM) complicates between 5 and 12% of pregnancies, with associated maternal, fetal, and neonatal complications. The ideal screening and diagnostic criteria to diagnose and treat GDM have not been established and, currently, diagnostic use with an oral glucose tolerance test occurs late in pregnancy and produces poor reproducibility. Therefore, in recent years, significant research has been undertaken to identify a first-trimester biomarker that can predict GDM later in pregnancy, enable early intervention, and reduce GDM-related adverse pregnancy outcomes. Possible biomarkers include glycemic markers (fasting glucose and hemoglobin A1c), adipocyte-derived markers (adiponectin and leptin), pregnancy-related markers (pregnancy-associated plasma protein-A and the placental growth factor), inflammatory markers (C-reactive protein and tumor necrosis factor-α), insulin resistance markers (sex hormone-binding globulin), and others. This review summarizes current data on first-trimester biomarkers, the advantages, and the limitations. Large multi-ethnic clinical trials and cost-effectiveness analyses are needed not only to build effective prediction models but also to validate their clinical use.

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.

Emerging Protein Biomarkers for the Diagnosis or Prediction of Gestational Diabetes-A Scoping Review

Introduction: Gestational diabetes (GDM), defined as hyperglycemia with onset or initial recognition during pregnancy, has a rising prevalence paralleling the rise in type 2 diabetes (T2DM) and obesity. GDM is associated with short-term and long-term consequences for both mother and child. Therefore, it is crucial we efficiently identify all cases and initiate early treatment, reducing fetal exposure to hyperglycemia and reducing GDM-related adverse pregnancy outcomes. For this reason, GDM screening is recommended as part of routine pregnancy care. The current screening method, the oral glucose tolerance test (OGTT), is a lengthy, cumbersome and inconvenient test with poor reproducibility. Newer biomarkers that do not necessitate a fasting sample are needed for the prompt diagnosis of GDM. The aim of this scoping review is to highlight and describe emerging protein biomarkers that fulfill these requirements for the diagnosis of GDM. Materials and Methods: This scoping review was conducted according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for scoping reviews using Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing & Allied Health Literature (CINAHL), PubMed, Embase and Web of Science with a double screening and extraction process. The search included all articles published in the literature to July 2020. Results: Of the 3519 original database citations identified, 385 were eligible for full-text review. Of these, 332 (86.2%) were included in the scoping review providing a total of 589 biomarkers studied in relation to GDM diagnosis. Given the high number of biomarkers identified, three post hoc criteria were introduced to reduce the items set for discussion: we chose only protein biomarkers with at least five citations in the articles identified by our search and published in the years 2017-2020. When applied, these criteria identified a total of 15 biomarkers, which went forward for review and discussion. Conclusions: This review details protein biomarkers that have been studied to find a suitable test for GDM diagnosis with the potential to replace the OGTT used in current GDM screening protocols. Ongoing research efforts will continue to identify more accurate and practical biomarkers to take GDM screening and diagnosis into the 21st century.

Prognostic models versus single risk factor approach in first-trimester selective screening for gestational diabetes mellitus: a prospective population-based multicentre cohort study

Objectives

To evaluate whether (1) first‐trimester prognostic models for gestational diabetes mellitus (GDM) outperform the currently used single risk factor approach, and (2) a first‐trimester random venous glucose measurement improves model performance.

Design

Prospective population‐based multicentre cohort.

Setting

Thirty‐one independent midwifery practices and six hospitals in the Netherlands.

Population

Women recruited before 14 weeks of gestation without pre‐existing diabetes.

Methods

The single risk factor approach (presence of at least one risk factor: BMI ≥30 kg/m², previous macrosomia, history of GDM, positive first‐degree family history of diabetes, non‐western ethnicity) was compared with the four best performing models in our previously published external validation study (Gabbay‐Benziv 2014, Nanda 2011, Teede 2011, van Leeuwen 2010) with and without the addition of glucose.

Main outcome measures

Discrimination was assessed by c‐statistics, calibration by calibration plots, added value of glucose by the likelihood ratio chi‐square test, net benefit by decision curve analysis and reclassification by reclassification plots.

Results

Of the 3723 women included, a total of 181 (4.9%) developed GDM. The c‐statistics of the prognostic models were higher, ranging from 0.74 to 0.78 without glucose and from 0.78 to 0.80 with glucose, compared with the single risk factor approach (0.72). Models showed adequate calibration, and yielded a higher net benefit than the single risk factor approach for most threshold probabilities. Teede 2011 performed best in the reclassification analysis.

Conclusions

First‐trimester prognostic models seem to outperform the currently used single risk factor approach in screening for GDM, particularly when glucose was added as a predictor.

Tweetable abstract

Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes.

Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes.

The Predictive Value of Selenium in Diagnosis of Gestational Diabetes: A Nested Case-Control Study

Aim

The present study was conducted to determine the predictive value of Selenium (Se) in the diagnosis of Geatational diabetes Mellitus (GDM).

Methods

This is a nested case-control study with 636 normal pregnant mothers in their 11th-13th weeks. Gestational diabetes screening was done in weeks 24-28. Twenty-five individuals were detected as GDM, and for every GDM two gestational age-matched normal pregnant women were selected. The blood selenium level was measured in both groups.

Results

The serum Se level in the case group was lower than that of the control group (50.60 ± 10.88 versus 66.02 ± 10.57) in the first trimester. Also, in the second trimester, Se was lower in the case group (39.87 ± 10.23 versus 63.17 ± 10.22). The best cut-off point for selenium in order to predict the incidence of gestational diabetes in our study was 48.2. Pregnant women with selenium levels below 48.2 were more likely to develop gestational diabetes.

Conclusion

Serum selenium was lower in the GDM subjects compared with age-matched control group; the clinical concept and mechanism of this finding need to be investigated through further studies.

Gestational Diabetes Mellitus Screening and Diagnosis

An ideal screening test for gestational diabetes should be capable of identifying not only women with the disease but also the women with a high risk of developing gestational diabetes mellitus (GDM). Screening and diagnosis are the main steps leading to the way of management. There is a lack of consensus among healthcare professionals regarding the screening methods worldwide. Different study groups advocate a variety of screening methods with the support of evidence-based comprehensive data. Some of the organizations suggest screening for high risk or all pregnant women, while others prefer to offer definitive testing without screening. Glycemic thresholds are also not standardized to decide GDM among different guidelines. Prevalence rates of GDM vary between populations and with the choice of glucose thresholds for both screening and definitive tests. One-step or two-step methods have been used for GDM diagnosis. However, screening includes selecting patients with historical risk factors, 50 g 1-h glucose challenge test, fasting plasma glucose, random plasma glucose, and hemoglobin A1c with different cutoffs. In this chapter, screening and diagnosis methods of GDM accepted by different study groups will be discussed which will be followed by the evaluation of different glycemic thresholds. Then the advantages and disadvantages of used methods will be explained and the chapter will finish with an evaluation of the current international guidelines.

Diagnostic Strategies for Gestational Diabetes Mellitus: Review of Current Evidence

PURPOSE OF REVIEW

Currently, the diagnosis of gestational diabetes mellitus (GDM) lacks uniformity. Several controversies are still under debate, especially on the method of screening and diagnosis. This review focuses on recent literature and provides current evidence for the screening and diagnosis of GDM.

RECENT FINDINGS

Selective screening would miss a significant number of women with GDM. In contrast, universal screening has been shown to be cost-effective, compared with selective screening, and is recommended by many medical societies. For the diagnostic methods for GDM, most observational cohort studies reported that the one-step method is associated with improved pregnancy outcomes and is cost-saving or cost-effective, compared with the two-step method, although these findings should be confirmed in the upcoming randomized controlled trials which compare the performance of one-step and two-step methods. On the other hand, the methods of early screening or diagnosis of GDM are varied, and current evidence does not justify their use during early pregnancy. In conclusion, current evidence favors universal screening for GDM using the one-step method. Early screening for GDM is not favorably supported by the literature.

Value of fasting plasma glucose to screen gestational diabetes mellitus before the 24th gestational week in women with different pre-pregnancy body mass index

BACKGROUND

Gestational diabetes mellitus (GDM) is usually diagnosed between 24th and 28th gestational week using the 75-g oral glucose tolerance test (OGTT). It is difficult to predict GDM before 24th gestational week because fast plasma glucose (FPG) decreases as the gestational age increases. It is controversial that if FPG ≥5.1 mmol/L before 24th gestational week should be intervened or not. The aim of this study was to evaluate the value of FPG to screen GDM before 24th gestational week in women with different pre-pregnancy body mass index (BMI).

METHODS

This was a multi-region retrospective cohort study in China. Women who had a singleton live birth between June 20, 2013 and November 30, 2014, resided in Beijing, Guangzhou and Chengdu, and received prenatal care in 21 selected hospitals, were included in this study. Pre-pregnancy BMI, FPG before the 24th gestational week, and one-step GDM screening with 75 g-OGTT at the 24th to 28th gestational weeks were extracted from medical charts and analyzed. The pregnant women were classified into four groups based on pre-pregnancy BMI: Group A (underweight, BMI < 18.5 kg/m), Group B (normal, BMI 18.5-23.9 kg/m), Group C (overweight, BMI 24.0-27.9 kg/m) and Group D (obesity, BMI ≥28.0 kg/m). The trend of FPG before 24th week of gestation was described, and the sensitivity and specificity of using FPG before the 24th gestational week to diagnose GDM among different pre-pregnancy BMI groups were reported. Differences in the means between groups were evaluated using independent sample t-test and analysis of variance. Pearson Chi-square test was used for categorical variables.

RESULTS

The prevalence of GDM was 20.0% (6806/34,087) in the study population. FPG decreased gradually as the gestational age increased in all pre-pregnancy BMI groups until the 19th gestational week. FPG was higher in women with higher pre-pregnancy BMI. FPG before the 24th gestational week and pre-pregnancy BMI could be used to predict GDM. The incidence of GDM in women with FPG ≥5.10 mmol/L in the 19th to 24th gestational weeks and pre-pregnancy overweight or obesity was significantly higher than that in women with FPG ≥5.10 mmol/L and pre-pregnancy BMI <24.0 kg/m (78.5% [62/79] vs. 52.9% [64/121], χ = 13.425, P < 0.001).

CONCLUSIONS

FPG decreased gradually as the gestational age increased in all pre-pregnancy BMI groups until the 19th gestational week. Pre-pregnancy overweight or obesity was associated with an increased FPG value before the 24th gestational week. FPG ≥5.10 mmol/L between 19 and 24 gestational weeks should be treated as GDM in women with pre-pregnancy overweight and obesity.

Role of mean platelet volume in pregnancy to predict gestational diabetes mellitus in the first trimester

Objectives: Gestational diabetes mellitus (GDM) is defined as glucose intolerance detected for the first time in pregnancy or identified during pregnancy. Mean platelet volume (MPV) is a marker of activation and function of platelet. Several studies investigated the relation between MPV and GDM. The purpose of the present study is to predict GDM in the first trimester by using MPV value.Materials and methods: Two hundred pregnant women with GDM and 200 normal pregnant women were enrolled in the study. The first trimester MPV values of GDM and control groups were compared to predict GDM in the first trimester.Results: Women with GDM had higher MPV value compared with the control group (p < .001). The area under the receiver-operator curve was 0.70 for MPV. The cutoff value of MPV was 7.38 fl with 70% sensitivity and 60% specificity. According to the ages, MPV value was higher in GDM group in the individuals who were above 28-year-old (p < .001).Conclusion: MPV can be used to predict GDM in the first trimester.

Prediction of gestational diabetes mellitus in the first trimester: comparison of maternal fetuin-A, N-terminal proatrial natriuretic peptide, high-sensitivity C-reactive protein, and fasting glucose levels

OBJECTIVE

We investigated the utility of maternal fetuin-A, N-terminal proatrial natriuretic peptide (pro-ANP), high-sensitivity C-reactive protein (hs-CRP), and fasting glucose levels at 11-14 gestation weeks for predicting pregnancies complicated by gestational diabetes mellitus (GDM).

SUBJECTS AND METHODS

This prospective cohort study included 327 low-risk pregnant women who completed antenatal follow-up at a tertiary research hospital between January and April 2014. Maternal blood samples were collected between 11-14 gestational weeks in the first trimester of pregnancy and then stored at -80 °C until further analyses. During follow-up, 29 (8.8%) women developed GDM. The study population was compared 1:2 with age- and body mass index-matched pregnant women who did not develop GDM (n = 59). Fasting plasma glucose (FPG) levels and serum fetuin-A, pro-ANP, and hs-CRP levels were measured using automated immunoassay systems.

RESULTS

There was a significant negative correlation between fetuin-A and hs-CRP (CC = -0.21, p = 0.047) and a positive correlation between FPG and hs-CRP (CC = 0.251, p = 0.018). The areas under the receiver operating characteristic curve for diagnosing GDM were 0.337 (p = 0.013), 0.702 (p = 0.002), and 0.738 (p < 0.001) for fetuin-A, hs-CRP, and FPG, respectively. The optimal cut-off values were > 4.65, < 166, and > 88.5 mg/dL for maternal hs-CRP, fetuin-A, and FPG, respectively.

CONCLUSION

Reduced fetuin-A, elevated hs-CRP, and FPG levels in women in the first trimester can be used for the early detection of GDM. Further research is needed before accepting these biomarkers as valid screening tests for GDM.

The post-HAPO situation with gestational diabetes: the bright and dark sides

AIM

In 2010, in light of the data coming from the HAPO study, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed a new detection strategy and diagnostic criteria for gestational diabetes based on a one-step approach with a 75 g OGTT. This review analyzes and discusses the bright and dark sides of their application.

METHODS

The assessment of these recommendations by the international organizations involved in the care of gestational diabetes and a series of observational, retrospective and prospective studies that have been published since 2010 regarding the use of the IADPSG recommendations have been evaluated.

RESULTS

The different international associations involved in the care of pregnancy and of pregnancy complicated by diabetes have not taken an univocal position some of which have accepted them, while others have criticized them. Then, the actual application of the approach recommended by the IADPSG for detecting and diagnosing GDM varies, even at centers that reportedly accept the new diagnostic criteria.

CONCLUSION

So the challenge lies in making every effort to achieve a global standardization of the strategies for detecting, diagnosing and treating GDM.

Early diabetes screening in pregnancy

The present literature review was conducted to evaluate early diabetes screening in pregnancy. The review focuses on the various guidelines for early screening, the target populations for screening, and the assessment of various early screening targets and strategies. The advantages and disadvantages of each screening method are highlighted. The review emphasizes that there are no validated criteria for selecting high-risk pregnant women for early screening. The different early screening modalities, including fasting plasma glucose, random plasma glucose, postload glucose, and hemoglobin A1c, lack concordance and have not been validated for the early diagnosis of diabetes in pregnancy. Moreover, the benefit of early screening by earlier initiation of treatment has not been shown. Until a randomized controlled trial demonstrates benefit to screening and validates a particular screening method, it is not possible to provide evidence to support any single strategy for early diabetes screening in pregnancy.

Angiopoietin-like protein 8 in early pregnancy improves the prediction of gestational diabetes

AIMS/HYPOTHESIS

Screening high-risk individuals for gestational diabetes mellitus (GDM) in early pregnancy conventionally relies on established maternal risk factors; however, the sensitivity and specificity of these factors are not satisfactory. The present study aimed to determine whether the concentration of angiopoietin-like protein 8 (ANGPTL8), either alone or combined with other risk factors in early pregnancy, could be used to predict subsequent GDM.

METHODS

From August 2015 to January 2016, 474 women receiving prenatal care at around 12-16 weeks of gestation were recruited into the study. ANGPTL8 levels were measured at the first prenatal visit. All the participants received a 75 g OGTT during weeks 24-28 of gestation.

RESULTS

ANGPTL8 levels in early pregnancy were considerably higher in women who developed GDM than those who maintained normal glucose tolerance (2822 ± 938 vs 2120 ± 1118 pg/ml, respectively; p < 0.0001). Multivariable logistic regression revealed that ANGPTL8 levels were significantly associated with risk of GDM independent of conventional risk factors. In addition, women in the highest quartile of ANGPTL8 concentration had an 8.75-fold higher risk of developing GDM compared with women in the lowest quartile (OR8.75, 95%CI 2.43, 31.58). More importantly, incorporating ANGPTL8 into the conventional prediction model significantly increased the AUC for prediction of GDM (0.772vs 0.725; p = 0.019).

CONCLUSIONS

Our study suggests that ANGPTL8 levels in early pregnancy are significantly and independently associated with risk of GDM at 24-28 weeks of gestation. Combining ANGPTL8 levels with conventional risk factors could thus improve the prediction of GDM.

Tumor necrosis factor- α, adiponectin and their ratio in gestational diabetes mellitus

Background:

It has been suggested that inflammation might be implicated in the gestational diabetes mellitus (GDM) complications, including insulin resistance. The aims of the current study were to explore maternal circulating values of TNF-α, adiponectin and the adiponectin/TNF-α ratio in women with GDM compared with normal pregnancy and their relationships with metabolic syndrome biomarkers.

Methods:

Forty women with GDM and 40 normal pregnant women were included in the study. Commercially available enzyme-linked immunosorbent assay methods were used to measure serum levels of TNF-α and total adiponectin.

Results:

Women with GDM had higher values of TNF-α (225.08±27.35 vs 115.68±12.64 pg/ml, p<0.001) and lower values of adiponectin (4.50±0.38 vs 6.37±0.59 µg/ml, p=0.003) and the adiponectin/TNF-α ratio (4.31±0.05 vs 4.80±0.07, P<0.001) than normal pregnant women. The adiponectin/TNF-α ratio showed negative correlations with insulin resistance (r=-0.68, p<0.001) and triglyceride (r=-0.39, p=0.014) and a positive correlation with insulin sensitivity (r=0.69, p<0.001). Multiple linear regression analysis showed that values of the adiponectin /TNF-α ratio were independently associated with insulin resistance. Binary logistic regression analysis showed that GDM was negatively associated with adiponectin /TNF-α ratio.

Conclusions:

In summary, the adiponectin/TNF-α ratio decreased significantly in GDM compared with normal pregnancy. The ratio might be an informative biomarker for assessment of pregnant women at high risk of insulin resistance and dyslipidemia and for diagnosis and therapeutic monitoring aims in GDM.

Screening and Treatment for Early-Onset Gestational Diabetes Mellitus: a Systematic Review and Meta-analysis

We conducted a systematic review to evaluate the current evidence for screening and treatment for early-onset gestational diabetes mellitus (GDM) RECENT FINDINGS: Many of the women with early GDM in the first trimester do not have evidence of hyperglycemia at 24-28 weeks' gestation. A high proportion (15-70%) of women with GDM can be detected early in pregnancy depending on the setting, criteria used and screening strategy. However, there remains no good evidence for any of the diagnostic criteria for early-onset GDM. In a meta-analysis of 13 cohort studies, perinatal mortality (relative risk (RR) 3.58 [1.91, 6.71]), neonatal hypoglycemia (RR 1.61 [1.02, 2.55]), and insulin use (RR 1.71 [1.45, 2.03]) were greater among early-onset GDM women compared to late-onset GDM women, despite treatment. Considering the high likelihood of benefit from treatment, there is an urgent need for randomized controlled trials that investigate any benefits and possible harms of treatment of early-onset GDM.

Different strategies for diagnosing gestational diabetes to improve maternal and infant health

BACKGROUND

Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy. If untreated, perinatal morbidity and mortality may be increased. Accurate diagnosis allows appropriate treatment. Use of different tests and different criteria will influence which women are diagnosed with GDM. This is an update of a review published in 2011 and 2015.

OBJECTIVES

To evaluate and compare different testing strategies for diagnosis of gestational diabetes mellitus to improve maternal and infant health while assessing their impact on healthcare service costs.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (9 January 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised trials if they evaluated tests carried out to diagnose GDM. We excluded studies that used a quasi-random model, cluster-randomised or cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included a total of seven small trials, with 1420 women. One trial including 726 women was identified by this update and examined the two step versus one step approach. These trials were assessed as having varying risk of bias, with few outcomes reported. We prespecified six outcomes to be assessed for quality using the GRADE approach for one comparison: 75 g oral glucose tolerance test (OGTT) versus 100 g OGTT; data for only one outcome (diagnosis of gestational diabetes) were available for assessment. One trial compared three different methods of delivering glucose: a candy bar (39 women), a 50 g glucose polymer drink (40 women) and a 50 g glucose monomer drink (43 women). We have included the results reported by this trial as separate comparisons. No trial reported on measures of costs of health services.We examined six main comparisons. 75 g OGTT versus 100 g OGTT (1 trial, 248 women): women who received 75 g OGTT had a higher relative risk of being diagnosed with GDM (risk ratio (RR) 2.55, 95% confidence interval (CI) 0.96 to 6.75; very-low quality evidence). No data were reported for the following additional outcomes prespecified for GRADE assessment: caesarean section, macrosomia > 4.5 kg or however defined in the trial, long-term type 2 diabetes maternal, long-term type 2 diabetes infant and economic costs. Candy bar versus 50 g glucose monomer drink (1 trial, 60 women): more women receiving the candy bar, rather than glucose monomer, preferred the taste of the candy bar (RR 0.60, 95% CI 0.42 to 0.86) and 1-hour glucose was less with the candy bar. There were no differences in the other outcomes reported (maternal side effects). No infant outcomes were reported or any review primary outcomes. 50 g glucose polymer drink versus 50 g glucose monomer drink (3 trials, 239 women): mean difference (MD) in gestation at birth was -0.80 weeks (1 trial, 100 women; 95% CI -1.69 to 0.09). Total side effects were less common with the glucose polymer drink (1 trial, 63 women; RR 0.21, 95% CI 0.07 to 0.59), and no clear difference in taste acceptability was reported (1 trial, 63 women; RR 0.99, 95% CI 0.76 to 1.29). Fewer women reported nausea following the 50 g glucose polymer drink compared with the 50 g glucose monomer drink (1 trial, 66 women; RR 0.29, 95% CI 0.11 to 0.78). No other measures of maternal morbidity or outcomes for the infant were reported. 50 g glucose food versus 50 g glucose drink (1 trial, 30 women): women receiving glucose in their food, rather than as a drink, reported fewer side effects (RR 0.08, 95% CI 0.01 to 0.56). No clear difference was noted in the number of women requiring further testing (RR 0.14, 95% CI 0.01 to 2.55). No other measures of maternal morbidity or outcome were reported for the infant or review primary outcomes. 75 g OGTT World Health Organization (WHO) criteria versus 75 g OGTT American Diabetes Association (ADA) criteria (1 trial, 116 women): no clear differences in included outcomes were observed between women who received the 75 g OGTT and were diagnosed using criteria based on WHO (1999) recommendations and women who received the 75 g OGTT and were diagnosed using criteria recommended by the ADA (1979). Outcomes measured included diagnosis of gestational diabetes (RR 1.47, 95% CI 0.66 to 3.25), caesarean section (RR 1.07, 95% CI 0.85 to 1.35), macrosomia defined as > 90th percentile by ultrasound or birthweight equal to or exceeding 4000 g (RR 0.73, 95% CI 0.19 to 2.79), stillbirth (RR 0.49, 95% CI 0.02 to 11.68) and instrumental birth (RR 0.21, 95% CI 0.01 to 3.94). No other secondary outcomes were reported. Two-step approach (50 g oral glucose challenge test followed by selective 100 g OGTT Carpenter and Coustan criteria) versus one-step approach (universal 75 g OGTT ADA criteria) (1 trial, 726 women): women allocated the two-step approach had a lower risk of being diagnosed with GDM at 11 to 14 weeks' gestation compared to women allocated the one-step approach (RR 0.51, 95% CI 0.28 to 0.95). No other primary or secondary outcomes were reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence to suggest which strategy is best for diagnosing GDM. Large randomised trials are required to establish the best strategy for correctly identifying women with GDM.

Application of One-Step IADPSG Versus Two-Step Diagnostic Criteria for Gestational Diabetes in the Real World: Impact on Health Services, Clinical Care, and Outcomes

PURPOSE OF REVIEW

This paper seeks to summarize the impact of the one-step International Association of Diabetes and Pregnancy Study Groups (IADPSG) versus the two-step gestational diabetes mellitus (GDM) criteria with regard to prevalence, outcomes, healthcare delivery, and long-term maternal metabolic risk.

RECENT FINDINGS

Studies demonstrate a 1.03-3.78-fold rise in the prevalence of GDM with IADPSG criteria versus baseline criteria. Women with GDM by IADPSG criteria have more adverse pregnancy outcomes than women with normal glucose tolerance (NGT). Treatment of GDM by IADPSG criteria may be cost effective. Use of the fasting glucose as a screen before the 75-g oral glucose tolerance test to rule out GDM with fasting plasma glucose (FPG) < 4.4 (80 mg/dl) and rule in GDM with FPG ≥ 5.1 mmol/l (92 mg/dl) reduces the need for OGTT by 50% and its cost and inconvenience. The prevalence of postpartum abnormal glucose metabolism is higher for women with GDM diagnosed by IADPSG criteria versus that for women with NGT. Data support the use of IADPSG criteria, if the cost of diagnosis and treatment can be controlled and if lifestyle can be optimized to reduce the risk of future diabetes.

Screening for gestational diabetes mellitus based on different risk profiles and settings for improving maternal and infant health

BACKGROUND

Gestational diabetes mellitus (GDM) is a form of diabetes that occurs in pregnancy. Although GDM usually resolves following birth, it is associated with significant morbidities for mothers and their infants in the short and long term. There is strong evidence to support treatment for GDM. However, there is uncertainty as to whether or not screening all pregnant women for GDM will improve maternal and infant health and if so, the most appropriate setting for screening. This review updates a Cochrane Review, first published in 2010, and subsequently updated in 2014.

OBJECTIVES

To assess the effects of screening for gestational diabetes mellitus based on different risk profiles and settings on maternal and infant outcomes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (31 January 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (14 June 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised and quasi-randomised trials evaluating the effects of different protocols, guidelines or programmes for screening for GDM based on different risk profiles and settings, compared with the absence of screening, or compared with other protocols, guidelines or programmes for screening. We planned to include trials published as abstracts only and cluster-randomised trials, but we did not identify any. Cross-over trials are not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included trials. We resolved disagreements through discussion or through consulting a third reviewer.

MAIN RESULTS

We included two trials that randomised 4523 women and their infants. Both trials were conducted in Ireland. One trial (which quasi-randomised 3742 women, and analysed 3152 women) compared universal screening versus risk factor-based screening, and one trial (which randomised 781 women, and analysed 690 women) compared primary care screening versus secondary care screening. We were not able to perform meta-analyses due to the different interventions and comparisons assessed.Overall, there was moderate to high risk of bias due to one trial being quasi-randomised, inadequate blinding, and incomplete outcome data in both trials. We used GRADEpro GDT software to assess the quality of the evidence for selected outcomes for the mother and her child. Evidence was downgraded for study design limitations and imprecision of effect estimates. Universal screening versus risk-factor screening (one trial) MotherMore women were diagnosed with GDM in the universal screening group than in the risk-factor screening group (risk ratio (RR) 1.85, 95% confidence interval (CI) 1.12 to 3.04; participants = 3152; low-quality evidence). There were no data reported under this comparison for other maternal outcomes including hypertensive disorders of pregnancy, caesarean birth, perineal trauma, gestational weight gain, postnatal depression, and type 2 diabetes. ChildNeonatal outcomes: large-for-gestational age, perinatal mortality, mortality or morbidity composite, hypoglycaemia; and childhood/adulthood outcomes: adiposity, type 2 diabetes, and neurosensory disability, were not reported under this comparison. Primary care screening versus secondary care screening (one trial) MotherThere was no clear difference between the primary care and secondary care screening groups for GDM (RR 0.91, 95% CI 0.50 to 1.66; participants = 690; low-quality evidence), hypertension (RR 1.41, 95% CI 0.77 to 2.59; participants = 690; low-quality evidence), pre-eclampsia (RR 0.80, 95% CI 0.36 to 1.78; participants = 690;low-quality evidence), or caesarean section birth (RR 1.00, 95% CI 0.80 to 1.27; participants = 690; low-quality evidence). There were no data reported for perineal trauma, gestational weight gain, postnatal depression, or type 2 diabetes. ChildThere was no clear difference between the primary care and secondary care screening groups for large-for-gestational age (RR 1.37, 95% CI 0.96 to 1.96; participants = 690; low-quality evidence), neonatal complications: composite outcome, including: hypoglycaemia, respiratory distress, need for phototherapy, birth trauma, shoulder dystocia, five minute Apgar less than seven at one or five minutes, prematurity (RR 0.99, 95% CI 0.57 to 1.71; participants = 690; low-quality evidence), or neonatal hypoglycaemia (RR 1.10, 95% CI 0.28 to 4.38; participants = 690; very low-quality evidence). There was one perinatal death in the primary care screening group and two in the secondary care screening group (RR 1.10, 95% CI 0.10 to 12.12; participants = 690; very low-quality evidence). There were no data for neurosensory disability, or childhood/adulthood adiposity or type 2 diabetes.

AUTHORS' CONCLUSIONS

There are insufficient randomised controlled trial data evaluating the effects of screening for GDM based on different risk profiles and settings on maternal and infant outcomes. Low-quality evidence suggests universal screening compared with risk factor-based screening leads to more women being diagnosed with GDM. Low to very low-quality evidence suggests no clear differences between primary care and secondary care screening, for outcomes: GDM, hypertension, pre-eclampsia, caesarean birth, large-for-gestational age, neonatal complications composite, and hypoglycaemia.Further, high-quality randomised controlled trials are needed to assess the value of screening for GDM, which may compare different protocols, guidelines or programmes for screening (based on different risk profiles and settings), with the absence of screening, or with other protocols, guidelines or programmes. There is a need for future trials to be sufficiently powered to detect important differences in short- and long-term maternal and infant outcomes, such as those important outcomes pre-specified in this review. As only a proportion of women will be diagnosed with GDM in these trials, large sample sizes may be required.

Fasting plasma glucose and body mass index during the first trimester of pregnancy as predictors of gestational diabetes mellitus in a Chinese population

This retrospective study assessed fasting plasma glucose (FPG) and body mass index (BMI) during the first trimester of pregnancy as potential screening indicators of later gestational diabetes mellitus (GDM). The study population included 820 pregnant women who delivered in our hospital between 17 September 2013 and 3 March 2014. Demographics and baseline characteristics were collected at the first antenatal visit; FPG levels were measured at 8 or 9 weeks. All participants underwent a 75-g oral glucose tolerance test at 24-28 weeks gestation. Multivariate logistic regression and receiver operating characteristic curve analysis were performed to determine the diagnostic power of risk factors. GDM was diagnosed in 20.3% of the women. There was an increased prevalence of GDM with advancing age, parity, high FPG, and obesity, but not in women with family predisposition. FPG (OR: 3.984; 95% CI: 2.397-6.62) and BMI (OR: 1.144; 95% CI: 1.083-1.208) were independent risk factors for later development of GDM (p<0.01). FPG level ≥4.6 mmol/L was the best threshold for predicting GDM with a sensitivity of 53.89 and specificity of 70.90%. BMI ≥23.5 kg/m² yielded a sensitivity of 48.5% and a specificity of 73.1% for predicting GDM. FPG and BMI combined markedly enhanced the predictive capability for GDM (OR, 3.861; 95% CI: 2.701-5.520). High FPG or BMI in the first trimester, especially in combination, may predict later GDM with limited accuracy and specificity in Chinese women.

Evaluation of serum zonulin for use as an early predictor for gestational diabetes

Diet has an important role in regulating intestinal permeability and subsequently the risk for metabolic disorders. In this observational study, we examined whether serum intestinal permeability marker zonulin, could be used as a predictor for gestational diabetes mellitus (GDM). Serum zonulin concentration was measured in early pregnancy in overweight or obese pregnant women (n=88) at risk for developing GDM. Serum zonulin was associated with higher odds of GDM (adjusted OR for 1 ng ml⁻¹ increase in zonulin: 1.08, 95% CI: 1.02–1.15; P=0.009), diagnosed by a 2-h 75-g oral glucose tolerance test at late pregnancy. The optimal cutoff value was 43.3 ng ml⁻¹, with sensitivity of 88% (95% CI: 71–100%) and specificity of 47% (95% CI: 33–58%). The area under the ROC-curve was 0.67 (95% CI: 0.54–0.81). Our results show an association between increased early-pregnancy serum zonulin concentration and GDM, suggesting zonulin as a possible predictor for GDM.

Early Pregnancy Biochemical Predictors of Gestational Diabetes Mellitus

PURPOSE OF REVIEW

Universal oral glucose tolerance-based screening is employed to identify pregnant women with gestational diabetes mellitus (GDM), as treatment of this condition decreases the risk of associated complications. A simple and accurate blood test which identifies women at low or high risk for GDM in the first trimester would have the potential to decrease costs and improve outcomes through prevention or treatment. This review summarizes published data on early pregnancy biomarkers which have been tested as predictors of GDM.

RECENT FINDINGS

A large number of first-trimester biochemical predictors of GDM have been reported, mostly in small case-control studies. These include glycemic markers (fasting glucose, post-load glucose, hemoglobin A1C), inflammatory markers (C-reactive protein, tumor necrosis factor-alpha), insulin resistance markers (fasting insulin, sex hormone-binding globulin), adipocyte-derived markers (adiponectin, leptin), placenta-derived markers (follistatin-like-3, placental growth factor, placental exosomes), and others (e.g., glycosylated fibronectin, soluble (pro)renin receptor, alanine aminotransferase, ferritin). A few large studies suggest that first-trimester fasting glucose or hemoglobin A1C may be useful for identifying women who would benefit from early GDM treatment. To translate the findings from observational studies of first-trimester biomarkers for GDM to clinical practice, trials or cost-effectiveness analyses of screening and treatment strategies based on these novel biomarkers are needed.

Gestational diabetes mellitus: Screening with fasting plasma glucose

Fasting plasma glucose (FPG) as a screening test for gestational diabetes mellitus (GDM) has had a checkered history. During the last three decades, a few initial anecdotal reports have given way to the recent well-conducted studies. This review: (1) traces the history; (2) weighs the advantages and disadvantages; (3) addresses the significance in early pregnancy; (4) underscores the benefits after delivery; and (5) emphasizes the cost savings of using the FPG in the screening of GDM. It also highlights the utility of fasting capillary glucose and stresses the value of the FPG in circumventing the cumbersome oral glucose tolerance test. An understanding of all the caveats is crucial to be able to use the FPG for investigating glucose intolerance in pregnancy. Thus, all health professionals can use the patient-friendly FPG to simplify the onerous algorithms available for the screening and diagnosis of GDM - thereby helping each and every pregnant woman.

Accuracy of circulating adiponectin for predicting gestational diabetes: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Universal screening for gestational diabetes mellitus (GDM) has not been implemented, and this has had substantial clinical implications. Biomarker-directed targeted screening might be feasible. We sought to determine the accuracy of circulating adiponectin for early prediction of GDM.

METHODS

A systematic review and meta-analysis of the literature to May 2015 identified studies in which circulating adiponectin was measured prior to a diagnosis of GDM. Data on diagnostic accuracy were synthesised by bivariate mixed effects and hierarchical summary receiver operating characteristic (HSROC) models.

RESULTS

Thirteen studies met the eligibility criteria, 11 of which (2,865 women; 794 diagnosed with GDM) had extractable data. Circulating adiponectin had a pooled diagnostic odds ratio (DOR) of 6.4 (95% CI 4.1, 9.9), a summary sensitivity of 64.7% (95% CI 51.0%, 76.4%) and a specificity of 77.8% (95% CI 66.4%, 86.1%) for predicting future GDM. The AUC of the HSROC was 0.78 (95% CI 0.74, 0.81). First trimester adiponectin had a pooled sensitivity of 60.3% (95% CI 46.0%, 73.1%), a specificity of 81.3% (95% CI 71.6%, 88.3%) and a DOR of 6.6 (95% CI 3.6, 12.1). The AUC was 0.79 (95% CI 0.75, 0.82). Pooled estimates were similar after adjustment for age, BMI or specific GDM diagnostic threshold.

CONCLUSIONS/INTERPRETATION

Pre-pregnancy and early pregnancy measurement of circulating adiponectin may improve the detection of women at high risk of developing GDM. Prospective evaluation of the combination of adiponectin and maternal characteristics for early identification of those who do and do not require OGTT is warranted.

Maternal circulating levels of some metabolic syndrome biomarkers in gestational diabetes mellitus

The aims of the present study were to explore serum levels of lipid profile, atherogenic indexes LDL-C/HDL-C, TG/HDL-C, and TC/HDL-C, bilirubin, adiponectin, pseudocholinesterase, activities of gamma-glutamyltransferase (GGT), adenosine deaminase (ADA), and α-amylase, insulin resistance using homeostasis model assessment of insulin resistance (HOMA-IR) formula, and assessment of correlations between them in gestational diabetes mellitus (GDM) compared with normal pregnancy. A cross-sectional study was designed. The patients consisted of 30 women with GDM. The normal group consisted of 30 healthy pregnant women. The Mann-Whitney U test and Spearman's correlation analysis were used for statistical analysis. A p value less than 0.05 was considered significant. Serum activities of enzymes GGT (p = 0.001) and ADA (p = 0.02) were significantly higher in GDM compared with normal pregnancy, while pseudocholinesterase were significantly decreased (p = 0.02). However, activity of enzyme α-amylase did not show significant difference between two groups (p = 0.75). Serum levels of both HDL-C and adiponectin were significantly decreased in GDM group (p = 0.001). The atherogenic indexes and the HOMA-IR index were significantly higher in GDM (p = 0.001). Serum activity of ADA showed positive correlation with total cholesterol (TC) (r = 0.46, p = 0.01) and CRP (r = 0.66, p = 0.001) in GDM group. Serum levels of total bilirubin correlated negatively with both ADA (r = -0.38, p = 0.04) and triglyceride (r = -0.45, p = 0.01) in women with GDM. Serum activity of GGT correlated positively with LDL-C (r = 0.48, p = 0.01) and TC (r = 0.52, p = 0.003) in GDM group. Increased atherogenic indexes, ADA, GGT, and decreased pseudocholinesterase might be risk factors for GDM.

Prediction of gestational diabetes mellitus in the first trimester: comparison of C-reactive protein, fasting plasma glucose, insulin and insulin sensitivity indices

OBJECTIVE

To develop a predictive index based on high sensitivity C-reactive protein (hs-CRP), fasting plasma glucose (FPG) and fasting plasma insulin (FPI) measurements for early diagnosis of gestational diabetes mellitus (GDM).

METHODS

Healthy pregnant women who were screened for GDM during their first antenatal visit were included in this retrospective cohort study. FPG, FPI and serum hs-CRP concentrations were measured between weeks 11 and 14. A two-step glucose challenge test was carried out between gestational weeks 24 and 28. Fasting glucose/insulin ratio (FIGR), Homeostatic Model Assessment Insulin Resistance (HOMA-IR), HOMA-β indices and Quantitative Insulin Sensitivity Check Index (QUICKI) were used to estimate insulin sensitivity and β-cell function.

RESULTS

Of the 450 women who were eligible for the study, 49 (11.2%) were diagnosed with GDM at weeks 24-28. The median FPG and hs-CRP levels were higher in the GDM diagnosed women compared to the others. Comparison of accuracy measures resulted in the highest specificity (87.2%; 95% CI 83.5-90.1) and diagnostic odds ratio (3.9; 95% CI 2.1-7.6) for hs-CRP.

CONCLUSION

FPG and hs-CRP in the first trimester are correlated with later development of GDM in the pregnancy. In our study, FPG provided a better sensitivity while hs-CRP exhibited a better specificity for prediction of GDM.

The first trimester: prediction and prevention of the great obstetrical syndromes

A number of groups are currently examining the potential of screening for pre-eclampsia and gestational diabetes at 12 weeks' gestation. This can be performed at the time of combined first-trimester screening for aneuploidy using a similar method of regression analysis to combine multiple demographic and investigative factors. At present, research into the prediction of pre-eclampsia is more robust and is associated with the potential for therapeutic intervention that can reduce the prevalence of early-onset pre-eclampsia and improve maternal and neonatal outcomes.

First trimester screening can predict adverse pregnancy outcomes

There has been an increasing drive over the last two decades to push the detection of women at risk of adverse pregnancy outcomes into the first trimester. This has led to a plethora of techniques, risk assessments and biomarkers, both fascinating and bewildering in its breadth. Despite the vast amount of knowledge available, it is often difficult to determine what is practicable and valuable for clinical practice. This is especially true as earlier diagnosis does not necessarily equate to improved outcomes for mother and child. We suggest that, at least for preeclampsia, fetal growth restriction, spontaneous preterm birth and gestational diabetes, there are effective first trimester tests available to identify the women at risk of subsequently developing complications. Unfortunately, there are no currently reliable first trimester tests available for identifying women at risk of stillbirth. It is likely that this field will continue to develop over time, and we hope that new and better strategies will continue to emerge to target these clinically important pathologies.