Intensified versus conventional management of gestational diabetes

Does the timing of postprandial glucose monitoring affect the obstetric and neonatal outcomes in patients with gestational diabetes? A prospective study comparing 1 and 2-h postprandial monitoring

OBJECTIVE

The aim of this study was to examine the obstetrical and neonatal outcomes in patients with gestational diabetes mellitus (GDM) who had postprandial glucose monitoring 1 vs. 2 h following meals.

STUDY DESIGN

In this prospective cohort study, we included patients with GDM who were referred to our medical center between July 2019 and June 2021. Patients chose the timing of postprandial glucose monitoring based on their own preferences. Obstetrical and neonatal outcomes, as well as patient satisfaction, were compared between patients who performed postprandial glucose monitoring 1 and 2 h after meals (PPG1 vs. PPG2). The primary outcome was birth weight. The study was powered to detect a 250 g increase in birth weight.

RESULTS

Overall, 99 patients were included: 50 in the PPG1 group and 49 in the PPG2 group. Baseline characteristics were comparable between the groups. Neonates in the PPG1 and PPG2 groups had similar birth weights (3319 ± 355 vs. 3319 ± 520 g, respectively, p = 0.99). Glycemic control, mode of delivery, gestational age at delivery, and satisfaction rates were also similar between the study groups.

CONCLUSION

In patients with GDM, performing1 vs. 2 h following meals resulted in similar obstetrical and neonatal outcomes and similar satisfaction rates. We therefore recommend counseling patients to choose either strategy based on their personal preference.

From Standard of Care to Emerging Innovations: Navigating the Evolution of Pharmacological Treatment of Gestational Diabetes

The incidence of gestational diabetes mellitus (GDM) continues to increase in the United States and globally. While the first-line treatment of GDM remains diet and exercise, 30% of patients with GDM will require pharmacotherapy. However, many controversies remain over the specific glycemic threshold values at which pharmacotherapy should be started, how intensified the therapy should be, and whether oral agents are effective in GDM and remain safe for long-term offspring health. This review will summarize recently completed and ongoing trials focused on GDM pharmacotherapy, including those examining different glycemic thresholds to initiate therapy and treatment intensity. KEY POINTS: · The incidence of GDM continues to increase in the United States and globally.. · While the first-line treatment of GDM remains diet, 30% of patients require pharmacotherapy.. · Controversies remain over the specific glycemic threshold values at which pharmacotherapy is needed.. · Another controversy is how tightly to control GDM.. · Additional controversies are the safety of metformin and incretins in terms of offspring's long-term health..

Risk for fetal malformations and unfavorable neonatal outcomes in early-onset gestational diabetes mellitus

BACKGROUND

Early-onset gestational diabetes mellitus (GDM) is diagnosed before the 24th gestational week. Since early GDM is associated with first trimester hyperglycemia, many clinicians treat these women as having pre-GDM. However, whether early GDM increases the risk for unfavorable pregnancy outcomes and particularly for fetal malformations to a greater extent than late-onset GDM were not studied sufficiently. We aimed to examine the effect of early-onset GDM on unfavorable pregnancy outcomes.

METHODS

A retrospective cohort study of women with GDM delivering singletons during 2005-2018 was conducted. Women were divided into GDM diagnosed at the first (Trimester1; up to 13.6 weeks; N = 117), the second (Trimester2; up to 23.6 weeks; N = 126), and the third trimester (Trimester3; N = 2334). The primary outcomes were neonatal malformations and a composite of large-for-age newborns, hypoglycemia and hyperbilirubinemia treated with phototherapy. Comparisons were made between early- (Trimester1 + Trimester2-groups) and late-onset GDM (Trimester3-group), and between the three trimesters.

RESULTS

Fetal malformations were low and comparable between the trimester1, trimester2, trimester3 groups (2 (1.7%), 3 (2.4%), and 110 (4.7%), respectively). The composite neonatal complications was similar between the groups (68 (58%), 58 (46%), and 1087 (47%), respectively). In early-onset, the rates of neonatal hypoglycemia and shoulder dystocia were higher than in the late-onset GDM group (OR 95% CI 3.5 [2.0-6.1] and 10.3 [2.4-44.6], respectively). Macrosomia was higher in trimester1 compared with trimester2 and trimester3 cohorts (OR 95% CI 5.3 [1.7-16.9] and 2.8 [1.5-5.2], respectively).

CONCLUSIONS

The risk for fetal malformations was low and comparable between the first, second and third trimester GDM. Since the risks for macrosomia, shoulder dystocia, and neonatal hypoglycemia are higher in early-onset GDM, these women should undergo strict glycemic control, intensive monitoring, and careful neonatal evaluation.

The effect of oral probiotics on glycemic control of women with gestational diabetes mellitus-a multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Gestational diabetes mellitus should be treated adequately to avoid maternal hyperglycemia-related complications. Previously, probiotic supplements were suggested to improve fasting blood glucose in women with gestational diabetes mellitus. However, a major limitation of previous studies was that preprandial and especially postprandial glucose values, which are important predictors of pregnancy outcomes, were not studied.

OBJECTIVE

This study aimed to examine the effect of a mixture of probiotic strains on maternal glycemic parameters, particularly preprandial and postprandial glucose values and pregnancy outcomes among women with gestational diabetes mellitus.

STUDY DESIGN

A multicenter prospective randomized, double-blind, placebo-controlled trial was conducted. Women newly diagnosed with gestational diabetes mellitus were randomly allocated into a research group, receiving 2 capsules of oral probiotic formula containing Bifidobacterium bifidum, B lactis, Lactobacillus acidophilus, L paracasei, L rhamnosus, and Streptococcus thermophilus (>6 × 109/capsule), and a control group, receiving a placebo (2 capsules/day) until delivery. Glycemic control was evaluated by daily glucose charts. After 2 weeks, pharmacotherapy was started in case of poor glycemic control. The primary outcomes were the rate of women requiring medications for glycemic control and mean daily glucose charts after 2 weeks of treatment with the study products.

RESULTS

Forty-one and 44 women were analyzed in the treatment and placebo cohorts, respectively. Mean daily glucose during the first 2 weeks in the probiotics and placebo groups was 99.7±7.9 and 98.0±9.3 mg/dL, respectively (P=.35). The rate of women needing pharmacotherapy because of poor glycemic control after 2 weeks of treatment in the probiotics and placebo groups was 24 (59%) and 18 (41%), respectively (P=.10). Mean preprandial and postprandial glucose levels throughout the study period were similar between the groups (P>.05). There were no differences in maternal and neonatal outcomes, including birthweight and adverse effect profile between the groups.

CONCLUSION

The oral probiotic product tested in this study did not affect glycemic control of women with gestational diabetes mellitus.

Differences in neonatal adverse outcomes among women with gestational diabetes mellitus managed by diet or medication: a propensity score matched analysis of a population-based sample

OBJECTIVE

Neonatal outcomes in women with and without medically managed gestational diabetes mellitus (GDM) were compared after accounting for differences in maternal baseline characteristics using a propensity score (PS) analysis.

METHODS

Women without preexisting diabetes, delivering singletons during 2010-2017 in a large hospital, were eligible for inclusion. Using nearest-neighbour PS matching, women with non-pharmacological managed GDM were matched with women whose GDM was medically managed. A conditional logistic regression consequently compared the neonatal adverse outcomes between the groups after adjusting for gestational age, induction of labor, birth type, and number of ultrasounds conducted during the pregnancy.

RESULTS

Of the overall 10028 births, GDM was diagnosed in 930 (9.3%), of whom 710 (76.3%) were successfully matched. The conditional regressions found higher risk of neonatal adverse outcomes in neonates of women with non-pharmacological managed GDM compared to neonates of women with medically managed GDM. These included a higher risk of hypoglycemia (odds ratio (OR) 1.56, 95% confidence interval (CI) 1.03-2.38, p = 0.037), hypothermia (OR 2.29, 95%CI 1.05-5.00, p = 0.037), and birth injuries (OR 3.50, 95%CI 1.62-7.58, p = 0.001), and a higher risk of being small for gestational age (OR 2.06, 95%CI 1.01-4.18, p = 0.046) and being admitted to a special care unit (OR 2.04, 95%CI 1.29-3.21, p = 0.002).

CONCLUSIONS

The increased neonatal morbidity associated with non-medicated GDM identified in our study may indicate that diet and lifestyle changes alone are not sufficient to achieve glycaemic control in some women with GDM. Our findings indicate that gestational diabetes management approach is independently associated with neonatal outcomes.

Self-monitoring of blood glucose two-weekly versus weekly in gestational diabetes on nutrition therapy: A randomized trial

OBJECTIVE

To evaluate 4-point per day self-monitoring of blood glucose (SMBG) every 2 weeks compared with every week.

METHODS

A total of 104 patients with lifestyle-controlled gestational diabetes (GDMA1) were randomized to 2-weekly or weekly 4-point per day (fasting on awakening and 2-h post-meals) SMBG. Primary outcome was the change in glycated hemoglobin (HbA1c) level from enrollment to 36 weeks of pregnancy across trial arms. The non-inferiority margin was an HbA1c increase of 0.2%.

RESULTS

The mean difference for change in HbA1c from enrollment to 36 weeks was 0.003% (95% confidence interval [CI] -0.098% to +0.093%), within the 0.2% non-inferiority margin. The change in HbA1c level increased significantly within both trial arms-0.275% ± 0.241% (P < 0.001) in 2-weekly arm versus 0.277% ± 0.236% (P < 0.001) in the weekly arm. Participants randomized to 2-weekly SMBG were significantly less likely to receive anti-glycemic treatment-5/52 (9.6%) versus 14/50 (28.0%) (relative risk 0.34, 95% CI 0.13-0.88; P = 0.017). All secondary outcomes-maternal weight gain, preterm delivery, cesarean delivery, birthweight, and neonatal admission-were not significantly different.

CONCLUSIONS

In GDMA1, 2-weekly is non-inferior to weekly SMBG on the change in HbA1c level. Two-weekly SMBG appeared to be adequate for monitoring women with GDMA1.

CLINICAL TRIAL REGISTRATION

This study was registered in ISRCTN registry on March 25, 2022 with trial identification number: ISRCTN13404790 (https://doi.org/10.1186/ISRCTN13404790). The first participant was recruited on April 12, 2022.

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used, and overall rates are increasing globally. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (26 September 2022), and reference lists of the retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs. Trials were eligible for inclusion if women were diagnosed with GDM during pregnancy and the trial compared tighter and less-tight glycaemic targets during management. We defined tighter glycaemic targets as lower numerical glycaemic concentrations, and less-tight glycaemic targets as higher numerical glycaemic concentrations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for carrying out data collection, assessing risk of bias, and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated risk of bias, and extracted data for the four included studies. We assessed the certainty of evidence for selected outcomes using the GRADE approach. Primary maternal outcomes included hypertensive disorders of pregnancy and subsequent development of type 2 diabetes. Primary infant outcomes included perinatal mortality, large-for-gestational-age, composite of mortality or serious morbidity, and neurosensory disability.

MAIN RESULTS

This was an update of a previous review completed in 2016. We included four RCTs (reporting on 1731 women) that compared a tighter glycaemic control with less-tight glycaemic control in women diagnosed with GDM. Three studies were parallel RCTs, and one study was a stepped-wedged cluster-RCT. The trials took place in Canada, New Zealand, Russia, and the USA. We judged the overall risk of bias to be unclear. Two trials were only published in abstract form. Tight glycaemic targets used in the trials ranged between ≤ 5.0 and 5.1 mmol/L for fasting plasma glucose and ≤ 6.7 and 7.4 mmol/L postprandial. Less-tight targets for glycaemic control used in the included trials ranged between < 5.3 and 5.8 mmol/L for fasting plasma glucose and < 7.8 and 8.0 mmol/L postprandial. For the maternal outcomes, compared with less-tight glycaemic control, the evidence suggests a possible increase in hypertensive disorders of pregnancy with tighter glycaemic control (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.80 to 1.69, 2 trials, 1491 women; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. Tighter glycaemic control likely results in little to no difference in caesarean section rates (RR 0.98, 95% CI 0.82 to 1.17, 3 studies, 1662 women; moderate certainty evidence) or induction of labour rates (RR 0.96, 95% CI 0.78 to 1.18, 1 study, 1096 women; moderate certainty evidence) compared with less-tight control. No data were reported for the outcomes of subsequent development of type 2 diabetes, perineal trauma, return to pre-pregnancy weight, and postnatal depression. For the infant outcomes, it was difficult to determine if there was a difference in perinatal mortality (RR not estimable, 2 studies, 1499 infants; low certainty evidence), and there was likely no difference in being large-for-gestational-age (RR 0.96, 95% CI 0.72 to 1.29, 3 studies, 1556 infants; moderate certainty evidence). The evidence suggests a possible reduction in the composite of mortality or serious morbidity with tighter glycaemic control (RR 0.84, 95% CI 0.55 to 1.29, 3 trials, 1559 infants; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. There is probably little difference between groups in infant hypoglycaemia (RR 0.92, 95% CI 0.72 to 1.18, 3 studies, 1556 infants; moderate certainty evidence). Tighter glycaemic control may not reduce adiposity in infants of women with GDM compared with less-tight control (mean difference -0.62%, 95% CI -3.23 to 1.99, 1 study, 60 infants; low certainty evidence), but the wide CI suggests significant uncertainty. We found no data for the long-term outcomes of diabetes or neurosensory disability. Women assigned to tighter glycaemic control experienced an increase in the use of pharmacological therapy compared with women assigned to less-tight glycaemic control (RR 1.37, 95% CI 1.17 to 1.59, 4 trials, 1718 women). Tighter glycaemic control reducedadherence with treatment compared with less-tight glycaemic control (RR 0.41, 95% CI 0.32 to 0.51, 1 trial, 395 women). Overall the certainty of evidence assessed using GRADE ranged from low to moderate, downgraded primarily due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

This review is based on four trials (1731 women) with an overall unclear risk of bias. The trials provided data on most primary outcomes and suggest that tighter glycaemic control may increase the risk of hypertensive disorders of pregnancy. The risk of birth of a large-for-gestational-age infant and perinatal mortality may be similar between groups, and tighter glycaemic targets may result in a possible reduction in composite of death or severe infant morbidity. However, the CIs for these outcomes are wide, suggesting both benefit and harm. There remains limited evidence regarding the benefit of different glycaemic targets for women with GDM to minimise adverse effects on maternal and infant health. Glycaemic target recommendations from international professional organisations vary widely and are currently reliant on consensus given the lack of high-certainty evidence. Further high-quality trials are needed, and these should assess both short- and long-term health outcomes for women and their babies; include women's experiences; and assess health services costs in order to confirm the current findings. Two trials are ongoing.

Flat maternal glucose response curve and adverse pregnancy outcome

OBJECTIVE

The significance of a flat oral glucose tolerance test (OGTT) response curve in pregnancy remains unclear. We investigated the association of a flat curve with pregnancy outcomes.

STUDY DESIGN

Retrospective cohort study. Flat OGTT curve was defined by an area under the curve below the 10th percentile. Pregnancy outcomes were compared between flat and normal curve.

RESULTS

Of the 2673 eligible women, 269 had a flat response curve. Compared with the normal-response group, the flat-curve group had a lower mean birthweight (3363 ± 547 g vs. 3459 ± 519 g, p < 0.005), higher probability of small for gestational age (SGA) (19% vs. 12%, p < 0.005, aOR = 1.75, 95% CI 1.24-2.47), and 5-min Apgar score < 7 (1.12% vs. 0.29%, p < 0.05, aOR = 3.95, 95% CI 1.01-15.5). There were no differences in obstetric or maternal outcomes.

CONCLUSIONS

Flat OGTT is associated with lower birthweight, higher rates of SGA, and low Apgar scores. Detecting this previously unrecognized risk group, could potentially reduce these complications.

MAGIC (maternal glucose in pregnancy) understanding the glycemic profile of pregnancy, intensive CGM glucose profiling and its relationship to fetal growth: an observational study protocol

BACKGROUND

Continuous glucose monitoring (CGM) provides the most objective method of assessing glucose in daily life. Although there have been small, short-term physiologic studies of glucose metabolism in 'healthy' pregnant women a comprehensive, longitudinal description of changes in glucose over the course of pregnancy and how glucose dysregulation earlier in pregnancy relates to traditional third trimester screening for gestational diabetes, fetal growth and pregnancy outcomes is lacking. This study aims to characterise longitudinal changes in glycemia across gestation using CGM, in order to understand the evolution of dysglycemia and its relationship to fetal growth.

METHOD/DESIGN

A multi-centre, prospective, observational, cohort study of 500 healthy pregnant women, recruited in the first trimester of pregnancy. Masked CGM will be performed for a 14-day period on five occasions across pregnancy at ~ 10-12, 18-20, 26-28, 34-36 weeks gestation and postnatally. Routinely collected anthropometric and sociodemographic information will be recorded at each visit including: weight, height, blood pressure, current medication. Age, parity, ethnicity, smoking will be recorded. Blood samples will be taken at each visit for HbA1c and a sample stored. Details on fetal growth from ultrasound scans and the OGTT results will be recorded. Maternal and neonatal outcomes will be collected. CGM glucose profiling is the exposure of interest, and will be performed using standard summary statistics, functional data analysis and glucotyping. The primary maternal outcome is clinical diagnosis of GDM. The primary neonatal outcome is large for gestational age (LGA) (> 90th centile defined by customised birthweight centile). The relationship of glucose to key secondary maternal and neonatal outcomes will be explored.

DISCUSSION

This study will ascertain the relationship of maternal dysglycemia to fetal growth and outcomes. It will explore whether CGM glucose profiling can detect GDM before the OGTT; or indeed whether CGM glucose profiling may be more useful than the OGTT at detecting LGA and other perinatal outcomes.

TRIAL REGISTRATION

ISRCTN 15,706,303 https://www.isrctn.com/ISRCTN15706303 Registration date: 13th March 2023.

Using flash glucose monitoring in pregnancies in routine care of patients with gestational diabetes mellitus: a pilot study

AIM

Flash glucose monitoring (FGM) has been approved for the care of pregnant women with preexisting diabetes since 2017. However, its use in gestational diabetes (GDM) has been critically discussed. Inaccuracy and missing recommendations for target values are the main arguments against the use of FGM in GDM. To date, there is a lack of data to justify routine use of FGM in GDM pregnancies. Consequently, this new technology has been withheld from GDM-patients. Aim of our pilot study was to analyze the impact of FGM use on pregnancy outcomes, patient's satisfaction and to confirm the safe use in GDM pregnancies.

METHODS

Cohort study of 37 FGM-managed GDM pregnancies compared with 74 matched women using self-monitoring of blood glucose (SMBG). Group comparison using nonparametric testing concerning patients characteristic and perinatal outcome focusing on adverse outcomes (preeclampsia, preterm delivery, large for gestational age, C-sections, neonatal intensive care unit admission, hyperbilirubinemia and hypoglycemia). Evaluation of patient's treatment satisfaction using the "Diabetes Treatment Satisfaction Questionnaire change" (DTSQc) and patient interviews.

RESULTS

No significant differences in patient's characteristics despite gestational age at diagnosis (FGM with 20 vs. SMBG with 25 weeks). No difference in gestational weight gain, HbA1c progression and perinatal outcome. Treatment satisfaction obtained by the DTSQc revealed a high level of satisfaction with FGM use.

CONCLUSION

FGM use was well accepted and did not affect perinatal outcome. Use of FGM during pregnancy is safe and non-inferior to the management with SBGM. FGM should be considered as an option in the management of GDM patients.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Noor AF, Tan PC. Three Days Compared to One Day Per Week of Self-Monitoring of Blood Glucose in Mild Gestational Diabetes: A Randomized Trial

Background: The International Diabetes Federation estimates that 16.2% of livebirths in 2017 were affected by hyperglycemia in pregnancy, with 85.1% due to gestational diabetes mellitus (GDM). Daily blood glucose monitoring compared with alternate day testing in mild GDM is associated with similar pregnancy outcomes. Data are sparse on the ideal frequency for self-monitoring of blood glucose (SMBG) in mild GDM for glycemic control. A higher HbA1c at late pregnancy is associated with adverse pregnancy outcomes. We sought to evaluate three days compared to one day per week of four-point self-monitoring of blood glucose (SMBG) in gestational diabetes mellitus (GDM) controlled by lifestyle changes for glycemic control. Methods: This randomized trial was conducted from February−December 2018. A total of 106 women with lifestyle-controlled GDM were randomized to three days (SMBG3) or one day (SMBG1) per week of four-point (fasting and two-hours post-meal) SMBG. The primary outcome was the change in the HbA1c level at recruitment and 36-weeks gestation within and across trial arms. The student t-test was used for between-arm analyses and a paired t-test for within-arm analyses. Results: The HbA1c level through pregnancy increased significantly in both trial arms: mean increase of 0.21% ± 0.26%, p < 0.001 (SMBG3), and 0.19% ± 0.24%, p < 0.001 (SMBG1), but the 0.02% difference across trial arms was not significant (p = 0.79). Maternal weight gain (3.1 ± 2.1 kg vs. 3.3 ± 3.0 kg, p = 0.72), cesarean delivery (24/52 (48%) vs. 23/53 (43%), RR 1.06, 95% CI: 0.69−1.62, p = 0.77), neonatal birthweight (3.1 ± 0.4 kg vs. 3.0 ± 0.4 kg, p = 0.53) and neonatal intensive care unit admission (4/52 (8%) vs. 3/53 (6%), RR 1.36, 95% CI: 0.32−5.78, p = 0.68) were not significantly different for SMBG3 vs. SMBG1, respectively. Other maternal and neonatal secondary outcomes were not significantly different. Conclusion: In mild GDM, three days compared to one day per week showed a similar HbA1c levels change at 36-weeks gestation. Maternal and neonatal outcomes were also not significantly different. Less frequent monitoring of SMBG as a standard of care in mild GDM deserves further study and consideration.

Glucose levels during gestational diabetes pregnancy and the risk of developing postpartum diabetes or prediabetes

BACKGROUND

Blood glucose levels during pregnancy may reflect the severity of insulin secretory defects and/or insulin resistance during gestational diabetes mellitus (GDM) pregnancy. We hypothesized that suboptimal glycemic control in women with GDM could increase the risk of postpartum type 2 diabetes mellitus (T2DM) or prediabetes. Our objective was to evaluate the impact of plasma glucose levels throughout GDM pregnancy on the risk of postpartum T2DM or prediabetes.

METHODS

The medical records of 706 women with GDM who underwent a postpartum 75-g, 2-hour oral glucose tolerance test at our institution between January 2011 and December 2018 were reviewed. These women were classified into 2 groups according to glycemic control during pregnancy: ≤ 1 occasion of either fasting glucose ≥ 95 mg/dL or 2-hour postprandial glucose ≥ 120 mg/dL was defined as optimal glycemic control or else was classified as suboptimal glycemic control. Rates of postpartum T2DM and prediabetes were compared between women with optimal (n = 505) and suboptimal (n = 201) glycemic control.

RESULTS

The rates of postpartum T2DM and prediabetes were significantly higher in the suboptimal glycemic control group than in the optimal glycemic control group: 22.4% vs. 3.0%, P < 0.001 for T2DM and 45.3% vs. 23.5%, P < 0.001 for prediabetes. In a multivariate analysis, suboptimal glucose control during pregnancy was an independent risk factor for developing either postpartum T2DM or prediabetes. The adjusted odds ratios were 8.4 (95% confidence interval, 3.5-20.3) for T2DM and 3.9 (95% confidence interval, 2.5-6.1) for prediabetes.

CONCLUSION

Our findings suggest that blood glucose levels during GDM pregnancy have an impact on the risk of postpartum T2DM and prediabetes.

Altered islet prohormone processing: A cause or consequence of diabetes?

Peptide hormones are first produced as larger precursor prohormones that require endoproteolytic cleavage to liberate the mature hormones. A structurally conserved but functionally distinct family of nine prohormone convertase enzymes (PCs) are responsible for cleavage of protein precursors of which PC1/3 and PC2 are known to be exclusive to neuroendocrine cells and responsible for prohormone cleavage. Differential expression of PCs within tissues define prohormone processing; whereas glucagon is the major product liberated from proglucagon via PC2 in pancreatic α-cells, proglucagon is preferentially processed by PC1/3 in intestinal L cells to produce glucagon-like peptides 1 and 2 (GLP-1, GLP-2). Beyond our understanding of processing of islet prohormones in healthy islets, there is convincing evidence that proinsulin, proIAPP, and proglucagon processing is altered during prediabetes and diabetes. There is predictive value of elevated circulating proinsulin or proinsulin : C-peptide ratio for progression to type 2 diabetes and elevated proinsulin or proinsulin : C-peptide is predictive for development of type 1 diabetes in at risk groups. After onset of diabetes, patients have elevated circulating proinsulin and proIAPP and proinsulin may be an autoantigen in type 1 diabetes. Further, preclinical studies reveal that α-cells have altered proglucagon processing during diabetes leading to increased GLP-1 production. We conclude that despite strong associative data, current evidence is inconclusive on the potential causal role of impaired prohormone processing in diabetes, and suggest that future work should focus on resolving the question of whether altered prohormone processing is a causal driver or merely a consequence of diabetes pathology.

Unique Biomarker Characteristics in Gestational Diabetes Mellitus Identified by LC-MS-Based Metabolic Profiling

BACKGROUND

Gestational diabetes mellitus (GDM) is a type of glucose intolerance disorder that first occurs during women's pregnancy. The main diagnostic method for GDM is based on the midpregnancy oral glucose tolerance test. The rise of metabolomics has expanded the opportunity to better identify early diagnostic biomarkers and explore possible pathogenesis.

METHODS

We collected blood serum from 34 GDM patients and 34 normal controls for a LC-MS-based metabolomics study.

RESULTS

184 metabolites were increased and 86 metabolites were decreased in the positive ion mode, and 65 metabolites were increased and 71 were decreased in the negative ion mode. Also, it was found that the unsaturated fatty acid metabolism was disordered in GDM. Ten metabolites with the most significant differences were selected for follow-up studies. Since the diagnostic specificity and sensitivity of a single differential metabolite are not definitive, we combined these metabolites to prepare a ROC curve. We found a set of metabolite combination with the highest sensitivity and specificity, which included eicosapentaenoic acid, docosahexaenoic acid, docosapentaenoic acid, arachidonic acid, citric acid, α-ketoglutaric acid, and genistein. The area under the curves (AUC) value of those metabolites was 0.984 between the GDM and control group.

CONCLUSIONS

Our results provide a direction for the mechanism of GDM research and demonstrate the feasibility of developing a diagnostic test that can distinguish between GDM and normal controls clearly. Our findings were helpful to develop novel biomarkers for precision or personalized diagnosis for GDM. In addition, we provide a critical insight into the pathological and biological mechanisms for GDM.

Maternal and neonatal outcomes after energy-restricted diet for women with gestational diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Gestational diabetes mellitus (GDM) affects 1% to 14% of pregnant women annually worldwide and is one of the most common pregnancy complications.

OBJECTIVE

We reviewed studies on maternal and neonatal outcomes after dietary managements for women with GDM comparing caloric-restricted (intervention group) and unrestricted diets (control group).

METHODS

We systematically searched online databases including Medline, Cochrane Controlled Register of Trials (CENTRAL), ScienceDirect, and Google Scholar from inception until September 2019. We performed a meta-analysis with random-effects model and reported pooled risk ratios (RRs) or pooled mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

We analyzed data from 6 randomized controlled trials including 1300 participants, most of them with high bias risks. We found that the women in the intervention group achieved slightly better glycemic control (pooled MD, -0.72 mg/dL; 95% CI, -7.10 to 5.66 mg/dL) and overall pregnancy outcomes (except neonatal hypoglycemia) than the women in the control group.

CONCLUSION

An energy-restricted diet does not seem superior to the usual/standard GDM diet based on maternal or neonatal outcomes. But, clinical recommendations cannot be made as the evidence is inconclusive.

Impact of gestational diabetes mellitus diagnosed during the third trimester on pregnancy outcomes: a case-control study

Background

In 2010, the International Association of Diabetes and Pregnancy Study Group (IADPSG) proposed new criteria indicating that gestational diabetes mellitus (GDM) can be diagnosed if the fasting threshold of ≤92 mg/dL, 1-h threshold of ≤180 mg/dL, or 2-h threshold of ≤153 mg/dL are exceeded during the 75-g 2-h oral glucose tolerance test (OGTT) performed at 24–28 weeks of gestation. The World Health Organization (WHO) recommends using the proposed diagnostic threshold values of the IADPSG to diagnose GDM; however, it does not limit the timing of the 75-g OGTT. Since 2010 in Japan, GDM has been diagnosed using the same criteria as that proposed by the WHO. However, neither the JSOG nor the WHO has provided any evidence that it is appropriate to use a threshold beyond the range recommended by the IADPSG.

Methods

This was a single-centre retrospective study based on the medical records and delivery registry database of our centre. We included women who underwent a 50-g glucose challenge test (GCT) with results < 140 mg/dL at 24–28 weeks of gestation and subsequently underwent a 75-g OGTT after 29 weeks of gestation with abnormal glucose tolerance suspected based on clinical findings. The reference values for the 75-g OGTT followed the IADPSG criteria. Subjects were classified into the normal glucose tolerance (NGT) group and the GDM group. The type of delivery and neonatal outcomes of the two groups were compared. A multivariable analysis was performed to match the backgrounds of both groups.

Results

In total, the NGT and GDM group comprised 189 and 49 women, respectively. Emergency caesarean delivery rates were similar in the GDM and NGT groups (10.6 and 12.2%, respectively; adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 0.43–3.64; p = 0.74); however, the elective caesarean delivery rate was higher in the GDM group than in the NGT group (16.3 and 5.3%, respectively, adjusted OR, 3.60; 95% CI, 1.27–10.19; p = 0.01). No significant differences were observed in other maternal and neonatal outcomes between both groups.

Conclusion

Although a diagnosis of GDM during the third trimester does not improve pregnancy outcomes, it increases the elective caesarean delivery rate.

The Effect of Gestational Diabetes Mellitus on the Chorionic Villi of Human Placenta Among Saudi Arabian Mothers: A Quantitative and Comparative Study

Background The placenta is a temporary pivotal organ - the gate between the mother and the fetus. It has multiple functions such as nutrient uptake, elimination of waste products, gas exchange, and production of some vital hormones. However, the pregnancy state is a diabetogenic condition caused by insulin resistance, resulting from physiological variations. Gestational diabetes mellitus (GDM) can have an impact on both the mother and the fetus by causing numerous complications. In our research study, we aim to study and compare the quantitative effect of GDM at the microscopical level within the chorionic villi of the placenta of both mothers diagnosed with GDM and healthy mothers as well as the clinical correlation. Methods After applying the inclusion and exclusion criteria, we collected 84 placental samples from February 2017 until May 2017, which were composed of 42 GDM samples and 42 healthy samples. All of these samples have been studied under a light microscope for measuring different parameters. Results We found that some of the measured parameters among diabetic villi were lower than those of healthy villi with a p-value < .05 being significant. These include the surface area of the blood vessels (P = .008), the perimeters of the blood vessels (P = .002), the placental barrier thickness/perimeters of the villous blood vessels ratio (P ≤ .001), the placental barrier thickness/surface area of the blood vessels ratio (P ≤ .001), the number of Hofbauer cells/surface area of the villous ratio (P ≤ .001), the number of the blood vessels/surface area of the villous ratio (P = .001), the surface area of the blood vessels/surface area of the villous ratio (P = .004), and the perimeters of the blood vessels/surface area of the villous ratio (P ≤ .001). These parameters have significant effects on fetal development as well as the mother's status. Conclusions GDM is associated with multiple changes in the placenta. Moreover, these changes can impact the fetoplacental circulation and cause multiple complications for the mother and the fetus. Therefore, identifying pregnant women with GDM and controlling hyperglycemia will improve the outcomes of the pregnancy.

Effects of gestational diabetes mellitus on risk of adverse maternal outcomes: a prospective cohort study in Northwest Ethiopia

Background

Gestational diabetes mellitus is a leading medical condition woman encounter during pregnancy with serious short- and long-term consequences for maternal morbidity. However, limited evidence was available on potential impacts of gestational diabetes mellitus using updated international diagnostic criteria on adverse maternal outcomes. Therefore, this study aimed to assess the effects of gestational diabetes mellitus on the risk of adverse maternal outcomes in Northwest Ethiopia.

Methods

A prospective cohort study was conducted among pregnant women followed from pregnancy to delivery. Gestational diabetes mellitus status was determined by using a two-hour 75 g oral glucose tolerance test and based on updated international diagnostic criteria. Multivariable log-binomial model was used to examine the effects of gestational diabetes mellitus on the risk of adverse maternal outcomes.

Results

A total of 694 women completed the follow-up and included in the analysis. Women with gestational diabetes mellitus had a higher risk of composite adverse maternal outcome (ARR=1.58, 95% CI: 1.22, 2.04), caesarean delivery (ARR=1.67; 95%: 1.15, 2.44), pregnancy induced hypertension (ARR= 3.32; 95%: 1.55, 7.11), premature rupture of membranes (ARR= 1.83; 95%: 1.02, 3.27), antepartum hemorrhage (ARR= 2.10; 95%: 1.11, 3.98) and postpartum hemorrhage (ARR= 4.85; 95%:2.28, 10.30) compared to women without gestational diabetes mellitus.

Conclusions

Gestational diabetes mellitus increased the risk of adverse maternal outcomes. This implies that maternal care and intervention strategies relating to women with gestational diabetes mellitus should be strengthened.

Influence of Foetal Macrosomia on the Neonatal and Maternal Birth Outcome

Introduction Foetal macrosomia is associated with various obstetrical complications and is a common reason for inductions and primary or secondary Caesarean sections. The objective of this study is the generation of descriptive data on the mode of delivery and on maternal and foetal complications in the case of foetal macrosomia. The causes and consequences of foetal macrosomia as well as the rate of shoulder dystocia are examined in relation to the severity of the macrosomia.

Patients The study investigated all singleton births ≥ 37 + 0 weeks of pregnancy with a birth weight ≥ 4000 g at the Charité University Medicine Berlin (Campus Mitte 2001 – 2017, Campus Virchow Klinikum 2014 – 2017).

Results 2277 consecutive newborns (birth weight 4000 – 4499 g [88%], 4500 – 4999 g [11%], ≥ 5000 g [1%]) were included. Maternal obesity and gestational diabetes were more common in the case of newborns weighing ≥ 4500 g than newborns weighing 4000 – 4499 g (p = 0.001 and p < 0.001). Women with newborns ≥ 5000 g were more often ≥ 40 years of age (p = 0.020) and multipara (p = 0.025). The mode of delivery was spontaneous in 60% of cases, vaginal-surgical in 9%, per primary section in 14% and per secondary section in 17%. With a birth weight ≥ 4500 g, a vaginal delivery was more rare (p < 0.001) and the rate of secondary sections was increased (p = 0.011). Women with newborns ≥ 4500 g suffered increased blood loss more frequently (p = 0.029). There was no significant difference with regard to the rate of episiotomies or serious birth injuries. Shoulder dystocia occurred more frequently at a birth weight of ≥ 4500 g (5 vs. 0.9%, p = 0.000). Perinatal acidosis occurred in 2% of newborns without significant differences between the groups. Newborns ≥ 4500 g were transferred to neonatology more frequently (p < 0.001).

Conclusion An increased birth weight is associated with an increased maternal risk and an increased rate of primary and secondary sections as well as shoulder dystocia; no differences in the perinatal outcome between newborns with a birth weight of 4000 – 4499 g and ≥ 4500 g were seen. In our collective, a comparably low incidence of shoulder dystocia was seen. In the literature, the frequency is indicated with a large range (1.9 – 10% at 4000 – 4499 g, 2.5 – 20% at 4500 – 5000 g and 10 – 20% at ≥ 5000 g). One possible cause for the low rate could be the equally low prevalence of gestational diabetes in our collective. A risk stratification of the pregnant women (e.g. avoidance of vacuum extraction, taking gestational diabetes into account during delivery planning) is crucial. If macrosomia is presumed, it is recommended that delivery take place at a perinatal centre in the presence of a specialist physician, due to the increased incidence of foetal and maternal complications.

Inverse association between 1,5-anhydroglucitol and neonatal diabetic complications

PURPOSE

A glycemic control marker to predict neonatal diabetic complications is unavailable. We aimed to examine if 1,5-anhydroglucitol (1,5-AG) can predict neonatal complications in women with diabetes in pregnancy.

METHODS

Prospective observational study from December 2011 to August 2013. We recruited 105 women, 70 diabetic (gestational and pregestational) and 35 nondiabetic. 1,5-AG at birth was compared between the two groups. In the diabetic group 1,5-AG, HbA1c, and fructosamine were measured before glycemic control initiation (first visit), after 4-6 weeks (second visit), and at delivery. Women were divided to poor (1,5-AG values below median at birth) and good (1,5-AG values at median and above) glycemic control groups. Mean daily glucose charts were collected. The primary outcome was a composite of neonatal diabetic complications: respiratory distress, hypoglycemia, polycythemia, hyperbilirubinemia, and large for gestational age.

RESULTS

Mean 1,5-AG in the nondiabetic group was similar to that of the diabetic group without the composite outcome and was significantly higher than in the diabetic group with the composite outcome. The rate of the composite outcome was higher in the poor glycemic control group compared with the good glycemic control group (adjusted odds ratio (OR) 3.8 95% CI [1.2-12.3]). Only 1,5-AG was inversely associated with the composite outcome at all time points; the second visit was the only independent risk factor in multivariable logistic regression (OR 0.7 95% CI 0.54-0.91). The rest of the glycemic markers were not associated with neonatal composite outcome.

CONCLUSIONS

1,5-AG is inversely associated with neonatal diabetic complications and is superior to other glycemic markers in predicting those complications.

The predictive value of weight gain and waist circumference for gestational diabetes mellitus

Objective:

The first objective of this study was to investigate the relationship between gestational diabetes mellitus (GDM) and gestational weight gain (WG), waist circumference (WC), prepregnancy, and gestational body mass index (BMI). The second aim of our study was to assess the ability of WG, WC, prepregnancy, and gestational BMI with special reference to their cut-off points on predicting the risk of GDM in pregnant women in Turkey.

Materials and Methods:

A total of 261 women who underwent screening for GDM with the 75-g glucose tolerance test (GTT) between 24^th and 28^th gestational weeks were included. According to the 75-g oral GTT results, women were classified into two groups: the GDM group and non-GDM group. The data collected included age, parity, plasma glucose level for fasting, 1- and 2-h tests, WC, prepregnancy and gestational BMI, prepregnancy weight, WG during pregnancy, gestational age at birth, and birth weight.

Results:

WC at 20-24 weeks of gestation, prepregnancy BMI, and gestational BMI had a predictive capacity for GDM. According to our results, optimal cut-off points for the best predictive value of GDM were WC of 100 cm with a sensitivity of 84% and specificity of 70%, prepregnancy BMI of 25 kg/m² with a sensitivity of 81.8% and specificity of 76%, and gestational BMI of 28.3 kg/m² with a sensitivity of 75% and specificity of 77.4%.

Conclusion:

The measurement of prepregnancy BMI, gestational BMI, and WC may be useful in predicting the risk of GDM. Pregnant women with increased prepregnancy BMI, gestational BMI, and WC measurements may be susceptible to the development of GDM.

Good glycemic control of gestational diabetes mellitus is associated with the attenuation of future maternal cardiovascular risk: a retrospective cohort study

BACKGROUND

To examine whether glycemic control of gestational diabetes mellitus (GDM) could modify the risk for future maternal metabolic and cardiovascular morbidities.

METHODS

A retrospective cohort study of women with a first diagnosis of GDM who delivered between 1991 and 2011. Women were divided into groups of good and poor glycemic control, defined as a mean daily glucose of up to 95 mg/dL (N = 230) and more than 95 mg/dL (N = 216), respectively. In addition, a control group of women without GDM (N = 352) was also analyzed. The primary outcomes were the development of type 2 diabetes mellitus (T2DM), obesity, hypertension, or dyslipidemia.

RESULTS

Mean follow-up time was 15.8 ± 5.1 years. Assessment was performed at a maternal age of 45 ± 7 years. The rates of the study outcomes in the control, GDM with good glycemic control and GDM with poor glycemic control were as follows: T2DM [19 (5.4%), 87 (38%), 127 (57%)]; hypertension [44 (13%), 42 (18%), 44 (20%)]; obesity [111 (32%), 112 (48%), 129 (58%)]; and dyslipidemia [49 (14%), 67 (29%), 106 (48%)]. Glycemic control was an independent risk factor for T2DM in multivariate Cox regression analysis (hazard ratio (HR) for poor glycemic control vs. controls 10.7 95% CI [6.0-19.0], good glycemic control vs. control HR 6.0 [3.3-10.8], and poor glycemic control vs. good glycemic control HR 1.8 [1.3-2.4]). Glycemic control was also an independent risk factor for dyslipidemia (poor glycemic control vs. controls HR 3.7 [2.3-5.8], good glycemic control vs. controls HR 2.0 [1.2-3.2], and poor glycemic control vs. good glycemic control HR 1.8 1.8 [1.3-2.6]). The fasting glucose level during oral glucose tolerance test (OGTT) was also an independent risk factor for these complications. The interaction term between glycemic control and the fasting value of the OGTT was not statistically significant, suggesting that the effect of glycemic control on the rate of future T2DM and dyslipidemia was not modified by the baseline severity of GDM.

CONCLUSION

GDM and especially poor glycemic control are associated with T2DM and dyslipidemia. Strict glycemic control for reducing that risk should be evaluated in prospective trials.

Suboptimal Nocturnal Glucose Control Is Associated With Large for Gestational Age in Treated Gestational Diabetes Mellitus

OBJECTIVE

Continuous glucose monitoring (CGM) provides far greater detail about fetal exposure to maternal glucose across the 24-h day. Our aim was to examine the role of temporal glucose variation on the development of large for gestational age (LGA) infants in women with treated gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

We performed a prospective observational study of 162 pregnant women with GDM in specialist multidisciplinary antenatal diabetes clinics. Participants undertook 7-day masked CGM at 30-32 weeks' gestation. Standard summary indices and glycemic variability measures of CGM were calculated. Functional data analysis was applied to determine differences in temporal glucose profiles. LGA was defined as birth weight ≥90th percentile adjusted for infant sex, gestational age, maternal BMI, ethnicity, and parity.

RESULTS

Mean glucose was significantly higher in women who delivered an LGA infant (6.2 vs. 5.8 mmol/L, P = 0.025, or 111.6 mg/dL vs. 104.4 mg/dL). There were no significant differences in percentage time in, above, or below the target glucose range or in glucose variability measures (all P > 0.05). Functional data analysis revealed that the higher mean glucose was driven by a significantly higher glucose for 6 h overnight (0030-0630 h) in mothers of LGA infants (6.0 ± 1.0 mmol/L vs. 5.5 ± 0.8 mmol/L, P = 0.005, and 108.0 ± 18.0 mg/dL vs. 99.0 ± 14.4 mg/dL).

CONCLUSIONS

Mothers of LGA infants run significantly higher glucose overnight compared with mothers without LGA infants. Detecting and addressing nocturnal glucose control may help to further reduce rates of LGA in women with GDM.

Noninvasive, continuous, real-time glucose measurements compared to reference laboratory venous plasma glucose values

Purpose: Current modalities for glucose monitoring are invasive and inconvenient. The search for a noninvasive technique is still ongoing, without a clinically viable product. The aim of our study was to evaluate the safety and accuracy of a novel non-invasive continuous glucometer - the Wizmi™ device. Methods: Prospective, observational, controlled clinical trial. We included healthy pregnant women designated to undergo a 3-hour oral glucose tolerance test. Each participant underwent synchronous and simultaneous glucose measurement by venous sampling of plasma glucose and non-invasive glucose by Wizmi device. Primary outcome was the accuracy of the Wizmi device as assessed by comparing between paired measurements, i.e. non-invasive glucose measurements by Wizmi versus standard plasma glucose levels, which were taken at the exact same time. Results: Thirty-two women underwent oral glucose tolerance test (OGTT), contributing 224 paired glucose measurements. Of the 224 paired measurements, all were within the clinically appropriate zones of the Clarke error grid analysis zones -208 (93%) in Zone A and 16 (7%) in zone B. Mean absolute relative difference of the Wizmi non-invasive glucose versus plasma glucose laboratory reference was 7.23% or 9.66 mg/dl. Overall, for all 224 paired measurements, across all Wizmi glucose ranges, the agreement was 86.6, 92.0, 97.8 and 99.5% for deviations within ±15, 20, 30, 40% (if glucose >80 mg/dl) or mg/dl (if glucose ≤80 mg/dl). Conclusions: Wizmi device is novel non-invasive continuous glucose monitor, safe to use, with overall high accuracy compared to a gold standard reference of plasma glucose.

Successful glycemic control using a flash glucose monitoring system for a pregnant woman with diabetes: a case report

Background

Glucose control for pregnant women with glucose intolerance is important, as hyperglycemia may adversely affect the mother and the fetus.

Case presentation

We report the case of a pregnant Japanese woman who experienced gestational diabetes mellitus during her first pregnancy and developed impaired glucose tolerance after the delivery. During her second pregnancy with twins, she required up to 75 units of injected insulin to control her postprandial hyperglycemia and occasionally experienced hypoglycemia. We used a newly developed flash glucose monitoring system, which allowed her to successfully achieve ideal glycemic control and experience an uncomplicated delivery.

Conclusion

We suggest that this flash glucose monitoring system may be clinically effective for similar cases that involve pregnant women with abnormal glucose tolerance.

Different methods and settings for glucose monitoring for gestational diabetes during pregnancy

BACKGROUND

Incidence of gestational diabetes mellitus (GDM) is increasing worldwide. Blood glucose monitoring plays a crucial part in maintaining glycaemic control in women with GDM and is generally recommended by healthcare professionals. There are several different methods for monitoring blood glucose which can be carried out in different settings (e.g. at home versus in hospital).

OBJECTIVES

The objective of this review is to compare the effects of different methods and settings for glucose monitoring for women with GDM on maternal and fetal, neonatal, child and adult outcomes, and use and costs of health care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-randomised controlled trials (qRCTs) comparing different methods (such as timings and frequencies) or settings, or both, for blood glucose monitoring for women with GDM.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, and extracted data. Data were checked for accuracy.We assessed the quality of the evidence for the main comparisons using GRADE, for:- primary outcomes for mothers: that is, hypertensive disorders of pregnancy; caesarean section; type 2 diabetes; and- primary outcomes for children: that is, large-for-gestational age; perinatal mortality; death or serious morbidity composite; childhood/adulthood neurosensory disability;- secondary outcomes for mothers: that is, induction of labour; perineal trauma; postnatal depression; postnatal weight retention or return to pre-pregnancy weight; and- secondary outcomes for children: that is, neonatal hypoglycaemia; childhood/adulthood adiposity; childhood/adulthood type 2 diabetes.

MAIN RESULTS

We included 11 RCTs (10 RCTs; one qRCT) that randomised 1272 women with GDM in upper-middle or high-income countries; we considered these to be at a moderate to high risk of bias. We assessed the RCTs under five comparisons. For outcomes assessed using GRADE, we downgraded for study design limitations, imprecision and inconsistency. Three trials received some support from commercial partners who provided glucose meters or financial support, or both. Main comparisons Telemedicine versus standard care for glucose monitoring (five RCTs): we observed no clear differences between the telemedicine and standard care groups for the mother, for:- pre-eclampsia or pregnancy-induced hypertension (risk ratio (RR) 1.49, 95% confidence interval (CI) 0.69 to 3.20; 275 participants; four RCTs; very low quality evidence);- caesarean section (average RR 1.05, 95% CI 0.72 to 1.53; 478 participants; 5 RCTs; very low quality evidence); and- induction of labour (RR 1.06, 95% CI 0.63 to 1.77; 47 participants; 1 RCT; very low quality evidence);or for the child, for:- large-for-gestational age (RR 1.41, 95% CI 0.76 to 2.64; 228 participants; 3 RCTs; very low quality evidence);- death or serious morbidity composite (RR 1.06, 95% CI 0.68 to 1.66; 57 participants; 1 RCT; very low quality evidence); and- neonatal hypoglycaemia (RR 1.14, 95% CI 0.48 to 2.72; 198 participants; 3 RCTs; very low quality evidence).There were no perinatal deaths in two RCTs (131 participants; very low quality evidence). Self-monitoring versus periodic glucose monitoring (two RCTs): we observed no clear differences between the self-monitoring and periodic glucose monitoring groups for the mother, for:- pre-eclampsia (RR 0.17, 95% CI 0.01 to 3.49; 58 participants; 1 RCT; very low quality evidence); and- caesarean section (average RR 1.18, 95% CI 0.61 to 2.27; 400 participants; 2 RCTs; low quality evidence);or for the child, for:- perinatal mortality (RR 1.54, 95% CI 0.21 to 11.24; 400 participants; 2 RCTs; very low quality evidence);- large-for-gestational age (RR 0.82, 95% CI 0.50 to 1.37; 400 participants; 2 RCTs; low quality evidence); and- neonatal hypoglycaemia (RR 0.64, 95% CI 0.39 to 1.06; 391 participants; 2 RCTs; low quality evidence). Continuous glucose monitoring system (CGMS) versus self-monitoring of glucose (two RCTs): we observed no clear differences between the CGMS and self-monitoring groups for the mother, for:- caesarean section (RR 0.91, 95% CI 0.68 to 1.20; 179 participants; 2 RCTs; very low quality evidence);or for the child, for:- large-for-gestational age (RR 0.67, 95% CI 0.43 to 1.05; 106 participants; 1 RCT; very low quality evidence) and- neonatal hypoglycaemia (RR 0.79, 95% CI 0.35 to 1.78; 179 participants; 2 RCTs; very low quality evidence).There were no perinatal deaths in the two RCTs (179 participants; very low quality evidence). Other comparisons Modem versus telephone transmission for glucose monitoring (one RCT): none of the review's primary outcomes were reported in this trial Postprandial versus preprandial glucose monitoring (one RCT): we observed no clear differences between the postprandial and preprandial glucose monitoring groups for the mother, for:- pre-eclampsia (RR 1.00, 95% CI 0.15 to 6.68; 66 participants; 1 RCT);- caesarean section (RR 0.62, 95% CI 0.29 to 1.29; 66 participants; 1 RCT); and- perineal trauma (RR 0.38, 95% CI 0.11 to 1.29; 66 participants; 1 RCT);or for the child, for:- neonatal hypoglycaemia (RR 0.14, 95% CI 0.02 to 1.10; 66 participants; 1 RCT).There were fewer large-for-gestational-age infants born to mothers in the postprandial compared with the preprandial glucose monitoring group (RR 0.29, 95% CI 0.11 to 0.78; 66 participants; 1 RCT).

AUTHORS' CONCLUSIONS

Evidence from 11 RCTs assessing different methods or settings for glucose monitoring for GDM suggests no clear differences for the primary outcomes or other secondary outcomes assessed in this review.However, current evidence is limited by the small number of RCTs for the comparisons assessed, small sample sizes, and the variable methodological quality of the RCTs. More evidence is needed to assess the effects of different methods and settings for glucose monitoring for GDM on outcomes for mothers and their children, including use and costs of health care. Future RCTs may consider collecting and reporting on the standard outcomes suggested in this review.

Emergency cesarean section rate between women with gestational diabetes and normal pregnant women

OBJECTIVE

Gestational diabetes mellitus (GDM) has been related to various maternal and neonatal complications. The degree to which GDM is related to an increased rate of cesarean section is less certain. This study was aimed at comparing the incidence of emergency cesarean delivery between pregnant women with GDM and normal pregnant women.

MATERIALS AND METHODS

The study group consisted of 237 term, singleton pregnant women with GDM. Another 237 uncomplicated, normal pregnant women were randomly selected and served as the comparison group. Those who were scheduled for elective cesarean delivery and overt DM were excluded. Data were retrieved from medical records, including demographic data, antenatal and intrapartum care data, route of delivery, indications for cesarean delivery, and neonatal outcomes.

RESULTS

The study group had a significantly higher mean age and body mass index, and the participants were more likely to be overweight/obese. The rate of emergency cesarean delivery was significantly higher in the study group than in the comparison group (31.6% vs. 19.4%, p = 0.002). The study group was more likely to have Cephalo-pelvic disproportion (CPD) (20.3% vs. 13.1%, p = 0.036) as an indication for cesarean delivery. Birth weight was significantly higher (by 200 g) in the study group. When stratified by parity, significant differences in cesarean delivery rates were observed only among nulliparous women. Logistic regression analysis showed that GDM significantly increased the risk of emergency cesarean delivery (adjusted odds ratio 1.9, 95% confidence interval 1.03-3.5, p = 0.039) only among nulliparous women, adjusted for age, body mass index, and gestational weight gain.

CONCLUSION

The incidence of emergency cesarean delivery increased significantly among nulliparous GDM pregnant women, compared with that in normal pregnant women.

Pregnancy outcome of gestational diabetes mellitus using a structured model of care : WINGS project (WINGS-10)

AIM

To evaluate the impact of a structured model of care (MOC) prepared for resource-constrained settings, on the pregnancy outcomes of Asian Indian women with gestational diabetes mellitus (GDM).

METHODS

Pregnant women were screened under the Women in India with GDM Strategy (WINGS) MOC for GDM using the International Association of Diabetes and Pregnancy Study Groups criteria. Women with GDM went through a structured MOC that included medical nutrition therapy (MNT), regular physical activity (PA); and insulin when indicated. Fasting blood glucose and post-prandial blood sugar were monitored every 2 weeks. The pregnancy outcomes of women with GDM who underwent the MOC were compared with those without GDM.

RESULTS

Under the MOC, 212 women with GDM were followed through pregnancy, of whom 33 (15.6%) required insulin and 179 (84.4%) were managed with MNT and PA. The maternal and neonatal outcomes of women with GDM were similar to the non-GDM women: there were no significant differences in pregnancy complications such as cesarean section, macrosomia, pre-eclampsia, oligo/polyhydramnios, preterm delivery, neonatal death, fetal distress, hyperbilirubinemia and low birthweight.

CONCLUSION

Implementation of a structured MOC for women with GDM helped achieve pregnancy outcomes similar to those without GDM.

Better than nothing? maternal, newborn, and child health services and perinatal mortality, Lubumbashi, democratic republic of the Congo: a cohort study

Background

The Democratic Republic of Congo (DRC) has a high rate of perinatal mortality (PMR), and health measures that could reduce this high rate of mortality are not accessible to all women. Where they are in place, their quality is not optimal. This study was initiated to assess the relationship between these suboptimal maternal, newborn and child health (MNCH) services and perinatal mortality (PM) in Lubumbashi, DRC’s second-largest city.

Methods

We conducted a prospective cohort study, comparing women who had no, low, moderate, or high numbers of antenatal care (ANC) visits; three different levels of delivery care; and who did or did not attend postnatal care (PNC). Women were followed for 50 days after delivery, with PM as the primary endpoint.

Results

Uptake of recommended prenatal interventions was between 11-43 % among ANC attenders, regardless of the frequency of their visits. PM was 26 per 1000. ANC attendance was associated with PM. Newborns of mothers who had the lowest attendance had a mortality two times higher than newborns of women who had not attended ANC (low visits: adjusted odds ratio (aOR) = 2.2; 95 % confidence interval (CI) = 1.4-3.8). However, moderate (aOR = 1.4; 95 % CI =0.7–2.2) and high (aOR = 1.3; 95 % CI 0.7–2.2) attendance were not statistically significantly associated with PM. PNC attendance was not significantly associated with lower PM (relative risk 0.4, 95 % CI 0.1–2.6). Emergency obstetric and newborn care (EmONC) was significantly associated with a reduction in mortality (aOR = 0.2; 95 % CI = 0.2–0.8), with an 84.4 % reduction among newborns at risk, and an overall reduction in mortality of 10 % for all births.

Conclusion

Perinatal mortality was high among the infants of women in the cohort under study (26 per 1000 live births). Availability of MNCH, specifically EmONC, was associated with lower perinatal mortality, and if this association is causal, might avert 84.4 % of perinatal deaths among newborns at high-risk.

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used and rates are increasing globally. Risk factors associated with GDM include advanced maternal age, obesity, ethnicity, family history of diabetes, and a previous history of GDM, macrosomia or unexplained stillbirth. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 February 2016) and reference lists of the retrieved studies.

SELECTION CRITERIA

We included one randomised controlled trial. Cluster-randomised and quasi-randomised controlled trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated methodological quality and extracted data for the one included study. We sought additional information from one trial author but had no response. We assessed the quality of evidence for selected outcomes using the GRADE approach.

MAIN RESULTS

We included one Canadian trial of 180 women, recruited between 20 to 32 weeks' gestation, who had been diagnosed with GDM. Data from 171 of the 180 women were published as a conference abstract and no full report has been identified. The overall risk of bias of the single included study was judged to be unclear.The included trial did not report on any of this review's primary outcomes. For the mother, these were hypertension disorders of pregnancy or subsequent development of type 2 diabetes. For the infant, our primary outcomes were (perinatal (fetal and neonatal) mortality; large-for-gestational age; composite of death or severe morbidity or later childhood neurosensory disability).The trial did report data relating to some of this review's secondary outcomes. There was no clear difference in caesarean section rates for women assigned to using strict glycaemic targets (pre-prandial 5.0 mmol/L (90 mg/L) and at one-hour postprandial 6.7 mmol/L (120 mg/dL)) (28/85, 33%) when compared with women assigned to using liberal glycaemic targets (pre-prandial 5.8 mmol/L (103 mg/dL) and at one-hour postprandial 7.8 mmol/L (140 mg/dL)) (21/86, 24%) (risk ratio (RR) 1.35, 95% confidence interval (CI) 0.83 to 2.18, one trial, 171 women; very low quality). Using the GRADE approach, we found the quality of the evidence to bevery low for caesarean section due to poor reporting of risk of bias, imprecision and publication bias. Strict glycaemic targets were associated with an increase in the use of pharmacological therapy (identified as the use of insulin in this study) (33/85; 39%) compared with liberal glycaemic targets (18/86; 21%) (RR 1.85, 95% CI 1.14 to 3.03; one trial, 171 women). CIs are wide suggesting imprecision and caution is required when interpreting the data. No other secondary maternal outcome data relevant to this review were reported. For the infant, there were no clear differences between the groups of women receiving strict and liberal glycaemic targets for macrosomia (birthweight greater than 4000 g) (RR 1.35, 95% CI 0.31 to 5.85, one trial, 171 babies); small-for-gestational age (RR 1.12, 95% CI 0.48 to 2.63, one trial, 171 babies); birthweight (mean difference (MD) -92.00 g, 95% CI -241.97 to 57.97, one trial, 171 babies) or gestational age (MD -0.30 weeks, 95% CI -0.73 to 0.13, one trial, 171 babies). Adverse effects data were not reported. No other secondary neonatal outcomes relevant to this review were reported.

AUTHORS' CONCLUSIONS

This review is based on a single study (involving 180 women) with an unclear risk of bias. The trial (which was only reported in a conference abstract) did not provide data for any of this review's primary outcomes but did provide data for a limited number of our secondary outcomes. There is insufficient evidence to guide clinical practice for targets for glycaemic control for women with GDM to minimise adverse effects on maternal and fetal health. Glycaemic target recommendations from international professional organisations for maternal glycaemic control vary widely and are reliant on consensus given the lack of high-quality evidence.Further high-quality trials are needed, and these should compare different glycaemic targets for guiding treatment of women with GDM, assess both short-term and long-term health outcomes for women and their babies, include women's experiences and assess health services costs. Four studies are ongoing.

Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth

AIM

To assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering at the late preterm period.

METHODS

Retrospective observational cohort of all women with GDM who delivered a singleton fetus at the late preterm birth period (34+0/7 to 36+6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.

RESULTS

1849 women were included in the study, of whom 132 (7.1%) were diagnosed with GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal delivery (45.5% vs. 62.9%, p<0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%, p<0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24-2.66, p=0.002). Neonates of mothers with GDM had significant higher mean birth weight and birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity.

CONCLUSION

according to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications.

Risk Factors for the Requirement of Antenatal Insulin Treatment in Gestational Diabetes Mellitus

Poor maternal glycemic control increases maternal and fetal risk for adverse outcomes, and strict management of gestational diabetes mellitus (GDM) is recommended to prevent neonatal and maternal complications. However, risk factors for the requirement of antenatal insulin treatment (AIT) are not well-investigated in the pregnant women with GDM. We enrolled 37 pregnant women with GDM and investigated the risk for AIT by comparing the patients with AIT (AIT group; n = 10) and without insulin therapy (Diet group; n = 27). The 1-h and 2-h plasma glucose levels and the number of abnormal values in 75 g OGTT were significantly higher in AIT group compared with Diet group. By logistic regression analysis, plasma glucose level at 1-h was significant predictor for AIT and the odds ratios were 1.115 (1.004-1.239) using forward selection method and 1.192 (1.006-1.413) using backward elimination method. There were no significant differences in obstetrical outcomes and neonatal complications. 1-h plasma glucose levels in 75 g OGTT are useful parameters in predicting the requirement for AIT in GDM. Both maternal and neonatal complications are comparable in GDM patients with and without insulin therapy.

Labor and neonatal outcomes after term induction of labor in gestational diabetes

OBJECTIVE

To identify the optimal gestational age (GA) for induction of labor (IOL) at term among patients with gestational diabetes (GDMA) according to perinatal outcomes.

STUDY DESIGN

The US Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were singleton delivery, IOL at 37 to 42 weeks and GDMA. Exclusion criteria included congenital anomalies, pre-gestational diabetes, hypertensive disorders, previous cesarean, breech presentation and rupture of membranes. Controls were non-GDMA cases delivered in geographic and temporal proximity. Delivery mode, macrosomia and perinatal complications were analyzed. Logistic regression adjusted for confounders was used to calculate odds ratios by GA using 39 weeks non-GDMA as reference.

RESULTS

In all, 96,964 cases and 176,079 controls were included. Increased risk for all adverse outcomes among GDMA cases was found. The nadir for intrapartum and neonatal complications was 38 and 40 weeks, respectively, whereas for cesarean and macrosomia was 39 weeks.

CONCLUSION

The optimal timing for IOL at term in GDMA appears to be 39 to 40 weeks.

Relationship between gestational fasting plasma glucose and neonatal birth weight, prenatal blood pressure and dystocia in pregnant Chinese women

BACKGROUND

Little is known about the optimal cut-off point of fasting plasma glucose for the diagnosis of gestational diabetes mellitus for pregnant Chinese women. This study investigates the relationship between gestational fasting plasma glucose and several variables: neonatal birth weight, prenatal blood pressure and dystocia rate of pregnant women. In this study, we hoped to provide a useful tool to screen gestational diabetes mellitus in pregnant Chinese women.

METHODS

For 1058 pregnant women enrolled in our hospital at pregnancy weeks 22-30, fasting plasma glucose, neonatal birth weight and prenatal blood pressure, as well as dystocia conditions, were examined. We analysed the correlations between the following: gestational fasting plasma glucose and neonatal birth weight; prenatal blood pressure and gestational fasting plasma glucose as well as dystocia rate and gestational fasting plasma glucose group.

RESULTS

A modest correlation was observed between gestational fasting plasma glucose and neonatal birth weight (r = 0.093, p = 0.003). The macrosomia rate was smallest when the gestational fasting plasma glucose was in the range 3.51-5.5 mmol/L. Prenatal blood pressure increased linearly with increasing gestational fasting plasma glucose (p = 0.000). There was a significant difference between the dystocia rates in different fasting plasma glucose groups (chi-squared = 13.015, p = 0.043). The results showed that the dystocia rate significantly increased when gestational fasting plasma glucose was >4.9 mmol/L; p = 0.03, OR = 2.156 (95% CI, 1.077-4.318).

CONCLUSION

We suggest that the optimal range of gestational fasting plasma glucose for pregnant Chinese women is in the range 3.5-4.9 mmol/L.

Placental histomorphometry in gestational diabetes mellitus: the relationship between subsequent type 2 diabetes mellitus and race/ethnicity

OBJECTIVES

We examined placental histomorphometry in gestational diabetes mellitus (GDM) for factors associated with race/ethnicity and subsequent type 2 diabetes mellitus (T2DM).

METHODS

We identified 124 placentas from singleton, full-term live births whose mothers had clinically defined GDM and self-reported race/ethnicity. Clinical and placental diagnoses were abstracted from medical records.

RESULTS

Forty-eight white and 76 nonwhite women were followed for 4.1 years (median, range 0.0-8.9 years). White women developed less T2DM (12.5% vs 35.5%; P = .005) but had higher systolic (mean ± SD, 116 ± 13 vs 109 ± 11 mm Hg; P < .001) and diastolic (71 ± 9 vs 68 ± 7 mm Hg; P = .02) blood pressure, more smoking (35.4% vs 10.5%; P = .004), and more chorangiosis (52.1% vs 30.3%; P = .02) than nonwhite women.

CONCLUSIONS

Although more nonwhite women developed T2DM, more white women had chorangiosis, possibly secondary to the higher percentage of smokers among them. Further study is necessary to elucidate the relationship among chorangiosis, subsequent maternal T2DM, and race.

Fructose-1,6-bisphosphatase deficiency: a case of a successful pregnancy by closely monitoring metabolic control

In patients with fructose-1,6-bisphosphatase (FBPase) deficiency, maternal and fetal neurodevelopmental abnormalities can be induced by severe hypoglycemia and lactic acidosis, which is triggered by pregnancy. The patient was a 24-year-old and primipara. Via pre-pregnancy education and management including self-monitoring of blood glucose and prompt medical intervention with glucose infusions, she never experienced hypoglycemia with impaired consciousness. She delivered a 2,406 g male infant at 38 weeks of gestation by cesarean section. No neurological abnormalities in either the mother or the child appeared during the following 2 years. This is the first report with detailed descriptions of the management of a pregnant woman with FDPase deficiency. This report suggests that for a patient with FBPase deficiency, the maternal and fetal complications can be reduced by pre-pregnancy education and self-monitoring of blood glucose to prevent hypoglycemia.

Amniotic fluid insulin and C-peptide as predictive markers for fetal macrosomia, birth injuries, and delivery complications?

Background

Gestational diabetes mellitus (GDM) occurs in 3–5% of all pregnancies. GDM increases both maternal and fetal risks, causes fetal macrosomia, and hence increases the rates of caesarean sections and delivery complications such as shoulder dystocia. An early predictive marker and consequent early treatment could be beneficial, so amniotic fluid insulin and C-peptide have been examined in several studies. Increased amniotic fluid insulin in early amniocentesis between the 14^th and 20^th gestational week predicted a later GDM. A potential direct association with fetal macrosomia remains to be determined.

Material/Methods

This retrospective study investigated amniotic fluid insulin/C-peptide from amniocenteses between 14 and 20 weeks of gestation in correlation with fetal birth weight, type of delivery, and complications. To focus on effects of fetal hyperinsulinism apart from therapeutic confounders, we included patients who did not participate in GDM screening. Insulin and C-peptide were measured in 144 samples of frozen amniotic fluid. Birth weight, type of delivery, complications, and birth injuries were noted.

Results

Birth weights ranged from 760 g to 4410 g with a mean weight of 3424 g at an average of 40 weeks gestation. The mean amniotic fluid insulin was 4.36 μU/ml and the mean C-peptide concentration was 0.076 ng/ml. There was no correlation between amniotic fluid insulin or C peptide and birth weight, type of delivery, complications, and birth injuries.

Conclusions

Amniotic fluid insulin and C-peptide are unsuitable as predictive marker for fetal macrosomia, type of delivery, complications, or birth injuries.

Maternal prepregnancy obesity and insulin treatment during pregnancy are independently associated with delayed lactogenesis in women with recent gestational diabetes mellitus

BACKGROUND

The timely onset of stage II lactogenesis (OL) is important for successful breastfeeding and newborn health. Several risk factors for delayed OL are common in women with a history of gestational diabetes mellitus (GDM), which may affect their chances for successful breastfeeding outcomes.

OBJECTIVE

We investigated the prevalence and risk factors associated with delayed OL in a racially and ethnically diverse cohort of postpartum women with recent GDM.

DESIGN

We analyzed data collected in the Study of Women, Infant Feeding and Type 2 Diabetes After GDM Pregnancy (SWIFT), which is a prospective cohort of women diagnosed with GDM who delivered at Kaiser Permanente Northern California hospitals from 2008 to 2011. At 6-9 wk postpartum, delayed OL was assessed by maternal report of breast fullness and defined as occurring after 72 h postpartum. We obtained data on prenatal course and postdelivery infant feeding practices from electronic medical records and in-person surveys. We used multivariable logistic regression models to estimate associations of delayed OL with prenatal, delivery, and postnatal characteristics.

RESULTS

The analysis included 883 SWIFT participants who initiated breastfeeding and did not have diabetes at 6-9 wk postpartum. Delayed OL was reported by 33% of women and was associated with prepregnancy obesity (OR: 1.56; 95% CI: 1.07, 2.29), older maternal age (OR: 1.05; 95% CI: 1.01, 1.08), insulin GDM treatment (OR: 3.11; 95% CI: 1.37, 7.05), and suboptimal in-hospital breastfeeding (OR: 1.65; 95% CI: 1.20, 2.26). A higher gestational age was associated with decreased odds of delayed OL but only in multiparous mothers (OR: 0.79; 95% CI: 0.67, 0.94).

CONCLUSIONS

One-third of women with recent GDM experienced delayed OL. Maternal obesity, insulin treatment, and suboptimal in-hospital breastfeeding were key risk factors for delayed OL. Early breastfeeding support for GDM women with these risk factors may be needed to ensure successful lactation. This trial was registered at clinicaltrials.gov as NCT01967030.