Type 2 diabetes in pregnancy - An increasing problem

Nutritional and Exercise-Focused Lifestyle Interventions and Glycemic Control in Women with Diabetes in Pregnancy: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Diabetes disrupts one in six pregnancies, bestowing immediate and long-term health risks to mother and child. Diet and exercise are commonly prescribed to control dysglycemia, but their effectiveness across sub-populations and types of diabetes (type-1; type-2; or gestational diabetes mellitus, GDM) is uncertain. Therefore, a systematic review and meta-analysis on the effect of diet and/or exercise on glycemia in pregnant women with diabetes was conducted. Random effects models were used to evaluate effect sizes across studies and anticipated confounders (e.g., age, ethnicity, BMI). Of the 4845 records retrieved, 26 studies (8 nutritional supplements, 12 dietary, and 6 exercise interventions) were included. All studies were conducted in patients with GDM. Overall, supplement- and exercise-based interventions reduced fasting glucose (−0.30 mmol/L; 95% CI = −0.55, −0.06; p = 0.02; and 0.10 mmol/L; 95% CI = −0.20, −0.01; p = 0.04); and supplement- and diet-based interventions reduced HOMA-IR (−0.40; 95% CI = −0.58, −0.22; p < 0.001; and −1.15; 95% CI = −2.12, −0.17; p = 0.02). Subgroup analysis by confounders only confirmed marginal changed effect sizes. Our results suggest a favorable role of certain nutritional supplements, diet, and exercise practices on glycemia in women with GDM and underline a lack of evidence in ~20% of other diabetes-related pregnancies (i.e., women with pre-existing diabetes).

Design and methods of a tailored approach for diabetes prevention in women with previous gestational diabetes

Aim: To describe the design and methods of an intervention that engaged women with previous gestational diabetes mellitus in a tailored approach for diabetes prevention. Methods: Women participated in biometric tests for BMI and hemoglobin A1c, psychosocial questionnaires and an informed decision-making process to select a lifestyle change program for type 2 diabetes prevention based on their needs and priorities. Measure time points were at baseline, 6 months and 12 months. Results: The authors recruited 116 women. The outcomes of this study will evaluate the effect of this strategy on participant engagement in lifestyle change programs for type 2 diabetes prevention. Conclusion: This paper describes a variety of lifestyle change programs and an informed decision-making process for tailoring diabetes prevention programs for a high-risk population.

Pregnancy Outcomes in Young Women With Youth-Onset Type 2 Diabetes Followed in the TODAY Study

OBJECTIVE

To assess pregnancy outcomes in young women with youth-onset type 2 diabetes followed in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study.

RESEARCH DESIGN AND METHODS

Pregnancy information (outcome and any maternal or fetal complications) was obtained from the female participants by self-report. Additionally, medical records for the pregnancy and the child's neonatal course were obtained with data abstracted into standardized forms.

RESULTS

Over a maximum of 15 years, 260 pregnancies were reported by 141 women (aged 21.5 ± 3.2 years, BMI 35.6 ± 7.2 kg/m2, and diabetes duration 8.1 ± 3.2 years). Contraception use prior to pregnancy was reported by 13.5% of the women. Complications were reported by 65% of the women during their pregnancy. Pregnancy loss was observed in 25.3% and preterm birth in 32.6% of pregnancies. HbA1c ≥8% was observed in 31.9% of the pregnancies, and 35% of the pregnancies were complicated by chronic hypertension. Nephropathy prior to pregnancy was observed in 25% of the women. In the offspring, 7.8% were classified as small for gestational age, 26.8% large for gestational age, and 17.9% in the macrosomic range.

CONCLUSIONS

Based on observations from the TODAY cohort, young women with pregestational, youth-onset type 2 diabetes had very high rates of maternal complications stemming from significant socioeconomic disadvantage. The substantial maternal and infant complications seen in these young moms could potentially be avoided with improved contraception rates and reproductive planning.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017–2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Optimizing Care Preconception for Women With Diabetes and Obesity

The prevalence of diabetes in reproductive age women has been reported to be as high as 6.8%, with pregestational diabetes affecting 2% of all pregnancies. As cases of diabetes in children and adolescents rise, more patients will be entering reproductive age and pregnancy with diagnoses of obesity, prediabetes, type 2 diabetes. Early interventions of diet modification and exercise to maintain healthy weights can delay or even prevent these complications. It is critical for health care providers to emphasize the importance of preconception counseling in this high-risk patient population to reduce the morbidities associated with obesity and diabetes in pregnancy.

Association of pregnancy outcomes in women with type 2 diabetes treated with metformin versus insulin when becoming pregnant

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.

Diabetes Leads to Alterations in Normal Metabolic Transitions of Pregnancy as Revealed by Time-Course Metabolomics

Women with diabetes during pregnancy are at increased risk of poor maternal and neonatal outcomes. Despite this, the effects of pre-gestational (PGDM) or gestational diabetes (GDM) on metabolism during pregnancy are not well understood. In this study, we utilized metabolomics to identify serum metabolic changes in women with and without diabetes during pregnancy and the cord blood at birth. We observed elevations in tricarboxylic acid (TCA) cycle intermediates, carbohydrates, ketones, and lipids, and a decrease in amino acids across gestation in all individuals. In early gestation, PGDM had elevations in branched-chain amino acids and sugars compared to controls, whereas GDM had increased lipids and decreased amino acids during pregnancy. In both GDM and PGDM, carbohydrate and amino acid pathways were altered, but in PGDM, hemoglobin A1c and isoleucine were significantly increased compared to GDM. Cord blood from GDM and PGDM newborns had similar increases in carbohydrates and choline metabolism compared to controls, and these alterations were not maternal in origin. Our results revealed that PGDM and GDM have distinct metabolic changes during pregnancy. A better understanding of diabetic metabolism during pregnancy can assist in improved management and development of therapeutics and help mitigate poor outcomes in both the mother and newborn.

Pregnancy in women with diabetic nephropathy

The number of pregnancies in women with pregestational diabetes has been steadily increasing worldwide. These pregnancies are associated with an increased risk of a variety of complications, including miscarriages, congenital malformations, macrosomia, fetal growth restriction, preeclampsia, preterm delivery and stillbirth. In pregnant women with diabetic nephropathy it is important to evaluate both the effect of pregnancy on kidney function and the effect of kidney disease on pregnancy outcomes. Pregnant women with normal renal function and microalbuminuria have a low risk of loss of kidney function during pregnancy, while women with GFR < 60 ml/min and/or proteinuria ≥ 3 g/24 h at the beginning of pregnancy are at risk of permanent kidney damage. The risk of fetal and maternal complications is associated with the severity of chronic kidney disease and glycemic control. Advances in prenatal care have improved fetal and maternal outcomes and preconception counseling has become key for a successful pregnancy in all women with diabetes and especially in those with diabetes and chronic kidney disease.

Metformin treatment of type 2 diabetes mellitus in pregnancy: update on safety and efficacy

With the increasing prevalence of type 2 diabetes mellitus (T2DM) in women of childbearing age, prescribing antidiabetic medications in first-trimester pregnancy is becoming more common. Metformin treatment during this time is usually avoided in countries with well-resourced healthcare. This is based on historical concerns about safety to the foetus and the widespread availability of insulin. However, there is now increasing interest in the potential benefits of metformin in pregnant women with T2DM. In this commentary, the main evidence supporting metformin safety in pregnancy is summarized, with an emphasis on the first trimester. Based on a structured literature search, the recent randomized controlled trials comparing metformin and insulin are reviewed. We then show that prescribing advice for metformin in pregnancy is inconsistent and product information/package inserts (PI) are universally out of date. This causes confusion and pushes some women and their clinicians to change from metformin to insulin. The potential advantages of metformin in pregnant women with T2DM are then discussed, including oral dosing and improved acceptability, lower resource utilization and cost, decreased insulin requirements, less maternal weight gain and less risk of maternal and neonatal hypoglycaemia. The conclusion is that metformin is a cheap and efficacious antidiabetic medication for many pregnant women with T2DM, with reasonable evidence for safety. Drug information resources should be updated so that metformin can be considered more broadly in women with T2DM who present for antenatal care.

Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study

AIMS/HYPOTHESIS

The aim of this prospective nationwide study was to examine antenatal pregnancy care and pregnancy outcomes in women with type 1 and type 2 diabetes, and to describe changes since 2002/2003.

METHODS

This national population-based cohort included 3036 pregnant women with diabetes from 155 maternity clinics in England and Wales who delivered during 2015. The main outcome measures were maternal glycaemic control, preterm delivery (before 37 weeks), infant large for gestational age (LGA), and rates of congenital anomaly, stillbirth and neonatal death.

RESULTS

Of 3036 women, 1563 (51%) had type 1, 1386 (46%) had type 2 and 87 (3%) had other types of diabetes. The percentage of women achieving HbA1c < 6.5% (48 mmol/mol) in early pregnancy varied greatly between clinics (median [interquartile range] 14.3% [7.7-22.2] for type 1, 37.0% [27.3-46.2] for type 2). The number of infants born preterm (21.7% vs 39.7%) and LGA (23.9% vs 46.4%) were lower for women with type 2 compared with type 1 diabetes (both p < 0.001). The prevalence rates for congenital anomaly (46.2/1000 births for type 1, 34.6/1000 births for type 2) and neonatal death (8.1/1000 births for type 1, 11.4/1000 births for type 2) were unchanged since 2002/2003. Stillbirth rates are almost 2.5 times lower than in 2002/2003 (10.7 vs 25.8/1000 births for type 1, p = 0.0012; 10.5 vs 29.2/1000 births for type 2, p = 0.0091).

CONCLUSIONS/INTERPRETATION

Stillbirth rates among women with type 1 and type 2 diabetes have decreased since 2002/2003. Rates of preterm delivery and LGA infants are lower in women with type 2 compared with type 1 diabetes. In women with type 1 diabetes, suboptimal glucose control and high rates of perinatal morbidity persist with substantial variations between clinics.

DATA AVAILABILITY

Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from http://content.digital.nhs.uk/npid .

Prevalence of undiagnosed diabetes among non-pregnant women of reproductive age in the United States, 1999-2010

Undiagnosed diabetes has particularly harmful consequences among women of reproductive age. We assessed the prevalence of undiagnosed diabetes among non-pregnant women of reproductive age. In our data 30 women had A1C ≥ 6.5 and 28 had FPG ≥ 126 mg/dl values suggesting approximately 300,000 women of reproductive age nationwide may have undiagnosed diabetes.

Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States

OBJECTIVE

Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC)-preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.

STUDY DESIGN

Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.

RESULTS

We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.

CONCLUSION

Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.

Comparison of placental findings in type 1 and type 2 diabetic pregnancies

INTRODUCTION

The aim of this study is to compare placental pathology and related clinical parameters between gravidas with type 1 and type 2 pregestational diabetes.

METHODS

This is a retrospective cohort study of women with singleton gestations and pregestational diabetes who delivered at Women and Infants Hospital from 2003 to 2011. Pathology reports, maternal and neonatal outcomes were extracted and compared between the two groups.

RESULTS

In our cohort, 293 pregnancies were studied, including 117 with type 1 diabetes and 176 with type 2 diabetes. Women with type 1 diabetes had worse glycemic control during pregnancy, as characterized by higher HbA1c values and average fasting and postprandial blood sugars. More infants from the type 1 group were admitted to Neonatal ICU. Pregestational diabetes led to small for gestational age (SGA) placentas in nearly 20% pregnancies and large for gestational age (LGA) placentas in 30% of cases. Both groups shared similar incidences of preeclampsia and significant placental pathology related to uteroplacental (maternal) and fetal circulatory disorders; however, maternal decidual vasculopathy and placentas with insufficiency (fetal-to-placental weight ratio < 10th %tile) were more commonly found in placentas from women with type 2 diabetes.

DISCUSSION

Both types of pregestational diabetes have significant impact on placental growth and development. The comparison between the two groups suggests different pathogenetic mechanisms and may be helpful for better management of diabetic pregnancy.

Fifteen-year trends and predictors of preparation for pregnancy in women with pre-conception Type 1 and Type 2 diabetes: a population-based cohort study

AIMS

To investigate trends in indicators of preparation for pregnancy in women with Type 1 and Type 2 diabetes and explore their predictors.

METHODS

Data on 2293 pregnancies delivered during 1996-2010 by women with Type 1 (n = 1753) and Type 2 (n = 540) diabetes were obtained from the Northern Diabetes in Pregnancy Survey. Multiple logistic regression was used to analyse the relationship between potential predictors and three indicators of inadequate pregnancy preparation: non-attendance for pre-conception care; no pre-conception folate consumption; and peri-conception HbA(1c) ≥ 53 mmol/mol (≥ 7%).

RESULTS

Overall, 40.3% of women with diabetes attended pre-conception care, 37.4% reported pre-conception folate consumption, and 28.2% had adequate peri-conception HbA1c . For all patients, pre-conception folate consumption improved over time, while peri-conception glucose control did not. Attendance for pre-conception care for women with Type 1 diabetes significantly declined. Residence in deprived areas, smoking and younger maternal age (for women aged < 35 years) were independently associated with all three indicators of inadequate preparation for pregnancy. Additional predictors of inadequate peri-conception HbA(1c) were: Type 1 diabetes (adjusted odds ratio 5.51, 95% CI 2.71-11.22), longer diabetes history (adjusted odds ratio 1.16, 95% CI 1.09-1.23 per year increase for those with < 15 years' diabetes duration), non-white ethnicity (adjusted odds ratio 3.13, 95% CI 1.23-7.97) and higher BMI (adjusted odds ratio 1.05, 95% CI 1.01-1.09 per 1-kg/m(2) increase). Non-attendance for pre-conception care was additionally associated with Type 2 diabetes (P = 0.003) and multiparity (P < 0.0001).

CONCLUSIONS

There are socio-demographic inequalities in preparation for pregnancy among women with diabetes. Women with Type 2 diabetes were less likely to attend pre-conception care. Pre-conception services need to be designed to maximize uptake in all groups.

Risk of birth defects associated with maternal pregestational diabetes

Maternal diabetes preceding pregnancy may increase the risk of birth defects in the offspring, but not all studies confirm this association, which has shown considerable variation over time, and the effect of having type 1 versus type 2 diabetes is unclear. We conducted a population-based cohort study in the Northern Italy Emilia-Romagna region linking administrative databases with a Birth Defects Registry. From hospital discharge records we identified all diabetic pregnancies during 1997-2010, and a population of non-diabetic parturients matched for age, residence, year and delivery hospital. We collected available information on education, smoking and drug prescriptions, from which we inferred the type of diabetes. We found 62 malformed infants out of 2,269 births among diabetic women, and 162 out of 10,648 births among non-diabetic women. The age-standardized prevalence ratio (PR) of malformation associated with maternal pregestational diabetes was 1.79 (95 % confidence interval 1.34-2.39), a value that varied little by age. Type of diabetes strongly influenced the PR, with higher values related to type 2 diabetic women. Most major subgroups of anomalies had PRs above 1, including cardiovascular, genitourinary, musculoskeletal, and chromosomal abnormalities. There was an unusually high PR for the rare defect 'extra-ribs', but it was based on only two cases. This study indicates that maternal pregestational type 2 diabetes is associated with a higher prevalence of specific birth defects in offspring, whereas for type 1 diabetic mothers, particularly in recent years, the association was unremarkable.

Diabetes in pregnancy among First Nations women in Alberta, Canada: a retrospective analysis

BACKGROUND

In addition to increasing the risk of adverse birth outcomes, diabetes in pregnancy is thought to be an important driver of the epidemic of type 2 diabetes affecting Canada's First Nations population. The relative contributions of gestational diabetes mellitus (GDM) and pre-existing diabetes are not well understood. We generated a comprehensive epidemiological profile of diabetes in pregnancy over a 10-year period among the First Nations population of Alberta, Canada.

METHODS

De-identified administrative data for 427,058 delivery records were obtained for the years 2000-2009. Pregnancy risk factors and delivery outcomes were described and compared by ethnicity (First Nations vs. non-First Nations) and diabetes status. Age-adjusted prevalence values for GDM and pre-existing diabetes were calculated and were compared by ethnicity. Longitudinal changes over time were also examined. Predictors were explored using logistic regression analysis.

RESULTS

First Nations women had more antenatal risk factors and adverse infant outcomes that were compounded by diabetes. First Nations descent was an independent predictor of diabetes in pregnancy (p < 0.001). GDM prevalence was significantly higher among First Nations (6.1%) compared to non-First Nations women (3.8%; p < 0.001), but prevalence values increased significantly over time only in non-First Nations women (4.5 average annual percent change; p < 0.05). The prevalence of pre-existing diabetes was stable over time in both groups, but First Nations women experienced a 2.5-fold higher overall prevalence compared with non-First Nations women (1.5% vs. 0.6%, respectively; p < 0.001).

CONCLUSIONS

Although First Nations women experience a higher overall prevalence of diabetes in pregnancy, the lack of increase in the prevalence over time is encouraging. However, because high-risk pregnancies and poor outcomes are more common among First Nations women, particularly those with diabetes, strategies to improve perinatal care must be implemented.

Pregnancy losses in women with Type 1 or Type 2 diabetes in the UK: an investigation using primary care records

AIM

This study aims to investigate pregnancy losses in women with Type 1 or Type 2 diabetes and compare this with the general population.

METHODS

Pregnancies ending between 1993 and 2006 in those with Type 1 or Type 2 diabetes were identified on the General Practice Research Database. Pregnancy losses were identified from medical records and the cohort described by their characteristics and prescribing for diabetes.

RESULTS

Of 2001 pregnancies identified in women with Type 1 diabetes, 678 ended in a pregnancy loss: 19.6% were spontaneous, 9.6% were induced and 4.3% were losses for unknown reasons. In women with Type 2 diabetes, there were 240 losses in 669 pregnancies: 21.1% were spontaneous, 10.3% induced and 4.0% were losses for unknown reasons. The proportion of spontaneous losses in women with diabetes was higher than in the general population (13.2%). Women with Type 1 diabetes treated with human and analogue insulins were 60% more likely to have a delivery than a loss (odds ratio 1.6, 95% CI 1.18-2.18) compared with human insulin treatment alone, although numbers were small.

CONCLUSION

We found that the proportions of spontaneous losses in women with Type 1 or Type 2 diabetes were similar at approximately 20%, which is higher than in the general population and also higher than previous studies have reported. While much emphasis has been placed on pre-conception care for women with Type 1 diabetes, the same is now needed for those with Type 2 diabetes, given the similarity in outcomes and increasing prevalence of this condition.

Perinatal outcomes in type 2 diabetes

Over the past decade the prevalence of type 2 diabetes in pregnancy has continued to increase. It is vital that health care professionals recognize that preconception care is just as important for mothers with type 2 diabetes as it is in type 1 diabetes. All women with type 2 diabetes should be advised regarding safe effective contraception and the benefits of optimal glycemic control, folic acid supplementation, and avoidance of potentially harmful mediations before attempting pregnancy. Glycemic control is the most important modifiable risk factor for congenital anomaly in women with type 2 diabetes, whereas maternal obesity and social disadvantage are associated with large for gestational age neonates. This review aims to bring the reader up to date with the burden of perinatal outcomes and clinical interventions to improve maternal and infant health. It warns that the consequences of type 2 diabetes pregnancy do not end at birth.

Poor glycemic control in younger women attending Malaysian public primary care clinics: findings from adults diabetes control and management registry

BACKGROUND

Women of reproductive age are a group of particular concern as diabetes may affect their pregnancy outcome as well as long-term morbidity and mortality. This study aimed to compare the clinical profiles and glycemic control of reproductive and non-reproductive age women with type 2 diabetes (T2D) in primary care settings, and to determine the associated factors of poor glycemic control in the reproductive age group women.

METHODS

This was a cross-sectional study using cases reported by public primary care clinics to the Adult Diabetes Control and Management registry from 1st January to 31st December 2009. All Malaysian women aged 18 years old and above and diagnosed with T2D for at least 1 year were included in the analysis. The target for glycemic control (HbA1c < 6.5%) is in accordance to the recommended national guidelines. Both univariate and multivariate approaches of logistic regression were applied to determine whether reproductive age women have an association with poor glycemic control.

RESULTS

Data from a total of 30,427 women were analyzed and 21.8% (6,622) were of reproductive age. There were 12.5% of reproductive age women and 18.0% of non-reproductive age women that achieved glycemic control. Reproductive age group women were associated with poorer glycemic control (OR = 1.5, 95% CI = 1.2-1.8). The risk factors associated with poor glycemic control in the reproductive age women were being of Malay and Indian race, longer duration of diabetes, patients on anti-diabetic agents, and those who had not achieved the target total cholesterol and triglycerides.

CONCLUSION

Women with T2D have poor glycemic control, but being of reproductive age was associated with even poorer control. Health care providers need to pay more attention to this group of patients especially for those with risk factors. More aggressive therapeutic strategies to improve their cardiometabolic control and pregnancy outcome are warranted.

The challenges and future considerations regarding pregnancy-related outcomes in women with pre-existing diabetes

Ineffective management of blood glucose levels during preconception and pregnancy has been associated with severe maternal and fetal complications in women with pre-existing diabetes. Studies have demonstrated that preconception counseling and pre-pregnancy care can dramatically reduce these risks. However, pregnancy-related outcomes in women with diabetes continue to be less than ideal. This review highlights and discusses a variety of patient, provider, and organizational factors that can contribute to these suboptimal outcomes. Based on the findings of studies reviewed and authors' clinical and research experiences, recommendations have been proposed focusing on various aspects of care provided, including improved accessibility to effective preconception and pregnancy-related care and better organized clinic consultations that are sensitive to women's diabetes and pregnancy needs.

Maternal and child undernutrition and overweight in low-income and middle-income countries

Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition and a growing problem with overweight and obesity. Low body-mass index, indicative of maternal undernutrition, has declined somewhat in the past two decades but continues to be prevalent in Asia and Africa. Prevalence of maternal overweight has had a steady increase since 1980 and exceeds that of underweight in all regions. Prevalence of stunting of linear growth of children younger than 5 years has decreased during the past two decades, but is higher in south Asia and sub-Saharan Africa than elsewhere and globally affected at least 165 million children in 2011; wasting affected at least 52 million children. Deficiencies of vitamin A and zinc result in deaths; deficiencies of iodine and iron, together with stunting, can contribute to children not reaching their developmental potential. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and, for survivors, of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. We estimate that undernutrition in the aggregate--including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc along with suboptimum breastfeeding--is a cause of 3·1 million child deaths annually or 45% of all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidity and infant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity, diabetes, and non-communicable diseases. The high present and future disease burden caused by malnutrition in women of reproductive age, pregnancy, and children in the first 2 years of life should lead to interventions focused on these groups.

Adiposity and hyperglycaemia in pregnancy and related health outcomes in European ethnic minorities of Asian and African origin: a review

BACKGROUND

Ethnic minorities in Europe have high susceptibility to type 2 diabetes (T2DM) and, in some groups, also cardiovascular disease (CVD). Pregnancy can be considered a stress test that predicts future morbidity patterns in women and that affects future health of the child.

OBJECTIVE

TO REVIEW ETHNIC DIFFERENCES IN: 1) adiposity, hyperglycaemia, and pre-eclampsia during pregnancy; 2) future risk in the mother of obesity, T2DM and CVD; and 3) prenatal development and possible influences of maternal obesity, hyperglycaemia, and pre-eclampsia on offspring's future disease risk, as relevant for ethnic minorities in Europe of Asian and African origin.

DESIGN

Literature review.

RESULTS

Maternal health among ethnic minorities is still sparsely documented. Higher pre-pregnant body mass index (BMI) is found in women of African and Middle Eastern descent, and lower BMI in women from East and South Asia compared with women from the majority population. Within study populations, risk of gestational diabetes mellitus (GDM) is considerably higher in many minority groups, particularly South Asians, than in the majority population. This increased risk is apparent at lower BMI and younger ages. Women of African origin have higher risk of pre-eclampsia. A GDM pregnancy implies approximately seven-fold higher risk of T2DM than normal pregnancies, and both GDM and pre-eclampsia increase later risk of CVD. Asian neonates have lower birth weights, and mostly also African neonates. This may translate into increased risks of later obesity, T2DM, and CVD. Foetal overgrowth can promote the same conditions. Breastfeeding represents a possible strategy to reduce risk of T2DM in both the mother and the child.

CONCLUSIONS

Ethnic minority women in Europe with Asian and African origin and their offspring seem to be at increased risk of T2DM and CVD, both currently and in the future. Pregnancy is an important window of opportunity for short and long-term disease prevention.

Women with pre-existing diabetes and their experiences of maternity care services

AIMS AND OBJECTIVES

the aims of the study were to explore the experience of maternity care services used by women whose pregnancy is complicated by pre-existing diabetes, to gain a deeper understanding of service use and to identify aspects of services that women with pre-existing diabetes would like improved.

BACKGROUND

for women with pre-existing diabetes; pregnancy, birth and the transition to motherhood can be complex and even chaotic. The aim of specialist diabetes care given during pregnancy and delivered by a specialist team of health-care professionals is to optimise pregnancy outcome. However, how health-care professionals within maternity services provide care and support women with pre-existing diabetes during pregnancy and early motherhood has received limited attention.

DESIGN

an exploratory study utilising a grounded theory approach was conducted. Data were collected via in-depth interviews with 20 respondents; one-to-one, dyad and group interviews were undertaken to fully explore issues. Analysis was undertaken by sub-groups of the research team with at least two members working on each of them.

FINDINGS

three themes were identified from interviews: empathic care with care more focused on diabetes not pregnancy; feeling judged by health-care professionals (with nearly all respondents reporting negative encounters of consultation with the specialist team); and the notion of expertise (with respondents reporting feeling frustrated when it seemed health-care professionals did not value their expertise).

CONCLUSIONS

the study emphasised the importance of the health-care relationship for pregnant women with pre-existing diabetes. For outcomes to be optimised women need to be able to form open and trusting relationships with the health-care team.

RELEVANCE TO CLINICAL PRACTICE

this study highlights the need for the health-care team not only to provide physical care to optimise outcome but also supportive care to assist women with pregnancies complicated by diabetes to achieve the best possible physical and emotional health and well-being.

Stillbirth in diabetic pregnancies

Pregnancy in women with pregestational diabetes is associated with high perinatal morbidity and mortality. Stillbirth accounts for the majority of cases with perinatal death. Intrauterine growth restriction, pre-eclampsia, foetal hypoxia and congenital malformations may be contributing factors, but more than 50% of stillbirths are unexplained. Majority of stillbirths are characterised by suboptimal glycaemic control during pregnancy. Foetal hypoxia and cardiac dysfunction secondary to poor glycaemic control are probably the most important pathogenic factors in stillbirths among pregnant diabetic women. There is thus a need for new strategies for improving glycaemic control to near-normal levels throughout pregnancy and for preventing and treating hypertensive disorders in pregnancy. Antenatal surveillance tests including ultrasound examinations of the foetal growth rate, kick counting and non-stress testing of foetal cardiac function are widely used. However, future research should establish better antenatal surveillance tests to identify the infants susceptible to stillbirth before it happens.