Gestational diabetes: the consequences of not treating

Impact of previous gestational diabetes management on perinatal outcomes in subsequent pregnancies affected by gestational diabetes mellitus

OBJECTIVE

To determine the impact of prior gestational diabetes mellitus (GDM) on perinatal outcomes in a subsequent GDM pregnancy.

METHODS

This retrospective cohort study included 544 multiparous patients with two consecutive pregnancies between 2012-2019, where the second (index) pregnancy was affected by GDM. The primary exposure was prior GDM diagnosis, categorized into medical and dietary management. The primary outcome was a composite including need for pharmacotherapy, large-for-gestational age, or neonatal hypoglycemia. Adjusted odds ratios (aOR) were calculated using multivariable logistic regression controlling for maternal age, pre-pregnancy body mass index, and gestational age at GDM diagnosis in the index pregnancy.

RESULTS

Of the 544 patients, 164 (30.1%) had prior GDM. Prior GDM significantly increased the likelihood of composite outcome compared to no prior GDM (74.4% vs. 57.4%; P < 0.001). After adjusting for confounders, prior GDM remained significantly associated with the composite outcome (aOR 2.03, 95% confidence interval [CI] 1.31-3.15). Stratifying by prior GDM treatment modality, a significant association was found for prior pharmacotherapy-controlled GDM (aOR 3.29, 95% CI 1.64-6.59), but not for prior diet-controlled GDM (aOR = 1.54, 95% CI 0.92-2.60).

CONCLUSION

A history of pharmacotherapy-controlled GDM in a previous pregnancy increases odds of adverse perinatal outcomes in a subsequent GDM pregnancy.

Gestational Diabetes-like Fuels Impair Mitochondrial Function and Long-Chain Fatty Acid Uptake in Human Trophoblasts

In the parent, gestational diabetes mellitus (GDM) causes both hyperglycemia and hyperlipidemia. Despite excess lipid availability, infants exposed to GDM are at risk for essential long-chain polyunsaturated fatty acid (LCPUFA) deficiency. Isotope studies have confirmed less LCPUFA transfer from the parent to the fetus, but how diabetic fuels impact placental fatty acid (FA) uptake and lipid droplet partitioning is not well-understood. We evaluated the effects of high glucose conditions, high lipid conditions, and their combination on trophoblast growth, viability, mitochondrial bioenergetics, BODIPY-labeled fatty acid (FA) uptake, and lipid droplet dynamics. The addition of four carbons or one double bond to FA acyl chains dramatically affected the uptake in both BeWo and primary isolated cytotrophoblasts (CTBs). The uptake was further impacted by media exposure. The combination-exposed trophoblasts had more mitochondrial protein (p = 0.01), but impaired maximal and spare respiratory capacities (p < 0.001 and p < 0.0001), as well as lower viability (p = 0.004), due to apoptosis. The combination-exposed trophoblasts had unimpaired uptake of BODIPY C12 but had significantly less whole-cell and lipid droplet uptake of BODIPY C16, with an altered lipid droplet count, area, and subcellular localization, whereas these differences were not seen with individual high glucose or lipid exposure. These findings bring us closer to understanding how GDM perturbs active FA transport to increase the risk of adverse outcomes from placental and neonatal lipid accumulation alongside LCPUFA deficiency.

Myoinositol and Metformin in the Prevention of Gestational Diabetes in High-Risk Patients: A Narrative Review

Our hypothesis is that myoinositol and metformin in pregnant women with high-risk factors for glucose intolerance would reduce insulin resistance and consequently lower the incidence of gestational diabetes mellitus (GDM), a metabolic disorder of pregnancy characterized by maternal hyperglycemia due to deficient response to physiological insulin resistance, which may have a negative impact on perinatal outcome and long-term sequelae. In recent years, this pathology has become increasingly important given the global obesity epidemic and the delay in becoming pregnant, especially in industrialized countries. For this reason, the attempt to prevent, rather than cure, gestational diabetes is particularly important. In addition to lifestyle changes (especially diet and doing more exercise), myoinositol and metformin are the most promising factors at the moment, although not all RCTs published so far agree on their real effectiveness. A review of the articles published so far allows us to assume, albeit with some distinctions, that they can play a positive role.

Does the gestational age at which the glucose challenge test (GCT) is conducted influence the diagnosis of gestational diabetes mellitus (GDM)?

PURPOSE

This study's objective is to investigate disparities in the rates of gestational diabetes mellitus (GDM) diagnosis, influenced by the timing of the glucose challenge test GCT.

METHODS

This retrospective cohort study included women with singleton or twin pregnancies exhibiting abnormal GCT result between 24 and 28 weeks of gestation, followed by an oral glucose tolerance test OGTT during the same period. Data regarding pregnancy follow-up from patients' deliveries at a singular tertiary medical from 2014 to 2022 were retrieved. The probability of GDM diagnosis was stratified based on the gestational week of the GCT and the definition of a positive OGTT, delineated by one or two abnormal values.

RESULTS

The study included 636 women with abnormal GCT between 24 and 28 weeks of gestation. Of them, 157 unerwent the GCT between 24.0 and 24.6 weeks, 204 between 25.0 and 25.6 weeks, 147 between 26.0 and 26.6 weeks, and 128 between 27.0 and 28.6 weeks. We found that the highest incidence of GDM, defined by one or two pathological values of the OGTT, following the initial screening with a GCT, where abnormal results were defined as values exceeding 140 mg/dL, was diagnosed in patients who underwent GCT between 26.0 and 26.6 weeks of gestation. Conversely, the lowest rates were observed in patients screened between 24.0 and 24.6 weeks of gestation.

CONCLUSION

The timing of screening for GDM using the GCT significantly affects the rate of diagnosis. Clinicians managing pregnancies should consider this data when formulating treatment plans.

Maternal Hypertriglyceridemia in Gestational Diabetes: A New Risk Factor?

Elevated maternal triglycerides (TGs) have been associated with excessive fetal growth. However, the role of maternal lipid profile is less studied in gestational diabetes mellitus (GDM). We aimed to study the association between maternal lipid profile in the third trimester and the risk for large-for-gestational-age (LGA) newborns in women with GDM. We performed an observational and retrospective study of pregnant women with GDM who underwent a lipid profile measurement during the third trimester. We applied a logistic regression model to assess predictors of LGA. A total of 100 singleton pregnant women with GDM and third-trimester lipid profile evaluation were included. In the multivariate analysis, pre-pregnancy BMI (OR 1.19 (95% CI 1.03-1.38), p = 0.022) and hypertriglyceridemia (OR 7.60 (1.70-34.10), p = 0.008) were independently associated with LGA. Third-trimester hypertriglyceridemia was found to be a predictor of LGA among women with GDM, independently of glycemic control, BMI, and pregnancy weight gain. Further investigation is needed to confirm the role of TGs in excessive fetal growth in GDM pregnancies.

Glu-Ensemble: An ensemble deep learning framework for blood glucose forecasting in type 2 diabetes patients

Diabetes is a chronic metabolic disorder characterized by elevated blood glucose levels, posing significant health risks such as cardiovascular disease, and nerve, kidney, and eye damage. Effective management of blood glucose is essential for individuals with diabetes to mitigate these risks. This study introduces the Glu-Ensemble, a deep learning framework designed for precise blood glucose forecasting in patients with type 2 diabetes. Unlike other predictive models, Glu-Ensemble addresses challenges related to small sample sizes, data quality issues, reliance on strict statistical assumptions, and the complexity of models. It enhances prediction accuracy and model generalizability by utilizing larger datasets and reduces bias inherent in many predictive models. The framework's unified approach, as opposed to patient-specific models, eliminates the need for initial calibration time, facilitating immediate blood glucose predictions for new patients. The obtained results indicate that Glu-Ensemble surpasses traditional methods in accuracy, as measured by root mean square error, mean absolute error, and error grid analysis. The Glu-Ensemble framework emerges as a promising tool for blood glucose level prediction in type 2 diabetes patients, warranting further investigation in clinical settings for its practical application.

Protein Profiling of Placental Extracellular Vesicles in Gestational Diabetes Mellitus

Throughout pregnancy, some degree of insulin resistance is necessary to divert glucose towards the developing foetus. In gestational diabetes mellitus (GDM), insulin resistance is exacerbated in combination with insulin deficiency, causing new-onset maternal hyperglycaemia. The rapid reversal of insulin resistance following delivery strongly implicates the placenta in GDM pathogenesis. In this case-control study, we investigated the proteomic cargo of human syncytiotrophoblast-derived extracellular vesicles (STBEVs), which facilitate maternal-fetal signalling during pregnancy, in a UK-based cohort comprising patients with a gestational age of 38-40 weeks. Medium/large (m/l) and small (s) STBEVs were isolated from GDM (n = 4) and normal (n = 5) placentae using ex vivo dual-lobe perfusion and subjected to mass spectrometry. Bioinformatics were used to identify differentially carried proteins and mechanistic pathways. In m/lSTBEVs, 56 proteins were differently expressed while in sSTBEVs, no proteins reached statistical difference. Differences were also observed in the proteomic cargo between m/lSTBEVs and sSTBEVs, indicating that the two subtypes of STBEVs may have divergent modes of action and downstream effects. In silico functional enrichment analysis of differentially expressed proteins in m/lSTBEVs from GDM and normal pregnancy found positive regulation of cytoskeleton organisation as the most significantly enriched biological process. This work presents the first comparison of two populations of STBEVs' protein cargos (m/l and sSTBEVs) from GDM and normal pregnancy isolated using placenta perfusion. Further investigation of differentially expressed proteins may contribute to an understanding of GDM pathogenesis and the development of novel diagnostic and therapeutic tools.

Physical activity, gestational weight gain in obese patients with early gestational diabetes and the perinatal outcome - a randomised-controlled trial

BACKGROUND

Excessive gestational weight gain, especially among women with gestational diabetes, is associated with several adverse perinatal outcomes. Our study aimed to analyse the impact of the use of pedometers to supervise physical activity on maternal health and the obstetric outcomes of pregnant women with obesity and early gestational diabetes.

METHODS

124 pregnant patients were enrolled in the presented research.

INCLUSION CRITERIA

singleton pregnancy, age > 18 years, gestational diabetes diagnosed in the first half of pregnancy (< 20th week of pregnancy), obesity according to the American Endocrine Society criteria. Each patient was advised to take at least 5000 steps daily. Patients were randomly assigned to pedometers (N = 62), and were recommended to monitor daily the number of steps. The group without pedometers (N = 62) was not observed. Visit (V1) was scheduled between the 28th and 32nd gestational week (GW), and visit (V2) occurred between the 37th and 39th GW. Anthropometric measurements and blood samples were collected from all patients at each appointment. Foetal and maternal outcomes were analysed at the end of the study.

RESULTS

In the group supervised by pedometers, there were significantly fewer newborns with macrosomia (p = 0,03). Only 45% of patients satisfied the recommended physical activity guidelines. Patients who walked more than 5000 steps per day had significantly higher body weight at baseline (p = 0,005), but weight gain was significantly lower than in the group that did not exceed 5000 steps per day (p < 0,001). The perinatal outcome in the group of patients performing more than 5000 steps did not demonstrate significant differences with when compared to less active group. ROC curve for weight gain above the guidelines indicated a statistically substantial cut-off point for this group at the level of 4210 steps/day (p = 0.00001).

CONCLUSIONS

Monitoring the activity of pregnant patients with gestational diabetes and obesity by pedometers did not have a significantly impact on their metabolic control and weight gain. However, it contributed to less macrosomia. Furthermore, physical activity over 5,000 steps per day positively affects weight loss, as well as contributes to improved obstetric and neonatal outcomes.

Multigenerational diabetes mellitus

Gestational diabetes (GDM) changes the maternal metabolic and uterine environment, thus increasing the risk of short- and long-term adverse outcomes for both mother and child. Children of mothers who have GDM during their pregnancy are more likely to develop Type 2 Diabetes (T2D), early-onset cardiovascular disease and GDM when they themselves become pregnant, perpetuating a multigenerational increased risk of metabolic disease. The negative effect of GDM is exacerbated by maternal obesity, which induces a greater derangement of fetal adipogenesis and growth. Multiple factors, including genetic, epigenetic and metabolic, which interact with lifestyle factors and the environment, are likely to contribute to the development of GDM. Genetic factors are particularly important, with 30% of women with GDM having at least one parent with T2D. Fetal epigenetic modifications occur in response to maternal GDM, and may mediate both multi- and transgenerational risk. Changes to the maternal metabolome in GDM are primarily related to fatty acid oxidation, inflammation and insulin resistance. These might be effective early biomarkers allowing the identification of women at risk of GDM prior to the development of hyperglycaemia. The impact of the intra-uterine environment on the developing fetus, "developmental programming", has a multisystem effect, but its influence on adipogenesis is particularly important as it will determine baseline insulin sensitivity, and the response to future metabolic challenges. Identifying the critical window of metabolic development and developing effective interventions are key to our ability to improve population metabolic health.

Monitoring gestational diabetes mellitus patients with myDiabby Healthcare® smartphone application vs classical diary. Results from the non-inferiority TELESUR-GDM study

OBJECTIVE

The aim of the TELESUR-GDM study was to demonstrate the non-inferiority of the onset of maternal, fœtal, and neonatal complications for patients with gestational diabetes mellitus (GDM) monitored by myDiabby HealthcareⓇ (app group) compared to patients with a classical glycaemic blood monitoring by diary (control group).

MATERIALS AND METHODS

TELESUR-GDM was a retrospective, monocentric, and non-inferiority study including 349 patients in the app group and 295 patients in the control group. The primary outcome was a composite score based on maternal, foetal, and neonatal complications. The statistical analysis used chi square or Student t tests for categorical or continuous variables, and Dunnett-Gent test for non-inferiority.

RESULTS

In the app and control groups, 46.3 % and 53.7 % of the patients respectively, observed complications. Non-inferiority of telemonitoring by application vs diary was confirmed (odds ratio=0.79 [95 % CI 0.58;1.07], P < 0.001). Caesarean section, labour induction, and insulin treatment rates were: 20 vs 23 % (P = 0.4), 36 vs 28 % (P = 0.047), and 22 vs 23 % (P = 0.8) in the app vs control group, respectively. Macrosomia, intrauterine growth restriction, neonatal hypoglycaemia, and neonatal jaundice rates were: 4.3 vs 6.1 % (P = 0.4), 6.9 vs 3.1 % (P = 0.04), 1.7 vs 14 % (P < 0.001), and 8.6 vs 1.0 % (P < 0.001), in the app versus control group, respectively.

CONCLUSION

GDM glycaemic telemonitoring compared to patients with classic glycaemic monitoring by diary was not inferior in terms of maternal, fœtal, and neonatal complications. Neonatal hypoglycaemia, a life-threatening event, was significantly reduced despite the observation of more neonatal jaundice cases.

Predicting adverse perinatal outcomes among gestational diabetes complicated pregnancies using neural network algorithm

OBJECTIVE

The primary aim of this study is to utilize a neural network model to predict adverse neonatal outcomes in pregnancies complicated by gestational diabetes (GDM).

DESIGN

Our model, based on XGBoost, was implemented using Python 3.6 with the Keras framework built on TensorFlow by Google. We sourced data from medical records of GDM-diagnosed individuals who delivered at our tertiary medical center between 2012 and 2016. The model included simple pregnancy parameters, maternal age, body mass index (BMI), parity, gravity, results of oral glucose tests, treatment modality, and glycemic control. The composite neonatal adverse outcomes defined as one of the following: large or small for gestational age, shoulder dystocia, fetal umbilical pH less than 7.2, neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), hyperbilirubinemia, or polycythemia. For the machine training phase, 70% of the cohort was randomly chosen. Each sample in this set consisted of baseline parameters and the composite outcome. The remaining samples were then employed to assess the accuracy of our model.

RESULTS

The study encompassed a total of 452 participants. The composite adverse outcome occurred in 29% of cases. Our model exhibited prediction accuracies of 82% at the time of GDM diagnosis and 91% at delivery. The factors most contributing to the prediction model were maternal age, pre-pregnancy BMI, and the results of the single 3-h 100 g oral glucose tolerance test.

CONCLUSION

Our advanced neural network algorithm has significant potential in predicting adverse neonatal outcomes in GDM-diagnosed individuals.

Prediction of birthweight and risk of macrosomia in pregnancies complicated by diabetes

BACKGROUND

Antenatal detection of accelerated fetal growth and macrosomia in pregnancies complicated by diabetes mellitus is important for patient counseling and management. Sonographic fetal weight estimation is the most commonly used tool to predict birthweight and macrosomia. However, the predictive accuracy of sonographic fetal weight estimation for these outcomes is limited. In addition, an up-to-date sonographic fetal weight estimation is often unavailable before birth. This may result in a failure to identify macrosomia, especially in pregnancies complicated by diabetes mellitus where care providers might underestimate fetal growth rate. Therefore, there is a need for better tools to detect and alert care providers to the potential risk of accelerated fetal growth and macrosomia.

OBJECTIVE

This study aimed to develop and validate prediction models for birthweight and macrosomia in pregnancies complicated by diabetes mellitus.

STUDY DESIGN

This was a completed retrospective cohort study of all patients with a singleton live birth at ≥36 weeks of gestation complicated by preexisting or gestational diabetes mellitus observed at a single tertiary center between January 2011 and May 2022. Candidate predictors included maternal age, parity, type of diabetes mellitus, information from the most recent sonographic fetal weight estimation (including estimated fetal weight, abdominal circumference z score, head circumference-to-abdomen circumference z score ratio, and amniotic fluid), fetal sex, and the interval between ultrasound examination and birth. The study outcomes were macrosomia (defined as birthweights >4000 and >4500 g), large for gestational age (defined as a birthweight >90th percentile for gestational age), and birthweight (in grams). Multivariable logistic regression models were used to estimate the probability of dichotomous outcomes, and multivariable linear regression models were used to estimate birthweight. Model discrimination and predictive accuracy were calculated. Internal validation was performed using the bootstrap resampling technique.

RESULTS

A total of 2465 patients met the study criteria. Most patients had gestational diabetes mellitus (90%), 6% of patients had type 2 diabetes mellitus, and 4% of patients had type 1 diabetes mellitus. The overall proportions of infants with birthweights >4000 g, >4500 g, and >90th percentile for gestational age were 8%, 1%, and 12%, respectively. The most contributory predictor variables were estimated fetal weight, abdominal circumference z score, ultrasound examination to birth interval, and type of diabetes mellitus. The models for the 3 dichotomous outcomes had high discriminative accuracy (area under the curve receiver operating characteristic curve, 0.929-0.979), which was higher than that achieved with estimated fetal weight alone (area under the curve receiver operating characteristic curve, 0.880-0.931). The predictive accuracy of the models had high sensitivity (87%-100%), specificity (84%-92%), and negative predictive values (84%-92%). The predictive accuracy of the model for birthweight had low systematic and random errors (0.6% and 7.5%, respectively), which were considerably smaller than the corresponding errors achieved with estimated fetal weight alone (-5.9% and 10.8%, respectively). The proportions of estimates within 5%, 10%, and 15% of the actual birthweight were high (52.3%, 82.9%, and 94.9%, respectively).

CONCLUSION

The prediction models developed in the current study were associated with greater predictive accuracy for macrosomia, large for gestational age, and birthweight than the current standard of care that includes estimated fetal weight alone. These models may assist care providers in counseling patients regarding the optimal timing and mode of delivery.

Profiles and Outcomes of Women with Gestational Diabetes Mellitus in the United States

Introduction Gestational diabetes mellitus (GDM) is a major contributor to adverse pregnancy outcomes both in the United States and globally. As the prevalence of obesity continues to rise, the incidence of GDM is anticipated to increase as well. Despite the significant impact of GDM on maternal and neonatal health, research examining the independent associations between GDM and adverse outcomes remains limited in the U.S. context. Objective This study aims to address this knowledge gap and further elucidate the relationship between GDM and maternal and neonatal health outcomes. Method We performed a retrospective study using data from the United States Vital Statistics Records, encompassing deliveries that occurred between January 2015 and December 2019. Our analysis aimed to establish the independent association between GDM and various adverse maternal and neonatal outcomes. The multivariate analysis incorporated factors such as maternal socioeconomic demographics, preexisting comorbidities, and conditions during pregnancy to account for potential confounders and elucidate the relationship between GDM and the outcomes of interest. Result Between 2015 and 2019, there were 1,212,589 GDM-related deliveries, accounting for 6.3% of the 19,249,237 total deliveries during the study period. Among women with GDM, 46.4% were Non-Hispanic Whites, 11.4% were Non-Hispanic Blacks, 25.7% were Hispanics, and 16.5% belonged to other racial/ethnic groups. The median age of women with GDM was 31 years, with an interquartile range of 27-35 years. The cesarean section rate among these women was 46.5%. GDM was identified as an independent predictor of adverse maternal and neonatal outcomes, including cesarean section (OR=1.40; 95% CI: 1.39-1.40), maternal blood transfusion (OR=1.15; 95% CI: 1.12-1.18), intensive care unit admission (OR=1.16; 95% CI: 1.10-1.21), neonatal intensive care unit admission (OR=1.53; 95% CI: 1.52-1.54), assisted ventilation (OR=1.37; 95% CI: 1.35-1.39), and low 5-minute Apgar score (OR=1.01; 95% CI: 1.00-1.03). Conclusion GDM serves as an independent risk factor for adverse maternal and neonatal outcomes, emphasizing the importance of early detection and management in pregnant women.

Association between One Abnormal Value on 3-Hour Oral Glucose Tolerance Test and Adverse Perinatal Outcomes in Twin Gestation

AIM

To investigate whether women with twin gestation and one abnormal value on the diagnostic 3-hour oral glucose tolerance test (OGTT) are at an increased risk of adverse perinatal outcomes.

METHODS

This was a retrospective multicenter study of women with twin gestation, comparing four groups: (1) normal 50-g screening, (2) normal 100-g 3-hour OGTT, (3) one abnormal value on the 3-hour OGTT, and (4) GDM. Multivariable logistic regressions adjusted for maternal age, gravidity, parity, previous CDs, fertility treatments, smoking, obesity and chorionicity were used.

RESULTS

The study included 2,597 women with twin gestations, of which 79.7% had a normal screen, and 6.2% had one abnormal value on the OGTT. In adjusted analyses, women with one abnormal value were found to have higher rates of preterm delivery <32 weeks, large for gestational age neonates, and composite neonatal morbidity of at least one fetus, however, similar maternal outcomes as those with a normal screen.

CONCLUSION

Our study provides evidence that women with twin gestation and one abnormal value on the 3-hour OGTT are at an increased risk of unfavorable neonatal outcomes. This was confirmed by multivariable logistic regressions. Further research is needed to determine whether interventions such as nutritional counseling, blood glucose monitoring, and treatment with diet and medication would improve perinatal outcomes in this population.

Associations between plant-based diets, plant foods and botanical supplements with gestational diabetes mellitus: a systematic review protocol

INTRODUCTION

Gestational diabetes mellitus (GDM) is one of the most common health complications during pregnancy. Medical nutrition therapy is the mainstay of treatment for GDM, however, there is no current consensus on optimal dietary approaches to prevent or control hyperglycaemia in pregnancy. The aim of this systematic review is to assess the relationships between plant-based dietary patterns, plant foods and botanical dietary supplements with GDM and maternal glycaemic biomarkers.

METHODS AND ANALYSIS

A predefined search strategy was used on 16 June 2021, to search PubMed, Embase and CINAHL Plus with Full Text (EBSCOhost), as well as ClinicalTrials.gov, for studies published as original articles in English. Articles will be included if they are human observational studies or clinical trials and will be excluded if they are review articles or conference abstracts. We will use Cochrane's risk of bias tools for interventions that are parallel arm (Risk of Bias tool for randomised trials version 2 (RoB 2)) and single arm, non-randomised intervention studies (Risk of Bias In Non-randomised Studies-of Interventions (ROBINS-I)). For observational, case-control and cross-sectional studies, we will use the National Heart, Lung and Blood Institute's quality assessment tools. Data will be synthesised in a narrative format describing significant results as well as presenting the results of the quality assessment of studies.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval as primary data will not be collected. The review will be published in a peer-reviewed journal and disseminated electronically and in print.

PROSPERO REGISTRATION NUMBER

CRD42022306915.

Insulin Resistance Is Associated with an Unfavorable Serum Lipoprotein Lipid Profile in Women with Newly Diagnosed Gestational Diabetes

Background: Gestational diabetes (GDM) is associated with various degrees of insulin resistance—a feature related to increased risk of adverse perinatal outcomes. We aimed to determine the previously poorly investigated associations between maternal insulin resistance and serum fasting metabolome at the time of GDM diagnosis. Methods: Serum lipoprotein and amino acid profile was analyzed in 300 subjects with newly diagnosed GDM using a validated nuclear magnetic resonance spectroscopy protocol. Associations between insulin resistance (homeostasis model assessment of insulin resistance, HOMA2-IR) and serum metabolites were examined with linear regression. Results: We found insulin resistance to be associated with a distinct lipid pattern: increased concentration of VLDL triglycerides and phospholipids and total triglycerides. VLDL size was positively related and LDL and HDL sizes were inversely related to insulin resistance. Of fatty acids, increased total fatty acids, relative increase in saturated and monounsaturated fatty acids, and relative decrease in polyunsaturated and omega fatty acids were related to maternal insulin resistance. Conclusions: In newly diagnosed GDM, the association between maternal insulin resistance and serum lipoprotein profile was largely as described in type 2 diabetes. Lifestyle interventions aiming to decrease insulin resistance from early pregnancy could benefit pregnancy outcomes via more advantageous lipid metabolism.

Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

BACKGROUND

Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation.

OBJECTIVE

Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 minute Apgar score <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P<.05.

RESULTS

Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P<.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P<.0001).

CONCLUSION

Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

The Effects of Gestational Diabetes on Fetus: A Surveillance Study

INTRODUCTION

Gestational diabetes is an intolerance to glucose diagnosed during pregnancy that goes away postpartum. Gestational diabetes may result in outcomes such as birth trauma, increased rates of cesarean sections, and macrosomia. This study aims to determine the outcomes of gestational diabetes mellitus (GDM) on maternal and fetal health in a tertiary care hospital setting.

MATERIALS AND METHODS

This is a retrospective study of 52 patients who presented with gestational diabetes mellitus (GDM) and were treated at Tentishev Satkynbai Memorial Asian Medical Institute, Kyrgyzstan, between April 2021 and January 2022. The information was taken from the medical records of the patients. The baby's age, the mother's body mass index (BMI), history of pregnancy, deaths, birth weight, and the number of births were all taken into account.

RESULTS

Out of all the cases during the study period at the Tentishev Satkynbai Memorial Asian Medical Institute, Kyrgyzstan, 52 were found to be complicated with gestational diabetes mellitus, which is 2.7% of the total deliveries. There was a significant difference found among both study groups in gestational age and history of GDM. The neonatal intensive care unit (NICU) admission rate of neonates born to GDM mothers was found to be significant with a difference of 10.9% (p < 0.0003), which is higher compared to the control group.

CONCLUSION

Incidences of macrosomia, NICU admissions of preterm babies, and large for gestational age (LGA) and increased rates of hypertensive disorders were found among GDM pregnancies compared to control cases. The study shows higher rates of maternal and fetal/neonatal complications in females with GDM.

Metabolic Characteristics of Gestational Diabetes Mellitus and the Effects on Pregnancy Outcomes

OBJECTIVE

To describe the metabolic characteristics of gestational diabetes mellitus (GDM) and assess their effects on perinatal outcomes.

METHODS

A two-center nested case‒control study was designed, including 192 pregnant women with GDM and 191 pregnant women with normal glucose tolerance (NGT). Serum glucose and insulin concentrations based upon the 75 g oral glucose tolerance test (OGTT) were measured. Several indices were calculated to describe the metabolic characteristics of the subjects. The relationship between glucose metabolism parameters and pregnancy outcomes was evaluated using stepwise linear regression and binary logistic regression.

RESULTS

Compared with the NGT group, the GDM group showed significantly higher fasting and postprandial glucose parameters but significantly lower fasting and postprandial insulin responses. Meanwhile, the GDM group had significantly lower HOMA-β, DI and ISI_Matsuda but comparable HOMA-IR. The IFG subgroup showed significantly lower FINS/FPG only, while the IGT and IFSG subgroups showed deficiency in both fasting and postprandial insulin response. The IFSG subgroup had the highest glucose parameters and the lowest insulin parameters, as well as significantly lower ISI_Matsuda and HOMA-β than the NGT group. FPG had a significant effect on infants' birth weight, and 1hPG and FINS/FPG had a significant effect on delivery gestational age. AUC-INS, IGI₆₀ and DI were related to premature delivery risk after adjusting for confounders. The IFG subgroup of GDM was 2.319 times more likely to be subject to cesarean section than the NGT group. FPG, FINS/FPG, AUC-GLU, AUC-INS/AUC-GLU and HOMA-β were related to macrosomia risk.

CONCLUSION

Beta cell dysfunction rather than insulin resistance determines the occurrence of GDM in the central Chinese population. Women with predominant insulin secretion defects had a similar risk of adverse perinatal outcomes to women with NGT. Our study provided a basis for the selection of glucose metabolism monitoring indicators useful for the prevention of adverse perinatal outcomes.

Association between growth differentiation factor 15 levels and gestational diabetes mellitus: A combined analysis

OBJECTIVE

Gestational diabetes mellitus (GDM) is a common glucose metabolism disease occurs in pregnancy that affects both maternal and neonatal health. Recently, increasing studies have attached importance to the relationship between growth differentiation factor 15 (GDF-15) and GDM, but the results were inconclusive. Therefore, we conducted a meta-analysis to examine the association between GDF-15 and GDM.

MATERIALS AND METHODS

A systematical search was performed in Gene Expression Omnibus (GEO), PubMed and Google Scholar till Oct 27, 2022. We first calculated the mean and standard deviation of GDF-15 expression levels from the included eligible datasets and articles. Then, a meta-analysis was conducted to depict the difference in GDF-15 mRNA or GDF-15 protein expression between case and control groups by using conservative random effect model. Moreover, the potential publication bias was checked with the aid of Begg's test and Egger's test. Finally, sensitivity analyses were performed by changing the inclusion criteria.

RESULTS

In summary, 12 GEO datasets and 5 articles were enrolled in our study, including 789 GDM patients and 1202 non-GDM pregnant women. It was found that the expression levels of GDF-15 mRNA and GDF-15 protein in late pregnancy were significantly higher in GDM patients compared with non-GDM pregnant women, with the standard mean difference (SMD) and 95% confidence interval (95% CI) of 0.48 (0.14, 0.83) and 0.82 (0.32-1.33), respectively. Meanwhile, a slightly weakened association between GDF-15 protein levels and GDM was also observed in the middle pregnancy, with SMD (95% CI) of 0.53 (0.04-1.02).

CONCLUSION

In all, our results suggested that the expression levels of GDF-15 were significantly higher in GDM patients compared with non-GDM pregnant women, especially in the late pregnancy.

Correlations between parameters of glycaemic variability and foetal growth, neonatal hypoglycaemia and hyperbilirubinemia in women with gestational diabetes

The diagnosis of gestational diabetes mellitus (GDM) is important to prevent maternal and neonatal complications. This study aimed to investigate the feasibility of parameters of glycaemic variability to predict neonatal complications in women with GDM. A retrospective study was conducted on pregnant women tested positive at the oral glucose tolerance test (OGTT) during 16-18 or 24-28 weeks of gestation. Glycaemic measures were extracted from patients' glucometers and expanded to obtain parameters of glycaemic variability. Data on pregnancy outcomes were obtained from clinical folders. Descriptive group-level analysis was used to assess trends in glycaemic measures and foetal outcomes. Twelve patients were included and analysed, accounting for 111 weeks of observations. The analysis of trends in parameters of glycaemic variability showed spikes of glycaemic mean, high blood glucose index and J-index at 30-31 weeks of gestation for cases with foetal macrosomia, defined as foetal growth >90° percentile, neonatal hypoglycaemia and hyperbilirubinemia. Specific trends in parameters of glycaemic variability observed at third trimester correlate with foetal outcomes. Further research is awaited to provide evidence that monitoring of glycaemic variability trends could be more clinically informative and useful than standard glycaemic checks to manage women with GDM at delivery.

Chemical inhibition of mitochondrial fission improves insulin signaling and subdues hyperglycemia induced stress in placental trophoblast cells

BACKGROUND

Gestational diabetes mellitus (GDM) is a metabolic complication that affects millions of pregnant women in the world. Placental tissue function is endangered by hyperglycemia during GDM, which is correlated to increased incidences of pregnancy complications. Recently we showed that due to a significant decrease in mitochondrial fusion, mitochondrial dynamics equilibrium is altered in placental tissues from GDM patients. Evidence for the role of reduced mitochondrial fusion in the disruption of mitochondrial function in placental cells is limited.

METHODS AND RESULTS

Here we show that chemical inhibition of mitochondrial fission in cultured placental trophoblast cells leads to an increase in mitochondrial fusion and improves the physiological state of these cells and hence, their capacity to cope in a hyperglycemic environment. Specifically, mitochondrial fission inhibition led to a reduction in reactive oxygen species (ROS) generation, mitochondrial unfolded protein marker expressions, and mitochondrial depolarization. It supported the increase in mitochondrial antioxidant enzyme expressions as well. Mitochondrial fission inhibition also increases the placental cell insulin sensitivity during hyperglycemia.

CONCLUSION

Our results suggest that mitochondrial fusion/fission equilibrium is critical for placental cell function and signify the therapeutic potential of small molecule inhibitors of fission during GDM.

Maternal and Placental DNA Methylation Changes Associated with the Pathogenesis of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is an important metabolic complication of pregnancy, which affects the future health of both the mother and the newborn. The pathogenesis of GDM is not completely clear, but what is clear is that with the development and growth of the placenta, GDM onset and blood glucose is difficult to control, while gestational diabetes patients' blood glucose drops and reaches normal after placenta delivery. This may be associated with placental secretion of insulin-like growth factor, adipokines, tumor necrosis factor-α, cytokines and insulin resistance. Therefore, endocrine secretion of placenta plays a key role in the pathogenesis of GDM. The influence of DNA methylation of these molecules and pathway-related genes on gene expression is also closely related to the pathogenesis of GDM. Here, this review attempts to clarify the pathogenesis of GDM and the related maternal and placental DNA methylation changes and how they affect metabolic pathways.

PM2.5 Constituents and Onset of Gestational Diabetes Mellitus: Identifying Susceptible Exposure Windows

Fine particulate matter (PM_2.5) has been linked to gestational diabetes mellitus (GDM). However, PM_2.5 is a complex mixture with large spatiotemporal heterogeneities, and women with early-onset GDM (i.e., diagnosed before 24^th gestation week) have distinct maternal characteristics and a higher risk of worse health outcomes compared with those with late-onset GDM (i.e., diagnosed in or after 24^th gestation week). We aimed to examine differential impacts of PM_2.5 and its constituents on early- vs. late-onset GDM, and to identify corresponding susceptible exposure windows. We leveraged statewide linked electronic health records and birth records data in Florida in 2012-2017. Exposures to PM_2.5 and its constituents (i.e., sulfate [SO₄ ^2-], ammonium [NH₄ ⁺], nitrate [NO₃ ^-], organic matter [OM], black carbon [BC], mineral dust [DUST], and sea-salt [SS]) were spatiotemporally linked to pregnant women based on their residential histories. Cox proportional hazards models and multinomial logistic regression were used to examine the associations of PM_2.5 and its constituents with GDM and its onsets. Distributed non-linear lag models were implemented to identify susceptible exposure windows. Exposures to PM_2.5, SO₄ ^2-, NH₄ ⁺, and BC were statistically significantly associated with higher hazards of GDM. Exposures to PM_2.5 during weeks 1-12 of gestation were positively associated with GDM. Associations of early-onset GDM with PM_2.5 in the 1^st and 2^nd trimesters, SO₄ ^2- in the 1^st and 2^nd trimesters, and NO₃ ^- in the preconception and 1^st trimester were considerably stronger than observations for late-onset GDM. Our findings suggest there are differential associations of PM_2.5 and its constituents with early- vs. late-onset GDM, with different susceptible exposure windows. This study helps better understand the impacts of air pollution on GDM accounting for its physiological heterogeneity.

Incidence of Gestational Diabetes Diagnosed on the 100-G Glucose Tolerance Test in Pregnancies with a 50-G Glucose Challenge Test Result of 200 mg/dL or Greater

OBJECTIVE

This study aimed to assess the positive predictive value (PPV) of a 1-hour, 50-g glucose challenge test (GCT) result ≥200 mg/dL for the diagnosis of gestational diabetes mellitus (GDM) on a 3-hour, 100-g glucose tolerance test (GTT).

STUDY DESIGN

Pregnancies between 2008 and 2016 with a GCT result ≥200 mg/dL were identified retrospectively. GCT and GTT dates and results, demographics, and working due date (EDD) were extracted. Gestational age at testing was calculated from test date and EDD. As some clinicians presumptively diagnose GDM in such cases, if a GTT result was not available, clinic notes were reviewed to determine whether a GTT was ordered. Positive predictive values (PPV) were calculated at GCT cut-offs at and beyond 200 mg/dL. Subgroups were compared including early GCT (<16 weeks) versus routine GCT (24-28 weeks), GTT result normal versus GTT diagnostic of GDM, and GTT ordered versus GTT not ordered. Rates of use of medication for glycemic control were assessed among these groups.

RESULTS

Of 236 pregnant women with a GCT result ≥200 mg/dL, 115 (48%) GTT was ordered for 115 (49%), whereas 123 (52%) were managed as presumed GDM. Of 100 (87%) who completed the test, 81 (81%) were diagnosed with GDM with a median intertest interval of 14 days. No statistically significant differences were found between groups stratified by GTT result. Use of rates of metformin, glyburide, and insulin were similar between those diagnosed with GDM by GTT and those diagnosed with GDM by GCT alone.

CONCLUSION

A GCT result of ≥200 mg/dL has a PPV of 81% for diagnosis of GDM by GTT in a contemporary U.S. population, with a median intertest interval of 14 days between GCT and GTT. However, those diagnosed by GCT alone were as likely as those diagnosed by GTT to require medication for glycemic control, including insulin, suggesting that requiring a GTT may result in underdiagnosis and delayed treatment of GDM.

KEY POINTS

· A 50-g GCT result of 200 mg/dL or greater has a PPV of 81% for GDM on the 100 g GTT.. · Patients diagnosed with GDM by GCT alone were as likely to require insulin as those diagnosed by GTT.. · 81% of patients diagnosed with GDM on the GTT completed their GTT at least 1 week after the GCT, thus requiring GTT in this population may lead to unnecessary delays in care..

The prevalence of gestational diabetes, associated factors and feto-maternal outcome among antenatal women attending health clinics in Terengganu

INTRODUCTION

Gestational diabetes mellitus (GDM) is a known risk factor for diabetes mellitus (DM). The rising prevalence of GDM in the Asian population (11.7%) may explain the increasing incidence of DM in women. This study examined the prevalence of GDM, its associated factors and the foeto-maternal outcomes of women with GDM in Terengganu.

METHOD

A cross-sectional study was conducted between April and September 2019 using secondary data from antenatal records in 40 health clinics in Terengganu for 2018. All pregnant women aged 25 years and above with or without risk factors for GDM were included in the study. Those with pre-existing type 1 or 2 DM were excluded. A total of 270 respondents were included. The prevalence of GDM and its associated factors were determined using descriptive statistics followed by multiple logistic regression.

RESULTS

The prevalence of GDM in Terengganu was 27.3% (n=72). Logistic regression analysis found that BMI at booking (adjusted OR=4.51, 95% CI 2.13-9.55, p<0.001), history of GDM (adjusted OR=5.31, 95% CI 2.17-12.99, p<0.001) and family history of DM (adjusted OR=4.24, 95% CI 2.23-8.05, p<0.001) were the significant associated risk factors. Of women with GDM, 17.7% (n=11) had postpartum pre-diabetes based on modified oral glucose tolerance at 6 weeks postpartum. Univariate analysis using chi-square tests showed a significant association of neonatal jaundice and hypoglycaemia with GDM.

CONCLUSION

Because the prevalence of GDM in Terengganu is high, surveillance of GDM in highrisk pregnancies and effective glycaemic management should be emphasised to prevent adverse foeto-maternal outcomes.

Maternal and neonatal outcomes with the use of long acting, compared to intermediate acting basal insulin (NPH) for managing diabetes during pregnancy: a systematic review and meta-analysis

BACKGROUND

To assess the impact of long-acting insulin analogues, compared to intermediate acting neutral protamine Hagedron (NPH), on maternal, perinatal and neonatal outcomes.

METHODS

Studies for inclusion in the review were identified using a structured search strategy in PubMed, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) database. Studies that were randomized controlled trials or observational in design were considered for inclusion. Eligible studies should have compared the maternal, perinatal and neonatal outcomes between pregnant women with gestational diabetes mellitus (GDM) managed by intermediate acting (NPH) and by long-acting insulin analogues. Statistical analysis was performed using STATA software.

RESULTS

We found 17 studies to be eligible for inclusion. The mean gestational weight gain and risk of maternal hypoglycaemia, hypertensive disorder, caesarean delivery, spontaneous abortion, endometritis and wound infection or dehiscence were similar among pregnant women with GDM managed using long-acting insulin analogues and NPH. Those receiving long-acting insulin analogues had significantly lower HbA1c values in the second (WMD - .09, 95% CI 0.12, - 0.06; N = 4) and third trimester (WMD - 0.08, 95% CI - 0.14, - 0.02; N = 12). The mean gestational age and birth weight and risk of perinatal mortality, prematurity, large for gestational age, small for gestational age, shoulder dystocia and congenital abnormalities was similar among babies in both groups. No statistically significant differences in risk of admission to neonatal intensive care unit, respiratory distress, neonatal hypoglycaemia, 5 min APGAR score of < 7, neonatal hyperbilirubinemia and sepsis was observed. The quality of pooled evidence, as per GRADE criteria, was judged to be "very low" for all the maternal and neonatal outcomes considered.

CONCLUSIONS

Findings suggest no significant differences in the maternal, perinatal and neonatal outcomes between intermediate and long-acting insulin analogues. The results provide support for use of long-acting insulin analogues in women with GDM. However, evidence is still needed from high quality randomized controlled trials to arrive at a recommendation for inclusion in routine clinical care.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Risk of hypoglycemia by anthropometric measurements in neonates of mothers with diabetes

Macrosomia in neonates of diabetic women is a risk factor for neonatal hypoglycemia, with an over-risk for asymmetric macrosomia. This study aimed to study the association between anthropometric measurements and hypoglycemia in neonates of mothers treated for gestational diabetes. This is a secondary analysis of the INDAO trial study conducted between May 2012 and November 2016 in 13 French tertiary care university hospitals in 890 pregnant women with gestational diabetes treated with either insulin or glyburide. Neonatal anthropometric measurements were birthweight and weight-length ratio (WLR, defined as birth weight/length). Neonatal hypoglycemia was defined as capillary blood glucose below 36 mg/dL (2 mmol/L) or below 45 mg/dL (2.5 mmol/L) associated with clinical signs after 2 h of life. Their relationships were modeled with logistic regressions using fractional polynomials. Extreme categories of birthweight or WLR adjusted for gestational age at birth and sex were defined as Z-score <  -1.28 or > 1.28. These categories were compared to Z-score between -1.28 and 1.28 by estimating odds ratios and confidence intervals for neonatal hypoglycemia. Neonatal hypoglycemia occurred in 9.1% of cases. The relationship between birthweight and WLR Z-scores and neonatal risk of hypoglycemia adjusted for maternal treatment was a U-shaped curve. Adjusted odds ratios for the risk of hypoglycemia were 9.6 (95% CI 3.5, 26.8) and 2.3 (95% CI 1.1, 4.9) for WLR Z-score below -1.28 and above 1.28, respectively, compared with WLR Z-score between -1.28 and 1.28.    Conclusion: Birthweight Z-score was associated with the risk of neonatal hypoglycemia in neonates from mothers treated for gestational diabetes. The risk of neonatal hypoglycemia was increased for both extreme birthweight Z-scores, regardless of maternal treatment. Small for gestational age neonates of diabetic mothers require special attention for the risk of neonatal hypoglycemia. What is Known: • Macrosomia in neonates of diabetic women is a risk factor for neonatal hypoglycemia, with an over-risk for asymmetric macrosomia. Few retrospective studies have assessed the risk for neonatal hypoglycemia among small for gestational age neonates born to diabetic mothers. What is New: • The risk of neonatal hypoglycemia among neonates of diabetic mothers increased for both low and high weight-length ratio, regardless of maternal medicinal treatment, gestational age at birth, and sex of the newborn.

Second-Trimester Constituents of the Metabolic Syndrome and Pregnancy Outcome: An Observational Cohort Study

Background: Gestational diabetes mellitus (GDM) increases the risk of type 2 diabetes mellitus and cardiovascular disease (CVD) in women in later life. In the general population, metabolic syndrome (MetS) shows identical associations. The aim of this study was to evaluate the association between GDM, constituents of MetS and pregnancy outcomes. Methods: Of 2041 pregnant women undergoing an oral glucose tolerance test (OGTT) between 22 and 30 weeks of gestation, data were collected to evaluate the constituents of MetS. Odds ratios (ORs) were calculated to determine the associations between MetS and pregnancy outcomes. Results: GDM and obesity did not affect the risk of fetal growth abnormalities (SGA/LGA), preterm birth or preeclampsia (PE). Hypertension significantly increased the risk of SGA (OR—1.59), PE (OR—3.14), and preterm birth <37 weeks (OR—2.17) and <34 weeks (OR—2.96) and reduced the occurrence of LGA (OR—0.46). Dyslipidemia increased the risk of PE (OR—2.25), while proteinuria increased the risk of PE (OR—12.64) and preterm birth (OR—4.72). Having ≥2 constituents increased the risk of PE and preterm birth. Conclusions: Constituents of metabolic syndrome, rather than treating impaired glucose handling, increased the risk of preeclampsia, altered fetal growth and preterm birth. Obesity was not related to adverse outcomes.

Gestational Diabetes Mellitus Prevalence, Screening, and Treatment Practices in American Samoa, 2016

Gestational diabetes mellitus (GDM) is a serious pregnancy complication and understudied public health issue in American Samoa. The goals of this study were to (1) estimate the prevalence of GDM in American Samoa, (2) evaluate current screening practices for GDM, and (3) evaluate obtainment of GDM treatments in 2016. This cross-sectional study used 3 data sources: electronic health records, a labor and delivery logbook, and the American Samoa Department of Health (ASDOH) Maternal and Children's Health (MCH) Postpartum database. Out of 995 women with a singleton birth in American Samoa during the study period, 60.1% (n=598) completed a glucose tolerance test for GDM. Of these women, 41.8% (n=250) completed the testing within the recommended 24-28 weeks gestation timeframe. The estimated prevalence of GDM was 14.0% (95% confidence interval: 11.2-16.8) but has many limitations due to missing data. There were 4 treatments analyzed: nutrition counseling, insulin, metformin, and diabetes counseling. Of all women diagnosed with GDM (n=84), 76% were prescribed any of the 4 treatments. However, only 52% of those women obtained the treatment prescribed. Access to testing and treatment needs to be expanded to provide adequate prenatal care to women in American Samoa.

Prediction of insulin therapy in women with gestational diabetes: a systematic review and meta-analysis of observational studies

OBJECTIVES

To identify antenatal risk factors that may predict the need for insulin treatment upon diagnosis of gestational diabetes (GDM), that is, to identify the specific characteristics of women diagnosed with GDM who did not achieve good glycemic control through lifestyle modifications.

METHODS

We performed a comprehensive literature search in PubMed, Science Direct, Ebsco, and Scielo for studies evaluating the associations between antenatal factors and the need for insulin treatment published until January 28th, 2021. Random-effects models were used to estimate risk ratios and their 95% confidence interval. The quality of studies was assessed using the Newcastle-Ottawa Scale. Random-effects models were used to estimate outcomes, and effects reported as risk ratio and their 95% confidence interval. The systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews.

RESULTS

Eighteen observational studies were selected, reporting 14,951 women with GDM of whom 5,371 received insulin treatment. There were statistically significant associations between the need for insulin treatment and BMI ≥ 30 (RR:2.2; 95%CI: 1.44-3.41), family history of type 2 diabetes mellitus (RR:1.74; 95%CI: 1.56-1.93), prior personal history of GDM (RR:2.10; 95%CI: 1.56-2.82), glycated hemoglobin value at GDM diagnosis (RR:2.12; 95%CI: 1.77-2.54), and basal glycemia obtained in the diagnostic curve (RR: 1.2; 95%CI: 1.12-1.28). Nulliparity and maternal age were not determinants factor. There was moderate-to-high heterogeneity among the included studies.

CONCLUSIONS

the strong causal association between BMI ≥ 30, family history of type 2 diabetes mellitus, prior history of GDM and glycosylated hemoglobin with the need for insulin treatment was revealed.

Role of Beta Cell Function and Insulin Resistance in the Development of Gestational Diabetes Mellitus

Background: Gestational diabetes mellitus (GDM) is a pregnancy complication characterized by second trimester hyperglycemia. Untreated, GDM is related to an increased risk for adverse pregnancy outcomes. Both beta cell dysfunction and insulin resistance underlie impaired glucose tolerance. Understanding the dominant mechanism predisposing to GDM may be important to provide effective treatment in order to improve perinatal outcomes. We hypothesize that insulin resistance rather that beta cell dysfunction predisposes to GDM. Methods: A 75g oral glucose tolerance test (OGTT) was performed on 2112 second-trimester pregnant women to determine the relationship between insulin resistance (HOMA-IR), beta cell function (HOMA-β), and the prevalence of abnormal glucose handling. Results: High insulin resistance raised the risk of GDM (relative risk (RR) 6.1, 95% confidence interval (CI) (4.4–8.5)), as did beta cell dysfunction (RR 3.8, 95% CI (2.7–5.4)). High insulin resistance, but not beta cell function, enhances the necessity for additional glucose lowering medication on top of a low carbohydrate diet in women diagnosed with GDM. Conclusions: Both high insulin resistance and beta cell dysfunction increase the risk of GDM. As increased insulin resistance, rather than beta cell function, is related to an insufficient response to a low carbohydrate diet, we speculate that insulin sensitizers rather than insulin therapy may be the most targeted therapeutic modality in diet-insensitive GDM.

Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis

OBJECTIVE

To investigate the association between gestational diabetes mellitus and adverse outcomes of pregnancy after adjustment for at least minimal confounding factors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Web of Science, PubMed, Medline, and Cochrane Database of Systematic Reviews, from 1 January 1990 to 1 November 2021.

REVIEW METHODS

Cohort studies and control arms of trials reporting complications of pregnancy in women with gestational diabetes mellitus were eligible for inclusion. Based on the use of insulin, studies were divided into three subgroups: no insulin use (patients never used insulin during the course of the disease), insulin use (different proportions of patients were treated with insulin), and insulin use not reported. Subgroup analyses were performed based on the status of the country (developed or developing), quality of the study, diagnostic criteria, and screening method. Meta-regression models were applied based on the proportion of patients who had received insulin.

RESULTS

156 studies with 7 506 061 pregnancies were included, and 50 (32.1%) showed a low or medium risk of bias. In studies with no insulin use, when adjusted for confounders, women with gestational diabetes mellitus had increased odds of caesarean section (odds ratio 1.16, 95% confidence interval 1.03 to 1.32), preterm delivery (1.51, 1.26 to 1.80), low one minute Apgar score (1.43, 1.01 to 2.03), macrosomia (1.70, 1.23 to 2.36), and infant born large for gestational age (1.57, 1.25 to 1.97). In studies with insulin use, when adjusted for confounders, the odds of having an infant large for gestational age (odds ratio 1.61, 1.09 to 2.37), or with respiratory distress syndrome (1.57, 1.19 to 2.08) or neonatal jaundice (1.28, 1.02 to 1.62), or requiring admission to the neonatal intensive care unit (2.29, 1.59 to 3.31), were higher in women with gestational diabetes mellitus than in those without diabetes. No clear evidence was found for differences in the odds of instrumental delivery, shoulder dystocia, postpartum haemorrhage, stillbirth, neonatal death, low five minute Apgar score, low birth weight, and small for gestational age between women with and without gestational diabetes mellitus after adjusting for confounders. Country status, adjustment for body mass index, and screening methods significantly contributed to heterogeneity between studies for several adverse outcomes of pregnancy.

CONCLUSIONS

When adjusted for confounders, gestational diabetes mellitus was significantly associated with pregnancy complications. The findings contribute to a more comprehensive understanding of the adverse outcomes of pregnancy related to gestational diabetes mellitus. Future primary studies should routinely consider adjusting for a more complete set of prognostic factors.

REVIEW REGISTRATION

PROSPERO CRD42021265837.

Comparison of glucose metabolism and anthropometry in women with previous gestational diabetes treated with metformin vs. insulin: 9-year follow-up of two randomized trials

INTRODUCTION

The main aim was to study whether the long-term incidences of type 2 diabetes, pre-diabetes and metabolic syndrome differed between women who were treated with metformin or insulin for gestational diabetes.

MATERIAL AND METHODS

This 9-year follow-up study of two open-label randomized trials compares metformin and insulin treatments of gestational diabetes. In all, 165 women, 88 previously treated with insulin and 77 treated with metformin in the index pregnancy, were included in the analyses. An oral glucose tolerance test was performed, and measures of anthropometry, glucose metabolism, serum lipids and inflammatory markers were compared between the treatment groups. Disorders of glucose metabolism (pre-diabetes and type 2 diabetes) at the 9-year follow-up was the primary outcome of this study. This study was registered at ClinicalTrials.gov: NCT02417090.

RESULTS

The incidences of pre-diabetes and type 2 diabetes (40.3% vs. 46.6%, odds ratio [OR] 0.77, 95% CI 0.40-1.50, p = 0.51), type 2 diabetes (14.3% vs. 15.9%, OR 0.88, 95% CI 0.34-2.26, p = 0.94), pre-diabetes (26.0% vs. 30.7%, OR 0.79, 95% CI 0.38-1.65, p = 0.62), and metabolic syndrome (45.9% vs. 55.2%, OR 0.69, 95% CI 0.35-1.35, p = 0.31) were comparable between the metformin and insulin groups. Moreover, there were no evident differences in the individual measures of anthropometry, glucose metabolism including HOMA-insulin resistance, serum lipids or inflammatory markers between the two treatment groups.

CONCLUSIONS

Treatment of gestational diabetes with metformin vs. insulin during pregnancy is unlikely to have diverging long-term effects on maternal anthropometry, glucose metabolism or serum lipids. From this perspective, both treatments may be considered in gestational diabetes.

The Quantose Insulin Resistance Test for Maternal Insulin Resistance: A Pilot Study

OBJECTIVE

Insulin resistance (IR) increases during pregnancy which can lead to hyperinsulinemia, gestational diabetes mellitus (GDM), and neonatal hypoglycemia (NH), especially in obese women. Glucose tolerance testing (GTT) is used clinically to evaluate IR in pregnancy. Quantose IR score index is a novel blood screen of IR validated in nonpregnant individuals. The score is generated using an algorithm that combines insulin and three biomarkers of fatty acid pathways (α-hydroxybutyrate, oleic acid, linoleoyl-glycerophospocholine). Our objective was to determine the validity of Quantose IR test (Metabolan Inc. Morrisville, NC) in assessing IR in pregnant obese women, as compared with the homeostatic model assessment of insulin resistance (HOMA-IR), and its ability to predict GDM and NH.

STUDY DESIGN

Women between 10^0/7 and 13^6/7 weeks of gestation with a pre-pregnancy or early pregnancy body mass index more than 30 kg/m², and no pregestational diabetes, were included. Fasting blood samples were collected at 10^0/7 to 13^6/7 (T1) and 24^0/7 to 28^0/7 (T2) weeks. Quantose IR and HOMA-IR were calculated. All women underwent an early (T1; indicated for women with obesity) and a T2 glucose tolerance tests. GDM was diagnosed using the two-step approach, and NH was defined as a neonatal glucose less than 40 mg/dL in the first 24 hours of life. Linear regression and receiver operating characteristic curves were used for analysis.

RESULTS

The trial enrolled 100 patients. Ten subjects (10%) were diagnosed with GDM in the second trimester and none in the first trimester. At T1, Quantose IR (R²= 0.48), but not 1-hour glucose tolerance test (R²= 0.07), correlated with HOMA-IR. Similar correlations were observed at T2. The 1-hour glucose tolerance test followed by HOMA-IR and Quantose IR (area under the curve [AUC]: 0.82, 0.68, and 0.62, respectively) were predictors of GDM. Quantose IR (AUC: 0.74) and 1-hour glucose tolerance test (AUC: 0.72) at T1 and T2 (AUC: 0.75; AUC: 0.93; respectively) were best predictors of NH. The best cut offs, sensitivities, and specificities for prediction of NH were determined.

CONCLUSION

Similar to nonpregnant individuals, Quantose IR appears to be a valid measure of IR in obese pregnant women. First trimester Quantose IR is a predictor of GDM diagnosed in the second trimester and NH. Given that it requires a single blood draw and no glucose challenge, it may be a useful test to evaluate and monitor IR in pregnancy. Our findings may be used as pilot data to explore the potential use of Quantose IR in pregnancy further.

KEY POINTS

· Traditional testing methods for insulin resistance in pregnancy are often performed late, are time consuming, and unpleasant to patients.. · The first trimester one-step Quantose IR test reflects insulin resistance in pregnancy and predicts GDM and neonatal hypoglycemia.. · This is the first known prospective clinical study validating Quantose IR score index in an obstetrical population at risk for developing GDM..

Association of Prenatal Care Expansion With Use of Antidiabetic Agents During Pregnancies Among Latina Emergency Medicaid Recipients With Gestational Diabetes

Importance

Access to necessary prenatal care is not guaranteed through Medicaid for some people with low income based on their immigration status. Although states have the option to extend emergency Medicaid coverage for prenatal care, many states have not expanded coverage.

Objective

To evaluate whether the receipt of prenatal care services through the extension of emergency Medicaid coverage is associated with an increase in antidiabetic medication use among Latina patients with gestational diabetes.

Design, Setting, and Participants

This cohort study used linked Medicaid claims and birth certificate data on live births to 4869 Latina patients from October 1, 2010, to December 31, 2019, with a difference-in-differences design to compare the rollout of prenatal care and services in Oregon in 2013 with a comparison state, South Carolina, that did not cover prenatal or postpartum care.

Exposure

Medicaid coverage of prenatal care.

Main Outcomes and Measures

The main outcome was the receipt of antidiabetic agents. Secondary outcomes included hypertensive disorders, cesarean delivery, postpartum contraception, and a newborn morbidity composite outcome (large size for gestational age, neonatal intensive care unit admission, and preterm birth).

Results

The study sample included live births to 4869 Latina patients (mean [SD] age, 32.7 [5.5] years [range, 12-44 years]) enrolled in emergency Medicaid who were mainly aged 25 to 34 years (1499 of 2907 [51.6%]), multiparous (2626 of 2907 [90.3%]), and living in urban areas (2299 of 2907 [79.1%]). After Oregon's policy change to offer prenatal coverage to individuals receiving emergency Medicaid, there was a large and significant increase in the receipt of antidiabetic agents among all people with diabetes during pregnancy (gestational diabetes). Prior to the policy, only 0.3% of all Latina emergency Medicaid recipients with gestational diabetes (2 of 617) received any medication (oral agents or insulin) to manage their blood glucose level. After the policy change, 28.8% of all patients with gestational diabetes (295 of 1023) received medication to manage their blood glucose level, translating to a 27.9-percentage-point increase (95% CI, 24.5-31.2 percentage points) in the receipt of antidiabetic agents in the adjusted model. The policy was also associated with a 10.4-percentage-point (95% CI, 5.3-15.5 percentage points) increase in insulin use during pregnancy among all patients with gestational diabetes. We observed an increase in postpartum contraceptive use (21.2 percentage points; 95% CI, 14.9-27.5 percentage points), the majority of which was due to postpartum sterilization (increase of 16.1 percentage points; 95% CI, 10.4-21.8 percentage points). We did not observe a significant association with gestational hypertension, cesarean births, or newborn health.

Conclusions and Relevance

This retrospective cohort study suggests that expanded emergency Medicaid benefits that included prenatal care were associated with an increased use of antidiabetic medications and postpartum contraception during pregnancy.

Association of Glyburide and Subcutaneous Insulin With Perinatal Complications Among Women With Gestational Diabetes

IMPORTANCE

Nearly 30% of individuals with gestational diabetes (GDM) do not achieve glycemic control with lifestyle modification alone and require medication treatment. Oral agents, such as glyburide, have several advantages over insulin for the treatment of GDM, including greater patient acceptance; however, the effectiveness of glyburide for the treatment of GDM remains controversial.

OBJECTIVE

To compare the perinatal and neonatal outcomes associated with glyburide vs insulin using causal inference methods in a clinical setting with information on glycemic control.

DESIGN, SETTING, AND PARTICIPANTS

The population-based cohort study included patients with GDM who required medication treatment from 2007 to 2017 in Kaiser Permanente Northern California. Machine learning and rigorous casual inference methods with time-varying exposures were used to evaluate associations of exposure to glyburide vs insulin with perinatal outcomes. Data analysis was conducted from March 2018 to July 2017.

EXPOSURES

Time-varying exposure to glyburide vs insulin during pregnancy.

MAIN OUTCOMES AND MEASURES

Outcomes evaluated separately included neonatal hypoglycemia, jaundice, shoulder dystocia, respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, size-for-gestational age, and cesarean delivery. Inverse probability weighting (IPW) estimation was used to separately compare perinatal outcomes between those initiating glyburide and insulin. This approach was combined with Super Learning for propensity score estimation to account for both baseline and time-dependent confounding in both per-protocol (primary) and intention-to-treat (secondary) analyses to evaluate sustained exposure to the same therapy.

RESULTS

From 2007 to 2017, 11 321 patients with GDM (mean [SD] age, 32.9 [4.9] years) initiated glyburide or insulin during pregnancy. In multivariate models, the risk of neonatal respiratory distress was 2.03 (95% CI, 0.13-3.92) per 100 births lower and the risk of NICU admission was 3.32 (95% CI, 0.20-6.45) per 100 births lower after continuous exposure to glyburide compared with insulin. There were no statistically significant differences in glyburide vs insulin initiation in risk for neonatal hypoglycemia (0.85 [95% CI, -1.17 to 2.86] per 100 births), jaundice (0.02 [95% CI, -1.46 to 1.51] per 100 births), shoulder dystocia (-1.05 [95% CI, -2.71 to 0.62] per 100 births), or large-for-gestational age categories (-2.75 [95% CI, -6.31 to 0.80] per 100 births).

CONCLUSIONS AND RELEVANCE

Using data from a clinical setting and contemporary causal inference methods, our findings do not provide evidence of a difference in the outcomes examined between patients with GDM initiating glyburide compared with those initiating insulin.

Clinical Outcomes Following a Change in Gestational Diabetes Mellitus Diagnostic Criteria Due to the COVID-19 Pandemic: A Case-Control Study

Background: Due to COVID-19, many centres adopted a change to the diagnosis of GDM. Methods: A case-control study of antenatal patients between 1 April and 30 June in 2019 and 2020 looking at detection rates of GDM, use of medication, obstetric, and fetal outcomes. Results: During COVID-19, the rate of positive GDM tests approximately halved (20% (42/210) in 2020 vs. 42.2% (92/218) in 2019, (p < 0.01)) with higher rates of requirement for insulin at diagnosis (21.4% (2020) vs. 2.2% (2019); p < 0.01), and at term (31% (2020) vs. 5.4% (2019); p < 0.01). and metformin at diagnosis (4.8% (2020) vs. 1.1% (2019); p < 0.01), and at term (14.3% (2020) vs. 7.6% (2019) p < 0.01), with no differences in birth outcomes. Conclusions: There was likely an underdiagnosis of GDM while women at a higher risk of hyperglycaemia were correctly identified. The GTT should be maintained as the gold-standard test where possible, with provisions made for social distancing during testing if required.

Diagnostic accuracy of first and early second trimester multiple biomarkers for prediction of gestational diabetes mellitus: a multivariate longitudinal approach

BACKGROUND

Gestational Diabetes Mellitus (GDM) is an underlying cause of maternal and newborn morbidity and mortality all around the world. Timely diagnosis of GDM plays an important role in reducing its adverse consequences and burden. This study aimed to determine diagnostic accuracy of multiple indicators in complete blood count (CBC) test for early prediction of GDM.

METHODS

In this prospective cohort study, the data from 600 pregnant women was analyzed. In the study sample, the two-step approach was utilized for the diagnosis of GDM at 24-28 weeks of gestation. We also used the repeated measures of hemoglobin (Hb), hematocrit (Hct), fasting blood sugar (FBS) and red blood cell count (RBC) in the first and early second trimesters of pregnancy as the longitudinal multiple indicators for early diagnosis of GDM. The classification of pregnant women to GDM and non-GDM groups was performed using a statistical technique based on the random-effects modeling framework.

RESULTS

Among the sample, 49 women (8.2%) were diagnosed with GDM. In the first and early second trimester of pregnancy, the mean HcT, Hb and FBS of women with GDM was significantly higher than non-GDMs (P < 0.001). The concurrent use of multiple longitudinal data from HcT, Hb, RBC and FBS in the first and early second trimester of pregnancy resulted in a sensitivity, specificity and area under the curve (AUC) of 87%, 70% and 83%, respectively, for early prediction of GDM.

CONCLUSIONS

In general, our findings showed that the concurrent use of repeated measures data on Hct, Hb, FBS and RBC in the first and early second trimester of pregnancy might be utilized as an acceptable tool to predict GDM earlier in pregnancy.

Gestational Diabetes Mellitus and Energy-Dense Diet: What Is the Role of the Insulin/IGF Axis?

Gestational diabetes mellitus (GDM), is one of the most important pregnancy complications affecting approximately 15% of pregnant women. It is related to several gestational adverse outcomes in the fetus, e.g., macrosomia, shoulder dystocia, stillbirth, neonatal hypoglycemia, and respiratory distress. Women with GDM have a high risk of developing type 2 diabetes in the future. The pathogenesis of GDM is not completely understood; nevertheless, two factors could contribute to its development: β-cell dysfunction and failure in insulin secretion in response to insulin resistance induced by gestation. Both processes, together with the physiological activities of the insulin-like growth factors (IGFs), play a crucial role in glucose transport to the fetus and hence, fetal growth and development. IGFs (both IGF-1 and IGF-2) and their binding proteins (IGFBPs) regulate glucose metabolism and insulin sensitivity. Maternal nutritional status determines the health of the newborn, as it has substantial effects on fetal growth and development. Maternal obesity and an energy-dense diet can cause an increase in insulin and IGF-1 serum levels, producing metabolic disorders, such as insulin resistance, GDM, and high birth weight (> 4,000 g) due to a higher level of body fat. In this way, in GDM pregnancies there is an increase in IGF-1 and IGF-2 serum levels, and a decrease in IGFBP-1 and 4 serum levels, suggesting the crucial role of the insulin/IGF system in this gestational outcome. Here, the present review tries to elucidate the role that energy-dense diets and the insulin/IGF-1 signaling pathway perform in GDM pregnancies.

Glycemic Variability in Early Pregnancy May Predict a Subsequent Diagnosis of Gestational Diabetes

PURPOSE

This study examined the prospective association between CGM-derived glycemic variability (GV) and glycemic control (GC) parameters in the first and second trimester, with subsequent diagnosis of GDM in the early third trimester.

METHODS

In a longitudinal observational study, 60 study participants in the first trimester (9-13 weeks' gestation), and 53 participants (18-23 weeks' gestation) in the second trimester of pregnancy had CGM data extracted after a minimum of 8 days' wear time (up to 14 days). At 24-31 weeks' gestation, participants underwent a 75 g, 2-hour oral glucose-tolerance test as per IADPSG criteria to diagnose GDM. GV parameters examined in both first and second trimesters were mean amplitude of glycemic excursion (MAGE), standard deviation (SD), mean glucose, and coefficient of variation (CV). GC parameters measured were J-Index and percentage of time spent in glucose target ranges.

RESULTS

The first trimester SD and MAGE were significantly higher in participants subsequently diagnosed with GDM (SD adjusted median 1.31 [interquartile range 1.2-1.3] mmol/L; MAGE 3.26 [3.2-3.3] mmol/L) than those who were not (SD 1.01 [0.9-1.0] mmol/L, MAGE 2.59 [2.4-2.6] mmol/L; p<0.05). Similarly, second trimester SD and MAGE were also significantly higher in participants subsequently diagnosed with GDM (SD 1.35 [1.3-1.4] mmol/L; MAGE 3.32 (3.31-3.41) mmol/L) than those who were not (SD 0.99 [0.98-1.01] mmol/L, MAGE 2.42 [2.42-2.55] mmol/L; p<0.05). Associations between SD and MAGE with GDM outcomes were adjusted for prepregnancy BMI and ethnicity. There were nonsignificant trends of higher J-Index scores in the first and second trimester, higher CV in the first trimester only, and higher mean in the second trimester only in participants diagnosed with GDM. Other study parameters measured were not significantly different between groups (p>0.003).

CONCLUSION

Our study suggests the potential value of CGM-derived SD and MAGE in early pregnancy as potential predictors of subsequent GDM diagnosis.

Risk factor-based screening compared to universal screening for gestational diabetes mellitus in marginalized Burman and Karen populations on the Thailand-Myanmar border: An observational cohort

Background: Gestational diabetes mellitus (GDM) contributes to maternal and neonatal morbidity. As data from marginalized populations remains scarce, this study compares risk-factor-based to universal GDM screening in a low resource setting. Methods: This is a secondary analysis of data from a prospective preterm birth cohort. Pregnant women were enrolled in the first trimester and completed a 75g oral glucose tolerance test (OGTT) at 24-32 weeks' gestation. To define GDM cases, Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO trial) criteria were used. All GDM positive cases were treated. Sensitivity and specificity of risk-factor-based selection for screening (criteria: age ≥30y, obesity (Body mass index (BMI) ≥27.5kg/m ²), previous GDM, 1 ^st degree relative with diabetes, previous macrosomia (≥4kg), previous stillbirth, or symphysis-fundal height ≥90th percentile) was compared to universal screening using the OGTT as the gold standard. Adverse maternal and neonatal outcomes were compared by GDM status. Results: GDM prevalence was 13.4% (50/374) (95% CI: 10.3-17.2). Three quarters of women had at least one risk factor (n=271 women), with 37/50 OGTT positive cases correctly identified: sensitivity 74.0% (59.7-85.4) and specificity 27.8% (3.0-33.0). Burman women (self-identified) accounted for 29.1% of the cohort population, but 38.0% of GDM cases. Percentiles for birthweight (p=0.004), head circumference (p=0.002), and weight-length ratio (p=0.030) were higher in newborns of GDM positive compared with non-GDM mothers. 21.7% (75/346) of newborns in the cohort were small-for-gestational age (≤10 ^th percentile). In Burman women, overweight/obese BMI was associated with a significantly increased adjusted odds ratio 5.03 (95% CI: 1.43-17.64) for GDM compared with normal weight, whereas in Karen women, the trend in association was similar but not significant (OR 2.36; 95% CI 0.95-5.89). Conclusions: Risk-factor-based screening missed one in four GDM positive women. Considering the benefits of early detection of GDM and the limited additional cost of universal screening, a two-step screening program was implemented.

The association between gestational diabetes and stillbirth: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Controversy exists over whether gestational diabetes increases the risk of stillbirth. The aim of this review was to examine the association between gestational diabetes and stillbirth.

METHODS

We performed searches of the published literature to May 2021. Study selection and data extraction were performed in duplicate by independent reviewers. Meta-analyses of summary measures were conducted using random-effect models for cohort and case-control studies separately. The study protocol was registered in PROSPERO (registration ID CRD42020166939).

RESULTS

From 9981 citations, 419 were identified for full-text review and 73 met inclusion criteria (n = 70,292,090). There was no significant association between gestational diabetes and stillbirth in cohort studies (pooled OR 1.04 [95% CI 0.90, 1.21]; I2 86.1%) or in case-control studies (pooled OR 1.57 [95% CI 0.83, 2.98]; I2 94.8%). Gestational diabetes was associated with lower odds of stillbirth among cohort studies presenting with an adjusted OR (pooled OR 0.78 [95% CI 0.68, 0.88]; I2 42.7%). Stratified analyses by stillbirth ≥28 weeks' gestation, studies published prior to 2013 and studies identified as low quality demonstrated a significantly higher odds of stillbirth in meta-regression (p = 0.016, 0.023 and 0.005, respectively). Egger's test for all included cohort studies (p = 0.018) suggests publication bias for the main meta-analysis.

CONCLUSIONS/INTERPRETATION

Given the substantial heterogeneity across studies, there are insufficient data to define the relationship between stillbirth and gestational diabetes adequately. In the main analyes, gestational diabetes was not associated with an increased risk of stillbirth. However, heterogeneity across studies means this finding should be interpreted cautiously.

Risk factor-based screening compared to universal screening for gestational diabetes mellitus in marginalized Burman and Karen populations on the Thailand-Myanmar border: An observational cohort

Background: Gestational diabetes mellitus (GDM) contributes significantly to maternal and neonatal morbidity, but data from marginalized populations remains scarce. This study aims to compare risk-factor-based screening to universal testing for GDM among migrants along the Thailand-Myanmar border. Methods: From the prospective cohort (September 2016, February 2019), 374 healthy pregnant women completed a 75g oral glucose tolerance test (OGTT) at 24-32 weeks gestation. Fasting, one hour and two hour cut-offs were based on Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO trial) criteria and cases were treated. The sensitivity and specificity of risk-factor-based screening criteria was calculated using OGTT as the gold standard. Risk factors included at least one positive finding among 10 criteria, e.g., obesity (body mass index (BMI) ≥27.5kg/m ²), 1 ^st degree relative with diabetes etc. Adverse maternal and neonatal outcomes were compared by GDM status, and risk factors for GDM were explored. Results: GDM prevalence was 13.4% (50/374) (95% CI: 10.3-17.2). Risk-factors alone correctly identified 74.0% (37/50) OGTT positive cases: sensitivity 74.0% (59.7-85.4) and specificity 27.8% (3.0-33.0). Burman women accounted for 29.1% of the cohort population, but 38.0% of GDM cases. Percentiles for birthweight (p=0.004), head circumference (p=0.005), and weight-length ratio (p=0.010) were higher in newborns of GDM mothers compared with non-GDM, yet 21.7% (75/346) of newborns in the cohort were small-for-gestational age. In Burman women, overweight/obese BMI was associated with a significantly increased adjusted odds ratio 5.03 (95% CI: 1.43-17.64) for GDM compared to normal weight, whereas underweight and overweight/obese in Karen women were both associated with similarly elevated adjusted odds, approximately 2.4-fold (non-significant) for GDM. GDM diagnosis by OGTT was highest prior to peak rainfall. Conclusions: Risk-factor-based screening was not sufficiently sensitive or specific to be useful to diagnose GDM in this setting among a cohort of low-risk pregnant women. A two-step universal screening program has thus been implemented.

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.

Screening for gestational diabetes mellitus and hyperglycemia in pregnancy with the glucose challenge test administered in early pregnancy

OBJECTIVE

To determine the cut-off value for the 75-g glucose challenge test administered in early pregnancy to screen for gestational diabetes mellitus and abnormal carbohydrate metabolism in pregnancy.

METHODS

A prospective study involving 1500 antenatal patients attending a community hospital. Patients were screened with the 75-g 1-h glucose challenge test in early pregnancy and subsequently tested with the 75-g 2-h glucose tolerance test to diagnose gestational diabetes mellitus. Statistical methods were employed to determine the optimal plasma glucose cut-off value for a positive result in early pregnancy.

RESULTS

A glucose challenge test value of 6.0 mmol/L (108 mg/dl) or more was selected as the preferred cut-off level for further testing with a sensitivity of 83.5% (95% confidence interval [CI] 77.0%-88.9%) and specificity of 49.2% (95% CI 46.5%-52.0%).

CONCLUSION

An early pregnancy glucose challenge test reading of 6.0 mmol/L (108 mg/dl) or more is effective in screening for gestational diabetes mellitus; a value of 10.0 mmol/L (180 mg/dl) or more is effective for finding pre-pregnancy abnormalities of carbohydrate metabolism. The false-positive glucose challenge test diagnoses gestational hyperglycemia, the treatment of which will improve perinatal outcome. Further testing based on risk factors will exclude a false-negative glucose challenge test. A combination of universal early pregnancy screening and selective risk-factor testing is recommended to detect the full range of abnormalities of carbohydrate metabolism encountered in pregnancy.