Importance of early elevated maternal HbA1c levels in identifying adverse fetal and neonatal events

Impact of experiencing multiple vulnerabilities on fetal growth and complications in women with hyperglycemia in pregnancy

BACKGROUND

In women with hyperglycemia in pregnancy living in France, psychosocial deprivation is associated with both earlier and greater exposure to the condition, as well as poorer maternofetal prognosis. We explored the impact of this and two other socioeconomic vulnerability indicators-food insecurity and poor language proficiency-on adherence to prenatal care and maternal and fetal outcomes.

METHODS

In a socially deprived suburb of Paris, we selected women who delivered between 01/01/2012 and 31/12/2018 and received care (nurse, dietician, diabetologist evaluation, advice, regular follow-up to adjust insulin doses if requested) for hyperglycemia in pregnancy. We analyzed the associations between individual psychosocial deprivation, food insecurity, French language proficiency (variables assessed by individual questionnaires) and fetal growth (main outcome), as well as other core maternal and fetal outcomes.

RESULTS

Among the 1,168 women included (multiethnic cohort, 19.3% of whom were Europeans), 56%, 17.9%, and 27.5% had psychosocial deprivation, food insecurity, and poor French language proficiency, respectively. Forty-three percent were prescribed insulin therapy. Women with more than one vulnerability had more consultations for diabetes. The rates for small (SGA), appropriate (AGA), and large-for-gestational-age (LGA) infant were 11.4%, 76.5% and 12.2%, respectively. These rates were similar in women with and without psychosocial deprivation, and in those with and without food insecurity. Interestingly, women with poor French language proficiency had a higher odds ratio of delivering a small- or large-for-gestational age infant than those with good proficiency.

CONCLUSION

We found similar pregnancy outcomes for women with hyperglycemia in pregnancy living in France, irrespective of whether or not they had psychosocial deprivation or food insecurity. Optimized single-center care with specialized follow-up could contribute to reduce inequalities in maternal and fetal outcomes in women with hyperglycemia in pregnancy.

Call for a More Specific Diagnosis of Infant of a Diabetic Mother to Optimize Neonatal Care

Hyperglycemia is the diagnostic feature of diabetes mellitus (DM), and during pregnancy, hyperglycemia has numerous serious implications for organogenesis and fetal growth. Each type of DM has different neonatal implications based on pathogenesis, length of disease, and comorbidities. Currently, limited attention is given to the woman's type of DM when evaluating risks for neonates. The diagnosis of infant of a diabetic mother is not sufficient because of the varying pathophysiology of diabetes classifications and associated neonatal outcomes. By expanding the diagnosis to include the woman's classification and glucose control, maternity and neonatal care providers could develop plans of care based on potential neonatal outcomes, including anticipatory guidance for families. In this commentary, we propose a more specific diagnosis, rather than infant of a diabetic mother, to better serve these infants.

The association between maternal HbA1c and adverse outcomes in gestational diabetes

BACKGROUND

The role of HbA1c in women with gestational diabetes mellitus (GDM) is still unclear, particularly in the Asian population.

AIM

To investigate the association between HbA1c levels and adverse outcomes considering maternal age, pre-pregnancy body mass index (BMI), and gestational weight gain (GWG) in women with GDM.

METHOD

A retrospective study included 2048 women with GDM and singleton live births. Using logistic regression, the associations between HbA1c and adverse pregnancy outcomes were assessed.

RESULT

Compared to women with HbA1c ≤ 5.0%, HbA1c was significantly associated with macrosomia (aOR 2.63,95%CI1.61,4.31), pregnancy-induced hypertension (PIH, aOR 2.56,95%CI1.57,4.19), preterm birth (aOR 1.64,95%CI 1.05,2.55), and primary Cesarean section (primary C-section, aOR1.49,95%CI1.09,2.03) in GDM women with HbA1c ≥5.5% while significantly associated with PIH (aOR 1.91,95%CI1.24,2.94) in women with HbA1c 5.1-5.4%. The associations between HbA1c and adverse outcomes varied with maternal age, pre-pregnancy BMI, and GWG. In women aged ≤29 years, there's significant association between HbA1c and primary C-section when HbA1c was 5.1-5.4% and ≥5.5%. In women aged 29-34 years and HbA1c ≥5.5%, HbA1c was significantly associated with macrosomia. In women aged ≥35 years, there's significant association between HbA1c and preterm birth when HbA1c was 5.1-5.4% and macrosomia and PIH when HbA1c ≥5.5%. In pre-pregnant normal-weight women, HbA1c was significantly associated with macrosomia, preterm birth, primary C-section, and PIH when HbA1c ≥5.5% while HbA1c was significantly associated with PIH when HbA1c was 5.1-5.4% . In pre-pregnant underweight women with HbA1c 5.1-5.4%, HbA1c was significantly associated with primary C-section. HbA1c was significantly associated with macrosomia among women with inadequate GWG or excess GWG and HbA1c≥5.5%. In women with adequate GWG, there's significant association between HbA1c and PIH when HbA1c was 5.1-5.4% and ≥5.5% .

CONCLUSION

Conclusively, HbA1c at the time of diagnosis is significantly associated with macrosomia, preterm birth, PIH, and primary C-section in Chinese women with GDM.

Is HbA1c in the first trimester associated with adverse outcomes among pregnant Asian Indian women without gestational diabetes?

AIMS

The aim of this study is to determine the association of elevated HbA1c in the first trimester (HbA1c-FT) with adverse events among pregnant Asian Indian women without gestational diabetes (GDM).

METHODS

This retrospective cohort study included 1618 pregnant women who delivered at a single urban tertiary care center and had HbA1c-FT estimation between January 2011 and September 2017. Those with GDM according to a 75-g OGTT after 24 gestational weeks were excluded. Multivariable logistic regression models assessed the association between elevated HbA1c-FT and adverse events.

RESULTS

At a cutoff of ≥37 mmol/mol (5.5%), HbA1c-FT was associated with preterm birth at <37 gestational weeks (adjusted odds ratio (OR) 2.10, 95% CI 1.11-3.98). There was a continuum of risk for primary caesarean delivery with higher HbA1c-FT levels (adjusted OR per 5-mmol/mol (0.5%) increase in HbA1c-FT for primary caesarean delivery: 1.27, 95% CI 1.06-1.52). In the crude analysis, gestational hypertension was associated with HbA1c-FT, but not after adjustment for confounding factors. HbA1c-FT was not associated with other adverse events (macrosomia, large for gestational age babies, or other neonatal complications).

CONCLUSIONS

Even without GDM, the results suggest an association of HbA1c-FT with preterm birth and primary caesarian delivery among Asian Indian women.

Association of Normal-Range Hemoglobin A1c Value During Midpregnancy with Adverse Birth Outcomes

Background

The midpregnancy normal-range HbA1c value and adverse birth outcomes were controversial. To address this lack of data, we examined the associations between midpregnancy normal-range HbA1c value and adverse birth outcomes.

Objective

To evaluate whether an association exists between the midpregnancy normal-range HbA1c value and adverse birth outcomes.

Materials and Methods

A total of 8389 women in their midpregnancy with normal gestational HbA1c value from the Affiliated Hospital of Jining Medical University in China participated in this study from January to December 2019. Subjects were stratified on the basis of their midpregnancy HbA1c value, and multivariate logistic regression was implemented to investigate the association between different HbA1c values and adverse birth outcomes.

Results

Incidence of preterm birth, macrosomia, and large for gestational age (LGA) for 8389 subjects were 4.8%, 6.3% and 16.5%, respectively. The multivariate logistic regression model demonstrated that the risk of preterm birth (adjusted odds ratio [OR]: 1.71 and 95% confidence interval [CI]: 1.25–2.34), macrosomia (OR: 1.68 and 95% CI: 1.26–2.22), and LGA (OR: 1.53 and 95% CI: 1.28–1.83) increase for every increase of 1% maternal HbA1c. Women with a prepregnancy body mass index (BMI) of < 25 kg/m² have a stronger correlation with HbA1c values and adverse birth outcomes than women with a prepregnancy BMI of ≥25 kg/m².

Conclusion

Our results indicated that the midpregnancy normal-range HbA1c level within the normal range is associated with adverse birth outcomes. Monitoring and controlling HbA1c may reduce the risk of adverse birth outcomes.

Fetal and Placental Weight in Pre-Gestational Maternal Obesity (PGMO) vs. Excessive Gestational Weight Gain (EGWG)-A Preliminary Approach to the Perinatal Outcomes in Diet-Controlled Gestational Diabetes Mellitus

Both pre-gestational maternal obesity (PGMO) and excessive gestational weight gain (EGWG) increase the risk of gestational diabetes mellitus (GDM). Here, we conducted a retrospective study to comparatively examine the relation between fetal birth weight (FW) and placental weight (PW) in PGMO (n = 100) compared to EGWG (n = 100) with respect to perinatal outcomes in diet-controlled GDM. The control group was made up of 100 healthy pregnancies. The mean FW and the mean PW in EGWG were correlated with lowered fetal weight/placental weight ratio (FW/PW ratio). The percentage of births completed by cesarean section accounted for 47%, 32%, and 18% of all deliveries (EGWG, PGMO, and controls, respectively), with the predominance of FW-related indications for cesarean section. Extended postpartum hospital stays due to neonate were more frequent in EGWG, especially due to neonatal jaundice (p < 0.05). The results indicate the higher perinatal risk in mothers with EGWG compared to PGMO during GDM-complicated pregnancy. Further in-depth comparative studies involving larger patient pools are needed to validate these findings, the intent of which is to formulate guidelines for GDM patients in respect to management of PGMO and EGWG.