Fructosamine as a screening-test for gestational diabetes mellitus: a reappraisal

The Correlation Between Three-Dimensional Ultrasound Measurement of Fetal Adrenal Gland and Maternal Serum Fructosamine Level in Gestational Diabetes Mellitus: Prospective Cohort Study

OBJECTIVE

Gestational diabetes mellitus (GDM) has an impact on fetal adrenal gland size and volume, which are greater in the GDM population. This study used 2D and 3D ultrasound scanning to determine the correlation of fetal adrenal gland size and volume with fructosamine levels, HbA1c levels, estimated fetal weight (EFW), and neonatal birth weight in GDM patients.

METHODS

This study included eighty singleton pregnant women diagnosed with GDM between 24-28 weeks of gestation. During weeks 32-34 of gestation, the length, width, and depth of the fetal zone and total adrenal gland were measured using transabdominal 2D ultrasound. Virtual organ computer-aided analysis (VOCAL) software was used to evaluate fetal zone and total adrenal gland volume in 3D ultrasound. All the participants were followed until delivery. Pearson's correlation analysis was conducted to examine the correlation between fetal adrenal gland ultrasound measurements and the factors of interest.

RESULTS

The study consisted of sixty-six (82.5%) pregnant women with diet-controlled GDM (GDMA1) and fourteen (17.5%) pregnant women with insulin-managed GDM (GDMA2). There was no difference in fetal adrenal gland measurements between the diet-controlled (GDMA1) and the insulin-managed (GDMA2) groups. All the participants had achieved optimal glucose levels at the time of ultrasound acquisition. The total adrenal gland length and fetal zone volume had statistically significant positive correlations with EFW (r = 0.69, p = 0.02 and r = 0.84, p = 0.01, respectively). After adjusting for EFW, only the fetal zone volume was significantly correlated with fructosamine levels (adjusted-OR = 2.4, 95% CI: 1.5, 3.9, p = 0.01) and HbA1c levels (adjusted-OR = 2.5, 95% CI: 1.6, 4.3, p = 0.01).

CONCLUSION

The fetal zone volume is correlated with EFW, fructosamine levels, and HbA1c levels. This non-invasive technique may be beneficial as an indirect marker for glycemic monitoring in GDM.

Trimester-Specific Serum Fructosamine in Association with Abdominal Adiposity, Insulin Resistance, and Inflammation in Healthy Pregnant Individuals

This study aimed to (1) characterize the variations in serum fructosamine across trimesters and according to pre-pregnancy BMI (ppBMI), and (2) examine associations between fructosamine and adiposity/metabolic markers (ppBMI, first-trimester adiposity, leptin, glucose homeostasis, and inflammation measurements) during pregnancy. Serum fructosamine, albumin, fasting glucose and insulin, leptin, adiponectin, interleukin-6 (IL-6), and C-reactive protein (CRP) concentrations were measured at each trimester. In the first trimester, subcutaneous (SAT) and visceral (VAT) adipose tissue thicknesses were estimated by ultrasound. In the 101 healthy pregnant individuals included (age: 32.2 ± 3.5 y.o.; ppBMI: 25.5 ± 5.5 kg/m2), fructosamine concentrations decreased during pregnancy whereas albumin-corrected fructosamine concentrations increased (p < 0.0001 for both). Notably, fructosamine concentrations were inversely associated with ppBMI, first-trimester SAT, VAT, and leptin (r = −0.55, r = −0.61, r = −0.48, r = −0.47, respectively; p < 0.0001 for all), first-trimester fasting insulin and HOMA-IR (r = −0.46, r = −0.46; p < 0.0001 for both), and first-trimester IL-6 (r = −0.38, p < 0.01). However, once corrected for albumin, most of the correlations lost strength. Once adjusted for ppBMI, fructosamine concentrations were positively associated with third-trimester fasting glucose and CRP (r = 0.24, r = 0.27; p < 0.05 for both). In conclusion, serum fructosamine is inversely associated with adiposity before and during pregnancy, with markers of glucose homeostasis and inflammation, but the latter associations are partially influenced by albumin concentrations and ppBMI.

Plasma-glycated CD59 as an early biomarker for gestational diabetes mellitus: prospective cohort study protocol

INTRODUCTION

The significant maternal and neonatal outcomes of gestational diabetes mellitus (GDM) make it a major public health concern. Mothers with GDM are at greater risk of pregnancy complications and their offspring are at higher risk of diabetes and obesity. Currently, GDM is diagnosed with glucose load methods which are time-consuming and inconvenient to administer more than once during pregnancy; for this reason, there is a recognised need for a more accurate and simpler test for GDM. Previous studies indicate that plasma-glycated CD59 (pGCD59) is a novel biomarker for GDM. We present here the protocol of a prospective cohort study designed to (1) determine the accuracy of pGCD59 as an early, first trimester predictor of GDM and gestational impaired glucose tolerance and (2) assess the associations between pGCD59 levels and adverse maternal and neonatal outcomes.

METHODS AND ANALYSIS

We will obtain discarded plasma samples from pregnant women at two time points: first prenatal visit (usually <14 weeks gestation) and gestational weeks 24-28. A study-specific medical record abstraction tool will be used to obtain relevant maternal and neonatal clinical data from the EPIC clinical database. The prevalence of GDM will be determined using standard of care glucose load test results. We will determine the sensitivity and specificity of pGCD59 to predict the diagnosis of GDM and gestational impaired glucose tolerance, as well as the associations between levels of pGCD59 and the prevalence of maternal and neonatal outcomes.

ETHICS AND DISSEMINATION

This study has been approved by the Mass General Brigham Institutional Review Board (protocol 2011P002254). The results of this study will be presented at international meetings and disseminated in peer-reviewed journals.

Does Universal Screening for Gestational Diabetes Mellitus Improve Neonatal Outcomes in a Socially Vulnerable Population: A Prospective Study in French Guiana

AIMS/INTRODUCTION

French Guiana has a high prevalence of metabolic diseases, which are risk factors for gestational diabetes mellitus. Despite routine screening for gestational diabetes, treatment is still challenging because of health inequalities and different cultural representations of disease and pregnancy. This study was conducted to assess the role of early and universal GDM screening on obstetrical and neonatal complications in a socially deprived population.

MATERIALS AND METHODS

A prospective study was conducted, in the level III maternity in French Guiana. Of 2136 deliveries, 223 had gestational diabetes mellitus, 110 of whom were followed-up for 6 month to detail their social and laboratory parameters.

RESULTS

The prevalence of gestational diabetes in French Guiana (Cayenne Hospital) was estimated at 10.3%. The study population was very precarious with 70% of patients on welfare (universal health coverage or state medical assistance). The following obstetrical complications were observed: cesarean delivery (32%), history of miscarriage (26%) and preeclampsia (7.4%). Nevertheless, neonatal complications were rarely present and included hypoglycemia (2.8%) and macrosomia (2.8%).

CONCLUSION

In French Guiana, gestational diabetes mellitus is very common. However, in a context of widespread poverty and diverse cultural representations, universal screening and monitoring limited the risk of macrosomia.

Mid-Pregnancy Fructosamine Measurement-Predictive Value for Gestational Diabetes and Association with Postpartum Glycemic Indices

Screening for gestational diabetes mellitus (GDM) during pregnancy is cumbersome. Measurement of plasma fructosamine may help simplify the first step of detecting GDM. We aimed to assess the predictive value of mid-pregnancy fructosamine for GDM, and its association with postpartum glycemic indices. Among 1488 women from Project Viva (mean ± SD: 32.1 ± 5.0 years old; pre-pregnancy body mass index 24.7 ± 5.3 kg/m²), we measured second trimester fructosamine and assessed gestational glucose tolerance with a 50 g glucose challenge test (GCT) followed, if abnormal, by a 100 g oral glucose tolerance test (OGTT). Approximately 3 years postpartum (median 3.2 years; SD 0.4 years), we measured maternal glycated hemoglobin (n = 450) and estimated insulin resistance (HOMA-IR; n = 132) from fasting blood samples. Higher glucose levels 1 h post 50 g GCT were associated with higher fructosamine levels (Pearson’s r = 0.06; p = 0.02). However, fructosamine ≥222 µmol/L (median) had a sensitivity of 54.8% and specificity of 48.6% to detect GDM (area under the receiver operating characteristic curve = 0.52); other fructosamine thresholds did not show better predictive characteristics. Fructosamine was also weakly associated with 3-year postpartum glycated hemoglobin (per 1 SD increment: adjusted β = 0.03 95% CI [0.00, 0.05] %) and HOMA-IR (per 1 SD increment: adjusted % difference 15.7, 95% CI [3.7, 29.0] %). Second trimester fructosamine is a poor predictor of gestational glucose tolerance and postpartum glycemic indices.

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.

Clinical profile, outcomes, and progression to type 2 diabetes among Indian women with gestational diabetes mellitus seen at a diabetes center in south India

AIM

To describe the clinical profile, maternal and fetal outcomes, and the conversion rates to diabetes in women with gestational diabetes mellitus (GDM) seen at a tertiary care diabetes center in urban south India.

MATERIALS AND METHODS

Clinical case records of 898 women with GDM seen between 1991 and 2011 were extracted from the Diabetes Electronic Medical Records (DEMR) of a tertiary care diabetes center in Chennai, south India and their clinical profile was analyzed. Follow-up data of 174 GDM women was available. To determine the conversion rates to diabetes, oral glucose tolerance test (OGTT) was done in these women. Glucose tolerance status postpartum was classified based on World Health Organization (WHO) 2006 criteria.

RESULTS

The mean maternal age of the women was 29 ± 4 years and mean age of gestation at first visit were 24 ± 8.4 weeks. Seventy percent of the women had a family history of diabetes. Seventy-eight percent of the women delivered full-term babies and 65% underwent a cesarean section. The average weight gain during pregnancy was 10.0 ± 4.2 kg. Macrosomia was present in 17.9% of the babies, hypoglycemia in 10.4%, congenital anomalies in 4.3%, and the neonatal mortality rate was 1.9%. Mean follow-up duration of the 174 women of whom outcome data was available was 4.5 years. Out of the 174, 101 women who were followed-up developed diabetes, of whom half developed diabetes within 5 years and over 90%, within 10 years of the delivery.

CONCLUSIONS

Progression to type 2 diabetes mellitus (T2DM) in Indian women with GDM is rapid. There is an urgent need to develop standardized protocols for GDM care in India that can improve the maternal and fetal outcomes and help prevent future diabetes in women with GDM.

Methods for the screening and diagnosis of gestational diabetes mellitus between 24 and 28 weeks of pregnancy

The aim of this review is to provide answers to the question “How does one screen for and diagnose gestational diabetes mellitus (GDM) between 24 and 28 weeks gestation?” Two methods are currently widely used: a one-step approach (the 75g-Oral Glucose Tolerance Test, OGTT) and a two-step approach (the 50g Glucose Challenge Test, GCT, followed by 100g-OGTT). A review of the literature showed that both methods had good reproducibility (around 80%), whilst neither required preliminary diet changes. The data of the Hyperglycaemia Adverse Pregnancy Outcomes (HAPO) study on materno-foetal morbidity provided consistent support in favour of the 75g-OGTT. In addition, this one-step method presents several advantages over the two-step method, i.e. it provides a faster diagnosis time, better tolerance and it is easier to remember. We thus recommend a 75g-OGTT including three measures of the glycaemia at times 0, 1 and 2 hours for the diagnosis of GDM between 24-28 weeks of pregnancy. A discussion of alternative methods revealed that measuring Fasting Glycaemia (FG) between 24 and 28 weeks of pregnancy was unsuitable, and that measuring HbA1c, fructosamine, glycosuria, or random and postprandial plasma glucose was not advisable. This is based on the fact that too few studies have evaluated these methods, and that the studies usually involved heterogeneous populations in varying numbers, using differing criteria and sensitivity values. However, HbA1c measurements may prove useful in detecting pre-pregnancy diabetes mellitus.

[Methods of screening of gestational diabetes between 24 and 28 weeks' gestation]

The aim of this review is to answer the question "how to detect the gestational diabetes mellitus (GDM) between 24 and 28 weeks of gestation?". Two approaches are well established: one-step approach (75 g-OGTT) and two-steps approach (50 g followed 100g-OGTT). The analysis of the literature shows that each of these methods has a good reproducibility close to 80 %, without requiring preliminary dietetics. The HAPO study provides consistent data about the 75 g-OGTT materno-fetal morbidity related. Furthermore, the one-step approach, relationship two-steps approach, has several advantages: reduction of time of diagnosis and primary care, better tolerance, simpler memorization. We recommend for the screening and the diagnosis of GDM an 75 g-OGTT with three measures: FPG, 1-h and 2-h. The various alternative methods are discussed. The measure of the fasting blood glucose isolated between 24 and 28 weeks of gestation is not a relevant approach. None of the other alternative methods (HbA1c, fructosamine, glycosuria, random and postprandial plasma glucose) cannot be recommended. Indeed, these methods have been addressed in little numerous studies, among heterogeneous populations, using variable criteria, and variable sensitivity values. Only the HbA1c might be useful to detect a pre-pregnancy diabetes mellitus.

Gestational diabetes: an evaluation of serum fructosamine as a screening test in a high-risk population

AIM

To evaluate the value of serum fructosamine as a screening test for gestational diabetes mellitus (GDM).

METHODS

849 pregnant women underwent the one-step 75 g oral glucose tolerance test (OGTT) for universal screening of GDM. The fasting serum fructosamine (cFruc) was assessed using the area under the receiver operating characteristic curve (AUC). The GDM diagnostic criteria used were those of the American Diabetes Association; however, the cFruc performance was also evaluated using criteria of the World Health Organization, Australian (ADIPS), European (EASD) and International Association of Diabetes and Pregnancy Study Groups (IADPSG).

RESULTS

113 (13.3%) women had GDM. The AUC of the cFruc was 0.60 (95% CI 0.54-0.66). A cFruc threshold of 237 μmol/l achieved an acceptable sensitivity of 85.8% (95% CI 78.0-91.0%), but the associated specificity remained poor at 23.4% (95% CI 20.0-27.0%) with a positive predictive value of just 14.7%. Overall, over 4 out of 5 pregnant women, being over this cutoff, would need the confirmatory OGTT. No cFruc threshold reached acceptable likelihood ratios to rule-in or rule-out GDM. The AUC for cFruc remained unacceptable independent of the diagnostic criteria.

CONCLUSIONS

Despite all the advances in technology, serum fructosamine is a poor test to screen for GDM.

Gestational diabetes: the need for a common ground

Gestational diabetes mellitus is a substantial and growing health concern in many parts of the world. Certain populations are especially vulnerable to developing this condition because of genetic, social, and environmental factors. Gestational diabetes has serious, long-term consequences for both baby and mother, including a predisposition to obesity, metabolic syndrome, and diabetes later in life. Early detection and intervention can greatly improve outcomes for women with this condition and their babies. Unfortunately, screening and diagnostic tests are not uniform worldwide, which could lead not only to underdiagnosis but also undermanagement of the illness. Here, we report the controversies surrounding the causes, screening, diagnosis, management, and prevention of gestational diabetes, and give specific recommendations for research studies to address the major issues of this medical condition.

Gestational Diabetes: A Review of the Current Literature and Guidelines

Despite large numbers of original research studies spanning 4 decades there is still no consensus on the subject of gestational diabetes. Should all pregnant women be screened or only those with risk factors? Or is it safe not to screen at all? Which screening test and which diagnostic test are the most reliable? Which cutoff values should we use? What are the risks involved for mother and baby and can treatment improve outcome? What is the connection between gestational diabetes and diabetes mellitus type II? Are there disadvantages to screening? A review of relevant articles shows that definitive answers to these questions are not yet available. There is no gold standard screening test and no threshold glucose value above which complications are markedly increased. On the contrary, there appears to be a continuum of slowly increasing risks with rising blood glucose values, where it seems difficult to draw a clear line between pathology and physiology. Moreover, treatment has thus far not been shown to significantly improve outcome. There seems to be an indistinct area between the diagnosis of gestational diabetes and diabetes mellitus type II, where women with risk factors for one are also predisposed to develop the other, thereby confusing the diagnosis. Finally, the disadvantages to diagnosing and treating women without a clearly proven benefit seem to be significant. Therefore it seems defensible to suspend all screening and treatment for gestational diabetes, or at least significantly raise the threshold for making a positive diagnosis and initiating treatment, until further research has proven a clear benefit.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize that there is still no worldwide consensus on the diagnosis, management, and adverse effects of Gestational Diabetes Mellitus (GDM); explain that all methods of screening vary in sensitivity and depend on very strict preparations for screening; state that there is no agreement on ideal levels of blood glucose to prevent untoward effects; and recall that there are two very large prospective studies that clarify the dark waters and that we should await their results.

Total peroxyl radical-trapping ability and anti-oxidant vitamins of the umbilical venous plasma and the placenta in pre-eclampsia

AIM

Our purpose was to investigate lipid peroxide levels, total peroxyl radical-trapping anti-oxidative parameter (TRAP) values, and anti-oxidant vitamin levels in umbilical venous plasma and placental tissues, and to evaluate their roles in the pathophysiology of pre-eclampsia.

METHODS

Samples of umbilical venous plasma and placental tissue homogenates were obtained from 23 normal and 18 pre-eclamptic women at between 33 and 40 weeks' gestation. The enzyme-linked immunosorbent assay method was used to assay alpha-tumor necrosis factor (TNF-alpha), and lipid peroxide levels were measured by thiobarbituric acid reaction. The TRAP values were measured using the modified Wayner's method. Ascorbic acid, retinol alpha-tocopherol and gamma-tocopherol were measured by high performance liquid chromatography.

RESULTS

Levels of TNF-alpha in placental tissue homogenates of women with pre-eclampsia were significantly higher than those of women with normal pregnancy (21.4 +/- 3.39 v. 10.3 +/- 1.06 pg/mL, P < 0.05). Lipid peroxide levels in umbilical venous plasma and placental tissue homogenates of women with pre-eclampsia were significantly higher than those of women with normal pregnancy (10.3 +/- 1.1 v. 5.85 +/- 0.53, P < 0.01, 5.14 +/- 0.40 v. 3.99 +/- 0.33 nmol/mg protein, P < 0.05, respectively). The TRAP values in umbilical venous plasma and placental tissue homogenates of women with pre-eclampsia were significantly lower than those of women with normal pregnancy (0.39 +/- 0.02 v. 0.45 +/- 0.02, P < 0.05, 0.27 +/- 0.02 v. 0.34 +/- 0.03 mM, P < 0.05, respectively). Ascorbic acid levels in umbilical venous plasma and placental tissue homogenates of women with pre-eclampsia were significantly lower than those of women with normal pregnancy (325.4 +/- 50.4 v. 543 +/- 73.8, P < 0.05, 219.0 +/- 21.0 v. 333.3 +/- 32.6 nmol/mL, P < 0.05, respectively).

CONCLUSIONS

The above results suggest that increased oxidative stress in the placenta is involved in the pathophysiology of pre-eclampsia, and ascorbic acid may act as an important preventative factor in the development of pre-eclampsia.

Association of human leucocyte antigen sharing with recurrent spontaneous abortions

An estimated 15% of clinically recognized pregnancies abort spontaneously. Recurrent spontaneous abortion (RSA) is defined as three or more consecutive miscarriages conceived with the same partner in the absence of uterine, genetic or autoimmune abnormalities. Evidence points to human leucocyte antigens (HLA) as playing a role in the successful development of the foetus. In particular, HLA compatibility is more prevalent in couples experiencing reproductive failure, especially RSA couples, compared to fertile couples. According to the immunological hypothesis, an adequate immune response is necessary for proper implantation of the embryo; conversely, a depressed response of maternal lymphocytes to the stimulation by paternal antigens because of HLA sharing can result in disorders, such as RSA. The genetic hypothesis implicates homozygosity for recessive lethal alleles in linkage disequilibrium with specific HLA haplotypes. The specificity of HLA alleles or haplotypes responsible for or linked to other RSA susceptibility genes remains unclear. In this study, we identified 40 observational studies (32 case-control, five cohort, one cross-sectional, one case series and one basic science) that examined the associations between HLA and RSA, focusing on HLA allele couple and maternal-foetal sharing, and the special role of HLA-G. We sought to identify consistent findings among studies examining similar questions. Evidence remains divided concerning the role of HLA allele couple sharing. Of major concern is the focus of many studies on couple sharing as a proxy measure of maternal-foetal sharing. Therefore, adequately powered studies are needed, which employ standard case definitions and reproducible methodologies to directly assess the role of maternal-foetal HLA sharing on the risk of RSA.

The utility of a single test to identify women at risk for gestational diabetes

A number of single tests have been proposed as both screening and definitive tests of glucose intolerance during pregnancy. Despite limitations imposed by a lack of uniformity in methodology and definitions of gestational diabetes mellitus, there appears to be an independent relationship between some single-test results and clinically meaningful outcomes. Further study is needed to identify those glucose values above which women and their babies who are at risk for glycemia-related adverse outcomes may be identified.

To screen or not to screen for gestational diabetes mellitus. The clinical quagmire

Although there continues to be a lack of agreement about the most appropriate way to screen for GDM, screening remains the standard of care in this country. Universal screening of all pregnant women maximizes sensitivity but has significant financial implications because of its increased costs. Additional studies are needed that apply cost-analysis to various screening protocols to identify cost-effective screening strategies.