Diastolic blood pressure is a potentially modifiable risk factor for preeclampsia in women with pre-existing diabetes

Danish Diabetes Birth Registry 2: a study protocol of a national prospective cohort study to monitor outcomes of pregnancies of women with pre-existing diabetes

INTRODUCTION

Despite technological developments and intensified care, pregnancies in women with pre-existing diabetes are still considered high-risk pregnancies. The rate of adverse outcomes in pregnancies affected by diabetes in Denmark is currently unknown, and there is a limited understanding of mechanisms contributing to this elevated risk. To address these gaps, the Danish Diabetes Birth Registry 2 (DDBR2) was established. The aims of this registry are to evaluate maternal and fetal-neonatal outcomes based on 5 years cohort data, and to identify pathophysiology and risk factors associated with short-term and long-term outcomes of pregnancies in women with pre-existing diabetes.

METHODS AND ANALYSIS

The DDBR2 registry is a nationwide 5-year prospective cohort with an inclusion period from February 2023 to February 2028 of pregnancies in women with all types of pre-existing diabetes and includes registry, clinical and questionnaire data and biological samples of mother-partner-child trios. Eligible families (parents age ≥18 years and sufficient proficiency in Danish or English) can participate by either (1) basic level data obtained from medical records (mother and child) and questionnaires (partner) or (2) basic level data and additional data which includes questionnaires (mother and partner) and blood samples (all). The primary maternal outcome is Hemoglobin A1c (HbA1c) levels at the end of pregnancy and the primary offspring endpoint is the birth weight SD score. The DDBR2 registry will be complemented by genetic, epigenetic and metabolomic data as well as a biobank for future research, and the cohort will be followed through data from national databases to illuminate possible mechanisms that link maternal diabetes and other parental factors to a possible increased risk of adverse long-term child outcomes.

ETHICS AND DISSEMINATION

Approval from the Ethical Committee is obtained (S-20220039). Findings will be sought published in international scientific journals and shared among the participating hospitals and policymakers.

TRIAL REGISTRATION NUMBER

NCT05678543.

Fourteen weeks of multicomponent training associated with flexibility training modifies postural alignment, joint range of motion and modulates blood pressure in physically inactive older women: a randomized clinical trial

Background: Body relaxation and pain reduction are some of the reported benefits of flexibility training (through active stretching exercises), however their effects on posture and blood circulation are uncertain. We aimed to investigate the effects of flexibility training (through active stretching exercises) in combination with multicomponent training (MT) on blood pressure (BP), and the correlation with changes in body alignment and flexibility in physically inactive women. Methods: Women aged 60-70 years were into three groups: multicomponent training group (MT), multicomponent training plus flexibility training group (FT), and control group (CG). After randomization, the resting blood pressure was measured and the participants were reallocated into subgroups according to pressure values >130/80 mmHg (This classification is according to the American Heart Association (AHA), resulting in the subgroups: flexibility training (FT); flexibility training for hypertensive patients (FTSAH); multicomponent training (MT); multicomponent training for hypertensive patients (MTSAH); control group (CG); control group of hypertensive patients (CGSAH). The interventions lasted 14 weeks. Systolic (sBP) and diastolic (dBP) BP, range of motion (flexion and extension), and postural analysis by asymmetry in the frontal plane and asymmetry in the sagittal plane, displacement and the flexibility test were collected before (Pre) and after training (Post). In total, 141 women participated in the study (without SAH: FT = 23, MT = 20, and CG = 21; with SAH: FTSAH = 28, MTSAH = 23, and CGSAH = 26). Results: Systolic blood pressure, in the pre and post moments were: FT (116 ± 6.7 vs. 114 ± 4.7); FTSAH (144 ± 16.5 vs. 121 ± 10.1); MT: (120 ± 6.8 vs. 121 ± 7.3); MTSAH: (137 ± 10.6 vs. 126 ± 13.0); CG: (122 ± 5.3 vs. 133 ± 19.2); and CGSAH: (140 ± 9.7 vs. 143 ± 26.2), presenting an F value (p-value - group x time) of 12.00 (<0.001), with improvement in the groups who trained. The diastolic blood pressure in the pre and post moments were: FT (71 ± 4.7 vs. 74 ± 6.8); FTSAH (88 ± 9.6 vs. 70 ± 12.0); MT: (74 ± 4.5 vs. 77 ± 11.7); MTSAH: (76 ± 10.4 vs. 76 ± 10.2); CG: (69 ± 7.11 vs. 82 ± 11.4); and CGSAH: (76 ± 13.4 vs. 86.6 ± 7.7), presenting an F value (p-value - group x time) of 8.00 (p < 0.001), with improvement in the groups who trained. In the Elastic Net Regression, sBP was influenced by height (β: -0.044); hip flexion (β: 0.071); Shoulder extension (β: 0.104); low back flexion (β: 0.119) and dBP (β: 0.115). In the Elastic Net Regression, dBP was influenced by asymmetry in the sagittal plane variables (0.040); asymmetry in the frontal plane (β: 0.007); knee flexion (β: -0.398); BM (β: 0.007); Shoulder flexion (β: -0.142); Hip flexion (β: -0.004); sBP (β: 0.155) and Ankle Flexion (β: -0.001). Conclusion: The displacement of the asymmetry in the frontal plane and asymmetry in the sagittal plane, and the increase in the flexion position in the hip, lumbar, head, and knee regions, influenced the highest-pressure levels. Multicomponent training associated with flexibility training promoted improvement in body alignment, COM, and joint angles, and decreased blood pressure.

Faster-acting insulin aspart versus insulin aspart in the treatment of type 1 or type 2 diabetes during pregnancy and post-delivery (CopenFast): an open-label, single-centre, randomised controlled trial

BACKGROUND

Faster-acting insulin aspart (faster aspart) is considered safe for use during pregnancy and breastfeeding but has not been evaluated in this population. We aimed to evaluate the effect of faster aspart versus insulin aspart on fetal growth, in women with type 1 or type 2 diabetes during pregnancy and post-delivery.

METHODS

This open-label, single-centre, superiority trial was conducted at Rigshospitalet, Copenhagen, Denmark. Participants aged 18 years or older with type 1 or type 2 diabetes were stratified by diabetes type and insulin treatment modality (multiple daily injections or insulin pump), randomly assigned 1:1 to faster aspart or insulin aspart, from 8 weeks and 0 days (8+0) of gestation to 13+6 weeks of gestation, and followed up until 3 months post-delivery. Primary outcome was infant birthweight SD score. Secondary outcomes included HbA1c as well as maternal and fetal outcomes in all participants during the trial. This trial is registered with ClinicalTrials.gov, NCT03770767.

FINDINGS

Between Nov 11, 2019 and May 10, 2022, 109 participants were included in the faster aspart group and 107 in the insulin aspart group. Primary outcome data were available in 203 (94%) of 216 participants, and no participants discontinued treatment during the trial. Mean birthweight SD score was 1·0 (SD 1·4) in the faster aspart group versus 1·2 (1·3) in the insulin aspart group; estimated treatment difference -0·22 [-0·58 to 0·14]; p=0·23. At 33 weeks of gestation, mean HbA1c was 42 mmol/mol (SD 6 mmol/mol; 6·0% [SD 0·9%]) versus 43 mmol/mol (SD 7 mmol/mol; 6·1% [SD 1·2%]); estimated treatment difference -1·01 (-2·86 to 0·83), p=0·28. No additional safety issues were observed with faster aspart compared with insulin aspart.

INTERPRETATION

Treatment with faster aspart resulted in similar fetal growth and HbA1c, relative to insulin aspart, in women with type 1 or type 2 diabetes. Faster aspart can be used in women with type 1 or type 2 diabetes during pregnancy and post-delivery with no additional safety issues.

FUNDING

Novo Nordisk.

TRANSLATION

For the Danish translation of the abstract see Supplementary Materials section.

Prediction and prevention of preeclampsia in women with preexisting diabetes: the role of home blood pressure, physical activity, and aspirin

Women with type 1 or type 2 (preexisting) diabetes are four times more likely to develop preeclampsia compared with women without diabetes. Preeclampsia affects 9%-20% of pregnant women with type 1 diabetes and 7%-14% of pregnant women with type 2 diabetes. The aim of this narrative review is to investigate the role of blood pressure (BP) monitoring, physical activity, and prophylactic aspirin to reduce the prevalence of preeclampsia and to improve pregnancy outcome in women with preexisting diabetes. Home BP and office BP in early pregnancy are positively associated with development of preeclampsia, and home BP and office BP are comparable for the prediction of preeclampsia in women with preexisting diabetes. However, home BP is lower than office BP, and the difference is greater with increasing office BP. Daily physical activity is recommended during pregnancy, and limiting sedentary behavior may be beneficial to prevent preeclampsia. White coat hypertension in early pregnancy is not a clinically benign condition but is associated with an elevated risk of developing preeclampsia. This renders the current strategy of leaving white coat hypertension untreated debatable. A beneficial preventive effect of initiating low-dose aspirin (150 mg/day) for all in early pregnancy has not been demonstrated in women with preexisting diabetes.

Management of type 2 diabetes in pregnancy: a narrative review

The prevalence of type 2 diabetes (T2DM) at reproductive age is rising. Women with T2DM have a similarly high risk for pregnancy complications as pregnant women with type 1 diabetes. To reduce adverse pregnancy and neonatal outcomes, such as preeclampsia and preterm delivery, a multi-target approach is necessary. Tight glycemic control together with appropriate gestational weight gain, lifestyle measures, and if necessary, antihypertensive treatment and low-dose aspirin is advised. This narrative review discusses the latest evidence on preconception care, management of diabetes-related complications, lifestyle counselling, recommendations on gestational weight gain, pharmacologic treatment and early postpartum management of T2DM.

Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets

Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.

Treatment of obstructive sleep apnea in high risk pregnancy: a multicenter randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) during pregnancy is a risk factor for preeclampsia possibly through a link to placental physiology. This study evaluates the efficacy of continuous positive airway pressure (CPAP) on the modulation of blood pressure and the reduction in preeclampsia in women with high-risk pregnancy and OSA.

METHODS

A multicenter open-label, randomized controlled trial comparing CPAP treatment versus usual antenatal care was conducted in three academic hospitals in Bangkok, Thailand. Participants included singleton pregnant women aged older than 18 years with any high-risk condition (i.e., chronic hypertension, obesity, history of preeclampsia or gestational diabetes in the previous pregnancy, or diabetes), and OSA (respiratory disturbance index 5-29.99 events/hour by polysomnography), who presented either in the first trimester (gestational age, GA 0-16 weeks) or subsequently developed OSA during the 2nd trimester (GA 24-28 weeks). The primary endpoint was blood pressure during antenatal care. Secondary endpoints included the incidence of preeclampsia. An intention-to-treat analysis was performed with additional per-protocol and counterfactual analyses for handling of nonadherence.

RESULTS

Of 340 participants, 96.5% were recruited during the first trimester. Thirty participants were later excluded leaving 153 and 157 participants in the CPAP and usual-care groups for the modified-intention-to-treat analysis. CPAP adherence rate was 32.7% with average use of 2.5 h/night. Overall, CPAP treatment significantly lowered diastolic blood pressure (DBP) by - 2.2 mmHg [95% CI (- 3.9, - 0.4), p = 0.014], representing approximately - 0.5 mmHg per hour of CPAP use [95%CI (- 0.89, - 0.10), p = 0.013]. CPAP treatment also altered the blood pressure trajectory by continuously lowering DBP throughout pregnancy with mean differences (95% CI) of - 3.09 (- 5.34, - 0.93), - 3.49 (- 5.67, - 1.31) and - 3.03 (- 5.20, - 0.85) mmHg at GA 18-20, 24-28, and 32-34 weeks, respectively compared to 0-16 weeks. Preeclampsia rate was 13.1% (20/153 participants) in the CPAP and 22.3% (35/157 participants) in the usual-care group with a risk difference (95% CI) of - 9% (- 18%, - 1%, p-value = 0.032) and a number-needed-to-treat (95% CI) of 11 (1, 21).

CONCLUSIONS

CPAP treatment in women with even mild-to-moderate OSA and high-risk pregnancy demonstrated reductions in both DBP and the incidence of preeclampsia. CPAP treatment also demonstrated a sustained reduction in DBP throughout gestation. Trial registration ClinicalTrial.GovNCT03356106, retrospectively registered November 29, 2017.

Alterations in the Gut Microbiota in Pregnant Women with Pregestational Type 2 Diabetes Mellitus

Human gut dysbiosis is associated with type 2 diabetes mellitus (T2DM); however, the gut microbiome in pregnant women with pregestational type 2 diabetes mellitus (PGDM) remains unexplored. We investigated the alterations in the gut microbiota composition in pregnant women with or without PGDM. The gut microbiota was examined using 16S rRNA sequencing data of 234 maternal fecal samples that were collected during the first (T1), second (T2), and third (T3) trimesters. The PGDM group presented a reduction in the number of gut bacteria taxonomies as the pregnancies progressed. Linear discriminant analyses revealed that Megamonas, Bacteroides, and Roseburia intestinalis were enriched in the PGDM group, whereas Bacteroides vulgatus, Faecalibacterium prausnitzii, Eubacterium rectale, Bacteroides uniformis, Eubacterium eligens, Subdoligranulum, Bacteroides fragilis, Dialister, Lachnospiraceae, Christensenellaceae R-7, Roseburia inulinivorans, Streptococcus oralis, Prevotella melaninogenica, Neisseria perflava, Bacteroides ovatus, Bacteroides caccae, Veillonella dispar, and Haemophilus parainfluenzae were overrepresented in the control group. Correlation analyses showed that the PGDM-enriched taxa were correlated with higher blood glucose levels during pregnancy, whereas the taxonomic biomarkers of normoglycemic pregnancies exhibited negative correlations with glycemic traits. The microbial networks in the PGDM group comprised weaker microbial interactions than those in the control group. Our study reveals the distinct characteristics of the gut microbiota composition based on gestational ages between normoglycemic and PGDM pregnancies. Further longitudinal research involving women with T2DM at preconception stages and investigations using shotgun metagenomic sequencing should be performed to elucidate the relationships between specific bacterial functions and PGDM metabolic statuses during pregnancy and to identify potential therapeutic targets. IMPORTANCE The incidence of pregestational type 2 diabetes mellitus (PGDM) is increasing, with high rates of serious adverse maternal and neonatal outcomes that are strongly correlated with hyperglycemia. Recent studies have shown that type 2 diabetes mellitus is associated with gut microbial dysbiosis; however, the gut microbiome composition and its associations with the metabolic features of patients with PGDM remain largely unknown. In this study, we investigated the changes in the gut microbiota composition in pregnant women with and without PGDM. We identified differential taxa that may be correlated with maternal metabolic statuses during pregnancy. Additionally, we observed that the number of taxonomic and microbial networks of gut bacteria were distinctly reduced in women with hyperglycemia as their pregnancies progressed. These results extend our understanding of the associations between the gut microbial composition, PGDM-related metabolic changes, and pregnancy outcomes.

Secular trend for increasing birthweight in offspring of pregnant women with type 1 diabetes: is improved placentation the reason?

Despite enormous progress in managing blood glucose levels, pregnancy in women with type 1 diabetes still carries risks for the growing fetus. While, previously, fetal undergrowth was not uncommon in these women, with improved maternal glycaemic control we now see an increased prevalence of fetal overgrowth. Besides short-term implications, offspring of women with type 1 diabetes are more likely to become obese and to develop diabetes and features of the metabolic syndrome. Here, we argue that the increase in birthweight is paradoxically related to improved glycaemic control in the pre- and periconceptional periods. Good glycaemic control reduces the prevalence of microangiopathy and improves placentation in early pregnancy, which may lead to unimpeded fetal nutrition. Even mild maternal hyperglycaemia may then later result in fetal overnutrition. This notion is supported by circumstantial evidence that lower HbA_1c levels as well as increases in markers of placental size and function in early pregnancy are associated with large-for-gestational age neonates. We also emphasise that neonates with normal birthweight can have excessive fat deposition. This may occur when poor placentation leads to initial fetal undergrowth, followed by fetal overnutrition due to maternal hyperglycaemia. Thus, the complex interaction of glucose levels during different periods of pregnancy ultimately determines the risk of adiposity, which can occur in fetuses with both normal and elevated birthweight. Prevention of fetal adiposity calls for revised goal setting to enable pregnant women to maintain blood glucose levels that are closer to normal. This could be supported by continuous glucose monitoring throughout pregnancy and appropriate maternal gestational weight gain. Future research should consider the measurement of adiposity in neonates.

Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding

In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m2. Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.

Complex Management of Nephrotic Syndrome and Kidney Failure during Pregnancy in a Type 1 Diabetes Patient: A Challenging Case

Pregnancy with chronic kidney disease is challenging, and patients with diabetic nephropathy are at particular risk of a rapid kidney function decline during pregnancy. While indications for the management of pregnant patients with initial diabetic nephropathy are widely available in the literature, data on patients with severe nephrotic syndrome and kidney function impairment are lacking, and the decision on whether and when dialysis should be initiated is not univocal. We report a type 1 diabetes patient who started pregnancy with a severe nephrotic syndrome and shifted from CKD stage 3b to stage 5 during pregnancy. The management was complicated by a fetal heart malformation and by poorly controlled diabetes. The evidence for and against starting dialysis was carefully evaluated, and the choice of strict nephrological and obstetrical monitoring, nutritional management, and diuretic treatment made it possible to avoid dialysis in pregnancy, after ruling out pre-eclampsia. This experience enables examination of some open issues and contributes to the discussion of when to start dialysis in pregnancy.

Home Blood Pressure for the Prediction of Preeclampsia in Women With Preexisting Diabetes

CONTEXT

Outside of pregnancy, home blood pressure (BP) has been shown to be superior to office BP for predicting cardiovascular outcomes.

OBJECTIVE

This work aimed to evaluate home BP as a predictor of preeclampsia in comparison with office BP in pregnant women with preexisting diabetes.

METHODS

A prospective cohort study was conducted of 404 pregnant women with preexisting diabetes; home BP and office BP were measured in early (9 weeks) and late pregnancy (35 weeks). Discriminative performance of home BP and office BP for prediction of preeclampsia was assessed by area under the receiver operating characteristic curves (AUC).

RESULTS

In total 12% (n = 49/404) developed preeclampsia. Both home BP and office BP in early pregnancy were positively associated with the development of preeclampsia (adjusted odds ratio (95% CI) per 5 mm Hg, systolic/diastolic): home BP 1.43 (1.21-1.70)/1.74 (1.34-2.25) and office BP 1.22 (1.06-1.40)/1.52 (1.23-1.87). The discriminative performance for prediction of preeclampsia was similar for early-pregnancy home BP and office BP (systolic, AUC 69.3 [61.3-77.2] vs 64.1 [55.5-72.8]; P = .21 and diastolic, AUC 68.6 [60.2-77.0] vs 66.6 [58.2-75.1]; P = .64). Similar results were seen when comparing AUCs in late pregnancy (n = 304). In early and late pregnancy home BP was lower than office BP (early pregnancy P < .0001 and late pregnancy P < .01 for both systolic and diastolic BP), and the difference was greater with increasing office BP.

CONCLUSION

In women with preexisting diabetes, home BP and office BP were positively associated with the development of preeclampsia, and for the prediction of preeclampsia home BP and office BP were comparable.

Improving preeclampsia risk prediction by modeling pregnancy trajectories from routinely collected electronic medical record data

Preeclampsia is a heterogeneous and complex disease associated with rising morbidity and mortality in pregnant women and newborns in the US. Early recognition of patients at risk is a pressing clinical need to reduce the risk of adverse outcomes. We assessed whether information routinely collected in electronic medical records (EMR) could enhance the prediction of preeclampsia risk beyond what is achieved in standard of care assessments. We developed a digital phenotyping algorithm to curate 108,557 pregnancies from EMRs across the Mount Sinai Health System, accurately reconstructing pregnancy journeys and normalizing these journeys across different hospital EMR systems. We then applied machine learning approaches to a training dataset (N = 60,879) to construct predictive models of preeclampsia across three major pregnancy time periods (ante-, intra-, and postpartum). The resulting models predicted preeclampsia with high accuracy across the different pregnancy periods, with areas under the receiver operating characteristic curves (AUC) of 0.92, 0.82, and 0.89 at 37 gestational weeks, intrapartum and postpartum, respectively. We observed comparable performance in two independent patient cohorts. While our machine learning approach identified known risk factors of preeclampsia (such as blood pressure, weight, and maternal age), it also identified other potential risk factors, such as complete blood count related characteristics for the antepartum period. Our model not only has utility for earlier identification of patients at risk for preeclampsia, but given the prediction accuracy exceeds what is currently achieved in clinical practice, our model provides a path for promoting personalized precision therapeutic strategies for patients at risk.

The impact of anti-hypertensive treatment on foetal growth and haemodynamics in pregnant women with pre-existing diabetes - An explorative study

OBJECTIVES

To explore the impact of anti-hypertensive treatment of pregnancy-induced hypertension on foetal growth and hemodynamics in women with pre-existing diabetes.

METHODS

A prospective cohort study of 247 consecutive pregnant women with pre-existing diabetes (152 type 1 diabetes; 95 type 2 diabetes), where tight anti-hypertensive treatment was initiated and intensified (mainly with methyldopa) when office blood pressure (BP) ≥135/85 mmHg and home BP ≥130/80 mmHg. Foetal growth was assessed by ultrasound at 27, 33 and 36 weeks and foetal hemodynamics were assessed by ultrasound Doppler before and 1-2 weeks after initiation of anti-hypertensive treatment.

RESULTS

In 215 initially normotensive women, anti-hypertensive treatment for pregnancy-induced hypertensive disorders was initiated in 42 (20%), whilst 173 were left untreated. Chronic hypertension was present in 32 (13%). Anti-hypertensive treatment for pregnancy-induced hypertensive disorders was not associated with foetal growth deviation (linear mixed model, p = 0.681). At 27 weeks, mainly before initiation of anti-hypertensive treatment, the prevalence of small foetuses with an estimated foetal weight <10th percentile was 12% in women initiating anti-hypertensive treatment compared with 4% in untreated women (p = 0.054). These numbers were close to the prevalence of birth weight ≤10th percentile (small for gestational age (SGA)) (17% vs. 4%, p = 0.003). Pulsatility index in the umbilical and middle cerebral artery remained stable after the onset of anti-hypertensive treatment in a representative subgroup (n = 12, p = 0.941 and p = 0.799, respectively).

CONCLUSION

There is no clear indication that antihypertensive treatment causes harm in this particular at-high-risk group of pregnant women with diabetes, such that a larger well-designed study to determine the value of tight antihypertensive control would be worthwhile.

Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis

BACKGROUND

The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population.

METHODS AND FINDINGS

We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes.

CONCLUSIONS

In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.

Potentially modifiable risk factors of preterm delivery in women with type 1 and type 2 diabetes

AIMS/HYPOTHESIS

We aimed to identify potentially modifiable risk factors and causes for preterm delivery in women with type 1 or type 2 (pre-existing) diabetes.

METHODS

A secondary analysis of a prospective cohort study of 203 women with pre-existing diabetes (117 type 1 and 86 type 2 diabetes) was performed. Consecutive singleton pregnancies were included at the first antenatal visit between September 2015 and February 2018.

RESULTS

In total, 27% (n = 55) of the 203 women delivered preterm at median 36 + 0 weeks. When stratified by diabetes type, 33% of women with type 1 diabetes delivered preterm compared with 20% in women with type 2 diabetes (p = 0.04). Women delivering preterm were characterised by a higher prevalence of pre-existing kidney involvement (microalbuminuria or diabetic nephropathy) (16% vs 3%, p = 0.002), preeclampsia (26% vs 5%, p < 0.001), higher positive ultrasound estimated fetal weight deviation at 27 gestational weeks (2.7% vs -1.6% from the mean, p = 0.008), higher gestational weight gain (399 g/week vs 329 g/week, p = 0.01) and similar HbA_1c levels in early pregnancy (51 mmol/mol [6.8%] vs 49 [6.6%], p = 0.22) when compared with women delivering at term. Independent risk factors for preterm delivery were pre-existing kidney involvement (OR 12.71 [95% CI 3.0, 53.79]), higher gestational weight gain (per 100 g/week, OR 1.25 [1.02, 1.54]), higher positive ultrasound estimated fetal weight deviation at 27 gestational weeks (% from the mean, OR 1.07 [1.03, 1.12]) and preeclampsia (OR 7.04 [2.34, 21.19]). Two-thirds of preterm deliveries were indicated and one-third were spontaneous. Several contributing factors to indicated preterm delivery were often present in each woman. The main indications were suspected fetal asphyxia (45%), hypertensive disorders (34%), fetal overgrowth (13%) and maternal indications (8%). Suspected fetal asphyxia mainly included falling insulin requirement and abnormal fetal haemodynamics.

CONCLUSIONS/INTERPRETATIONS

Presence of preeclampsia, higher positive ultrasound estimated fetal weight deviation at 27 gestational weeks and higher gestational weight gain were independent potentially modifiable risk factors for preterm delivery in this cohort of women with pre-existing diabetes. Indicated preterm delivery was common with suspected fetal asphyxia or preeclampsia as the most prevalent causes. Prospective studies evaluating whether modifying these predictors will reduce the prevalence of preterm delivery are warranted.

CopenFast trial: Faster-acting insulin Fiasp versus insulin NovoRapid in the treatment of women with type 1 or type 2 diabetes during pregnancy and lactation - a randomised controlled trial

INTRODUCTION

Faster-acting insulin aspart (Fiasp) is approved for use in pregnancy and lactation, but no clinical study has evaluated its effects during this life stage in women with pre-existing diabetes. The aim of the CopenFast trial is to evaluate the effect of Fiasp compared with insulin aspart (NovoRapid) on maternal glycaemic control during pregnancy, delivery and lactation and on fetal growth and infant health.

METHODS AND ANALYSIS

An open-label randomised controlled trial of pregnant women with type 1 or type 2 diabetes including women on multiple daily injection (MDI) therapy or insulin pump therapy. During a 2-year inclusion period, approximately 220 women will be randomised 1:1 to Fiasp or NovoRapid in early pregnancy and followed until 3 months after delivery. At 9, 21 and 33 gestational weeks and during planned induction of labour or caesarean section, women are offered blinded continuous glucose monitoring (CGM) for 7 days. Randomisation will stratify for type of diabetes and insulin treatment modality (MDI or insulin pump therapy, respectively). Health status of the infants will be followed until 3 months of age. The primary outcome is birth weight SD score adjusted for gestational age and gender. Secondary outcomes include maternal glycaemic control including glycated haemoglobin, preprandial and postprandial self-monitored plasma glucose levels, episodes of mild and severe hypoglycaemia, maternal gestational weight gain and weight retention, CGM time spent in, above and below target ranges as well as pregnancy outcomes including pre-eclampsia, preterm delivery, perinatal mortality and neonatal morbidity. Data analysis will be performed according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

The trial has been approved by the Regional Ethics Committee (H-19029966) on 7 August 2019. Results will be sought disseminated in peer-reviewed journals and at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03770767.

Pregnancy Outcomes in Women with Long-Duration Type 1 Diabetes-25 Years of Experience

AIMS

Our study aimed to examine the pregnancy outcomes (maternal and fetal) concerning different models of antenatal care across a period of over 25 years (1993-2018) in 459 women with type 1 diabetes. Data from patients with a history of the condition lasting at least 15 years were considered eligible for analysis.

METHODS

The study group was divided into three cohorts based on the different models of treatment used in Poznan University Hospital, Poland: 1993-2000 (cohort I, n = 91), 2001-2005 (cohort II, n = 83), 2006-2018 (cohort III, n = 284). To identify predictors for the selected dichotomous outcomes, we calculated the risks for fetal or maternal complications as dependent variables for cohorts II and III against cohort I, using multivariate logistic regression analysis.

RESULTS

The mean gestational age was 36.8 ± 2.4 weeks in the total cohort. The percentages of deliveries before the 33rd and the 37th weeks was high. We observed a decreasing percentage during the following periods, from 41.5% in the first period to 30.4% in the third group. There was a tendency for newborn weight to show a gradual increase across three time periods (2850, 3189, 3321 g, p < 0.0001). In the last period, we noticed significantly more newborns delivered after 36 weeks with a weight above 4000 g and below 2500 g. Caesarean section was performed in 88% of patients from the whole group, but in the subsequent periods this number visibly decreased (from 97.6%, 86.7%, to 71%, p = 0.001). The number of emergency caesarean sections was lowest in the third period (27.5%, 16.7%, 11.2%, p = 0.006). We observed a decreasing number of "small for gestational age" newborns (SGA) in consecutive periods of treatment (from 24.4% to 8.7%, p = 0.002), but also a higher percentage of "large for gestational age" (LGA) newborns (from 6.1% to 21.6%, p = 0.001). Modification of treatment might be associated with the gradual reduction of SGA rates (cohort I 3.6%, cohort III 2.3% p < 0,0005).

CONCLUSIONS

Strict glycemic and blood pressure control from the very beginning of pregnancy, as well as modern fetal surveillance techniques, may contribute to the improvement of perinatal outcomes in women with long-duration type 1 diabetes.

Implementing a community-level intervention to control hypertensive disorders in pregnancy using village health workers: lessons learned

INTRODUCTION

Hypertensive disorders in pregnancy result in about 76,000 maternal deaths per year worldwide. Pre-eclampsia and eclampsia cause the most deaths. Interventions for managing these disorders are available in health facilities. We assess the effect of monitoring pregnant women's blood pressure (BP) in their homes using village health workers (VHWs) equipped with a BP-measuring device on hypertension in pregnancy, in a resource-poor setting. Also, we assess the VHWs' competence with the BP device, acceptability and appropriateness of the intervention, and factors that affect the implementation of the intervention.

METHOD

This is a mixed method study comprising quantitative and qualitative data collection. We implemented the intervention over 6 months across three local government areas in Gombe state, northeast Nigeria. The Replicating Effective Program (REP) framework guided the development of the implementation strategy. The quantitative data include routine measurement of pregnant women's blood pressure and observation of 118 VHW-client interactions. The routine data collection occurred between February and June 2019, and the observation occurred in January and June 2019. The qualitative data collection occurred via six focus group discussions with VHWs and ten in-depth interviews with community health extension workers in June 2019. We analyzed the data from the quantitative arm with SPSS version 23. For the qualitative arm, we transcribed the audio files, coded the texts, and categorized them using thematic analysis.

RESULT

Nine thousand pregnant women were recruited into the program. We observed a significant reduction in the prevalence of hypertension in pregnancy from 1.5 to 0.8% (Z = 4.04; p < 0.00001) after starting the program. Also, we found that VHWs can assess pregnant women's BP using a semi-automatic BP-measuring device. The intervention is acceptable and appropriate in resource-poor settings. Poor payment of VHW stipend and cooperation of local health staff are barriers to sustaining the intervention.

CONCLUSION

In resource-poor settings, health systems can train and equip non-technical people to identify and refer cases of high blood pressure in pregnancy to local health facilities on time. This may contribute to reducing maternal mortality and morbidity in these settings.

Visit-to-visit blood pressure variability and risk of adverse birth outcomes in pregnancies in East China

To investigate the potential associations between visit-to-visit blood pressure variability (VVV) and adverse birth outcomes in pregnancies, 48,209 pregnant women without proteinuria or chronic hypertension before 20 weeks of gestation who delivered live singletons between January 2014 and November 2019 in Taizhou or Taicang cities were recruited. VVV was estimated as the standard deviation and coefficient of variation of blood pressure [i.e., systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP)] measured from 20 weeks of gestation onwards. Pregnant women were classified into four groups according to the corresponding quartiles for each VVV index. It was found that VVV was significantly higher in women with small for gestational age (SGA) or low birth weight (LBW) infants than in their counterparts. Graded associations between VVV categories and poor birth outcomes were observed. In particular, when comparing the women with the highest to the lowest quartiles of standard deviation and coefficient variation of DBP, the odds ratios (95% confidence interval) for SGA was 1.15 (1.06-1.26) and 1.14 (1.05-1.25), respectively. Interestingly, the addition of DBP-VVV to established risk factors improved risk prediction of SGA; DBP-VVV demonstrated modestly superior predictive performance to VVV obtained from SBP or MAP. Similar results were found even among normotensive pregnancies. Our findings indicated that VVV during pregnancy, especially DBP-VVV, was independently associated with poor birth outcomes of pregnancies in East China. The inclusion of DBP-VVV with established risk factors may help in identifying pregnancies at high risk of SGA. Validations are needed.

Enhancement of heat shock protein 70 attenuates inducible nitric oxide synthase in preeclampsia complicated with fetal growth restriction

OBJECTIVES

Preeclampsia (PE) and fetal growth restriction (FGR) have abnormal placental implantation and endothelial dysfunction in common. However, their etiologies are not well understood. Both heat shock protein 70 (Hsp70) and nitric oxide (NO) are suggested to play a major role in the regulation of maternal and fetoplacental hemodynamics. In this study, the association of PE with FGR and Hsp70 or NO was analyzed.

METHODS

A total of 30 cases of PE, 25 cases of PE complicated with FGR and 50 cases of normal pregnant women were chose, and PE and normal animal models were constructed. Subsequently, the levels of Hsp70 and NO in serum and placental tissues of humans and animals were measured and compared. Further, rats were injected with pLV-NC-shRNA, pLV-Hsp70-shRNA, pLV-EFIa-NC, and pLV-EFIa-Hsp70, respectively, the weight of each conceptus, number of pups, fetal crown to tail length, total weight of the placenta/fetus unit, and the content of NO were analyzed.

RESULTS

The expression of Hsp70 in serum and placental tissues of PE complicated with or without FGR group was increased, whereas the content of NO was decreased compared to the normal group. The fetal weight (FW) of the Hsp70 targeted suppression group was higher than the other two groups, whereas the placental weight (PW) was reversed. Also, NO synthase (NOS) expression was decreased in the Hsp70 over-expression group.

CONCLUSIONS

We speculated that the enhancement of Hsp70 might be related to the development of PE combined with FGR through inhibiting the synthesis of NOS.

Physical activity, sedentary behavior and development of preeclampsia in women with preexisting diabetes

AIMS

To explore the association between physical activity in early pregnancy and development of preeclampsia in women with preexisting diabetes.

METHODS

In a prospective cohort study of 189 women with preexisting diabetes (110 type 1 and 79 type 2 diabetes), physical activity during pregnancy including sedentary behavior was evaluated with the Pregnancy Physical Activity Questionnaire. Primary outcome was preeclampsia. Secondary outcomes were preterm delivery, large and small for gestational age infants.

RESULTS

Women developing preeclampsia (n = 23) had higher diastolic blood pressure in early pregnancy (mean 82 ± 9 SD vs. 77 ± 8, p = 0.004) and were more often nulliparous (91 vs. 52%, p < 0.001) compared with the remaining women (n = 166). Total physical activity in early pregnancy was similar between the groups (median 148 metabolic equivalent of task hours per week (MET-h/week) (interquartile range 118-227) versus 153 (121-205), p = 0.97). In early pregnancy, women developing preeclampsia reported a higher level of sedentary behavior (15 MET-h/week (7-18) versus 7 (4-15); p = 0.04); however, when adjusting for parity, diastolic blood pressure and smoking, the association attenuated (p = 0.13). Total physical activity and sedentary behavior in early pregnancy were not associated with preterm delivery, large or small for gestational age infants.

CONCLUSIONS

Among women with diabetes, sedentary behavior was reported higher in early pregnancy in women developing preeclampsia compared with the remaining women, while total physical activity was similar. Sedentary behavior was a predictor of preeclampsia in the univariate analysis, but not in the multiple regression analysis, and larger studies are needed to evaluate this possible modifiable risk factor. Trial registration The study was registered at ClinicalTrials.gov (ID: NCT02890836).

Preeclampsia in women with pregestational diabetes - a cohort study

Aims: To evaluate risk factors for preeclampsia (PE) in women with pregestational diabetes.Methods: Retrospective cohort study of women with pregestational diabetes cared for at a specialized prenatal care facility. Maternal characteristics at booking and during pregnancy were studied for their association with preeclampsia. Multivariable models were tested using Poisson regression with robust estimates; results were expressed as relative risk (RR) and 95% confidence interval (CI).Results: Preeclampsia was diagnosed in 62 of 206 women (30%, 95% CI 24-37%). Previous chronic hypertension was found in 53 subjects (26%; 95% CI 20-32%), of whom 41 (77%, 95% CI 64-88) were type 2 women. Type 1 diabetes, chronic hypertension, systolic blood pressure >124 mmHg at booking and gestational weight gain, either total or excessive for body mass index category, behaved as independent risk factors.Conclusions: In women with pregestational diabetes, some risk factors may predict PE, similar to those found in non-diabetic pregnant women. Two non-modifiable factors (type of diabetes and chronic hypertension) and two modifiable ones (systolic blood pressure levels and gestational weight gain) were found relevant in this cohort. A policy of close monitoring of blood pressure and weight gain, aiming adequate weight gain, may be added to current recommended measures. The high prevalence of PE in women with prepregnancy diabetes, especially those with initial pregnancy systolic blood pressure >124 mmHg, supports a policy of early institution of low dose aspirin. Further multicentric studies will help define the role of these risk factors as contributors to PE in pregestational diabetes.

White coat hypertension in early pregnancy in women with pre-existing diabetes: prevalence and pregnancy outcomes

AIMS/HYPOTHESIS

Hypertensive disorders are prevalent among pregnant women with pre-existing diabetes, but the prevalence and impact of white coat hypertension are unknown. Measurement of home BP before initiation of antihypertensive treatment is necessary to identify white coat hypertension since international guidelines recommend that white coat hypertension is left untreated. The aim of this study, conducted among women with pre-existing diabetes, was therefore to examine the prevalence of white coat hypertension in early pregnancy, and pregnancy outcome in women with white coat hypertension in early pregnancy.

METHODS

A prospective cohort study was undertaken involving women with pre-existing diabetes from a geographically well-defined area. Based on office BP in early pregnancy and home BP measured for 3 days, women were categorised in three groups: (1) white coat hypertension, defined as office BP ≥ 135/85 mmHg and mean home BP < 130/80 mmHg; (2) chronic hypertension, defined as pre-pregnancy hypertension including newly detected office BP ≥ 135/85 mmHg with home BP ≥ 130/80 mmHg; and (3) normotension. Office BP was measured every 2 weeks and, if ≥ 135/85 mmHg, home BP measurements were performed. White coat hypertension was left untreated, and tight antihypertensive treatment was initiated when both office BP ≥ 135/85 mmHg and home BP ≥ 130/80 mmHg. Pregnancy-induced hypertensive disorders were defined as office BP ≥ 140/90 mmHg with home BP ≥ 130/80 mmHg when available, with onset after 20 weeks of gestation.

RESULTS

In total, 32 out of 222 women with pre-existing diabetes had newly detected office BP ≥ 135/85 mmHg in early pregnancy. White coat hypertension was present in 84% (27/32) of these women, representing 12% (95% CI 8%, 17%) of the whole cohort. Chronic hypertension was present in 14% (n = 32) and normotension in 74% (n = 163). Women with white coat hypertension were characterised by higher pre-pregnancy BMI (p = 0.011), higher home BP (p < 0.001) and higher prevalence of type 2 diabetes (p = 0.009), but similar HbA_1c (p = 0.409) compared to women with normotension. Regarding pregnancy outcome, pregnancy-induced hypertensive disorders developed in 44% (12/27) of women with white coat hypertension in comparison with 22% (36/163) among initially normotensive women (p = 0.013), while the prevalence of preterm delivery was comparable (p = 0.143). The adjusted analysis, performed post hoc, suggested approximately double the risk of developing pregnancy-induced hypertensive disorders (OR 2.43 [CI 0.98, 6.05]) if white coat hypertension was present in early pregnancy, independently of pre-pregnancy BMI and parity.

CONCLUSIONS/INTERPRETATION

White coat hypertension is prevalent in women with pre-existing diabetes and may indicate a high risk of later development of pregnancy-induced hypertensive disorders. To distinguish between persistent white coat hypertension and onset of pregnancy-induced hypertension, repeated home BP monitoring is recommended when elevated office BP is detected. The study was registered at ClinicalTrials.gov (ID: NCT02890836).

Improving pregnancy outcomes in women with diabetes mellitus: modern management

Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.

Treatment with the long-acting insulin analog degludec during pregnancy in women with type 1 diabetes: An observational study of 22 cases

AIM

To report glycemic control and pregnancy outcome in pregnant women with type 1 diabetes on insulin degludec.

METHODS

Twenty-two women with type 1 diabetes on degludec from conception to delivery between 2014 and 2018 were compared with 51 pregnant women with type 1 diabetes on glargine.

RESULTS

Baseline characteristics were comparable, however HbA1c was higher at median 9 (range 5-19) weeks in women on degludec compared to women on glargine (6.9% (5.7-8.7); (52 (39-72) mmol/mol) versus 6.4% (5.1-10.1); (46 (32-87) mmol/mol), p = 0.04). HbA1c was similar in late pregnancy (6.3% (5.6-7.1); (45 (38-54) mmol/mol) versus 6.1% (5.2-9.0); (43 (33-75) mmol/mol), p = 0.28). The prevalence of severe hypoglycemia was 3 (14%) versus 6 (12%), p = 1.00 during pregnancy and 0 versus 1, p = 1.00 during hospital admittance after delivery. Most women on degludec used one daily injection in early (20 (91%) versus 25 (49%), p = 0.001) and late pregnancy (21 (96%) versus 19 (37%), p < 0.001). No significant differences in obstetrical and neonatal outcomes were found between the groups. Maternal hospital admittance after delivery was 2 (1-5) versus 3 (2-11) days (p = 0.004).

CONCLUSIONS

Glycemic control in late pregnancy, severe hypoglycemia during and immediately after pregnancy as well as pregnancy outcome were comparable in women on degludec or glargine. Degludec initiated preconceptionally may be continued in pregnancy.

The association of metabolic syndrome components and diabetes mellitus: evidence from China National Stroke Screening and Prevention Project

Background

The metabolic syndrome (MetS) is related with cardiovascular disease. However, its relationship with diabetes mellitus (DM) has not been examined in Chinese population with a larger sample. We aimed to assess the relationship between metabolic syndrome (MetS) and its components, and DM, and to determine the best one from the available definitions of Mets when assessing the risk of DM.

Methods

This was a cross-sectional survey in a nationally representative sample of 109,551 Chinese adults aged ≥40 years in 2014–15. MetS was defined according to three criteria including the updated International Diabetes Federation (IDF) criterion, the National Cholesterol Education Program Third Adult Treatment Panel (NCEP ATP III) criterion and American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI) criterion. Logistic regression models were used to estimate the odds of DM.

Results

MetS as defined by three criteria including IDF, NCEP ATP III,and AHA/NHLBI all increased the prevalence of DM, and the adjusted ORs with 95% CI was more higher using NCEP ATP III (3.65, 3.52–3.79) than IDF (2.50, 2.41–2.60) and AHA/NHLBI (3.03, 2.92–3.24). The odds of DM was highest in hyperglycemia with cut-off glucose≥6.1 mmol/L (14.55, 13.97–15.16), and other components were also associated significantly with DM. There was heterogeneity for OR of DM associated with various trait combinations.

Conclusions

The NCEP ATPIII MetS definition may be more suitable for assessment of DM risk in Chinese population. Hyperglycemia, as previous study reported, are important risk factors of DM. Besides, other traits of Mets are also significantly associated with DM and should therefore be of greater concern.