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Wu R, Zhang Q, Li Z. A meta-analysis of metformin and insulin on maternal outcome and neonatal outcome in patients with gestational diabetes mellitus. J Matern Fetal Neonatal Med 2024; 37:2295809. [PMID: 38124287 DOI: 10.1080/14767058.2023.2295809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The use of metformin for treating gestational diabetes mellitus (GDM) remains controversial because it can pass through the placenta. This meta-analysis aimed to compare the effects of metformin and insulin on maternal and neonatal outcomes in patients with GDM. METHODS We conducted a comprehensive search of the PubMed, Embase, and Cochrane Library databases, focusing on randomized controlled trials (RCTs) that evaluated the impacts of metformin and insulin on both maternal and neonatal outcomes in patients with GDM. RESULTS Twenty-four RCTs involving 4934 patients with GDM were included in this meta-analysis. Compared with insulin, metformin demonstrated a significant reduction in the risks of preeclampsia (RR 0.61, 95% CI 0.48 to 0.78, p < .0001), induction of labor (RR 0.90, 95% CI 0.82 to 0.98, p = .02), cesarean delivery (RR 0.91, 95% CI 0.85 to 0.98, p = .01), macrosomia (RR 0.67, 95% CI 0.53 to 0.83, p = .0004), neonatal intensive care unit (NICU) admission (RR 0.75, 95% CI 0.66 to 0.86, p < .0001), neonatal hypoglycemia (RR 0.55, 95% CI 0.48 to 0.63, p < .00001), and large for gestational age (LGA) (RR 0.80, 95% CI 0.68 to 0.94, p = .007). Conversely, metformin showed no significant impact on gestational hypertension (RR 0.84, 95% CI 0.67 to 1.06, p = .15), spontaneous vaginal delivery (RR 1.13, 95% CI 1.00 to 1.08, p = .05), emergency cesarean section (RR 0.94, 95% CI 0.77 to 1.16, p = .58), shoulder dystocia (RR 0.65, 95% CI 0.31 to 1.39, p = .27), premature birth (RR 0. 92, 95% CI 0.61 to 1.39, p = .69), polyhydramnios (RR 1.11, 95% CI 0.54 to 2.30, p = .77), birth trauma (RR 0.87, 95% CI 0.54 to 1.39, p = .56), 5-min Apgar score < 7 (RR 1.13, 95% CI 0.76 to 1.68, p = .55), small for gestational age (SGA) (RR 0.93, 95% CI 0.71 to 1.22, p = .62), respiratory distress syndrome (RDS) (RR 0.74, 95% CI 0.50 to 1.08, p = .11), jaundice (RR 1.09, 95% CI 0.95 to 1.25, p = .24) or birth defects (RR 0.80, 95% CI 0.37 to 1.74, p = .57). CONCLUSIONS The findings suggest that metformin can reduce the risk of certain maternal and neonatal outcomes compared with insulin therapy for GDM. However, long-term follow-up studies of patients with GDM taking metformin and their offspring are warranted to provide further evidence.
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Affiliation(s)
- Rui Wu
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Qingqing Zhang
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, China
| | - Zuojing Li
- School of Medical Devices, Shenyang Pharmaceutical University, Shenyang, China
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Toft JH, Økland I. Metformin use in pregnancy: What about long-term effects in offspring? Acta Obstet Gynecol Scand 2024; 103:1238-1241. [PMID: 38757307 PMCID: PMC11168263 DOI: 10.1111/aogs.14878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
Metformin use in pregnancy is increasing worldwide. Unlike insulin, metformin crosses the placenta. Consequently, maternal and fetal concentrations are comparable. Teratogenic effects are not reported, nor are adverse pregnancy outcomes. Reduced risk of hypertensive disorders, hypoglycemia, and macrosomia are potential benefits, together with lower gestational weight gain. Although metformin has been prescribed for pregnant women during the last 40 years, long-term data regarding offspring outcomes are still lacking. Independent of maternal glycemic control, recent meta-analyses report lower birthweight but accelerated postnatal growth and higher body mass index in metformin-exposed children. The longest follow-up study of placebo-controlled metformin exposure in utero found an increased prevalence of central adiposity and obesity among children 5-10 years old. Recently, a Danish study reported a threefold increased risk of genital anomalies in boys, whose fathers used metformin around the time of conception. This commentary addresses the current controversies on metformin use in pregnancy.
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Affiliation(s)
- Johanne Holm Toft
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
- Department of Clinical ScienceUniversity of BergenBergenNorway
| | - Inger Økland
- Department of Caring and EthicsUniversity of StavangerStavangerNorway
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3
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van Hoorn EGM, Rademaker D, van der Wel AWT, DeVries JH, Franx A, van Rijn BB, Kooy A, Siegelaar SE, Roseboom TJ, Ozanne SE, Hooijmans CR, Painter RC. Fetal and post-natal outcomes in offspring after intrauterine metformin exposure: A systematic review and meta-analysis of animal experiments. Diabet Med 2024; 41:e15243. [PMID: 37845186 DOI: 10.1111/dme.15243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Abstract
AIMS The impact of maternal metformin use during pregnancy on fetal, infant, childhood and adolescent growth, development, and health remains unclear. Our objective was to systematically review the available evidence from animal experiments on the effects of intrauterine metformin exposure on offspring's anthropometric, cardiovascular and metabolic outcomes. METHODS A systematic search was conducted in PUBMED and EMBASE from inception (searched on 12th April 2023). We extracted original, controlled animal studies that investigated the effects of maternal metformin use during pregnancy on offspring anthropometric, cardiovascular and metabolic measurements. Subsequently, risk of bias was assessed and meta-analyses using the standardized mean difference and a random effects model were conducted for all outcomes containing data from 3 or more studies. Subgroup analyses were planned for species, strain, sex and type of model in the case of 10 comparisons or more per subgroup. RESULTS We included 37 articles (n = 3133 offspring from n = 716 litters, containing n = 51 comparisons) in this review, mostly (95%) on rodent models and 5% pig models. Follow-up of offspring ranged from birth to 2 years of age. Thirty four of the included articles could be included in the meta-analysis. No significant effects in the overall meta-analysis of metformin on any of the anthropometric, cardiovascular and metabolic offspring outcome measures were identified. Between-studies heterogeneity was high, and risk of bias was unclear in most studies as a consequence of poor reporting of essential methodological details. CONCLUSION This systematic review was unable to establish effects of metformin treatment during pregnancy on anthropometric, cardiovascular and metabolic outcomes in non-human offspring. Heterogeneity between studies was high and reporting of methodological details often limited. This highlights a need for additional high-quality research both in humans and model systems to allow firm conclusions to be established. Future research should include focus on the effects of metformin in older offspring age groups, and on outcomes which have gone uninvestigated to date.
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Affiliation(s)
- E G M van Hoorn
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - D Rademaker
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center location AMC, Amsterdam, The Netherlands
| | - A W T van der Wel
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center location AMC, Amsterdam, The Netherlands
| | - J H DeVries
- Department of Internal Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - A Franx
- Department of Obstetrics and Gynecology Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - B B van Rijn
- Department of Obstetrics and Gynecology Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Kooy
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Bethesda Diabetes Research Center, Hoogeveen, The Netherlands
- Department of Internal Medicine, Care Group Treant, Location Bethesda Hoogeveen, Hoogeveen, The Netherlands
| | - S E Siegelaar
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - T J Roseboom
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center location AMC, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - S E Ozanne
- Welcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories and MRC Metabolic Diseases Unit, University of Cambridge, Cambridge, UK
| | - C R Hooijmans
- Department of Anesthesiology, Pain and Palliative Care (Meta Research Team), Radboud University Medical Center, Nijmegen, The Netherlands
| | - R C Painter
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
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Locatelli A, Ornaghi S, Terzaghi A, Belleudi V, Fortinguerra F, Poggi FR, Perna S, Trotta F. Antidiabetic Therapy during Pregnancy: The Prescription Pattern in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7139. [PMID: 38063570 PMCID: PMC10706431 DOI: 10.3390/ijerph20237139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023]
Abstract
Pregestational and gestational diabetes mellitus are relevant complications of pregnancy, and antidiabetic drugs are prescribed to obtain glycemic control and improve perinatal outcomes. The objective of this study was to describe the prescription pattern of antidiabetics before, during and after pregnancy in Italy and to evaluate its concordance with the Italian guideline on treatment of diabetes mellitus. A multi-database cross-sectional population study using a Common Data Model was performed. In a cohort of about 450,000 women, the prescribing profile of antidiabetics seemed to be in line with the Italian guideline, which currently does not recommend the use of oral antidiabetics and non-insulin injection, even if practice is still heterogeneous (up to 3.8% in the third trimester used oral antidiabetics). A substantial variability in the prescription pattern was observed among the Italian regions considered: the highest increase was registered in Tuscany (4.2%) while the lowest was in Lombardy (1.5%). Women with multiple births had a higher proportion of antidiabetic prescriptions than women with singleton births both in the preconception period and during pregnancy (1.3% vs. 0.7%; 3.4% vs. 2.6%) and used metformin more frequently. The consumption of antidiabetics in foreign women was higher than Italians (second trimester: 1.8% vs. 0.9%, third trimester: 3.6% vs. 1.8%).
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Affiliation(s)
- Anna Locatelli
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy; (A.L.); (A.T.)
| | - Sara Ornaghi
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy; (A.L.); (A.T.)
| | - Alessandra Terzaghi
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy; (A.L.); (A.T.)
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, 00147 Rome, Italy; (V.B.); (F.R.P.)
| | | | - Francesca Romana Poggi
- Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, 00147 Rome, Italy; (V.B.); (F.R.P.)
| | - Serena Perna
- Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
| | - Francesco Trotta
- Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
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Fernández-Valero A, Peña-Montero N, Lima-Rubio F, Gutiérrez-Repiso C, Linares-Pineda TM, Picón-César MJ, Sancho-Marín R, Tinahones FJ, Morcillo S, Molina-Vega M. Changes in Oxidative Stress and Intestinal Permeability during Pregnancy in Women with Gestational Diabetes Mellitus Treated with Metformin or Insulin and Healthy Controls: A Randomized Controlled Trial. Antioxidants (Basel) 2023; 12:1981. [PMID: 38001834 PMCID: PMC10669428 DOI: 10.3390/antiox12111981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/26/2023] Open
Abstract
Both oxidative stress and intestinal permeability are increased in hyperglycemic situations and have been shown to be reduced by metformin in type 2 diabetes mellitus (T2DM) patients. The aim of this study was to elucidate the effect of metformin on oxidative stress and intestinal permeability in women with gestational diabetes mellitus (GDM) treated with metformin compared to those treated with insulin and healthy controls. A total of 120 women were included from August 2016 to February 2022: 41 received metformin (MET group), 38 received insulin (INS group), and 41 were healthy controls. Baseline and antenatal visits were carried out at 25.4 ± 4.8 and 36.1 ± 0.8 weeks of pregnancy, respectively. Advanced oxidation protein products (AOPPs), total antioxidant capacity (TAC), and zonulin levels were measured at every visit. Zonulin levels from baseline to prepartum visit increased significantly in both healthy controls (0.6 ± 0.9 to 1.2 ± 1.7 ng/mL, p = 0.004) and the INS group (0.4 ± 0.3 to 0.6 ± 0.5 ng/mL, p = 0.034) but did not significantly change in the MET group (0.4 ± 0.4 to 0.5 ± 0.4 ng/mL, p = 0.202). However, TAC and AOPP levels significantly increased in women with GDM, both in the INS and MET groups but not in the healthy controls. In conclusion, in our population, metformin has been shown to avoid an increase in intestinal permeability but failed to avoid an increase in oxidative stress related to hyperglycemia.
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Affiliation(s)
- Andrea Fernández-Valero
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria de Málaga, 29010 Málaga, Spain (M.M.-V.)
- Department of Medicine and Dermatology, Málaga University, 29010 Málaga, Spain
| | - Nerea Peña-Montero
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
| | - Fuensanta Lima-Rubio
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
| | - Carolina Gutiérrez-Repiso
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Fisiopatología de la Obesidad y Nutrición, Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Teresa María Linares-Pineda
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
| | - María José Picón-César
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria de Málaga, 29010 Málaga, Spain (M.M.-V.)
| | - Raquel Sancho-Marín
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
| | - Francisco J. Tinahones
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria de Málaga, 29010 Málaga, Spain (M.M.-V.)
- Department of Medicine and Dermatology, Málaga University, 29010 Málaga, Spain
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Fisiopatología de la Obesidad y Nutrición, Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Sonsoles Morcillo
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria de Málaga, 29010 Málaga, Spain (M.M.-V.)
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Fisiopatología de la Obesidad y Nutrición, Instituto Salud Carlos III, 28029 Madrid, Spain
| | - María Molina-Vega
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria de Málaga, 29010 Málaga, Spain (M.M.-V.)
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, 29010 Málaga, Spain
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Tocci V, Mirabelli M, Salatino A, Sicilia L, Giuliano S, Brunetti FS, Chiefari E, De Sarro G, Foti DP, Brunetti A. Metformin in Gestational Diabetes Mellitus: To Use or Not to Use, That Is the Question. Pharmaceuticals (Basel) 2023; 16:1318. [PMID: 37765126 PMCID: PMC10537239 DOI: 10.3390/ph16091318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
In recent years, there has been a dramatic increase in the number of pregnancies complicated by gestational diabetes mellitus (GDM). GDM occurs when maternal insulin resistance develops and/or progresses during gestation, and it is not compensated by a rise in maternal insulin secretion. If not properly managed, this condition can cause serious short-term and long-term problems for both mother and child. Lifestyle changes are the first line of treatment for GDM, but if ineffective, insulin injections are the recommended pharmacological treatment choice. Some guidance authorities and scientific societies have proposed the use of metformin as an alternative pharmacological option for treating GDM, but there is not yet a unanimous consensus on this. Although the use of metformin appears to be safe for the mother, concerns remain about its long-term metabolic effects on the child that is exposed in utero to the drug, given that metformin, contrary to insulin, crosses the placenta. This review article describes the existing lines of evidence about the use of metformin in pregnancies complicated by GDM, in order to clarify its potential benefits and limits, and to help clinicians make decisions about who could benefit most from this drug treatment.
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Affiliation(s)
- Vera Tocci
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Maria Mirabelli
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Alessandro Salatino
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Luciana Sicilia
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Stefania Giuliano
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Francesco S. Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Eusebio Chiefari
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Giovambattista De Sarro
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Daniela P. Foti
- Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Antonio Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
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Palatnik A, Saffian E, Flynn KE, Pan AY, Yee LM, Basir MA, Cruz M. GAP (gestational diabetes and pharmacotherapy) - study protocol for a randomized controlled, two-arm, single-site trial. Contemp Clin Trials 2023; 131:107237. [PMID: 37245726 PMCID: PMC10527045 DOI: 10.1016/j.cct.2023.107237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Gestational diabetes (GDM) complicates 10% of pregnancies in the US. First-line treatment is medical nutrition therapy (MNT) and exercise. Second line is pharmacotherapy. The definition of what constitutes an unsuccessful trial of MNT and exercise has not been established. Tight glycemic control has been demonstrated to reduce GDM-related neonatal and maternal clinical complications. However, it could also increase rates of small-for-gestational age and carry negative effects on patient-reported outcomes such as anxiety and stress. We will study the effect of earlier and stricter pharmacotherapy in GDM on clinical and patient-reported outcomes. METHODS GDM and pharmacotherapy (GAP) study is a two-arm parallel, pragmatic randomized controlled trial, where 416 participants with GDM are randomized 1:1 to: 1) Intervention group - insulin initiation at 20% elevated glucose values on a weekly glucose log following MNT and exercise trial and insulin titration to keep elevated glucose values <20%; or 2) Active control group - insulin initiation at 40% elevated glucose values on a weekly log following MNT and exercise and insulin titration to keep elevated glucose values <40%. The primary outcome is a composite neonatal outcome of large-for-gestational-age, macrosomia, birth trauma, preterm birth, hypoglycemia, and hyperbilirubinemia. Secondary outcomes include preeclampsia, cesarean birth, small-for-gestational-age, maternal hypoglycemia, and patient-reported outcomes of anxiety, depression, perceived stress, and diabetes self-efficacy. CONCLUSIONS The GAP study will investigate the optimal glycemic threshold for pharmacotherapy addition to MNT and exercise in GDM. The GAP study will promote standardization in GDM management and will have direct relevance for clinical practice.
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Affiliation(s)
- Anna Palatnik
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States of America.
| | - Eleanor Saffian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Kathryn E Flynn
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Services, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University, Chicago, IL, United States of America
| | - Mir Abdul Basir
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Meredith Cruz
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
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Sheng B, Ni J, Lv B, Jiang G, Lin X, Li H. Short-term neonatal outcomes in women with gestational diabetes treated using metformin versus insulin: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol 2023; 60:595-608. [PMID: 36593391 PMCID: PMC10063481 DOI: 10.1007/s00592-022-02016-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/08/2022] [Indexed: 01/04/2023]
Abstract
AIMS To expand the evidence base for the clinical use of metformin, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing the efficacy and safety of metformin versus insulin with respect to short-term neonatal outcomes. METHODS A comprehensive search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed. Two reviewers extracted the data and calculated pooled estimates by use of a random-effects model. In total, 24 studies involving 4355 participants met the eligibility criteria and were included in the quantitative analyses. RESULTS Unlike insulin, metformin lowered neonatal birth weights (mean difference - 122.76 g; 95% confidence interval [CI] - 178.31, - 67.21; p < 0.0001), the risk of macrosomia (risk ratio [RR] 0.68; 95% CI 0.54, 0.86; p = 0.001), the incidence of neonatal intensive care unit admission (RR 0.73; 95% CI 0.61, 0.88; p = 0.0009), and the incidence of neonatal hypoglycemia (RR 0.65; 95% CI 0.52, 0.81; p = 0.0001). Subgroup analysis based on the maximum daily oral dose of metformin indicated that metformin-induced neonatal birth weight loss was independent of the oral dose. CONCLUSIONS Our meta-analysis provides further evidence that metformin is a safe oral antihyperglycemic drug and has some benefits over insulin when used for the treatment of gestational diabetes, without an increased risk of short-term neonatal adverse outcomes. Metformin may be particularly useful in women with gestational diabetes at high risk for neonatal hypoglycemia, women who want to limit maternal and fetal weight gain, and women with an inability to afford or use insulin safely.
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Affiliation(s)
- Bo Sheng
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Juan Ni
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Bin Lv
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Guoguo Jiang
- Department of Hospital Infection Management, The Second Hospital of Chengdu City, Chengdu, 610041 Sichuan China
| | - Xuemei Lin
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Hao Li
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
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Medications for Managing Preexisting and Gestational Diabetes in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:121-136. [PMID: 36822698 DOI: 10.1016/j.ogc.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Persons with gestational and pregestational diabetes during pregnancy may require pharmacologic agents to achieve pregnancy glycemic targets, and the available medications for use in pregnancy are limited. Insulin is the only FDA-approved medication for use in pregnancy and has the greatest evidence for safety and efficacy. Metformin and glyburide are the most commonly used oral agents in pregnancy. Understanding each medication's unique pharmacokinetics, potential side effects, fetal or childhood risks, gestational age of medication initiation and patient's diabetes care barriers are important aspects of shared decision-making and choosing a regimen that will achieve glycemic and pregnancy goals.
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10
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Chen KR, Yu T, Lien YJ, Chou YY, Kuo PL. Childhood neurodevelopmental disorders and maternal diabetes: A population-based cohort study. Dev Med Child Neurol 2022. [PMID: 36541040 DOI: 10.1111/dmcn.15488] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
AIM To assess the risk of a wide spectrum of neurodevelopmental disorders (NDDs) in offspring of mothers with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM). METHOD This retrospective cohort study included 877 233 singletons born between 2004 and 2008 in Taiwan. Children were followed up to 2015 for diagnoses of NDDs, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), developmental delay, intellectual disability, cerebral palsy, and epilepsy/infantile spasms using health insurance claims data. We performed Cox regression models to estimate the relative risks of NDDs associated with maternal diabetes. Covariates included parental age, year of birth, child sex, family income, urbanization level, hypertensive disorder, and preterm delivery status. RESULTS In utero there were 338 (0.04%) children exposed to T1DM, 8749 (1.00%) to T2DM, and 90 200 (10.28%) to GDM. The effect of T1DM on NDDs was the largest, followed by T2DM, then GDM. T1DM was associated with an increased risk of developmental delay, intellectual disability, and epilepsy/intellectual spasms in offspring. T2DM was associated with an increased risk of ASD, ADHD, developmental delay, intellectual disability, cerebral palsy, and epilepsy/intellectual spasms. GDM was associated with an increased risk of ASD, ADHD, and developmental delay. INTERPRETATION Maternal diabetes during pregnancy, including T1DM, T2DM, and GDM, is associated with an increased risk of some NDDs in offspring.
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Affiliation(s)
- Kuan-Ru Chen
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.,Department of Obstetrics and Gynecology, National Cheng Kung University, College of Medicine, Tainan, Taiwan
| | - Tsung Yu
- Department of Public Health, National Cheng Kung University, College of Medicine, Tainan, Taiwan
| | - Yueh-Ju Lien
- Department of Psychiatry, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Yin Chou
- Department of Pediatrics, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Pao-Lin Kuo
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan.,Department of Obstetrics and Gynecology, National Cheng Kung University, College of Medicine, Tainan, Taiwan
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11
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Li F, Liu L, Hu Y, Marx CM, Liu W. Efficacy and safety of metformin compared to insulin in gestational diabetes: a systemic review and meta-analysis of Chinese randomized controlled trials. Int J Clin Pharm 2022; 44:1102-1113. [PMID: 35834091 DOI: 10.1007/s11096-022-01438-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/01/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Metformin is widely used for the treatment of gestational diabetes. Although some meta-analyses are conducted on the efficacy and safety of metformin, none of them are focused on the Chinese population. The efficacy and safety of metformin in the Chinese GDM population are unknown. AIM The study aimed to compare metformin to insulin regarding the safety and efficacy in Chinese GDM patients using randomized controlled trials (RCTs) conducted in China. METHOD Chinese databases (Wanfang, CNKI, VIP, and CBM), PubMed, Embase, Cochrane library, and Scopus were searched for RCTs. The last search date was October 18, 2021. RESULTS Fifty RCTs (4663 patients) were included in this study after screening. Six outcomes were analyzed. In the main analysis, metformin had lower risk of respiratory distress syndrome (RDS, OR, 0.28; 95% CI 0.16-0.51; P < 0.0001), premature birth (OR, 0.42; 95% CI 0.21-0.85, P = 0.02), and neonatal hypoglycemia (OR, 0.34; 95% CI 0.24-0.48; P < 0.00001) compared to insulin. Moreover, the metformin group is better than the insulin group concerning all other outcomes such as maternal glycemic control and glycated hemoglobin. Subgroup analysis confirmed that metformin has better outcomes than all types of insulin except for RDS, premature birth, 2 h postprandial blood glucose, and glycated hemoglobin. CONCLUSION Metformin is considered to be a safe and effective alternative to insulin for the management of GDM if patients refuse insulin due to any reasons in China.
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Affiliation(s)
- Fang Li
- Department of Pharmacy, Beijing You An Hospital, Capital Medical University, Beijing, 100069, China
| | - Ligang Liu
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Yang Hu
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Carrie McAdam Marx
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Wei Liu
- Department of Pharmacy, Beijing You An Hospital, Capital Medical University, Beijing, 100069, China.
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12
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Abstract
Diabetes is a chronic metabolic disease affecting an increasing number of people. Although diabetes has negative health outcomes for diagnosed individuals, a population at particular risk are pregnant women, as diabetes impacts not only a pregnant woman's health but that of her child. In this review, we cover the current knowledge and unanswered questions on diabetes affecting an expectant mother, focusing on maternal and fetal outcomes.
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Affiliation(s)
- Cecilia González Corona
- Center for Cell and Gene Therapy, Stem Cells and Regenerative Medicine Center, One Baylor Plaza, Houston, TX 77030, USA
| | - Ronald J. Parchem
- Center for Cell and Gene Therapy, Stem Cells and Regenerative Medicine Center, One Baylor Plaza, Houston, TX 77030, USA,Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA
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13
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Ramirez Zegarra R, Dall’Asta A, Revelli A, Ghi T. COVID-19 and Gestational Diabetes: The Role of Nutrition and Pharmacological Intervention in Preventing Adverse Outcomes. Nutrients 2022; 14:nu14173562. [PMID: 36079820 PMCID: PMC9460671 DOI: 10.3390/nu14173562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/14/2022] [Accepted: 08/23/2022] [Indexed: 12/15/2022] Open
Abstract
Pregnant women with GDM affected by COVID-19 seem to be at higher risk of adverse maternal and neonatal outcomes, especially those with overweight or obesity. Good glycemic control seems to be the most effective measure in reducing the risk of GDM and severe COVID-19. For such purposes, the Mediterranean diet, micronutrient supplementation, and physical activity are considered the first line of treatment. Failure to achieve glycemic control leads to the use of insulin, and this clinical scenario has been shown to be associated with an increased risk of adverse maternal and neonatal outcomes. In this review, we explore the current evidence pertaining to the pathogenesis of SARS-CoV-2 leading to the main complications caused by COVID-19 in patients with GDM. We also discuss the incidence of complications caused by COVID-19 in pregnant women with GDM according to their treatment.
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Affiliation(s)
- Ruben Ramirez Zegarra
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Department of Obstetrics and Gynaecology, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Andrea Dall’Asta
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Alberto Revelli
- Sant’Anna Hospital, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Tullio Ghi
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence:
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14
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Alvarez-Silvares E, Bermúdez-González M, Vilouta-Romero M, García-Lavandeira S, Seoane-Pillado T. Prediction of insulin therapy in women with gestational diabetes: a systematic review and meta-analysis of observational studies. J Perinat Med 2022; 50:608-619. [PMID: 35313096 DOI: 10.1515/jpm-2021-0247] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 02/20/2022] [Indexed: 11/15/2022]
Abstract
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.
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15
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Badr DA, Kassem C, Carlin A, Dobrescu O, Iconaru L, Baleanu F, Taujan GC, Jani JC. Antenatal insulin therapy in gestational diabetes mellitus: validation of the new Brugmann scores. Gynecol Endocrinol 2022; 38:411-415. [PMID: 35277105 DOI: 10.1080/09513590.2022.2048296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Following the adoption of the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) diagnosis by the World Health Organization (WHO) in 2014, many investigators have tried to identify independent risk factors for antenatal insulin therapy (AIT). The purpose of the current study is to build and validate a score that stratifies patients according to their need for AIT. METHODS All pregnant women diagnosed with GDM according to the IADPSG definition were included. Group 1 comprised patients of 2018, and group 2 comprised patients of 2019. Each group was divided into two subgroups: subgroup A comprised patients diagnosed according to the 75-g oral glucose tolerance test (OGTT), and subgroup B comprised patients diagnosed according to fasting plasma glucose (FPG). RESULTS A total of 1298 patients were included; 19.3% of those diagnosed by OGTT and 40.9% by FPG required AIT. The risk for AIT was stratified as low, moderate, and high. Brugmann FPG score comprised six risk factors and Brugmann OGTT score 12. Higher scores were associated with higher risk for AIT. The use of these scores in the two subgroups of group 2 showed no statistical differences compared to group 1. CONCLUSIONS Both Brugmann FPG and OGTT scores may be useful to stratify patients with GDM according to their need for AIT. Future studies should be conducted to prospectively validate these scores, and to examine whether or not using oral anti-hyperglycemic agents in a high-risk group may decrease the need for AIT.
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Affiliation(s)
- Dominque A Badr
- Department of Obstetrics and Gynaecology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Chirine Kassem
- Department of Obstetrics and Gynaecology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew Carlin
- Department of Obstetrics and Gynaecology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Oana Dobrescu
- Department of Obstetrics and Gynaecology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Laura Iconaru
- Department of Endocrinology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Felicia Baleanu
- Department of Endocrinology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Georgiana Cristina Taujan
- Department of Endocrinology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Department of Obstetrics and Gynaecology, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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16
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van Hoorn EGM, van Dijk PR, Prins JR, Lutgers HL, Hoogenberg K, Erwich JJHM, Kooy A. Pregnancy Outcomes: Effects of Metformin (POEM) study: a protocol for a long-term, multicentre, open-label, randomised controlled trial in gestational diabetes mellitus. BMJ Open 2022; 12:e056282. [PMID: 35354633 PMCID: PMC8968576 DOI: 10.1136/bmjopen-2021-056282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) is a common disorder of pregnancy with health risks for mother and child during pregnancy, delivery and further lifetime, possibly leading to type 2 diabetes mellitus (T2DM). Current treatment is focused on reducing hyperglycaemia, by dietary and lifestyle intervention and, if glycaemic targets are not reached, insulin. Metformin is an oral blood glucose lowering drug and considered safe during pregnancy. It improves insulin sensitivity and has shown advantages, specifically regarding pregnancy-related outcomes and patient satisfaction, compared with insulin therapy. However, the role of metformin in addition to usual care is inconclusive and long-term outcome of metformin exposure in utero are lacking. The primary aim of this study is to investigate the early addition of metformin on pregnancy and long-term outcomes in GDM. METHODS AND ANALYSIS The Pregnancy Outcomes: Effects of Metformin study is a multicentre, open-label, randomised, controlled trial. Participants include women with GDM, between 16 and 32 weeks of gestation, who are randomised to either usual care or metformin added to usual care, with insulin rescue in both groups. Metformin is given up to 1 year after delivery. The study consists of three phases (A-C): A-until 6 weeks after delivery; B-until 1 year after delivery; C-observational study until 20 years after delivery. During phase A, the primary outcome is a composite score consisting of: (1) pregnancy-related hypertension, (2) large for gestational age neonate, (3) preterm delivery, (4) instrumental delivery, (5) caesarean delivery, (6) birth trauma, (7) neonatal hypoglycaemia, (8) neonatal intensive care admission. During phase B and C the primary outcome is the incidence of T2DM and (weight) development in mother and child. ETHICS AND DISSEMINATION The study was approved by the Central Committee on Research Involving Human Subjects in the Netherlands. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02947503.
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Affiliation(s)
- Eline G M van Hoorn
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Peter R van Dijk
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Helen L Lutgers
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | - Klaas Hoogenberg
- Department of Internal Medicine, Martini Hospital, Groningen, Netherlands
| | - Jan Jaap H M Erwich
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adriaan Kooy
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Bethesda Diabetes Research Center, Hoogeveen, Netherlands
- Department of Internal Medicine, Treant Care Group, Hoogeveen, Netherlands
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17
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Zera CA, Seely EW. Controversies in Gestational Diabetes. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 17:102-107. [PMID: 35118455 DOI: 10.17925/ee.2021.17.2.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Abstract
Gestational diabetes mellitus (GDM) complicates approximately 7% of pregnancies in the USA. Despite recognition of the benefits of diagnosing and treating GDM, there are several areas of controversy that remain unresolved. There is debate as to whether to screen for GDM with the one-step versus the two-step approach. While the former identifies more pregnancies with potential adverse outcomes, data are lacking as to whether treatment of these pregnancies will improve outcomes, while increasing costs by diagnosing more women. Though it is well established that the diagnosis of even mild GDM, and treatment with lifestyle recommendations and insulin, improves pregnancy outcomes, it is controversial as to which type and regimen of insulin is optimal, and whether oral agents can be used safely and effectively to control glucose levels. Finally, it is recommended that women with GDM get tested for type 2 diabetes within several months of delivery; however, many women do not undergo this testing and alternative approaches are needed. These controversies are discussed with data from both sides of the debate to enable clinicians to make patient-centered decisions until more definitive data are available.
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Affiliation(s)
- Chloe A Zera
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ellen W Seely
- Harvard Medical School, Boston, MA, USA.,Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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18
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Hufnagel A, Fernandez-Twinn DS, Blackmore HL, Ashmore TJ, Heaton RA, Jenkins B, Koulman A, Hargreaves IP, Aiken CE, Ozanne SE. Maternal but not fetoplacental health can be improved by metformin in a murine diet-induced model of maternal obesity and glucose intolerance. J Physiol 2022; 600:903-919. [PMID: 34505282 PMCID: PMC7612651 DOI: 10.1113/jp281902] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/26/2021] [Indexed: 12/19/2022] Open
Abstract
Maternal obesity is a global problem that increases the risk of short- and long-term adverse outcomes for mother and child, many of which are linked to gestational diabetes mellitus. Effective treatments are essential to prevent the transmission of poor metabolic health from mother to child. Metformin is an effective glucose lowering drug commonly used to treat gestational diabetes mellitus; however, its wider effects on maternal and fetal health are poorly explored. In this study we used a mouse (C57Bl6/J) model of diet-induced (high sugar/high fat) maternal obesity to explore the impact of metformin on maternal and feto-placental health. Metformin (300 mg kg-1 day-1 ) was given to obese females via the diet and was shown to achieve clinically relevant concentrations in maternal serum (1669 ± 568 nM in late pregnancy). Obese dams developed glucose intolerance during pregnancy and had reduced uterine artery compliance. Metformin treatment of obese dams improved maternal glucose tolerance, reduced maternal fat mass and restored uterine artery function. Placental efficiency was reduced in obese dams, with increased calcification and reduced labyrinthine area. Consequently, fetuses from obese dams weighed less (P < 0.001) at the end of gestation. Despite normalisation of maternal parameters, metformin did not correct placental structure or fetal growth restriction. Metformin levels were substantial in the placenta and fetal circulation (109.7 ± 125.4 nmol g-1 in the placenta and 2063 ± 2327 nM in fetal plasma). These findings reveal the distinct effects of metformin administration during pregnancy on mother and fetus and highlight the complex balance of risk vs. benefits that are weighed in obstetric medical treatments. KEY POINTS: Maternal obesity and gestational diabetes mellitus have detrimental short- and long-term effects for mother and child. Metformin is commonly used to treat gestational diabetes mellitus in many populations worldwide but the effects on fetus and placenta are unknown. In a mouse model of diet-induced obesity and glucose intolerance in pregnancy we show reduced uterine artery compliance, placental structural changes and reduced fetal growth. Metformin treatment improved maternal metabolic health and uterine artery compliance but did not rescue obesity-induced changes in the fetus or placenta. Metformin crossed the placenta into the fetal circulation and entered fetal tissue. Metformin has beneficial effects on maternal health beyond glycaemic control. However, despite improvements in maternal physiology, metformin did not prevent fetal growth restriction or placental ageing. The high uptake of metformin into the placental and fetal circulation highlights the potential for direct immediate effects of metformin on the fetus with possible long-term consequences postnatally.
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Affiliation(s)
- Antonia Hufnagel
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Denise S Fernandez-Twinn
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Heather L Blackmore
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Thomas J Ashmore
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Robert A Heaton
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Benjamin Jenkins
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Albert Koulman
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Iain P Hargreaves
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Catherine E Aiken
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, University of Cambridge, United Kingdom
| | - Susan E Ozanne
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
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19
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Vu A, Turk N, Duru OK, Mangione CM, Panchal H, Amaya S, Castellon-Lopez Y, Norris K, Moin T. Association of Type 2 Diabetes Risk Perception With Interest in Diabetes Prevention Strategies Among Women With a History of Gestational Diabetes. Diabetes Spectr 2022; 35:335-343. [PMID: 36072816 PMCID: PMC9396721 DOI: 10.2337/ds21-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The aims of this study were to identify predictors of perception of type 2 diabetes risk in women with a history of gestational diabetes mellitus (GDM) and to determine factors associated with interest in evidence-based strategies for type 2 diabetes prevention. RESEARCH DESIGN AND METHODS We surveyed women with a history of GDM who had not progressed to type 2 diabetes from a large academic medical center. We used multivariate logistic regression to assess predictors of high levels of perception of type 2 diabetes risk. We also tested associations between risk perception and interest in a lifestyle change program and/or metformin therapy. RESULTS In our diverse sample of 264 women, 28% were unaware that GDM is a risk factor for incident type 2 diabetes after pregnancy, and 48% believed their personal risk of type 2 diabetes was low. In multivariate analyses, family history of diabetes (odds ratio [OR] 2.2, 95% CI 1.2-4.4) and knowledge of GDM as a risk factor for incident type 2 diabetes (OR 4.5, 95% CI 2.1-9.8) were significant predictors of greater perception of type 2 diabetes risk. Women with higher risk perception were more likely to express interest in a lifestyle change program compared with women with lower risk perception (OR 2.4, 95% CI 1.3-4.5). CONCLUSION Although some women are aware that GDM is a risk factor for incident type 2 diabetes, many still perceive their own risk of developing type 2 diabetes as low. Higher risk perception predicted interest in an evidence-based diabetes prevention program, highlighting the importance of personalized risk assessment and communication about risk for women who have had GDM.
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Affiliation(s)
- Amanda Vu
- Department of Medicine, Division of General Internal Medicine-Health Services Research, University of California, Los Angeles, Los Angeles, CA
- Corresponding author: Amanda Vu,
| | - Norman Turk
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - O. Kenrik Duru
- Department of Medicine, Division of General Internal Medicine-Health Services Research, University of California, Los Angeles, Los Angeles, CA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Carol M. Mangione
- Department of Medicine, Division of General Internal Medicine-Health Services Research, University of California, Los Angeles, Los Angeles, CA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
- Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - Hemali Panchal
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Amaya
- Department of Medicine, Division of General Internal Medicine-Health Services Research, University of California, Los Angeles, Los Angeles, CA
| | - Yelba Castellon-Lopez
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Keith Norris
- Department of Medicine, Division of General Internal Medicine-Health Services Research, University of California, Los Angeles, Los Angeles, CA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Tannaz Moin
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
- Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Health System, Los Angeles, CA
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20
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Molina-Vega M, Picón-César MJ, Gutiérrez-Repiso C, Fernández-Valero A, Lima-Rubio F, González-Romero S, Moreno-Indias I, Tinahones FJ. Metformin action over gut microbiota is related to weight and glycemic control in gestational diabetes mellitus: A randomized trial. Biomed Pharmacother 2021; 145:112465. [PMID: 34844107 DOI: 10.1016/j.biopha.2021.112465] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Metformin, which is known to produce profound changes in gut microbiota, is being increasingly used in gestational diabetes mellitus (GDM). The aim of this study was to elucidate the differences in gut microbiota composition and function in women with GDM treated with metformin compared to those treated with insulin. METHODS From May to December 2018, 58 women with GDM were randomized to receive insulin (INS; n = 28) or metformin (MET; n = 30) at the University Hospital Virgen de la Victoria, Málaga, Spain. Basal visits, with at least 1 follow-up visit and prepartum visit, were performed. At the basal and prepartum visits, blood and stool samples were collected. The gut microbiota profile was determined through 16S rRNA analysis. RESULTS Compared to INS, women on MET presented a lower mean postprandial glycemia and a lower increase in weight and body mass index (BMI). Firmicutes and Peptostreptococcaceae abundance declined, while Proteobacteria and Enterobacteriaceae abundance increased in the MET group. We found inverse correlations between changes in the abundance of Proteobacteria and mean postprandial glycemia (p = 0.023), as well as between Enterobacteriaceae and a rise in BMI and weight gain (p = 0.031 and p = 0.036, respectively). Regarding the metabolic profile of gut microbiota, predicted metabolic pathways related to propionate degradation and ubiquinol biosynthesis predominated in the MET group. CONCLUSION Metformin in GDM affects the composition and metabolic profile of gut microbiota. These changes could mediate, at least in part, its clinical effects. Studies designed to assess how these changes influence metabolic control during and after pregnancy are necessary.
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Affiliation(s)
- María Molina-Vega
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, Málaga, Spain
| | - María J Picón-César
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Carolina Gutiérrez-Repiso
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red (CIBER) de Fisiopatología de la Obesidad y Nutrición, Instituto Salud Carlos III, Madrid, Spain
| | - Andrea Fernández-Valero
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Fuensanta Lima-Rubio
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, Málaga, Spain
| | - Stella González-Romero
- Department of Endocrinology and Nutrition, Hospital Regional Universitario Carlos Haya, Málaga, Spain
| | - Isabel Moreno-Indias
- Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red (CIBER) de Fisiopatología de la Obesidad y Nutrición, Instituto Salud Carlos III, Madrid, Spain.
| | - Francisco J Tinahones
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Laboratory of the Biomedical Research Institute of Málaga, Virgen de la Victoria University Hospital, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red (CIBER) de Fisiopatología de la Obesidad y Nutrición, Instituto Salud Carlos III, Madrid, Spain
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21
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Picón-César MJ, Molina-Vega M, Suárez-Arana M, González-Mesa E, Sola-Moyano AP, Roldan-López R, Romero-Narbona F, Olveira G, Tinahones FJ, González-Romero S. Metformin for gestational diabetes study: metformin vs insulin in gestational diabetes: glycemic control and obstetrical and perinatal outcomes: randomized prospective trial. Am J Obstet Gynecol 2021; 225:517.e1-517.e17. [PMID: 33887240 DOI: 10.1016/j.ajog.2021.04.229] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/03/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gestational diabetes that is not properly controlled with diet has been commonly treated with insulin. In recent years, several studies have published that metformin can lead to, at least, similar obstetrical and perinatal outcomes as insulin. Nevertheless, not all clinical guidelines endorse its use, and clinical practice is heterogeneous. OBJECTIVE This study aimed to test whether metformin could achieve the same glycemic control as insulin and similar obstetrical and perinatal results, with a good safety profile, in women with gestational diabetes that is not properly controlled with lifestyle changes. STUDY DESIGN The metformin for gestational diabetes study was a multicenter, open-label, parallel arms, randomized clinical trial performed at 2 hospitals in Málaga (Spain), enrolling women with gestational diabetes who needed pharmacologic treatment. Women at the age of 18 to 45 years, in the second or third trimesters of pregnancy, were randomized to receive metformin or insulin (detemir or aspart). The main outcomes were (1) glycemic control (mean glycemia, preprandial and postprandial) and hypoglycemic episodes and (2) obstetrical and perinatal outcomes and complications (hypertensive disorders, type of labor, prematurity, macrosomia, large for gestational age, neonatal care unit admissions, respiratory distress syndrome, hypoglycemia, jaundice). Outcomes were analyzed on an intention-to-treat basis. RESULTS Between October 2016 and June 2019, 200 women were randomized, 100 to the insulin-treated group and 100 to the metformin-treated group. Mean fasting and postprandial glycemia did not differ between groups, but postprandial glycemia was significantly better after lunch or dinner in the metformin-treated-group. Hypoglycemic episodes were significantly more common in the insulin-treated group (55.9% vs 17.7% on metformin; odds ratio, 6.118; 95% confidence interval, 3.134-11.944; P=.000). Women treated with metformin gained less weight from the enrollment to the prepartum visit (36-37 gestational weeks) (1.35±3.21 vs 3.87±3.50 kg; P=.000). Labor inductions (45.7% [metformin] vs 62.5% [insulin]; odds ratio, 0.506; 95% confidence interval, 0.283-0.903; P=.029) and cesarean deliveries (27.6% [metformin] vs 52.6% [insulin]; odds ratio, 0.345; 95% confidence interval, 0.187-0.625; P=.001) were significantly lower in the metformin-treated group. Mean birthweight, macrosomia, and large for gestational age and babies' complications were not different between treatment groups. The lower cesarean delivery rate for women treated with metformin was not associated with macrosomia, large or small for gestational age, or other complications of pregnancy. CONCLUSION Metformin treatment was associated with a better postprandial glycemic control than insulin for some meals, a lower risk of hypoglycemic episodes, less maternal weight gain, and a low rate of failure as an isolated treatment. Most obstetrical and perinatal outcomes were similar between groups.
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Affiliation(s)
- María J Picón-César
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - María Molina-Vega
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - María Suárez-Arana
- Department of Obstetrics and Gynecology, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Ernesto González-Mesa
- Department of Obstetrics and Gynecology, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga, Málaga, Spain; Universidad de Málaga, Málaga, Spain
| | - Ana P Sola-Moyano
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Reyes Roldan-López
- Department of Neonatology, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Francisca Romero-Narbona
- Department of Neonatology, Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Gabriel Olveira
- Department of Endocrinology and Nutrition, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga, Málaga, Spain; Universidad de Málaga, Málaga, Spain; CIBER de Diabetes y Enfermedades Metabólicas, Madrid, Spain.
| | - Francisco J Tinahones
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Málaga, Spain; Universidad de Málaga, Málaga, Spain; CIBER de Fisiopatología de la Obesidad y la Nutrición, Madrid, Spain.
| | - Stella González-Romero
- Department of Endocrinology and Nutrition, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga, Málaga, Spain; CIBER de Diabetes y Enfermedades Metabólicas, Madrid, Spain
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Jain R, Kazmerski TM, Zuckerwise LC, West NE, Montemayor K, Aitken ML, Cheng E, Roe AH, Wilson A, Mann C, Ladores S, Sjoberg J, Poranski M, Taylor-Cousar JL. Pregnancy in cystic fibrosis: Review of the literature and expert recommendations. J Cyst Fibros 2021; 21:387-395. [PMID: 34456158 DOI: 10.1016/j.jcf.2021.07.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis (CF) was historically a disease largely afflicting children. Due to therapeutic advancements, there are now more adults with CF than children. In the past decade, medications including Cystic Fibrosis Transmembrane conductance Regulator (CFTR) modulators became available that treat the underlying cause of CF and are dramatically improving lung function as well as quality and quantity of life for people with CF. As a result, more women with CF are becoming pregnant. We gathered a panel of experts in CF care, family planning, high risk obstetrics, nutrition, genetics and women with CF to review current literature on pregnancies and to provide care recommendations for this unique population.
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Affiliation(s)
- Raksha Jain
- Department of Medicine, University of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390-8558, United States.
| | - Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, 120 Lytton Ave. Suite M060 University Center, Pittsburgh, PA 15213, United States
| | - Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 MCN, Nashville, TN 37232, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St. 5th Floor, Baltimore, MD 21205, United States
| | - Kristina Montemayor
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St. 5th Floor, Baltimore, MD 21205, United States
| | - Moira L Aitken
- Department of Medicine, University of Washington, 1959 NE Pacific Street - Rm BB 1361, Seattle WA 98195-6522, United States
| | - Edith Cheng
- Maternal Fetal Medicine, Maternal Fetal Medicine, Medical Genetics, University of Washington, United States
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19106, United States
| | - Alexandra Wilson
- Department of Medicine, Cystic Fibrosis Clinical Research, National Jewish Health, 1400 Jackson Street, K333b, Denver, CO 80206, United States
| | - Caitlin Mann
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 MCN, Nashville, TN 37232, United States
| | - Sigrid Ladores
- School of Nursing, The University of Alabama at Birmingham, NB 470L, 1720 2nd Avenue South, Birmingham, AL 35294-1210, United States
| | - Jacqui Sjoberg
- Adult with Cystic Fibrosis, 130 Johnston Dr, Highland Park, IL 60035, United States
| | - Madeline Poranski
- Adult with Cystic Fibrosis, 2700 University Ave. W. Apt. 416, St. Paul, MN 55114, United States
| | - Jennifer L Taylor-Cousar
- Departments of Medicine and Pediatrics, National Jewish Health, 1400 Jackson Street; J318, Denver, CO 80206, United States
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23
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A Glimpse at the Size of the Fetal Liver-Is It Connected with the Evolution of Gestational Diabetes? Int J Mol Sci 2021; 22:ijms22157866. [PMID: 34360631 PMCID: PMC8346004 DOI: 10.3390/ijms22157866] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 12/17/2022] Open
Abstract
Gestational diabetes mellitus (GDM) is defined as an impairment of glucose tolerance, manifested by hyperglycemia, which occurs at any stage of pregnancy. GDM is more common in the third trimester of pregnancy and usually disappears after birth. It was hypothesized that the glycemic status of the mother can modulate liver development and growth early during the pregnancy. The simplest modality to monitor the evolution of GDM employs noninvasive techniques. In this category, routinely obstetrical ultrasound (OUS) examinations (simple or 2D/3D) can be employed for specific fetal measurements, such as fetal liver length (FLL) or volume (FLV). FLL and FLV may emerge as possible predictors of GDM as they positively relate to the maternal glycated hemoglobin (HbA1c) levels and to the results of the oral glucose tolerance test. The aim of this review is to offer insight into the relationship between GDM and fetal nutritional status. Risk factors for GDM and the short- and long-term outcomes of GDM pregnancies are also discussed, as well as the significance of different dietary patterns. Moreover, the review aims to fill one gap in the literature, investigating whether fetal liver growth can be used as a predictor of GDM evolution. To conclude, although studies pointed out a connection between fetal indices and GDM as useful tools in the early detection of GDM (before 23 weeks of gestation), additional research is needed to properly manage GDM and offspring health.
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Sociodemographic Factors Associated with Adherence to Dietary Guidelines in Women with Gestational Diabetes: A Cohort Study. Nutrients 2021; 13:nu13061884. [PMID: 34072685 PMCID: PMC8228016 DOI: 10.3390/nu13061884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 12/16/2022] Open
Abstract
Dietary advice is the cornerstone of care for women with gestational diabetes mellitus (GDM). However, adherence to this advice is variable. We aimed to identify the proportion of women with GDM who adhere to the New Zealand nutrition guideline recommendations and assess the sociodemographic factors linked to dietary adherence. We assessed dietary intake at 36 weeks’ gestation in a cohort of 313 women with GDM and compared this with the dietary recommendations for the management of GDM. Associations between maternal characteristics and dietary adherence were assessed using ANOVA, chi square, logistic regression, and linear regression tests. Women with GDM had an average adherence score of 6.17 out of 10 to dietary recommendations, but no one adhered to all the recommendations. Adherence to recommendations was lowest for saturated fat, and wholegrain breads and cereals. While 85% visited a dietitian, only 28% of women achieved their recommended weight gain. Maternal factors associated with lower dietary adherence were primiparity, no previous history of GDM, being underweight, and smoking. Adherence to the dietary recommendations by women with GDM in New Zealand for the management could be improved. Further research is needed to identify ways for women with GDM to improve their dietary adherence.
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25
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Musa OAH, Syed A, Mohamed AM, Chivese T, Clark J, Furuya-Kanamori L, Xu C, Toft E, Bashir M, Abou-Samra AB, Thalib L, Doi SA. Metformin is comparable to insulin for pharmacotherapy in gestational diabetes mellitus: A network meta-analysis evaluating 6046 women. Pharmacol Res 2021; 167:105546. [PMID: 33716167 DOI: 10.1016/j.phrs.2021.105546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT The comparative efficacy of gestational diabetes (GDM) treatments lack conclusive evidence for choice of first-line treatment. OBJECTIVES The aim of this study was to compare the efficacy of metformin and glibenclamide to insulin using a core outcome set (COS) to unify outcomes across trials investigating the treatment of gestational diabetes mellitus. STUDY DESIGN A network meta-analysis (NMA) was conducted. DATA-SOURCE PubMed, Embase, and Cochrane Controlled Register of Trials were searched from inception to January 2020. STUDY SELECTION RCTs that enrolled pregnant women who were diagnosed with GDM and that compared the efficacy of different pharmacological interventions for the treatment of GDM were included. META-ANALYSIS A generalized pairwise modelling framework was employed. RESULTS A total of 38 RCTs with 6046 participants were included in the network meta-analysis. Compared to insulin, the estimated effect of metformin indicated improvements for weight gain (WMD -2·39 kg; 95% CI -3·31 to -1·46), maternal hypoglycemia (OR 0.34; 95% CI 0.12 to 0·97) and LGA (OR 0.61; 95% CI 0.38 to 0·98). There were also improvements in estimated effects for neonatal hypoglycemia (OR 0.48; 95% CI 0.19 to 1·25), pregnancy induced hypertension (OR 0.63; 95% CI 0.37 to 1·06), and preeclampsia (OR 0.74; 95% CI 0.538 to 1·04), though with limited evidence against our model hypothesis of equivalence with insulin for these outcomes. CONCLUSION Metformin is, at least, comparable to insulin for the treatment of GDM. Glibenclamide appears less favorable, in comparison to insulin, than metformin.
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Affiliation(s)
- Omran A H Musa
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Asma Syed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Aisha M Mohamed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Justin Clark
- The Center for Research into Evidence Based Practice, Bond University, Gold Coast, Australia
| | - Luis Furuya-Kanamori
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Chang Xu
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Egon Toft
- Deans Office, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Mohammed Bashir
- Division of Endocrinology, Hamad General Hospital, Doha, Qatar
| | - Abdul Badi Abou-Samra
- Division of Endocrinology, Hamad General Hospital, Doha, Qatar; Qatar Metabolic Institute, Hamad General Hospital, Doha, Qatar
| | - Lukman Thalib
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Suhail A Doi
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar.
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26
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Ayaz R, Günay T, Yardımcı OD, Turgut A, Ankaralı H. The effect of 75-g oral glucose tolerance test on maternal and foetal Doppler parameters in healthy pregnancies: a cross-sectional observational study. J OBSTET GYNAECOL 2021; 41:83-88. [PMID: 33583317 DOI: 10.1080/01443615.2020.1849072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hyperglycaemia can alter placental resistance to blood flow and hyperglycaemia has adverse perinatal outcomes. Oral glucose tolerance testing (OGTT) increases the maternal plasma glucose levels temporarily and mimics metabolic hyperglycaemia. The blood flow of the uterine artery (UtA), umbilical artery (UA), middle cerebral artery (MCA) were assessed before, 1 and 2 h following the OGTT by using Doppler ultrasonography. Z-score of cerebroplacental ratio (CPR), pulsatility index (PI) for three vessels were evaluated separately. All measurements of the MCA, UA, UtA Doppler parameters were not statistically different for fasting, and 1 and 2 h following the 75 g OGTT in the 53 pregnant women with a singleton gestation in the low-risk group. This study results show that acute hyperglycaemia induced by OGTT has no effect on maternal and foetal Doppler parameters in healthy pregnancies.IMPACT STATEMENTWhat is already known on this subject? Foetal glucose is affected by maternal blood glucose concentrations and placental blood flow. Acute hyperglycaemia may have an effect on maternal, and foetal Doppler parameters among healthy pregnanciesWhat do the results of this study add? Our findings indicate that blood flow velocity metric measurements in the UA, MCA and UtA were not affected by the OGTT in healthy pregnant women.What are the implications of these findings for clinical practice and/or further research? Acute hyperglycaemia induced by OGTT does not have any effect on fetomaternal circulation, especially foetal brain blood flow. Other foetal vessels including ductus venosus, renal artery, etc. may be affected by maternal blood glucose levels during the OGTT or in diabetic patients. Future prospective studies consisting of diabetic patients are warranted to verify the exact effect of glucose levels on foetal and maternal circulation.
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Affiliation(s)
- Reyhan Ayaz
- Faculty of Medicine, Department of Perinatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Taner Günay
- Faculty of Medicine, Department of Obstetrics and Gynecology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Oguz Devrim Yardımcı
- Faculty of Medicine, Department of Obstetrics and Gynecology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Abdulkadir Turgut
- Faculty of Medicine, Department of Obstetrics and Gynecology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Handan Ankaralı
- Faculty of Medicine, Department of Biostatistics, Istanbul Medeniyet University, Istanbul, Turkey
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27
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Egan AM, Dow ML, Vella A. A Review of the Pathophysiology and Management of Diabetes in Pregnancy. Mayo Clin Proc 2020; 95:2734-2746. [PMID: 32736942 DOI: 10.1016/j.mayocp.2020.02.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/24/2020] [Accepted: 02/18/2020] [Indexed: 12/13/2022]
Abstract
Diabetes is a common metabolic complication of pregnancy and affected women fall into two subgroups: women with pre-existing diabetes and those with gestational diabetes mellitus (GDM). When pregnancy is affected by diabetes, both mother and infant are at increased risk for multiple adverse outcomes. A multidisciplinary approach to care before, during, and after pregnancy is effective in reducing these risks. The PubMed database was searched for English language studies and guidelines relating to diabetes in pregnancy. The following search terms were used alone and in combination: diabetes, pregnancy, gestational diabetes, GDM, prepregnancy, and preconception. A date restriction was not applied. Results were reviewed by the authors and selected for inclusion based on relevance to the topic. Additional articles were identified by manually searching reference lists of included articles. Using data from this search we herein summarize the evidence relating to pathophysiology and management of diabetes in pregnancy. We discuss areas of controversy including the method and timing of diagnosis of GDM, and choice of pharmacologic agents to treat hyperglycemia during pregnancy. Therefore, this review is intended to serve as a practical guide for clinicians who are caring for women with diabetes and their infants.
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Affiliation(s)
- Aoife M Egan
- Department of Endocrinology, Mayo Clinic, Rochester, MN.
| | - Margaret L Dow
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Adrian Vella
- Department of Endocrinology, Mayo Clinic, Rochester, MN
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28
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Lin SF, Chang SH, Kuo CF, Lin WT, Chiou MJ, Huang YT. Association of pregnancy outcomes in women with type 2 diabetes treated with metformin versus insulin when becoming pregnant. BMC Pregnancy Childbirth 2020; 20:512. [PMID: 32887578 PMCID: PMC7487639 DOI: 10.1186/s12884-020-03207-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/25/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Metformin use in pregnancy is controversial because metformin crosses the placenta and the safety on the fetus has not been well-established. This retrospective study aimed to compare pregnancy outcomes in women with preexisting type 2 diabetes receiving metformin or standard insulin treatment. METHODS The cohort of this population-based study includes women of age 20-44 years with preexisting type 2 diabetes and singleton pregnancies in Taiwan between 2003 and 2014. Subjects were classified into three mutually exclusive groups according to glucose-lowering treatments received before and after becoming pregnant: insulin group, switching group (metformin to insulin), and metformin group. A generalized estimating equation model adjusted for patient age, duration of type 2 diabetes, hypertension, hyperlipidemia, retinopathy, and aspirin use was used to estimate the adjusted odds ratio (aOR) and 95% confidence interval (CI) of adverse pregnancy outcomes. RESULTS A total of 1166 pregnancies were identified in the insulin group (n = 222), the switching group (n = 318) and the metformin group (n = 626). The insulin group and the switching group had similar pregnancy outcomes for both the mother and fetus, including risk of primary cesarean section, pregnancy-related hypertension, preeclampsia, preterm birth (< 37 weeks), very preterm birth (< 32 weeks), low birth weight (< 2500 g), high birth weight (> 4000 g), large for gestational age, and congenital malformations. The metformin group had a lower risk of primary cesarean section (aOR = 0.57; 95% CI, 0.40-0.82) and congenital malformations (aOR, 0.51; 95% CI; 0.27-0.94) and similar risk for the other outcomes as compared with the insulin group. CONCLUSIONS Metformin therapy was not associated with increased adverse pregnancy outcomes in women with type 2 diabetes as compared with standard insulin therapy.
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Affiliation(s)
- Shu-Fu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, No.15, Wunhua 1st Rd., Gueishan Dist, Taoyuan City, 333, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wan-Ting Lin
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, No.15, Wunhua 1st Rd., Gueishan Dist, Taoyuan City, 333, Taiwan
| | - Meng-Jiun Chiou
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, No.15, Wunhua 1st Rd., Gueishan Dist, Taoyuan City, 333, Taiwan.
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Fonge YN, Jain VD, Harrison C, Brooks M, Sciscione AC. Examining the relationship between food environment and gestational diabetes. Am J Obstet Gynecol MFM 2020; 2:100204. [PMID: 33345920 DOI: 10.1016/j.ajogmf.2020.100204] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/29/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies have shown an association between the incidence of gestational diabetes and living in neighborhoods oversaturated with unhealthy foods. OBJECTIVE This study sought to determine if the food environment also affects the management of gestational diabetes. We hypothesized that living in areas with a higher quality of food decreased the risk of requiring medication to treat gestational diabetes. STUDY DESIGN This was a retrospective cohort study of singleton births at the Christiana Care Health System between 2015 and 2018. Patients with gestational diabetes who live in Delaware (N=1327) were geocoded and classified according to their census tract food environment. The food environment was assessed using the modified Retail Food Environment Index, which measures the percentage of healthy food retailers among all food retailers within a half-mile radius of the census tract boundaries. The modified Retail Food Environment Index scores were divided into 3 categories: poor (modified Retail Food Environment Index score, 0-3), average (modified Retail Food Environment Index score, 4-10), and good or above average (modified Retail Food Environment Index score, ≥11) food environments. The primary outcome was the prevalence of A2 gestational diabetes mellitus. Several neonatal and obstetrical outcomes were also examined including type II diabetes mellitus (defined as a 2-hour glucose tolerance test with at least 1 value above the threshold), cesarean delivery, shoulder dystocia, admission to the neonatal intensive care unit, neonatal hypoglycemia, neonatal hyperbilirubinemia, neonatal respiratory distress syndrome, and macrosomia. RESULTS A total of 689 (52%) women were diagnosed as having A2 gestational diabetes mellitus. Women in the average or good or above average food environment groups had a lower prevalence of A2 gestational diabetes mellitus than women in the poor food environment group (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.92] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.56; 95% confidence interval, 0.40-0.82]). They also had a lower prevalence of type II diabetes mellitus (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.25; 95% confidence interval, 0.09-0.72] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.48; 95% confidence interval, 0.27-0.86]). There were no differences in the other secondary outcomes of interest. CONCLUSION The food environment affects the requirement for medication to obtain glycemic levels that are within the target range for those with gestational diabetes.
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Affiliation(s)
- Yaneve N Fonge
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE.
| | - Vanita D Jain
- Division of Maternal Fetal Medicine, Christiana Care Health System, Newark, DE
| | | | | | - Anthony C Sciscione
- Division of Maternal Fetal Medicine, Christiana Care Health System, Newark, DE
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Pérez-Pérez A, Vilariño-García T, Guadix P, Dueñas JL, Sánchez-Margalet V. Leptin and Nutrition in Gestational Diabetes. Nutrients 2020; 12:E1970. [PMID: 32630697 PMCID: PMC7400219 DOI: 10.3390/nu12071970] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
Leptin is highly expressed in the placenta, mainly by trophoblastic cells, where it has an important autocrine trophic effect. Moreover, increased leptin levels are found in the most frequent pathology of pregnancy: gestational diabetes, where leptin may mediate the increased size of the placenta and the fetus, which becomes macrosomic. In fact, leptin mediates the increased protein synthesis, as observed in trophoblasts from gestational diabetic subjects. In addition, leptin seems to facilitate nutrients transport to the fetus in gestational diabetes by increasing the expression of the glycerol transporter aquaporin-9. The high plasma leptin levels found in gestational diabetes may be potentiated by leptin resistance at a central level, and obesity-associated inflammation plays a role in this leptin resistance. Therefore, the importance of anti-inflammatory nutrients to modify the pathology of pregnancy is clear. In fact, nutritional intervention is the first-line approach for the treatment of gestational diabetes mellitus. However, more nutritional intervention studies with nutraceuticals, such as polyphenols or polyunsaturated fatty acids, or nutritional supplementation with micronutrients or probiotics in pregnant women, are needed in order to achieve a high level of evidence. In this context, the Mediterranean diet has been recently found to reduce the risk of gestational diabetes in a multicenter randomized trial. This review will focus on the impact of maternal obesity on placental inflammation and nutrients transport, considering the mechanisms by which leptin may influence maternal and fetal health in this setting, as well as its role in pregnancy pathologies.
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Affiliation(s)
- Antonio Pérez-Pérez
- Department of Medical Biochemistry and Molecular Biology, and Immnology, School of Medicine, Virgen Macarena University Hospital, 41009 Seville, Spain;
| | - Teresa Vilariño-García
- Department of Medical Biochemistry and Molecular Biology, and Immnology, School of Medicine, Virgen Macarena University Hospital, 41009 Seville, Spain;
| | - Pilar Guadix
- Obstetrics and Gynecology Service, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.G.); (J.L.D.)
| | - José L. Dueñas
- Obstetrics and Gynecology Service, Virgen Macarena University Hospital, 41009 Seville, Spain; (P.G.); (J.L.D.)
| | - Víctor Sánchez-Margalet
- Department of Medical Biochemistry and Molecular Biology, and Immnology, School of Medicine, Virgen Macarena University Hospital, 41009 Seville, Spain;
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Murray SR, Reynolds RM. Short- and long-term outcomes of gestational diabetes and its treatment on fetal development. Prenat Diagn 2020; 40:1085-1091. [PMID: 32946125 DOI: 10.1002/pd.5768] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022]
Abstract
Globally the prevalence of gestational diabetes mellitus (GDM) is rising mainly due to the increase in maternal obesity. A number of different methods to screen for and diagnose GDM have been described although consensus on the preferred methods does not yet exist. GDM has significant short- and long-term health risks for the mother, developing fetus and the children born to mothers with GDM. Short-term risks for the fetus include macrosomia (excessive birthweight), shoulder dystocia, birth trauma, and hypoglycaemia in the immediate postpartum period. Long-term risks for offspring born to mothers with GDM include increased rates of childhood and adulthood obesity and an increased cardiometabolic risk. A number of pharmacological treatments for GDM have been identified, these include insulin and oral glucose-lowering drugs metformin and glibenclamide. Whilst these oral glucose-lowering drugs show similar short-term childhood outcomes to insulin there is increasing evidence that these drugs may have adverse long-term outcomes on children and adults exposed to the drugs in utero. Future research on treatments for GDM should include long-term follow- up of children exposed to glucose lowering medication in utero to determine the long-term cardiometabolic risk in the offspring born to mothers with GDM.
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Affiliation(s)
- Sarah R Murray
- MRC Centre for Reproductive Health, University of Edinburgh Queen's Medical Research Institute, Edinburgh, Scotland
| | - Rebecca M Reynolds
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, Scotland
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Jorquera G, Echiburú B, Crisosto N, Sotomayor-Zárate R, Maliqueo M, Cruz G. Metformin during Pregnancy: Effects on Offspring Development and Metabolic Function. Front Pharmacol 2020; 11:653. [PMID: 32625081 PMCID: PMC7311748 DOI: 10.3389/fphar.2020.00653] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
Maternal obesity during pregnancy and gestational diabetes mellitus (GDM) are both associated with of several postnatal diseases in the offspring, including obesity, early onset hypertension, diabetes mellitus, and reproductive alterations. Metformin is an oral drug that is being evaluated to treat GDM, obesity-associated insulin resistance, and polycystic ovary syndrome (PCOS) during pregnancy. The beneficial effects of metformin on glycemia and pregnancy outcomes place it as a good alternative for its use during pregnancy. In this line of thought, improving the metabolic status of the pregnant mother by using metformin should avoid the consequences of insulin resistance on the offspring's fetal and postnatal development. However, some human and animal studies have shown that metformin during pregnancy could amplify these alterations and be associated with excessive postnatal weight gain and obesity. In this minireview, we discuss not only the clinical and experimental evidence that supports the benefits of using metformin during pregnancy but also the evidence showing a possible negative impact of this drug on the offspring's development.
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Affiliation(s)
- Gonzalo Jorquera
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
| | - Bárbara Echiburú
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Nicolás Crisosto
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile.,Unit of Endocrinology, Clínica Las Condes, Santiago, Chile
| | - Ramón Sotomayor-Zárate
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
| | - Manuel Maliqueo
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Gonzalo Cruz
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
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Jiang S, Teague AM, Tryggestad JB, Jensen ME, Chernausek SD. Role of metformin in epigenetic regulation of placental mitochondrial biogenesis in maternal diabetes. Sci Rep 2020; 10:8314. [PMID: 32433500 PMCID: PMC7239922 DOI: 10.1038/s41598-020-65415-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/30/2020] [Indexed: 12/30/2022] Open
Abstract
Adverse maternal environments, such as diabetes and obesity, impair placental mitochondrial function, which affects fetal development and offspring long-term health. The underlying mechanisms and effective interventions to abrogate such effect remain unclear. Our previous studies demonstrated impaired mitochondrial biogenesis in male human placenta of diabetic mothers. In the present studies, epigenetic marks possibly related to mitochondrial biogenesis in placentae of women with diabetes (n = 23) and controls (n = 23) were analyzed. Effects of metformin were examined in human placental explants from a subgroup of diabetic women and in a mouse model of maternal high fat diet feeding. We found that maternal diabetes was associated with epigenetic regulation of mitochondrial biogenesis in human placenta in a fetal sex-dependent manner, including decreased histone acetylation (H3K27 acetylation) and increased promoter methylation of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α). In male placenta, the levels of H3K27 acetylation and PGC-1α promoter methylation correlated significantly with the activity of AMP-activated protein kinase (AMPK). Metformin treatment on male diabetic placental explant activated AMPK and stimulated PGC-1α expression, concomitant with increased H3K27 acetylation and decreased PGC-1α promoter methylation. In vivo, we show that maternal metformin treatment along with maternal high fat diet significantly increased mouse placental abundance of PGC-1α expression and downstream mitochondrial transcription factor A (TFAM) and inhibited maternal high fat diet-impaired placental efficiency and glucose tolerance in offspring. Together, these findings suggest the capability of metformin to stimulate placental mitochondrial biogenesis and inhibit the aberrant epigenetic alterations occurring in maternal diabetes during pregnancy, conferring protective effects on offspring.
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Affiliation(s)
- Shaoning Jiang
- Department of Pediatrics, Section of Diabetes and Endocrinology, Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - April M Teague
- Department of Pediatrics, Section of Diabetes and Endocrinology, Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jeanie B Tryggestad
- Department of Pediatrics, Section of Diabetes and Endocrinology, Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mary E Jensen
- Department of Pediatrics, Section of Diabetes and Endocrinology, Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Steven D Chernausek
- Department of Pediatrics, Section of Diabetes and Endocrinology, Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Tarry-Adkins JL, Aiken CE, Ozanne SE. Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: A systematic review and meta-analysis. PLoS Med 2020; 17:e1003126. [PMID: 32442232 PMCID: PMC7244100 DOI: 10.1371/journal.pmed.1003126] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 04/23/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fetal growth in gestational diabetes mellitus (GDM) is directly linked to maternal glycaemic control; however, this relationship may be altered by oral anti-hyperglycaemic agents. Unlike insulin, such drugs cross the placenta and may thus have independent effects on fetal or placental tissues. We investigated the association between GDM treatment and fetal, neonatal, and childhood growth. METHODS AND FINDINGS PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov, and Cochrane databases were systematically searched (inception to 12 February 2020). Outcomes of GDM-affected pregnancies randomised to treatment with metformin, glyburide, or insulin were included. Studies including preexisting diabetes or nondiabetic women were excluded. Two reviewers independently assessed eligibility and risk of bias, with conflicts resolved by a third reviewer. Maternal outcome measures were glycaemic control, weight gain, and treatment failure. Offspring anthropometric parameters included fetal, neonatal, and childhood weight and body composition data. Thirty-three studies (n = 4,944), from geographical locations including Europe, North Africa, the Middle East, Asia, Australia/New Zealand, and the United States/Latin America, met eligibility criteria. Twenty-two studies (n = 2,801) randomised women to metformin versus insulin, 8 studies (n = 1,722) to glyburide versus insulin, and 3 studies (n = 421) to metformin versus glyburide. Eleven studies (n = 2,204) reported maternal outcomes. No differences in fasting blood glucose (FBS), random blood glucose (RBS), or glycated haemoglobin (HbA1c) were reported. No studies reported fetal growth parameters. Thirty-three studies (n = 4,733) reported birth weight. Glyburide-exposed neonates were heavier at birth (58.20 g, 95% confidence interval [CI] 10.10-106.31, p = 0.02) with increased risk of macrosomia (odds ratio [OR] 1.38, 95% CI 1.01-1.89, p = 0.04) versus neonates of insulin-treated mothers. Metformin-exposed neonates were born lighter (-73.92 g, 95% CI -114.79 to -33.06 g, p < 0.001) with reduced risk of macrosomia (OR 0.60, 95% CI 0.45-0.79, p < 0.001) than insulin-exposed neonates. Metformin-exposed neonates were born lighter (-191.73 g, 95% CI -288.01 to -94.74, p < 0.001) with a nonsignificant reduction in macrosomia risk (OR 0.32, 95% CI 0.08-1.19, I2 = 0%, p = 0.09) versus glyburide-exposed neonates. Glyburide-exposed neonates had a nonsignificant increase in total fat mass (103.2 g, 95% CI -3.91 to 210.31, p = 0.06) and increased abdominal (0.90 cm, 95% CI 0.03-1.77, p = 0.04) and chest circumferences (0.80 cm, 95% CI 0.07-1.53, p = 0.03) versus insulin-exposed neonates. Metformin-exposed neonates had decreased ponderal index (-0.13 kg/m3, 95% CI -0.26 to -0.00, p = 0.04) and reduced head (-0.21, 95% CI -0.39 to -0.03, p = 0.03) and chest circumferences (-0.34 cm, 95% CI -0.62 to -0.05, p = 0.02) versus the insulin-treated group. Metformin-exposed neonates had decreased ponderal index (-0.09 kg/m3, 95% CI -0.17 to -0.01, p = 0.03) versus glyburide-exposed neonates. Study limitations include heterogeneity in dosing, heterogeneity in GDM diagnostic criteria, and few studies reporting longitudinal growth outcomes. CONCLUSIONS Maternal randomisation to glyburide resulted in heavier neonates with a propensity to increased adiposity versus insulin- or metformin-exposed groups. Metformin-exposed neonates were lighter with reduced lean mass versus insulin- or glyburide-exposed groups, independent of maternal glycaemic control. Oral anti-hyperglycaemics cross the placenta, so effects on fetal anthropometry could result from direct actions on the fetus and/or placenta. We highlight a need for further studies examining the effects of intrauterine exposure to antidiabetic agents on longitudinal growth, and the importance of monitoring fetal growth and maternal glycaemic control when treating GDM. This review protocol was registered with PROSPERO (CRD42019134664/CRD42018117503).
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Affiliation(s)
- Jane L. Tarry-Adkins
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, the Rosie Hospital and NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Catherine E. Aiken
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, the Rosie Hospital and NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Susan E. Ozanne
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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Chen C, Huang Y, Dong G, Zeng Y, Zhou Z. The effect of dipeptidyl peptidase-4 inhibitor and glucagon-like peptide-1 receptor agonist in gestational diabetes mellitus: a systematic review. Gynecol Endocrinol 2020; 36:375-380. [PMID: 31858859 DOI: 10.1080/09513590.2019.1703943] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Gestational diabetes mellitus (GDM) is the most common complication in pregnancy and affects 13% pregnant women around the world. GDM has both short-term and long-term negative effect on mother and offspring. Dipeptidyl peptidase-4 (DPP-4) inhibitor and glucagon-like peptide-1 receptor agonist (GLP-1 Ra) have shown many extra-benefits in diabetes patients, and may be a promising choice to GDM. Here, we conducted a systematic review of randomized controlled trials to investigate the effect of DPP-4 inhibitor and GLP-1 Ra in GDM. This project was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement. We searched PubMed, EMBASE and Cochrane library up to November 8 2019 for eligible trials. A total of 982 records were identified and 4 trials (516 participants) met the criteria in the end. The results suggested that DPP-4 inhibitor and GLP-1 Ra can reduce the rate of developing postpartum diabetes, help to normalization of blood glucose and improve insulin resistance and β-cell function. Although the treatments showed beneficial effects in GDM patients, but the present data could not prove it use in GDM. Further clinical trials will be needed.
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Affiliation(s)
- Chengcong Chen
- Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
| | - Ying Huang
- Faculty of Medicine, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Guoqing Dong
- Section of Endocrinology, Department of Pediatrics, Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
| | - Yongmei Zeng
- Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
| | - Ziqiong Zhou
- Obstetrics Department, Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
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Management of Gestational Diabetes Mellitus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:257-272. [PMID: 32548833 DOI: 10.1007/5584_2020_552] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Once a woman is diagnosed with gestational diabetes mellitus (GDM), two strategies are considered for management; life-style modifications and pharmacological therapy. The management of GDM aims to maintain a normoglycemic state and to prevent excessive weight gain in order to reduce maternal and fetal complications. Lifestyle modifications include nutritional therapy and exercise. Calorie restriction with a low glycemic index diet is recommended to avoid postprandial hyperglycemia and to reduce insulin resistance. Blood glucose levels, HbA1c levels, and ketonuria are monitored to analyze the efficacy of conservative management. Pharmacological treatment is initiated if conservative strategies fail to provide expected glucose levels during follow-ups.Insulin has been the first choice for the treatment of diabetes during pregnancy. Recently, metformin has been used more commonly in diabetic pregnant women in cases when insulin cannot be prescribed, after its safety has been proven. However, a high percentage of women, which may be up to 46% may require additional insulin to maintain expected blood glucose levels. The evidence on the long-term safety of other oral anti-diabetics has been lacking yet.Women with diet-controlled GDM can wait for spontaneous labor expectantly in case there are no obstetric indications for birth. However, in women with GDM under insulin therapy or with poor glycemic control, elective induction at term is recommended by authorities.The women who have GDM during pregnancy should be counseled about their increased risks of impaired glucose tolerance, type 2 diabetes mellitus, hypertensive disorders, cardiovascular diseases, and metabolic syndrome.
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Abstract
Importance Diabetes affects 6% to 9% of pregnancies, with gestational diabetes mellitus accounting for more than 90% of cases. Pregestational and gestational diabetes are associated with significant maternal and fetal risks; therefore, screening and treatment during pregnancy are recommended. Recommendations regarding the preferred treatment of diabetes in pregnancy have recently changed, with slight differences between American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommendations. Objective Our review discusses the diagnosis, management, and treatment of pregestational and gestational diabetes with the oral hypoglycemic agents metformin and glyburide as well as insulin. We also review the evidence for the safety and efficacy of these medications in pregnancy. Evidence Acquisition Articles were obtained from PubMed, the ACOG Practice Bulletin on Gestational Diabetes Mellitus, and the SMFM statement on the pharmacological treatment of gestational diabetes. Results Insulin does not cross the placenta and has an established safety profile in pregnancy and is therefore considered a first-line treatment for gestational diabetes. Metformin and glyburide have also been shown to be relatively safe in pregnancy but with more limited long-term data. Regarding maternal and fetal outcomes, metformin is superior to glyburide and similar to insulin. Conclusions and Relevance Insulin is the preferred pharmacologic treatment according to ACOG. However, SMFM has stated that outcomes with metformin are similar, and it may also be considered as first-line therapy. Both agree that the available data show that metformin is safer and superior to glyburide, and glyburide is no longer recommended as a first-line therapy for the treatment of gestational diabetes.
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Blair RA, Rosenberg EA, Palermo NE. The Use of Non-insulin Agents in Gestational Diabetes: Clinical Considerations in Tailoring Therapy. Curr Diab Rep 2019; 19:158. [PMID: 31811400 PMCID: PMC7213051 DOI: 10.1007/s11892-019-1243-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW To assess evidence to date for use of non-insulin agents in treatment of gestational diabetes mellitus. RECENT FINDINGS There has been increasing interest in the use of non-insulin agents, primarily metformin and glyburide (which both cross the placenta). Metformin has been associated with less maternal weight gain; however, recent studies have shown a trend toward increased weight in offspring exposed to metformin in utero. Glyburide has been associated with increased neonatal hypoglycemia. Glycemic control during pregnancy is essential to optimize both maternal and fetal outcomes. There are a myriad of factors to consider when designing treatment programs including patient preference, phenotype, and glucose patterns. While insulin is typically recommended as first-line, some women refuse or cannot afford insulin and in those cases, non-insulin agents may be used. Further studies are needed to assess treatment in pregnancy, perinatal outcomes, and particularly long-term metabolic profiles in mothers and offspring.
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Affiliation(s)
- Rachel A Blair
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Emily A Rosenberg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA.
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Bettencourt-Silva R, Neves JS, Ferreira MJ, Souteiro P, Belo S, Oliveira AI, Carvalho D, Namora G, Montenegro N, Queirós J. Metformin in overweight and obese women with gestational diabetes: a propensity score-matched study. Endocrine 2019; 66:192-200. [PMID: 31401725 DOI: 10.1007/s12020-019-02043-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/02/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Obesity and gestational diabetes mellitus (GDM) have an independent negative impact in pregnancy outcomes. Excessive gestational weight gain (GWG) represents an additional high-risk condition for adverse outcomes. The aims of this study were to evaluate the potential effect of metformin in GWG in overweight or obese women with GDM, to report our experience and to assess metformin's safety in this population. METHODS Retrospective observational cohort study involving pregnant women with GDM and pregestational overweight or obesity. Demographic, anthropometric, glycemic control data, obstetric, fetal and neonatal outcomes were evaluated. The sample was divided into two groups according to metformin treatment. A propensity score-matched analysis was performed using age, initial body mass index (BMI), trimester at GDM diagnosis and previous history of GDM or macrosomia as covariates. RESULTS Of the 457 enrolled in the study, 177 (38.7%) were treated with metformin. Two groups of 130 well matched patients were balanced regarding baseline characteristics. Women in metformin group had significantly less excessive GWG (29.23% vs. 42.31%, OR 0.56, 95% CI 0.34-0.94, p = 0.028) and more adequate GWG (36.92% vs. 23.08%, OR 1.95, 95% CI 1.14-3.35, p = 0.015). No significant differences were found between both groups regarding glycemic control, rate of insulinization, and obstetric, fetal, and neonatal outcomes. CONCLUSIONS This study highlights metformin as an important and safe tool to prevent excessive GWG and promote adequate GWG in overweight or obese women with GDM, regardless of age, BMI, timing of GDM diagnosis, previous history of GDM or macrosomia.
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Affiliation(s)
- Rita Bettencourt-Silva
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal.
- Faculty of Medicine of University of Porto, Porto, Portugal.
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal.
| | - João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Maria João Ferreira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Pedro Souteiro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Sandra Belo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Outpatient Clinic of Obstetrics and Endocrinology, Centro Hospitalar Universitário S. João, Porto, Portugal
- Diabetes and Pregnancy Study Group, Portuguese Society of Diabetology, Porto, Portugal
| | - Ana Isabel Oliveira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Outpatient Clinic of Obstetrics and Endocrinology, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Gabriela Namora
- Faculty of Medicine of University of Porto, Porto, Portugal
- Outpatient Clinic of Obstetrics and Endocrinology, Centro Hospitalar Universitário S. João, Porto, Portugal
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Nuno Montenegro
- Faculty of Medicine of University of Porto, Porto, Portugal
- Outpatient Clinic of Obstetrics and Endocrinology, Centro Hospitalar Universitário S. João, Porto, Portugal
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Joana Queirós
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário S. João, Porto, Portugal
- Outpatient Clinic of Obstetrics and Endocrinology, Centro Hospitalar Universitário S. João, Porto, Portugal
- Diabetes and Pregnancy Study Group, Portuguese Society of Diabetology, Porto, Portugal
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Wexler DJ, Powe CE, Barbour LA, Buchanan T, Coustan DR, Corcoy R, Damm P, Dunne F, Feig DS, Ferrara A, Harper LM, Landon MB, Meltzer SJ, Metzger BE, Roeder H, Rowan JA, Sacks DA, Simmons D, Umans JG, Catalano PM. Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Obstet Gynecol 2019; 132:496-505. [PMID: 29995731 DOI: 10.1097/aog.0000000000002726] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated. Despite many small randomized controlled trials of glucose-lowering medication treatment in GDM, our understanding of medication management of GDM is incomplete as evidenced by discrepancies among professional society treatment guidelines. The comparative effectiveness of insulin, metformin, and glyburide remains uncertain, particularly with respect to long-term outcomes. Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches. Further research on these topics is likely to improve our understanding of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children.
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Affiliation(s)
- Deborah J Wexler
- Diabetes Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; the Divisions of Endocrinology, Metabolism, and Diabetes and Maternal-Fetal Medicine, University of Colorado School of Medicine and Anschutz Medical Campus, Aurora, Colorado; the Division of Endocrinology and Diabetes, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; Women & Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Diabetes Unit, Hospital de la Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, CIBER-BBN, Spain; the Center for Pregnant Women with Diabetes, Department of Obstetrics, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; College Medicine Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland; the Diabetes & Endocrine in Pregnancy Program, Mount Sinai Hospital and University of Toronto, Toronto, Canada; the Division of Research, Kaiser Permanente Northern California, Oakland, California; the Department of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio; the Departments of Medicine and Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Kaiser Permanente Southern California, San Diego, California; National Women's Health, Auckland, New Zealand; the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California; Campbelltown Hospital and Western Sydney University, Sydney, Australia; MedStar Health Research Institute, Hyattsville, Maryland; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC; and the Center for Reproductive Health, Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio
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Egan AM, Dunne FP. Optimal management of gestational diabetes. Br Med Bull 2019; 131:97-108. [PMID: 31504226 DOI: 10.1093/bmb/ldz025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/11/2019] [Accepted: 07/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is highly prevalent and has both short- and long-term implications for mother and infant. SOURCES OF DATA Literature search using PubMed with keywords 'Gestational diabetes' and 'diabetes in pregnancy' together with published papers known to the authors. AREAS OF AGREEMENT The cornerstone of management is medical nutrition therapy with regular self-monitoring of capillary blood glucose levels and intensification of therapy if glycaemic goals are not achieved. Post-partum, annual assessment for type 2 diabetes is recommended. AREAS OF CONTROVERSY Diagnostic criteria and new biomarkers for GDM and the clinical and economic benefits of treating women with milder levels of glucose intolerance during pregnancy. GROWING POINTS Women with GDM are a heterogeneous group with varying degrees of insulin resistance and beta cell dysfunction. AREAS TIMELY FOR DEVELOPING RESEARCH Development of alternative diagnostic markers and application of novel technologies for GDM management.
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Affiliation(s)
- Aoife M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
| | - Fidelma P Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway H91 TK33, Ireland
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Abstract
Although it has been accepted for decades that women with gestational diabetes mellitus (GDM) are at high risk for future development of type 2 diabetes, vigorous debate regarding the value of detecting and treating GDM has persisted into the twenty-first century. Although results from 2 randomized trials provide strong evidence that treating GDM reduces adverse perinatal outcomes, it remains to be determined whether treatment impacts long-term offspring outcomes. Insulin is the first-line pharmacologic treatment and is added when glycemic goals are not met with nutritional modifications. Oral agent use is controversial, as data on long-term offspring outcomes are lacking.
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Affiliation(s)
- Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, 530-24, Chicago, IL 60611, USA
| | - Jami L Josefson
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 54, Chicago, IL 60611, USA
| | - Boyd E Metzger
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Tarry Building, Room 12-703, 300 East Superior, Chicago, IL 60611, USA.
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de Wit L, Rademaker D, Voormolen DN, Akerboom BMC, Kiewiet-Kemper RM, Soeters MR, Verwij-Didden MAL, Assouiki F, Schippers DH, Vermeulen MAR, Kuppens SMI, Oosterwerff MM, Zwart JJ, Diekman MJM, Vogelvang TE, Gallas PRJ, Galjaard S, Visser W, Horree N, Klooker TK, Laan R, Heijligenberg R, Huisjes AJM, van Bemmel T, van Meir CA, van den Beld AW, Hermes W, Vidarsdottir S, Veldhuis-Vlug AG, Dullemond RC, Jansen HJ, Sueters M, de Koning EJP, van Laar JOEH, Wouters-van Poppel P, Sanson-van Praag ME, van den Akker ES, Brouwer CB, Hermsen BB, Potter van Loon BJ, van der Heijden OWH, de Galan BE, van Leeuwen M, Wijbenga JAM, de Boer K, van Bon AC, van der Made FW, Eskes SA, Zandstra M, van Houtum WH, Braams-Lisman BAM, Daemen-Gubbels CRGM, Wouters MGAJ, IJzerman RG, Mensing van Charante NA, Zwertbroek R, Bosmans JE, Evers IM, Mol BW, de Valk HW, Groenendaal F, Naaktgeboren CA, Painter RC, deVries JH, Franx A, van Rijn BB. SUGAR-DIP trial: oral medication strategy versus insulin for diabetes in pregnancy, study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial. BMJ Open 2019; 9:e029808. [PMID: 31427334 PMCID: PMC6701578 DOI: 10.1136/bmjopen-2019-029808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/11/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM. METHODS The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NTR6134; Pre-results.
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Affiliation(s)
- Leon de Wit
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Doortje Rademaker
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Daphne N Voormolen
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bettina M C Akerboom
- Department of Obstetrics and Gynaecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Maarten R Soeters
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Fahima Assouiki
- Department of Internal Medicine, Bernhoven Hospital, Uden, The Netherlands
| | - Daniela H Schippers
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Mechteld A R Vermeulen
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Simone M I Kuppens
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Joost J Zwart
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | | | - Tatjana E Vogelvang
- Department of Obstetrics and Gynaecology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - P Rob J Gallas
- Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Sander Galjaard
- Department of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Willy Visser
- Department of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole Horree
- Department of Obstetrics and Gynaecology, Flevoziekenhuis, Almere, The Netherlands
| | - Tamira K Klooker
- Department of Internal Medicine, Flevoziekenhuis, Almere, The Netherlands
| | - Rosemarie Laan
- Department of Obstetrics and Gynaecology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Rik Heijligenberg
- Department of Internal Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Anjoke J M Huisjes
- Department of Obstetrics and Gynaecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Claudia A van Meir
- Department of Obstetrics and Gynaecology, Groene Hart Hospital, Gouda, The Netherlands
| | | | - Wietske Hermes
- Department of Obstetrics and Gynaecology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Solrun Vidarsdottir
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Anneke G Veldhuis-Vlug
- Department of Internal Medicine, Medical Center Jan van Goyen, Amsterdam, The Netherlands
| | - Remke C Dullemond
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Henrique J Jansen
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Marieke Sueters
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eelco J P de Koning
- Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics and Gynaecology, Máxima Medical Center, Veldhoven, The Netherlands
| | | | | | | | | | - Brenda B Hermsen
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, The Netherlands
| | | | - Olivier W H van der Heijden
- Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Marsha van Leeuwen
- Department of Obstetrics and Gynaecology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Johanna A M Wijbenga
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Karin de Boer
- Department of Obstetrics and Gynaecology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Arianne C van Bon
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Flip W van der Made
- Department of Obstetrics and Gynaecology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Silvia A Eskes
- Department of Internal Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Mirjam Zandstra
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Haarlem, The Netherlands
| | | | | | | | - Maurice G A J Wouters
- Department of Obstetrics and Gynaecology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Richard G IJzerman
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Rolf Zwertbroek
- Department of Internal Medicine, Dijklander Hospital, Hoorn, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam, The Netherlands
| | - Inge M Evers
- Department of Obstetrics and Gynaecology, Meander Medical Center, Amersfoort, The Netherlands
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, Australia, Melbourne, The Netherlands
| | - Harold W de Valk
- Department of Internal Medicine and Endocrinology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - J Hans deVries
- Department of Internal Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bas B van Rijn
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Tarry-Adkins JL, Aiken CE, Ozanne SE. Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002848. [PMID: 31386659 PMCID: PMC6684046 DOI: 10.1371/journal.pmed.1002848] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Metformin is increasingly offered as an acceptable and economic alternative to insulin for treatment of gestational diabetes mellitus (GDM) in many countries. However, the impact of maternal metformin treatment on the trajectory of fetal, infant, and childhood growth is unknown. METHODS AND FINDINGS PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov, and the Cochrane database were systematically searched (from database inception to 26 February 2019). Outcomes of GDM-affected pregnancies randomised to treatment with metformin versus insulin were included (randomised controlled trials and prospective randomised controlled studies) from cohorts including European, American, Asian, Australian, and African women. Studies including pregnant women with pre-existing diabetes or non-diabetic women were excluded, as were trials comparing metformin treatment with oral glucose-lowering agents other than insulin. Two reviewers independently assessed articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Outcome measures were parameters of fetal, infant, and childhood growth, including weight, height, BMI, and body composition. In total, 28 studies (n = 3,976 participants) met eligibility criteria and were included in the meta-analysis. No studies reported fetal growth parameters; 19 studies (n = 3,723 neonates) reported measures of neonatal growth. Neonates born to metformin-treated mothers had lower birth weights (mean difference -107.7 g, 95% CI -182.3 to -32.7, I2 = 83%, p = 0.005) and lower ponderal indices (mean difference -0.13 kg/m3, 95% CI -0.26 to 0.00, I2 = 0%, p = 0.04) than neonates of insulin-treated mothers. The odds of macrosomia (odds ratio [OR] 0.59, 95% CI 0.46 to 0.77, p < 0.001) and large for gestational age (OR 0.78, 95% CI 0.62 to 0.99, p = 0.04) were lower following maternal treatment with metformin compared to insulin. There was no difference in neonatal height or incidence of small for gestational age between groups. Two studies (n = 411 infants) reported measures of infant growth (18-24 months of age). In contrast to the neonatal phase, metformin-exposed infants were significantly heavier than those in the insulin-exposed group (mean difference 440 g, 95% CI 50 to 830, I2 = 4%, p = 0.03). Three studies (n = 520 children) reported mid-childhood growth parameters (5-9 years). In mid-childhood, BMI was significantly higher (mean difference 0.78 kg/m2, 95% CI 0.23 to 1.33, I2 = 7%, p = 0.005) following metformin exposure than following insulin exposure, although the difference in absolute weights between the groups was not significantly different (p = 0.09). Limited evidence (1 study with data treated as 2 cohorts) suggested that adiposity indices (abdominal [p = 0.02] and visceral [p = 0.03] fat volumes) may be higher in children born to metformin-treated compared to insulin-treated mothers. Study limitations include heterogeneity in metformin dosing, heterogeneity in diagnostic criteria for GDM, and the scarcity of reporting of childhood outcomes. CONCLUSIONS Following intrauterine exposure to metformin for treatment of maternal GDM, neonates are significantly smaller than neonates whose mothers were treated with insulin during pregnancy. Despite lower average birth weight, metformin-exposed children appear to experience accelerated postnatal growth, resulting in heavier infants and higher BMI by mid-childhood compared to children whose mothers were treated with insulin. Such patterns of low birth weight and postnatal catch-up growth have been reported to be associated with adverse long-term cardio-metabolic outcomes. This suggests a need for further studies examining longitudinal perinatal and childhood outcomes following intrauterine metformin exposure. This review protocol was registered with PROSPERO under registration number CRD42018117503.
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Affiliation(s)
- Jane L. Tarry-Adkins
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Catherine E. Aiken
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, Rosie Hospital and NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Susan E. Ozanne
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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Farabi SS, Hernandez TL. Low-Carbohydrate Diets for Gestational Diabetes. Nutrients 2019; 11:E1737. [PMID: 31357598 PMCID: PMC6723585 DOI: 10.3390/nu11081737] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023] Open
Abstract
Nutrition therapy provides the foundation for treatment of gestational diabetes (GDM), and has historically been based on restricting carbohydrate (CHO) intake. In this paper, randomized controlled trials (RCTs) are reviewed to assess the effects of both low- and higher CHO nutrition approaches in GDM. The prevailing pattern across the evidence underscores that although CHO restriction improves glycemia at least in the short-term, similar outcomes could be achievable using less restrictive approaches that may not exacerbate IR. The quality of existing studies is limited, in part due to dietary non-adherence and confounding effects of treatment with insulin or oral medication. Recent evidence suggests that modified nutritional manipulation in GDM from usual intake, including but not limited to CHO restriction, improves maternal glucose and lowers infant birthweight. This creates a platform for future studies to further clarify the impact of multiple nutritional patterns in GDM on both maternal and infant outcomes.
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Affiliation(s)
- Sarah S Farabi
- Goldfarb School of Nursing, Office of Nursing Research, Barnes-Jewish College, St. Louis, MO 63110, USA
- Department of Medicine, Division of Nutritional Science, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Teri L Hernandez
- Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
- College of Nursing, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
- Department of Research, Innovation, and Professional Practice, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
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Abstract
Diabetes is a common complication of pregnancy associated with both short- and long-term adverse maternal and offspring effects. All types of diabetes in pregnancy are increasing in prevalence. Treatment of diabetes in pregnancy, targeting glycemic control, improves both maternal and offspring outcomes, albeit imperfectly for many women. Pharmacologic treatment recommendations differ between pregestational and gestational diabetes. Improved treatment of diabetes in pregnancy will need to consider maternal disease heterogeneity and comorbidities as well as long-term offspring outcomes. In this review, the authors summarize recent clinical studies to highlight established pharmacologic treatments for diabetes in pregnancy and provide suggestions for further research.
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Affiliation(s)
- Maisa N Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Women's Research Institute, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA.
| | - Jason G Umans
- Department of Medicine, Georgetown-Howard Universities Center for Clinical and Translational Science, Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007, USA; Department of Obstetrics and Gynecology, Georgetown-Howard Universities Center for Clinical and Translational Science, Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007, USA
| | - Patrick M Catalano
- Maternal Infant Research Institute, Obstetrics and Gynecology Research, Tufts University School of Medicine, Friedman School of Nutrition Science and Policy, 800 Washington Street, Box 394, Boston, MA 02111, USA
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Barbour LA, Feig DS. Metformin for Gestational Diabetes Mellitus: Progeny, Perspective, and a Personalized Approach. Diabetes Care 2019; 42:396-399. [PMID: 30787061 DOI: 10.2337/dci18-0055] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Linda A Barbour
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Denice S Feig
- Department of Medicine, Division of Endocrinology and Metabolism, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
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Abbott DH. Metformin use in polycystic ovary syndrome pregnancy impacts on offspring obesity. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:132-134. [PMID: 30704878 DOI: 10.1016/s2352-4642(19)30001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- David H Abbott
- Department of Obstetrics and Gynecology, Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, USA.
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Schäfer-Graf UM. Gestational Diabetes - Major New Clinically Relevant Aspects. Geburtshilfe Frauenheilkd 2018; 78:977-983. [PMID: 30364451 PMCID: PMC6195425 DOI: 10.1055/a-0707-6697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/15/2022] Open
Abstract
The implementation of screening for gestational diabetes (GDM) in the German Prenatal Care guidelines of 2012 and the publication of numerous new studies have led to clinically relevant changes in the care of pregnant women with GDM to whom consideration was given in the new S3 Guideline on the Diagnosis, Management and Follow-up of Gestational Diabetes (AWMF 057/008) published in March this year. Certain aspects are addressed and discussed on the basis of additional background information.
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Barbour LA, Scifres C, Valent AM, Friedman JE, Buchanan TA, Coustan D, Aagaard K, Thornburg KL, Catalano PM, Galan HL, Hay WW, Frias AE, Shankar K, Simmons RA, Moses RG, Sacks DA, Loeken MR. A cautionary response to SMFM statement: pharmacological treatment of gestational diabetes. Am J Obstet Gynecol 2018; 219:367.e1-367.e7. [PMID: 29959933 DOI: 10.1016/j.ajog.2018.06.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/07/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023]
Abstract
Use of oral agents to treat gestational diabetes mellitus remains controversial. Recent recommendations from the Society for Maternal-Fetal Medicine assert that metformin may be a safe first-line alternative to insulin for gestational diabetes mellitus treatment and preferable to glyburide. However, several issues should give pause to the widespread adoption of metformin use during pregnancy. Fetal concentrations of metformin are equal to maternal, and metformin can inhibit growth, suppress mitochondrial respiration, have epigenetic modifications on gene expression, mimic fetal nutrient restriction, and alter postnatal gluconeogenic responses. Because both the placenta and fetus express metformin transporters and exhibit high mitochondrial activity, these properties raise important questions about developmental programming of metabolic disease in offspring. Animal studies have demonstrated that prenatal metformin exposure results in adverse long-term outcomes on body weight and metabolism. Two recent clinical randomized controlled trials in women with gestational diabetes mellitus or polycystic ovary syndrome provide evidence that metformin exposure in utero may produce a metabolic phenotype that increases childhood weight or obesity. These developmental programming effects challenge the conclusion that metformin is equivalent to insulin. Although the Society for Maternal-Fetal Medicine statement endorsed metformin over glyburide if oral agents are used, there are few studies directly comparing the 2 agents and it is not clear that metformin alone is superior to glyburide. Moreover, it should be noted that prior clinical studies have dosed glyburide in a manner inconsistent with its pharmacokinetic properties, resulting in poor glycemic control and high rates of maternal hypoglycemia. We concur with the American Diabetes Association and American Congress of Obstetricians and Gynecologists, which recommend insulin as the preferred agent, but we believe that it is premature to embrace metformin as equivalent to insulin or superior to glyburide. Due to the uncertainty of the long-term metabolic risks of either metformin or glyburide, we call for carefully controlled studies that optimize oral medication dosing according to their pharmacodynamic and pharmacokinetic properties in pregnancy, appropriately target medications based on individual patterns of hyperglycemia, and follow the offspring long-term for metabolic risk.
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