Overweight and obese in gestational diabetes: the impact on pregnancy outcome

The environmental risk factors associated with fetal macrosomia: An umbrella review

The present umbrella review evaluated the environmental risk factors prior to conception associated with fetal macrosomia based on meta-analyses and systematic reviews. We systematically searched international databases, including PubMed, Scopus, and Web of Science, until April 2023 by using some relevant keywords. The quality of the included studies was assessed using the AMSTAR 2checklist. The risk factor of advanced maternal age 35-39 years compared with <30 years (OR 1·42, 95 % CI: 1·25, 1·60), prepregnancy obesity (OR 1.93, 95 % CI: 1.65, 2.27) and excessive weight gain before and during pregnancy (OR 2.35, 95 % CI: 1.95, 2.85) were graded as suggestive evidence (class III). Two risk factors of advanced maternal age >40 years compared with <30 years (OR 1.40, 95 % CI: 1.02, 1.78) and gestational diabetes mellitus (GDM) without insulin use (OR 1.70, 95 % CI: 1.23, 2.36) were graded as risk factors with weak evidence (class IV). Advanced maternal age, prepregnancy obesity, excessive weight gain before and during pregnancy, and GDM without insulin use were environmental risk factors for macrosomia.

Neurodevelopmental Programming of Adiposity: Contributions to Obesity Risk

This review analyzes the published evidence regarding maternal factors that influence the developmental programming of long-term adiposity in humans and animals via the central nervous system (CNS). We describe the physiological outcomes of perinatal underfeeding and overfeeding and explore potential mechanisms that may mediate the impact of such exposures on the development of feeding circuits within the CNS-including the influences of metabolic hormones and epigenetic changes. The perinatal environment, reflective of maternal nutritional status, contributes to the programming of offspring adiposity. The in utero and early postnatal periods represent critically sensitive developmental windows during which the hormonal and metabolic milieu affects the maturation of the hypothalamus. Maternal hyperglycemia is associated with increased transfer of glucose to the fetus driving fetal hyperinsulinemia. Elevated fetal insulin causes increased adiposity and consequently higher fetal circulating leptin concentration. Mechanistic studies in animal models indicate important roles of leptin and insulin in central and peripheral programming of adiposity, and suggest that optimal concentrations of these hormones are critical during early life. Additionally, the environmental milieu during development may be conveyed to progeny through epigenetic marks and these can potentially be vertically transmitted to subsequent generations. Thus, nutritional and metabolic/endocrine signals during perinatal development can have lifelong (and possibly multigenerational) impacts on offspring body weight regulation.

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.

Social Vulnerability and Initiation of Pharmacotherapy for Gestational Diabetes Mellitus in a Medicaid Population

OBJECTIVE

Our study examines the association between social vulnerability index (SVI) and pharmacotherapy initiation for gestational diabetes mellitus (GDM).

METHODS

We studied a retrospective cohort of pregnant patients with GDM, enrolled in Tennessee Medicaid, who gave birth between 2007 and 2019. Enrollment files were linked to birth and death certificates, state hospitalization registries, and pharmacy claims. SVI, measured at the community level and determined by residential census tract, ranged from 0 to 100 (low to high vulnerability). Multivariable logistic regression assessed the association between SVI and the odds of initiating the most common pharmacotherapies for GDM-insulin, glyburide, or metformin-and adjusted for relevant covariates. SVI was modeled with restricted cubic splines to account for nonlinear associations, using the median Tennessee SVI as a reference. Secondary analysis assessed associations with the SVI subthemes.

RESULTS

Among 33,291 patients with GDM, 21.7% (7,209) initiated pharmacotherapy during pregnancy. Patients from areas with higher SVI were more likely to be non-Hispanic Black with higher body mass index, whereas those with lower SVI were more likely to be nulliparous. Multivariable modeling demonstrated a complex nonlinear association between SVI and GDM pharmacotherapy initiation, relative to the reference. Higher SVI was associated with elevated odds of GDM pharmacotherapy initiation (e.g., odds ratio 1.11 [95% confidence interval 1.02-1.22] for SVI 80) and low to medium SVI had variable nonsignificant associations with GDM pharmacotherapy initiation, relative to the reference (lower odds of initiation for values 25-50, higher odds of initiation for values < 25). Secondary analysis demonstrated a nonlinear association between subtheme 3 and the odds of GDM pharmacotherapy initiation.

CONCLUSION

Social vulnerability is associated with initiation of pharmacotherapy for GDM, highlighting the possible role of social determinants of health in achieving glycemic control.

Cesarean delivery rates and indications in pregnancies complicated by diabetes

OBJECTIVE

Rates of pregestational (PGDM) and gestational diabetes (GDM), and their associated pregnancy complications, are rising. Pregnancies complicated by diabetes have increased cesarean delivery (CD) rates; however, there are limited data regarding the current rates of, and contributing factors to, these deliveries. The Robson Ten Group Classification System (TGCS) is a clinically relevant, standardized framework that can be used to evaluate and analyze cesarean rates. The objective of this study was to evaluate rates of, and indications for, intrapartum, unplanned CD among pregnancies complicated by diabetes, compared to normoglycemic (NG) pregnancies, in a large United States birth cohort.

METHODS

This retrospective cohort study used chart-abstracted data on births between 24 and 42 weeks' gestation at 17 hospitals that contributed to the Obstetrical Care Outcome Assessment Program database between 01/2016 and 03/2019. The CD rate for NG pregnancies, and pregnancies complicated by gestational and PGDM was calculated and compared using the Robson TGCS. The indications for intrapartum CD in patients with term, singleton, vertex gestations without a prior cesarean were then analyzed. Univariate and multivariate logistic regression models were used to compare the cesarean rate and indications for CD, between the diabetic groups and the NG group. Results were adjusted for maternal age, BMI, neonatal birth weight, and insurance status, as well as clustering by hospital.

RESULTS

A total of 86,381 pregnant people were included in the study cohort. Of these 76,272 (88.3%) were NG, 8591 (9.9%) had GDM, and 1518 (1.8%) had PGDM. Compared to NG patients, overall cesarean rates were higher in patients with GDM (40.3% vs. 29.7%; aOR 1.25, 95%CI 1.18-1.31) and PGDM (60.0% vs. 29.7%; aOR 2.53, 95%CI 2.04-3.13). This finding remained true when the cohort was restricted to term, singleton, vertex laboring patients without a prior cesarean; compared to NG patients, the cesarean rate was higher in patients with GDM (17.4% vs. 12.2%, aOR 1.37, 95%CI 1.29-1.45) and PGDM (26.0% vs. 12.2%, aOR 2.55, 95%CI 2.00-3.25). The cesarean rate for fetal indications was similar in the GDM (5.7%) and NG (4.4%) groups, while those patients with PGDM had a significantly higher rate (10.4%; aOR 2.01, 95%CI 1.43-2.83). Similarly, the rate of cesarean for labor dystocia in patients with PGDM was significantly higher than in NG patients (16.9% vs. 7.0%, and aOR 2.28, 95%CI 1.66-3.13) while patients with GDM had an intermediate rate (10.6% vs. 7.0%, aOR 1.49, 95%CI 1.40-1.57).

CONCLUSIONS

The CD rate is significantly higher in pregnancies complicated by diabetes, particularly pregestational, compared to NG pregnancies. Despite controlling for maternal factors and birth weight, pregnancies complicated by diabetes are more likely to undergo an unplanned intrapartum cesarean secondary to labor dystocia than their NG counterparts, but only pregnancies complicated by PGDM have an increased risk of cesarean for fetal indications. More research is needed to understand whether this higher cesarean rate is due to factors intrinsic to diabetes in laboring patients or is due to a difference in the way clinicians manage diabetics in labor.

Upregulation of Klotho Aggravates Insulin Resistance in Gestational Diabetes Mellitus Trophoblast Cells

Objective. Insulin resistance (IR) plays a key role in gestational diabetes mellitus (GDM) pathogenesis. The antiaging protein klotho has been proven to be closely related to IR. The purpose of this study was to investigate the effect of klotho on IR in GDM trophoblast cells. Methods. The GDM cell model of HTR-8/SVneo cells was induced by high glucose (HG). Plasmid transfection was used to mediate the overexpression or silencing of klotho. The effects of klotho on cell viability, IR, and the IGF-1/PI3K pathways were observed by RT-qPCR, western blot, Cell Counting Kit-8 detection, glucose uptake assay, and immunofluorescence detection. Results. Klotho expression was up-regulated in HG-induced cells. Overexpression of klotho could reduce the cell viability, insulin signaling molecules (INSR-α, INSR-β, IRS1, IRS2, and GLUT4), and glucose uptake in HTR-8/SVneo cells of the HG group. In addition, the overexpression of klotho inhibited the levels of IGF-1, IGF-1R/p-IGF-1R, and the phosphorylation and activation of the signal transduction molecules PI3K/Akt/mTOR. On the contrary, klotho deletions could reverse these changes of HTR-8/SVneo cells induced by HG. Conclusion. In a word, the results of this study showed that the regulation of klotho played an important role in the IR of trophoblast cells induced by HG, which was mediated at least in part by the IGF-1/PI3K/Akt/mTOR pathway.

The association between an oral glucose tolerance test performed at term pregnancy and obstetric outcomes

Aims

Assessing the value of oral glucose tolerance test performed at term pregnancy in identifying obstetric complications.

Methods

Retrospective cohort study of women with a normal 50 g glucose challenge test who also had an oral glucose tolerance test at term (defined as at or after 37 weeks of gestation). Comparison between the pathological and normal oral glucose tolerance test groups was performed.

Results

The mean glucose in the glucose challenge test of women in the normal oral glucose tolerance test (n = 256) group was lower than that in the pathological oral glucose tolerance test (N = 16) group (105 ± 17 mg/dl (5.8 ± 0.9 mmol/l) vs 117 ± 13 mg/dl (6.5 ± 0.7 mmol/l), p = 0.007). Relevant obstetrical complications did not differ significantly between the groups. Of note, in the pathological oral glucose tolerance test group only one woman delivered a macrosomic infant.

Conclusions

A pathological oral glucose tolerance test performed at term was unable to identify women at risk for impaired glucose metabolism-related obstetric complications and is therefore of limited clinical value and seems to be unjustified.

Maternal AA/EPA Ratio and Triglycerides as Potential Biomarkers of Patients at Major Risk for Pharmacological Therapy in Gestational Diabetes

Gestational diabetes mellitus (GD) is characterized by glycemic and lipid metabolism alterations in an environment of low-grade inflammation. Our trial aimed to assess the effect of nutraceutical supplements (omega-3 fatty acids, anthocyanins, and alpha-cyclodextrins) in GD patients and evaluate the role of anthropometric, metabolic, and inflammatory parameters as biomarkers to identify subjects who require pharmacological hypoglycemic treatment during gestation. Pregnant women with GD at 24-28 weeks of gestation were enrolled in a double-blind trial and randomized to receive either nutraceutical supplements or a placebo for 12 weeks. No statistically significant differences were observed between the two groups in blood and urine measurements of metabolic, inflammatory, and antioxidant parameters. In the whole cohort, pre-pregnancy BMI and anthropometric measurements were significantly different in patients who required pharmacological intervention. These patients showed higher triglycerides, CRP, and insulin levels and gave birth to newborns with significantly higher weights. Subjects with a greater AA/EPA ratio had higher PAF levels and gave birth four days earlier. In conclusion, one-to-one nutritional coaching and poor compliance with nutraceutical supplementation might have outweighed the impact of this intervention. However, triglyceride concentration and the AA/EPA ratio seems to be a biomarker for higher inflammatory levels and GD candidates for pharmacological treatment. An adequate assumption of omega-3 in women with GD, either by a controlled diet or by nutraceutical supplementation, reduces the need for pharmacological therapy.

Gestational Diabetes Mellitus and Preeclampsia: Correlation and Influencing Factors

Gestational diabetes mellitus (GDM) and preeclampsia (PE) are common pregnancy complications with similar risk factors and pathophysiological changes. Evidence from previous studies suggests that the incidence of PE is significantly increased in women with GDM, but whether GDM is independently related to the occurrence of PE has remained controversial. GDM complicated by PE further increases perinatal adverse events with greater impact on the future maternal and offspring health. Identify factors associated with PE in women with GDM women, specifically those that are controllable, is important for improving pregnancy outcomes. This paper provides the findings of a review on the correlation between GDM and PE, factors associated with PE in women with GDM, possible mechanisms, and predictive markers. Most studies concluded that GDM is independently associated with PE in singleton pregnancy, and optimizing the treatment and management of GDM can reduce the incidence of PE, which is very helpful to improve pregnancy outcomes.

Impact Of Prepregnancy Overweight And Obesity On Treatment Modality And Pregnancy Outcome In Women With Gestational Diabetes Mellitus

BACKGROUND

We aim to evaluate the impact of prepregnancy overweight on treatment modalities of Gestational Diabetes Mellitus (GDM). We assessed the association of increased pregravid Body Mass Index (BMI) with dosing of basal and rapid acting insulin as well as pregnancy outcome.

METHODS

We included 509 gestational diabetic women (normal weight: 200, overweight: 157, obese: 152), attending the pregnancy outpatient clinic at the Department of Obstetrics and Gynecology, Medical University of Vienna, in this retrospective study. We used a prospectively compiled database to assess patient characteristics, treatment approaches - particularly maximum doses of basal and rapid acting insulin or metformin - and pregnancy outcome.

RESULTS

Increased BMI was associated with the need of glucose lowering medication (odds ratio (OR): 1.08 for the increase of 1 kg/m² BMI, 95%CI 1.05-1.11, p<0.001). Mothers with pregestational obesity received the highest amount of insulin. Metformin was more often used in patients with obesity who also required higher daily doses. Maternal BMI was associated with increased risk of cesarean section (OR 1.04, 95%CI 1.01-1.07, p<0.001) and delivering large for gestational age offspring (OR 1.09, 95%CI 1.04-1.13, p<0.001). Birthweight percentiles were highest in patients with obesity who required glucose lowering therapy.

CONCLUSIONS

Treatment modalities and outcome in GDM pregnancies are closely related to the extent of maternal BMI. Patients with obesity required glucose lowering medication more often and were at higher risk of adverse pregnancy outcomes. It is crucial to further explore the underlying pathophysiologic mechanisms to optimize clinical management and individual treatment approaches.

Feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain

INTRODUCTION

Gestational weight gain (GWG) and postpartum weight retention (PPWR) are significant, potentially modifiable, contributors to women's future weight and health trajectories. There is a need for feasible and patient-centered (i.e., convenient, remotely-delivered, technology-enhanced, and accessible through the prenatal care setting) behavioural interventions that limit GWG and PPWR. This study tests the feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain and postpartum weight retention.

METHODS

Pregnant women (11-16 weeks gestation) were recruited from two prenatal clinics and randomized to the active intervention or health education comparison group. Completion of the program was monitored and perceived helpfulness was rated (0-100).

RESULTS

Twenty-six women were randomized (n = 13 per arm; mean age = 31.6 years, SD = 3.6; mean BMI = 26.7 kg/m2, SD = 7.4). Participants completed a median of 18 coaching calls and 16/19 learning activities during pregnancy, and a median of 6 calls and 5/6 learning activities postpartum. They logged weights at least once/week for a median of 36/38 expected weeks and tracked daily calories and exercise for a median of 154/266 days and 72/266 days, respectively. Median (Q1, Q3) helpfulness ratings of the program during pregnancy were 80 (64, 91) and 62 (50, 81) postpartum; helpfulness ratings of coaching calls were 85 (58, 98). At 37 weeks gestation, 77% of participants achieved IOM weight gain recommendations compared to 54% in the comparison group.

CONCLUSIONS

This study provides evidence for the feasibility and acceptability of a remotely-delivered behavioural weight control intervention in pregnancy and postpartum.

Influence of weight gain on risk for cesarean delivery in obese pregnant women by class of obesity: pregnancy risk assessment monitoring system (PRAMS)

BACKGROUND

Currently, all obese women in the United States (US) are recommend to gain the same amount of weight during pregnancy, regardless of class of obesity. Limited literature has looked at the risk of cesarean, and possible mitigation of this risk, by specific class of obesity.

OBJECTIVE

To determine the influence of weight gain on the odds of cesarean delivery for obese women (as determined by pre-pregnancy body mass index [BMI]), by class of obesity.

STUDY DESIGN

Retrospective cohort, from the Pregnancy Risk Assessment Monitoring System (PRAMS) in the US. Specifically, the unadjusted odds of cesarean delivery were determined for each class of BMI (underweight, normal weight, overweight, class I obesity, class II obesity, and class III obesity). These odds were then adjusted by demographic and prenatal care factors influencing either weight gain during pregnancy or risk of cesarean delivery. Finally, the association of weight gain (insufficient <11 lbs, adequate 11-20 lbs, and excessive >20 lbs) on the odds of cesarean delivery in obese women was noted via multivariate logistic regression analysis.

RESULTS

60,431 women (including 21,208 with a cesarean delivery) were included in this study, with an adjusted odds ratios (OR) of cesarean delivery by BMI: underweight 0.92 (95% CI 0.83, 1.01), normal weight (referent group), overweight 1.38 (95% CI 1.32, 1.45), class I obesity 1.77 (95% CI 1.68, 1.88), class II obesity 2.17 (95% CI 2.02, 2.34), and class III obesity 3.07 (95% CI 2.82, 3.34). Class I and II obese women are more likely to have a cesarean with excessive weight gain, with class I OR 1.20 (95% CI 1.06, 1.36) and class II OR 1.24 (1.04, 1.48) when compared to women in their same class of obesity with adequate weight gain. There was no difference in risk for cesarean for class III obese women by weight gain.

CONCLUSION

Although obesity is a known risk factor for cesarean delivery, this risk is thought to be mitigatable by appropriate weight gain during the pregnancy. Weight gain of 11-20 pounds was associated with the least risk of cesarean delivery among obese (specifically class I and II) individuals.

Reduction of hepatorenal and pancreatic damage by Ferula elaeochytris extract in STZ induced diabetic rats

The therapeutic potential and antioxidant capacity of Ferula elaeochytris extract (FE) in the liver, kidney and pancreas of rats with diabetes induced by streptozotocin (STZ) was assessed using biochemistry, histopathology and immunohistochemistry. Forty adult Wistar albino male rats were divided randomly into five groups of eight rats each. The normal control (NC) group was untreated. The diabetes control (DC) group was treated with STZ to induce diabetes. The diabetes + acarbose group (DAC) was treated with STZ, then with acarbose daily for 28 days. The diabetes + FE (DFE) group was treated with STZ, then FE daily for 28 days. DC rats had inflammatory cell infiltration, hydropic degeneration and necrosis, whereas the DFE rats exhibited nearly normal histology. Insulin immunostaining in the pancreatic beta cells was decreased in the DC group compared to the NC group, whereas the DFE group was similar to the NC group. Many serum biomarkers of damage to liver, kidneys or pancreas were elevated in the DC group compared to the NC group; these biomarkers were decreased in the DFE group. The DC group exhibited increased malondialdehyde levels and decreased levels of the antioxidant defense system constituents compared to the NC group. The level of biomarkers the DFE group was close to the NC group. FE exhibited a protective effect against tissue damage owing to its antioxidant activities and to its ability to effect regeneration of β-cells in STZ induced diabetic rats.

Impact of overweight and obesity on pregnancy outcomes in women with gestational diabetes - results from a retrospective multicenter study

Objective The aim of this study was to evaluate the impact of pre-pregnancy body mass index (BMI) on pregnancy outcomes in women with gestational diabetes (GD). Subjects and methods Retrospective multicenter study using data from the Portuguese National Register. We included women with GD with a singleton pregnancy. GD diagnosis was according to the International Association of the Diabetes and Pregnancy Study Group criteria. Women were divided into groups according to their pre-pregnancy BMI: < 18.5 kg/m2 (underweight), ≥ 18.5 and < 25.0 kg/m2 (normal weight), ≥ 25 and < 30 kg/m2 (overweight) and ≥ 30 kg/m2 (obese). Results We included 3,103 pregnant women with GD, 29.6% (n = 918) were overweight and 27.3% (n = 846) were obese. Compared to normal weight, the overweight and obese groups had a higher percentage of gestational hypertension (4.0% and 8.5% vs. 2.1%), cesarean delivery (32.8% and 41.3% vs. 27.9%), macrosomia (3.9% and 6.7% vs. 2.4%), and large for gestational age (LGA) newborns (8.3% and 13.5% vs. 6.0%). Obesity increased the risk of gestational hypertension (OR 4.5, p < 0.001), preeclampsia (OR 1.9, p = 0.034), cesarean delivery (OR 2.0, p < 0.001), macrosomia (OR 3.1, p < 0.001) and LGA (OR 2.3, p < 0.001). Conclusion In pregnant women with GD, pregnancy complications increase with pre-pregnancy BMI. In obese women, appropriate diet and counseling prior to gestation and more aggressive medical intervention during pregnancy are needed in order to prevent macrosomic and LGA newborns and to reduce maternal complications.

Bariatric Surgery Impacts Levels of Serum Lipids during Pregnancy

INTRODUCTION

Bariatric surgery confers a high risk for nutritional deficiencies that could affect physiologic adaptation of lipids during pregnancy. We aimed to evaluate differences in serum lipids in pregnant women after bariatric surgery compared to obese and lean mothers.

METHODS

25 women with a history of Roux-en-Y gastric bypass (RYGB), 19 obese and 19 normal-weight controls were included at the 24th-28th gestational week for determination of fasting lipids with follow-up in a subgroup after delivery. Data on neonatal biometry were additionally assessed.

RESULTS

Women after RYGB showed lower total-cholesterol (TC), low-density lipoprotein C (LDL-C), non-high-density lipoprotein C (non-HDL-C) and triglycerides (TG) compared to obese mothers. Despite their higher BMI, women after RYGB showed lower TC, LDL-C and non-HDL-C than normal-weight mothers. Ultrasensitive C-reactive protein was lower in RYGB mothers than in obese ones, reaching values of lean controls. Differences remained unchanged in BMI-matched comparison. Birth weight percentiles of RYGB offspring were associated with maternal TC (r = 0.59, p = 0.021), LDL-C (r = 0.71, p = 0.003), non-HDL (r = 0.59, p = 0.021) but not HDL-C or TG. After delivery, lipids decreased in all women; however, TC and LDL-C showed more attenuated decline in mothers after RYGB than control women.

CONCLUSION

Pregnancies after RYGB show alterations of physiologic patterns in lipid profile. Further studies are required to evaluate whether imbalances in maternal lipids constitute a risk for abnormal fetal growth in this special cohort.

Increased risk of neonatal complications or death among neonates born small for gestational age to mothers with gestational diabetes

AIMS

To evaluate if neonatal complications or death were poorer for neonates born small for gestational age (SGA) than for those born with adequate weight or large for gestation age (LGA) to women with gestational diabetes mellitus (GDM).

METHODS

Retrospective analysis of the clinical outcomes of neonates born to 3413 women with GDM. The prevalence of neonatal hypoglycaemia, hypocalcaemia, hyperbilirubinemia, polycythaemia, and death was compared among three birthweight groups: SGA, adequate, and LGA. A two-sided chi-squared or Fisher's exact test was used for between-group comparisons. A forward multiple logistic regression was performed to determine the odds ratio (OR) associated with SGA.

RESULTS

Neonatal complications were more frequent in the SGA group (20.1%) than in the adequate (9.9%) or LGA (15.2%) groups. There were four deaths (1.6%) in the SGA group compared to one in the LGA (0.4%) and six in the adequate (0.2%) groups (P = 0.002). SGA was a risk factor for neonatal complications or death (OR. 2.122; 95% confidence interval, 1.552-2.899), independent of maternal age, weight gain, fasting glucose, glycaemic control, gestational hypertension, pre-eclampsia, smoking, or neonatal prematurity.

CONCLUSION

SGA birthweight is an important risk factor for neonatal complications or death among neonates born to mothers with GDM.

Birth outcomes in women with gestational diabetes managed by lifestyle modification alone: The PANDORA study

AIMS

To assess outcomes of women in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort with gestational diabetes mellitus (GDM) managed by lifestyle modification compared with women without hyperglycaemia in pregnancy.

METHODS

Indigenous (n = 97) and Europid (n = 113) women managed by lifestyle modification were compared to women without hyperglycaemia (n = 235). Multivariate linear and logistic regressions assessed whether GDM-lifestyle women had poorer outcomes compared to women without hyperglycaemia.

RESULTS

Women with GDM-lifestyle had higher body mass index and lower gestational weight gain than women without hyperglycaemia. On univariate analysis, gestational age at delivery was lower and induction rates were higher in women with GDM-lifestyle than without hyperglycaemia. On multivariable regression, GDM-lifestyle was associated with lower gestational age at delivery (by 0.73 weeks), lower birthweight z-score (by 0.26, p = 0.007), lower likelihood of large for gestational age (LGA) [OR (95% CI): 0.55 (0.28, 1.02), p = 0.059], and greater likelihood of labour induction [2.34 (1.49, 3.66), p < 0.001] than women without hyperglycaemia.

CONCLUSION

Women with GDM managed by lifestyle modification had higher induction rates and their offspring had lower birthweight z-scores, with a trend to lower LGA than those without hyperglycaemia in pregnancy. Further studies are indicated to explore reasons for higher induction rates.

Adverse perinatal outcomes for obese women are influenced by the presence of comorbid diabetes and hypertensive disorders

Maternal obesity often occurs together with comorbid diabetes and hypertensive disorders. All three conditions are independently associated with negative perinatal outcomes. Our objective was to determine the risk and burden of adverse perinatal outcome that could be attributed to maternal obesity in combination with a comorbid status. We analyzed data from 324'664 singleton deliveries in Switzerland between 2005 and 2016. For the association of maternal obesity in the presence or absence of comorbidities with various perinatal outcomes, we estimated adjusted relative risk (RR) using multivariable regression modeling and determined the multivariable-adjusted attributable fraction of the population (AFp). Obesity was a main predictor for macrosomia, fracture of the clavicle, failure to progress in labor and prolonged labor. By stratifying women based on comorbidities, we identified significantly increased risk for preterm birth and early neonatal death only for women diagnosed with a comorbidity. However, various other outcomes were independently associated with either obesity or comorbidities. The AFp showed greatest reduction in comorbidities (15.4/15.0/13.2%), in macrosomia (6.3%) and in shoulder dystocia (4.8%) if all women were to become non-obese. We suggest that comorbidities such as diabetes and hypertensive disorders should be considered when relating maternal obesity to adverse perinatal outcomes.

Effects of Social Media and Mobile Health Apps on Pregnancy Care: Meta-Analysis

Background

The use of social media and mobile health (mHealth) apps has been increasing in pregnancy care. However, the effectiveness of these interventions is still unclear.

Objectives

We conducted a meta-analysis to examine the effectiveness of these interventions with regard to different health outcomes in pregnant and postpartum women and investigate the characteristics and components of interventions that may affect program effectiveness.

Method

We performed a comprehensive literature search of major electronic databases and reference sections of related reviews and eligible studies. A random effects model was used to calculate the effect size.

Results

Fifteen randomized controlled trial studies published in and before June 2018 that met the inclusion criteria were included in the meta-analysis. The interventions were effective in promoting maternal physical health including weight management, gestational diabetes mellitus control, and asthma control with a moderate to large effect size (d=0.72). Large effect sizes were also found for improving maternal mental health (d=0.84) and knowledge about pregnancy (d=0.80). Weight control interventions using wearable devices were more effective.

Conclusion

Social media and mHealth apps have the potential to be widely used in improving maternal well-being. More large-scale clinical trials focusing on different health outcomes are suggested for future studies.

Predictive factors of subsequent insulin requirement for glycemic control during pregnancy at diagnosis of gestational diabetes mellitus

OBJECTIVE

To determine maternal and biological parameters at diagnosis of gestational diabetes mellitus (GDM) as predictors of antenatal insulin therapy (AIT) for glycemic control.

METHODS

In this planned secondary analysis of a prospective observational study, we recruited women diagnosed with GDM between July 1, 2014, and October 31, 2015. Maternal and biological parameters were analyzed as predictors of AIT using multivariable logistic regression analyses. Predictive accuracy of a cut-off value for a biological predictor was determined using the area under the receiver operating characteristic curve (AUC) and the Youden index (J).

RESULTS

Of 200 women included (mean gestational age 22 ± 6 weeks), 72 (36%) required AIT. No maternal characteristic was associated with AIT. Glycated hemoglobin (HbA1c; adjusted odds ratio [aOR] 3.15, 95% CI 1.03-9.69) and elevated 1-hour oral glucose tolerance test (OGTT; aOR 1.23, 95% CI 1.13-1.46) were predictors of AIT. Analyses suggested inaccurate prediction of AIT, with an optimal cut-off HbA1c value of 5.4% (J=0.14; AUC 0.58, 95% CI 0.48-0.67), and an optimal 1-hour plasma glucose OGTT value of 1.77 mg/dL (J=0.24; AUC 0.62, 95% CI 0.50-0.74).

CONCLUSION

HbA1c at diagnosis of GDM and elevated 1-hour OGTT were independent predictors of AIT for glycemic control. Clinicaltrials.gov: NCT02159378.

A Slow-Digesting, Low-Glycemic Load Nutritional Beverage Improves Glucose Tolerance in Obese Pregnant Women Without Gestational Diabetes

BACKGROUND

Obesity is a risk factor for gestational diabetes (gestational diabetes). Low-glycemic index diets attenuate hyperglycemia. We designed a study to determine whether a slow-digesting, low-glycemic load (SD-LGL) beverage improves glucose tolerance in obese pregnant women without GDM.

METHODS

This was a 3-arm comparison study comparing the effects of an SD-LGL nutritional beverage (glycemic load [GL] 730), an isocaloric control beverage (GL 1124), and habitual diet on glycemia in obese pregnant women. Sixteen women (mean body mass index 37 kg/m²) were recruited at 24-28 weeks to receive either the SD-LGL or eucaloric control beverage. This was consumed with breakfast and as a midafternoon snack over 2 days with a controlled diet. Following a 2-day washout period of habitual diet, women completed 2 days on the alternative beverage with controlled diet. A 10-h fast preceded each intervention phase. Twenty-four hour glucose was measured using continuous glucose monitoring.

RESULTS

Consumption of the lower GL beverage was associated with improved measures of glycemia, compared with the control beverage and habitual diet at different time periods. Glucose estimates for control versus SD-LDL at 24 h (0.23 mmol/L [0.16 to 0.31], P < 0.001), daytime (0.26 mmol/L [0.18 to 0.34], P < 0.001), and nighttime (0.05 mmol/L [-0.01 to 0.11], P = 0.09). Postprandial glucose was lower after breakfast but not after dinner, compared with the control beverage (0.09 mmol/L [0.01 to 0.18], P = 0.03).

CONCLUSION

A slow-digesting, low-glycemic nutritional beverage may facilitate improved glucose control in obese pregnant women. To address potential benefit for clinical outcomes, a randomized controlled trial is warranted.

Pre-pregnancy obesity, gestational diabetes or gestational weight gain: Which is the strongest predictor of pregnancy outcomes?

AIMS

Both obesity and gestational diabetes (GDM) are risk factors for adverse pregnancy outcomes. The aim of our study is to ascertain the independent role of prepregnancy BMI (pp-BMI), gestational weight gain (GWG), and GDM on pregnancy outcomes.

METHODS

We analyzed data of 1198 pregnant women, who underwent selective screening for GDM. Data on pregnancy outcomes was collected from hospital discharge records.

RESULTS

Cesarean section (CS) was comparable in GDM and NGT women. Prevalence of fetal macrosomia was 5.9%, with no difference between GDM and normal glucose tolerance (NGT), neonatal hyperbilirubinemia were more frequent in newborns of GDM women (63.3% vs. 52.2%; p < 0.01). Offspring of women with excessive GWG weighed more than those of women with regular GWG (3405 ± 510 g vs. 3287 ± 524 g; p < 0.01). On a logistic regression analysis, GWG was an independent risk factor for macrosomia (OR 1.08, 95% CI 1.02-1.13; p < 0.01) and delivery at a gestational age <37 weeks (OR 0.29, 95% CI 0.16-0.53; p < 0.0001). GDM and pp-BMI were not independent risk factors for adverse outcomes in this cohort.

CONCLUSIONS

GWG rather than GDM is associated with adverse pregnancy outcomes. These findings call for an early education and implementation of a healthy lifestyle in women planning a pregnancy.

Joint impact of gestational diabetes and obesity on perinatal outcomes

OBJECTIVE

Gestational diabetes and obesity are independent risk factors for obstetric and neonatal complications. The purpose of our study was to evaluate the impact of their association on pregnancy outcomes.

MATERIAL AND METHODS

Monocentric retrospective cohort study including patients with obesity and gestational diabetes (GDM), those with GD without obesity, and those with obesity without GDM, who gave birth between 01 January 2012 and 31 December 2014, and whose GDM was exclusively monitored at our centre. The diagnostic criteria and management modalities of GDM were based on the 2010 CNGOF (Collège National des Gynécologues et Obstétriciens Français [French national college of obstetricians and gynaecologists]) Clinical Practice Recommendations. Obesity was defined as having a body mass index ≥30 Kg/m².

RESULTS

A total of 1,484 patients were included, 259 with GDM and obesity, 549 with GDM without obesity, 676 with obesity without GDM. In the GDM + obesity group, GDM was treated earlier and was more uncontrolled and more often treated with insulin in relation to non-obese women with GDM. These patients also presented a higher risk of caesarean section (OR 2.92, CI 95% 2.04-4.16, P<0.001), preeclampsia (OR 4.62, CI 95% 1.31-16.32, P=0.017), maternal morbidity (OR 2.05, CI 95% 1.37-3.04, P<0.001) and large foetus for gestational age (OR 1.91, CI 95% 1.26-2.88, P=0.002). Obesity alone was a risk factor in its own right for preeclampsia (OR 7.32, CI 95% 2.50-21.45, P<0.001) and macrosomia (OR 3.55, IC 95% 2.24-5.62, P<0.001), compared to non-obese patients with GDM. Uncontrolled GDM was associated independently of obesity with the risk of induced labour and large foetus for gestational age.

CONCLUSION

Obesity on its own is a risk factor for obstetric complications and its association with GDM strongly impacts on pregnancy outcomes.

Review shows that maternal obesity induces serious adverse neonatal effects and is associated with childhood obesity in their offspring

AIM

Obesity at the start of pregnancy has been rising worldwide, increasing the risk of maternal complications. We reviewed the independent effects of maternal obesity during pregnancy on neonatal adverse outcomes and the risk of childhood obesity and adverse cardio-metabolic profiles.

METHODS

We searched MEDLINE for papers published in English between December 2007 and November 2017, focusing primarily on human studies published in the last five years. However, we also chose to highlight examples derived from model animals that could bring mechanistic insight and preventive and therapeutic avenues.

RESULTS

Our review showed that maternal obesity had independent effects on neonatal adverse outcomes such as macrosomia, perinatal mortality and birth defects. Maternal obesity alone increased the risks for adverse neonatal outcomes, including macrosomia, perinatal mortality, induced preterm birth and birth defects. In association with excess gestational weight gain, mainly early in pregnancy, increased the risks of childhood obesity, higher fat mass and, to a smaller extent, adverse cardio-metabolic profiles. Animal models highlighted sexually dimorphic responses to maternal obesity.

CONCLUSION

Maternal obesity induced serious adverse neonatal effects and was associated with childhood obesity in their offspring. The peri-conceptional period is critical for metabolic programming, and obese women need close monitoring from conception.

Maternal overweight is not an independent risk factor for increased birth weight, leptin and insulin in newborns of gestational diabetic women: observations from the prospective 'EaCH' cohort study

BACKGROUND

Both gestational diabetes mellitus (GDM) as well as overweight/obesity during pregnancy are risk factors for detrimental anthropometric and hormonal neonatal outcomes, identified to 'program' adverse health predispositions later on. While overweight/obesity are major determinants of GDM, independent effects on critical birth outcomes remain unclear. Thus, the aim of the present study was to evaluate, in women with GDM, the relative/independent impact of overweight/obesity vs. altered glucose metabolism on newborn parameters.

METHODS

The prospective observational 'Early CHARITÉ (EaCH)' cohort study primarily focuses on early developmental origins of unfavorable health outcomes through pre- and/or early postnatal exposure to a 'diabetogenic/adipogenic' environment. It includes 205 mother-child dyads, recruited between 2007 and 2010, from women with treated GDM and delivery at the Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, Germany. Recruitment, therapy, metabolite/hormone analyses, and data evaluation were performed according to standardized guidelines and protocols. This report specifically aimed to identify maternal anthropometric and metabolic determinants of anthropometric and critical hormonal birth outcomes in 'EaCH'.

RESULTS

Group comparisons, Spearman's correlations and unadjusted linear regression analyses initially confirmed that increased maternal prepregnancy body-mass-index (BMI) is a significant factor for elevated birth weight, cord-blood insulin and leptin (all P < 0.05). However, consideration of and adjustment for maternal glucose during late pregnancy showed that no maternal anthropometric parameter (weight, BMI, gestational weight gain) remained significant (all n.s.). In contrast, even after adjustment for maternal anthropometrics, third trimester glucose values (fasting and postprandial glucose at 32nd and 36th weeks' gestation, HbA1c in 3rd trimester and at delivery), were clearly positively associated with critical birth outcomes (all P < 0.05).

CONCLUSIONS

Neither overweight/obesity nor gestational weight gain appear to be independent determinants of increased birth weight, insulin and leptin. Rather, 3rd trimester glycemia seems to be crucial for respective neonatal outcomes. Thus, gestational care and future research studies should greatly consider late pregnancy glucose in overweight/obese women with or without GDM, for evaluation of critical causes and interventional strategies against 'perinatal programming of diabesity' in the offspring.

Controversies and Advances in Gestational Diabetes-An Update in the Era of Continuous Glucose Monitoring

Diabetes in pregnancy, both preexisting type 1 or type 2 and gestational diabetes, is a highly prevalent condition, which has a great impact on maternal and fetal health, with short and long-term implications. Gestational Diabetes Mellitus (GDM) is a condition triggered by metabolic adaptation, which occurs during the second half of pregnancy. There is still a lot of controversy about GDM, from classification and diagnosis to treatment. Recently, there have been some advances in the field as well as recommendations from international societies, such as how to distinguish previous diabetes, even if first recognized during pregnancy, and newer diagnostic criteria, based on pregnancy outcomes, instead of maternal risk of future diabetes. These new recommendations will lead to a higher prevalence of GDM, and important issues are yet to be resolved, such as the cost-utility of this increase in diagnoses as well as the determinants for poor outcomes. The aim of this review is to discuss the advances in diagnosis and classification of GDM, as well as their implications in the field, the issue of hyperglycemia in early pregnancy and the role of hemoglobin A1c (HbA1c) during pregnancy. We have looked into the determinants of the poor outcomes predicted by the diagnosis by way of oral glucose tolerance tests, highlighting the relevance of continuous glucose monitoring tools, as well as other possible pathogenetic factors related to poor pregnancy outcomes.

Association of Maternal Factors with Perinatal Complications in Pregnancies Complicated with Diabetes: A Single-Center Retrospective Analysis

OBJECTIVE

The aim of this study was to clarify the association of maternal factors with perinatal complications in pregnancies complicated with type 1 (T1D) or type 2 diabetes (T2D).

METHODS

We conducted a retrospective chart review and enrolled 26 Japanese pregnant women with diabetes who received perinatal care at our hospital between 2008 and 2015. Perinatal complications were defined as one or more of the following: miscarriage, fetal death, fetal dysfunction, fetal structural anomaly, small-for-gestational age, large-for-gestational age (LGA), premature birth, neonatal hypoglycemia, pregnancy-induced hypertension (PIH), deterioration of maternal kidney function, and urgent Caesarean section (CS). The associations between perinatal complications and maternal factors were examined.

RESULTS

Approximately 70% and 50% of women with T1D and T2D experienced perinatal complications, respectively. LGA, neonatal hypoglycemia, and urgent CS were major perinatal complications in women with T1D, while PIH and urgent CS were major complications in those with T2D. In women with T1D, pre-gestational HbA1c was significantly higher in women with perinatal complications than in those without. In women with T2D, pre-gestational body mass index was significantly higher in women with perinatal complications than in those without.

CONCLUSIONS

These findings suggest that while pre-gestational glycemic control remains the most important issue in women with T1D, pre-gestational weight control in addition to glycemic control should be greater emphasized in women with T2D to reduce the risk of perinatal complications.

Gestational diabetes-Predictors of response to treatment and obstetric outcome

OBJECTIVE

Evaluate patient characteristics that are predictors of treatment response and outcomes in gestational diabetes STUDY DESIGN: Retrospective cohort of 265 women with gestational diabetes treated with diet/metformin and/or insulin in a single centre over 2 years.

RESULTS

Multinomial logistic regression showed that (after adjusting for age and ethnicity) women who were of normal weight were more likely to be on diet and women who were obese were more likely to be on metformin or metformin and insulin(p=0.014). Women who were obese were twice more likely to have labour induced than those with normal weight. Onset of labour was the only parameter significantly associated with a treatment modality among the three groups (p<0.001). There was no difference in the incidence of large for gestational age, neonatal admission, shoulder dystocia or still birth between the three groups.

CONCLUSIONS

Maternal BMI appears to be the only parameter that is predictive of need for treatment with metformin/insulin and the modality of treatment does not have an effect on maternal and neonatal outcomes.

Is gestational diabetes an independent risk factor of neonatal severe respiratory distress syndrome after 34 weeks of gestation? A prospective study

PURPOSE

To evaluate if neonates delivered after 34^0/7 weeks from mothers diagnosed with gestational diabetes (GD) are exposed to an increased risk of neonatal severe respiratory distress syndrome (SRDS).

METHODS

Women with singleton pregnancy in labour after 34^0/7 weeks of gestation or admitted for planned caesarean section and who had been systematically screened for GD were eligible to participate to this prospective cohort study. Diagnosis of SRDS was defined by the association of clinical signs of early neonatal respiratory distress, with consistent radiologic features and requiring mechanical ventilation with a fraction of inspired oxygen (FiO₂) >0.25 for a minimum of 24 h and admission to neonatal intensive care unit.

RESULTS

A total of 444 women were included. GD was diagnosed in 60 patients (13.5%). A neonatal SRDS was diagnosed in 32 cases (7.2%). Compared to others, neonatal SRDS was significantly more often observed in neonates from women diagnosed with GD: 12 (20%) vs. 20 (5.2%), respectively (p < 0.001). Women whose neonates presented neonatal SRDS were significantly more likely to be obese (p = 0.002), to have undergone a caesarean section (p < 0.001) and to have received corticosteroids therapy before 34^0/7 weeks (p = 0.013). In multivariate analysis, GD was identified as an independent risk factor of neonatal SRDS (aOR 3.6; 95% CI 1.5-8.6; p = 0.005). Other risk factors were maternal obesity (aOR 2.8; 95% CI 1.1-7.1; p = 0.029) and assisted vaginal delivery (aOR 5.5; 95% CI 1.9-15.9; p = 0.002).

CONCLUSIONS

GD is an independent risk factor of neonatal SRDS after 34^0/7 weeks.

The effect of gestational diabetes, pre-gravid maternal obesity, and their combination ('diabesity') on outcomes of singleton gestations

OBJECTIVE

To assess the effect of the combination of gestational diabetes mellitus (GDM) and pre-gravid obesity ('diabesity') in singleton gestations.

METHODS

We compared perinatal outcomes of singleton gestations in mothers with GDM and pre-gravid obesity, with GDM but with normal pre-gravid BMI, and obese mothers without GDM.

RESULTS

We compared diabesity mothers (n = 1525, 24.4% of mothers with GDM, 9.9% of all obese women) to mothers with GDM but with normal BMI (n = 4704, 75.6% of mothers with GDM) and to obese mothers without GDM (n = 13,937, 90.1% of all obese mothers). Obesity, with and without GDM, increased the odds of having chronic hypertension whereas preeclampsia appears to be influenced by obesity only, as were the risk of births at <33 weeks' gestation, of birth weight >4000 g, low 5-min Apgar scores and NICU admissions.

CONCLUSION

Obesity (without diabetes) is more frequently associated with adverse perinatal outcomes than diabesity or GDM in non-obese mothers. A campaign to decrease pre-gravid obesity should have at least the same priority as any campaign to control GDM.

A systematic review of interventions for Hispanic women with or at risk of Gestational diabetes mellitus (GDM)

BACKGROUND AND OBJECTIVE

Gestational Diabetes Mellitus (GDM) is a serious health concern for pregnant women, with Hispanic women at particular risk for developing the condition. The aim of this review was to critically examine GDM intervention programs for Hispanic women, in the United States of America (US).

METHODS

English and Spanish electronic databases were searched for relevant studies published between 1995 and 2015. Eligible study designs included randomized controlled trial, pre/post-test and quasi experimental methods.

RESULTS

Findings indicated that there was a dearth of literature reporting on GDM interventions for Hispanic women and just seven papers met inclusion criteria. These seven studies were included in the review and they reported on interventions for: (1) pregnant women at high risk of developing GDM; (2) pregnant women with GDM. Results suggest that a combination of intensive counselling over a prolonged period of time, together with a low calorie, possibly low glycemic index diet, produces best results.

CONCLUSION

The review found that intensive nutritional counselling approaches which promote low calorie/low GI diets appear to be most effective in BGL management in this population. Interventions that are delivered in Spanish and culturally tailored may be more acceptable to participants. More research is needed to develop suitable interventions to improve GDM management among Hispanic women.

Impact of Gestational Diabetes Mellitus and Maternal Obesity on Cord Blood Dynamic Thiol/Disulfide Homeostasis

AIM

Our aim in this study was to investigate the effect of maternal obesity and gestational diabetes mellitus (GDM) on cord blood dynamic thiol/disulfide homeostasis.

METHODS

A prospective case-control study was carried out in 125 pregnant women (27 GDM, 30 obese, 68 controls). Cord blood samples were collected from all participants and native thiol-disulfide exchanges were examined with automated method enabling the measurement of both sides of thiol-disulfide balance.

RESULTS

Disulfide amounts, disulfide/native thiol and disulfide/total thiol ratios were increased (p < 0.001), while native thiol/total thiol was decreased in the cord blood of babies born to an obese or diabetic mother (p < 0.001). Moreover, increased disulfide amounts, disulfide/native thiol, disulfide/totalthiol ratios and decreased native/total thiol were found to be significantly associated with adverse outcomes in GDM.

CONCLUSION

The current study suggests that the offsprings born to obese or diabetic mothers are exposed to increased oxidative stress.

Pregnancy and Infants' Outcome: Nutritional and Metabolic Implications

Pregnancy is a complex period of human growth, development, and imprinting. Nutrition and metabolism play a crucial role for the health and well-being of both mother and fetus, as well as for the long-term health of the offspring. Nevertheless, several biological and physiological mechanisms related to nutritive requirements together with their transfer and utilization across the placenta are still poorly understood. In February 2009, the Child Health Foundation invited leading experts of this field to a workshop to critically review and discuss current knowledge, with the aim to highlight priorities for future research. This paper summarizes our main conclusions with regards to maternal preconceptional body mass index, gestational weight gain, placental and fetal requirements in relation to adverse pregnancy and long-term outcomes of the fetus (nutritional programming). We conclude that there is an urgent need to develop further human investigations aimed at better understanding of the basis of biochemical mechanisms and pathophysiological events related to maternal-fetal nutrition and offspring health. An improved knowledge would help to optimize nutritional recommendations for pregnancy.

Translation of fetal abdominal circumference-guided therapy of gestational diabetes complicated by maternal obesity to a clinical outpatient setting

OBJECTIVE

To evaluate the effectiveness of fetal abdominal circumference-guided therapy for gestational diabetes (GDM) in an outpatient population characterized by highly-prevalent maternal obesity.

METHODS

Data for this translational retrospective cohort study come from medical records. Fetal abdominal circumference was assessed by ultrasound in late second trimester, and sex- and gestational age-specific percentiles assigned. Taking fetal abdominal circumference percentile as a marker for adequacy of fetal growth, maternal glucose targets were set accordingly: loose, moderate or tight. Associations between mother's targets and neonatal outcomes (small for gestational age (SGA), large for gestational age (LGA), macrosomia, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia) were assessed using unconditional logistic regression, controlling for pre-gravid body mass index (BMI) and gestational weight gain.

RESULTS

In 419 consecutive pregnancies complicated by GDM, neonatal outcomes compared favorably with previous randomized trials of intensive GDM management. Importantly, adverse outcomes were observed less often than might be expected in an obese GDM population. BMI did not have an independent effect on neonatal outcomes.

CONCLUSIONS

Ultrasound-guided therapy of GDM, in general clinic use, can limit excess macrosomia and LGA, even in a population with significant maternal obesity.

The impact of preconceptional obesity on trajectories of maternal lipids during gestation

Growing challenges of maternal obesity necessitate to focus metabolic management on alternative factors than glycaemia. The objective is to assess longitudinal changes in lipids and inflammatory parameters during pregnancies stratified by pregestational BMI. Therefore, 222 pregnant women (normal-weight BMI < 25: n = 91 (41%), overweight BMI 25–29.9: n = 69 (31%), obese BMI ≥ 30: n = 62 (28%)) underwent a detailed metabolic characterization including fasting lipids and glucometabolic parameters at <21^st gestational week (GW) with follow-up assessments at further three visits (24–28^th GW, 32–34^th GW, >36^th GW). Overweight and obesity was related to dyslipidemia already at baseline, i.e. elevated triglycerides (TG, p < 0.001), decreased high-density-lipoprotein-C (p = 0.009) and increased ultrasensitive-c-reactive-protein (usCRP, p < 0.001) independent of gestational diabetes prevalence. Trajectories of lipids during pregnancy progress revealed an unexpected less pronounced increase in TG, low-density-lipoprotein-C and total-cholesterol in overweight/obese women. usCRP remained associated with higher BMI throughout pregnancy showing no time-dependent longitudinal changes. Newborns of obese/overweight women were affected by higher birth-weight percentiles. Regarding lipids only maternal TG showed tendency for relation to prevalence of large-for-gestational-age offspring, particularly at the end of pregnancy (p = 0.048). Overweight and obese women show significant differences in trajectories of lipids during pregnancy that distinguish them from normal-weight women. Further studies should evaluate if targeting lipid metabolism could improve clinical management of maternal obesity.

Comparison of glyburide with metformin in treating gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Controversy has surrounded the treatment of gestational diabetes mellitus (GDM) for a long time. Although the use of both glyburide and metformin are recommended as an alternate to insulin if dietary therapy fails in GDM patients, it remains unclear whether both drugs are equally safe and efficacious. Therefore, in this review we compared the efficacy and safety of glyburide with metformin in treating GDM.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted that compared the efficacy and safety of glyburide with metformin in GDM patients. Electronic databases were used to conduct the literature search for study identification along with a hand search of pertinent journals and conference proceedings. The effect measure used to present the results was risk ratio (RR) with 95% confidence interval (CI). A fixed-effects model was used to pool the data if no significant heterogeneity was reported and a random-effects model was used in the case of significant heterogeneity being reported for an outcome.

RESULTS

Three studies involving 508 patients met the inclusion criteria of this review. A significant increase in the risk of the composite outcome, i.e., macrosomia and large for gestational age (LGA) births (RR 1.94; 95% CI 1.03-3.66, p = 0.04), was observed in the glyburide group, whereas a non-significant increase in the risk of neonatal hypoglycemia (RR 1.92; 95% CI 0.31-12.02) was also noticed. Results remained statistically non-significant for preterm births (RR 0.65; 95% CI 0.24-1.77), neonatal birth weight (mean difference (MD) 120.63 g; 95% CI -62.08 to 303.33), and cesarean section (RR 0.86; 95% CI 0.55-1.34). A significant decrease in fasting glucose levels (MD -2.40 mg/dL; 95% CI -4.60 to -0.21; p = 0.03) was noticed in glyburide group while the difference was non-significant for postprandial glucose levels (MD -0.84 mg/dL; 95% CI -4.03 to 2.35).

CONCLUSION

Metformin seems to be a superior choice to glyburide if oral antidiabetic drug therapy is to be initiated in GDM patients.

Bariatric Surgery and the Pregnancy Complicated by Gestational Diabetes

Gestational diabetes mellitus (GDM) is an increasingly common obstetrical problem. Due to the global escalation in the prevalence of obesity, as many as 15 % of pregnant women may soon be classified as having GDM. While often not diagnosed until late gestation, GDM is now recognized as a disorder of glucose and lipid metabolism, systemic inflammation, and insulin resistance that begins early in pregnancy. Recent large randomized trials have clarified the risk of maternal and neonatal complications caused by GDM, as well as the potential to ameliorate these risks. There is significant interest in the potential to reduce the risk for developing GDM in obese women through the performance of bariatric surgery (BS) before pregnancy. BS significantly reduces the risk for GDM, preeclampsia, and large neonates. However, it seems that the risk for small neonates and preterm delivery is increased. No significant differences are observed in regard to cesarean section, postpartum hemorrhage, or perinatal mortality. In this article, we address the effects of GDM on the mother and child, and explore the risks and benefits of BS in the obstetrical population.

Early pregnancy fasting plasma glucose and lipid concentrations in pregnancy and association to offspring size: a retrospective cohort study

Background

Hyperlipidemia and high fasting plasma glucose levels at the first prenatal visit (First Visit FPG) are both related to gestational diabetes mellitus, maternal obesity/overweight and fetal overgrowth. The purpose of the present study is to investigate the correlation between First Visit FPG and lipid concentrations, and their potential association with offspring size at delivery.

Materials and methods

Pregnant women that received regular prenatal care and delivered in our center in 2013 were recruited for the study. Fasting plasma glucose levels were tested at the first prenatal visit (First Visit FPG) and prior to delivery (Before Delivery FPG). HbA1c and lipid profiles were examined at the time of OGTT test. Maternal and neonatal clinical data were collected for analysis. Data was analyzed by independent sample t test, Pearson correlation, and Chi-square test, followed by partial correlation and multiple linear regression analyses to confirm association. Statistical significance level was α =0.05.

Results

Analyses were based on 1546 mother-baby pairs. First Visit FPG was not correlated with any lipid parameters after adjusting for maternal pregravid BMI, maternal age and gestational age at First Visit FPG. HbA1c was positively correlated with triglyceride and Apolipoprotein B in the whole cohort and in the NGT group after adjusting for maternal age and maternal BMI at OGTT test. Multiple linear regression analyses showed neonatal birth weight, head circumference and shoulder circumference were all associated with First Visit FPG and triglyceride levels.

Conclusion

Fasting plasma glucose at first prenatal visit is not associated with lipid concentrations in mid-pregnancy, but may influence fetal growth together with triglyceride concentration.

Antepartum Care of the Obese Patient

In the United States, roughly half of women are either overweight (24.5%) or obese (21.4%) when they become pregnant. Women who are obese before pregnancy are at increased risk for a number of pregnancy complications relative to normal-weight women. Specifically, obesity is associated with significantly increased maternal risks, including gestational diabetes mellitus, hypertensive disorders of pregnancy, and sleep disordered breathing. Maternal obesity is also associated with increased risks of adverse fetal outcomes, including prematurity, stillbirth, congenital anomalies, and abnormal fetal growth. In this review, we will discuss the implications of obesity with respect to antepartum care.

Increasing maternal body mass index during pregnancy increases neonatal intensive care unit admission in near and full-term infants

BACKGROUND

Obesity is becoming an increasingly commonplace health problem. Obesity during pregnancy is important because the condition adversely affects not only the mother, but also the developing fetus and the newborn.

OBJECTIVE

The primary objective of this study was to evaluate the association between maternal body mass index (mBMI) at the time of delivery and neonatal intensive care unit (NICU) admission of offspring and to analyze the role of possible confounding variables that are often associated with obesity. Comorbidities, such as gestational diabetes mellitus (DM), hypertension (HT) and/or pre-eclampsia (PEC), are more common in more obese mothers, as is a higher association of obesity among non-Caucasian patients.

METHODS

Using a retrospective cohort design, 1736 mothers and their singleton live-born at  ≥35 weeks' gestation were analyzed for mBMI, maternal conditions of DM, HT and/or PEC, and whether NICU care was required and the reason for NICU admission.

RESULTS

NICU admission rate was significantly associated with maternal obesity. In comparing women with mBMI  < 30 versus mBMI ≥ 30, OR was 1.39 (p = 0.045); OR increased to 1.76 (p = 0.006) in comparing patients with mBMI  ≥ 35. mBMI was significantly associated with an increased rate of maternal DM, HT and PEC (p < 0.05 each); however, NICU admission rate was not correlated with DM, HT or PEC. The relationship between NICU admission and mBMI was significant in Caucasian mothers versus a borderline significance in African-American mothers (p = 0.035 versus p = 0.05). After controlling for neonatal hypoglycemia (NH) as the reason for admission to the NICU, no mBMI-NICU association persisted. The rate of infants with NH increased in higher mBMI groups, independent of maternal DM diagnosis.

CONCLUSION

This study demonstrated a significant association between higher mBMI groups and NICU admissions independent of diagnosis of maternal comorbidities. However, accounting for NH eliminating this association suggests a pre-clinical diabetic pathology in obese women that affects newborn outcome. Despite increased percentage of nonwhite mothers in higher mBMI groups, African-American race does not seem to be a significant contributing factor in the increased rate of NICU admission in our population.

Treatment With Diet and Exercise for Women With Gestational Diabetes Mellitus Diagnosed Using IADPSG Criteria

CONTEXT

Prevalence of gestational diabetes mellitus (GDM) and obesity continue to increase.

OBJECTIVE

This study aimed to ascertain whether diet and exercise is a successful intervention for women with GDM and whether a subset of these women have comparable outcomes to those with normal glucose tolerance (NGT).

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study of five antenatal centers along the Irish Atlantic seaboard of 567 women diagnosed with GDM and 2499 women with NGT during pregnancy.

INTERVENTION

Diet and exercise therapy on diagnosis of GDM were prescribed and multiple maternal and neonatal outcomes were examined.

RESULTS

Infants of women with GDM were more likely to be hypoglycemic (adjusted odds ratio [aOR], 7.25; 95% confidence interval [CI], 2.94-17.9) at birth. They were more likely to be admitted to the neonatal intensive care unit (aOR, 2.16; 95% CI, 1.60-2.91). Macrosomia and large-for-gestational-age rates were lower in the GDM group (aOR, 0.48; 95% CI, 0.37-0.64 and aOR, 0.61; 95% CI, 0.46-0.82, respectively). There was no increase in small for gestational age among offspring of women with GDM (aOR, 0.81; 95% CI, 0.49-1.34). Women with diet-treated GDM and body mass index (BMI) < 25 kg/m(2) had similar outcomes to those with NGT of the same BMI group. Obesity increased risk for poor pregnancy outcomes regardless of diabetes status.

CONCLUSION

Medical nutritional therapy and exercise for women with GDM may be successful in lowering rates of large for gestational age and macrosomia without increasing small-for-gestational-age rates. Women with GDM and a BMI less than 25 kg/m(2) had outcomes similar to those with NGT suggesting that these women could potentially be treated in a less resource intensive setting.

The associations between triglyceride to high-density lipoprotein cholesterol ratios and the risks of gestational diabetes mellitus and large-for-gestational-age infant

OBJECTIVE

To evaluate the associations between triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratios and the risks of gestational diabetes mellitus (GDM) and delivering large-for-gestational-age (LGA) infant.

DESIGN

This was a single-centre prospective observational study.

PATIENTS

Six hundred and thirty-six women with a singleton pregnancy were recruited.

MEASUREMENTS

Lipids profile, HbA1c and glucose were measured at the time of oral glucose tolerance test (OGTT) during 24-28 gestational weeks. TG/HDL-C ratios were calculated and clinical data including perinatal parameters were analysed.

RESULTS

The prevalence of GDM was 17·30% (n = 110) and LGA was 3·93% (n = 25) in this study. TG/HDL-C ratios were found to be significantly higher in GDM group (P < 0·01) and LGA group (P = 0·045) compared with those in non-GDM group and non-LGA group, respectively. TG/HDL-C ratios were independently associated with the risks of GDM (OR = 1·64, P = 0·02) and LGA (OR = 2·87, P < 0·01). The area under the combined ROC curve of TG/HDL-C ratio and HbA1c to detect GDM was 0·705 (95% CI, 0·637-0·772). Furthermore, the area under the ROC curve of TG/HDL-C ratio combined with HbA1c and prepregnancy BMI to detect LGA was 0·806 (95% CI, 0·719-0·893).

CONCLUSIONS

TG/HDL-C ratios in combination with HbA1c and prepregnancy BMI can be good markers to predict the risks of GDM and delivering LGA infant.

Adiponectin supplementation in pregnant mice prevents the adverse effects of maternal obesity on placental function and fetal growth

Mothers with obesity or gestational diabetes mellitus have low circulating levels of adiponectin (ADN) and frequently deliver large babies with increased fat mass, who are susceptible to perinatal complications and to development of metabolic syndrome later in life. It is currently unknown if the inverse correlation between maternal ADN and fetal growth reflects a cause-and-effect relationship. We tested the hypothesis that ADN supplementation in obese pregnant dams improves maternal insulin sensitivity, restores normal placental insulin/mechanistic target of rapamycin complex 1 (mTORC1) signaling and nutrient transport, and prevents fetal overgrowth. Compared with dams on a control diet, female C57BL/6J mice fed an obesogenic diet before mating and throughout gestation had increased fasting serum leptin, insulin, and C-peptide, and reduced high-molecular-weight ADN at embryonic day (E) 18.5. Placental insulin and mTORC1 signaling was activated, peroxisome proliferator-activated receptor-α (PPARα) phosphorylation was reduced, placental transport of glucose and amino acids in vivo was increased, and fetal weights were 29% higher in obese dams. Maternal ADN infusion in obese dams from E14.5 to E18.5 normalized maternal insulin sensitivity, placental insulin/mTORC1 and PPARα signaling, nutrient transport, and fetal growth without affecting maternal fat mass. Using a mouse model with striking similarities to obese pregnant women, we demonstrate that ADN functions as an endocrine link between maternal adipose tissue and fetal growth by regulating placental function. Importantly, maternal ADN supplementation reversed the adverse effects of maternal obesity on placental function and fetal growth. Improving maternal ADN levels may serve as an effective intervention strategy to prevent fetal overgrowth caused by maternal obesity.