Flexible treatment of Gestational Diabetes modulated on ultrasound evaluation of intrauterine growth: a controlled randomized clinical trial

Third Trimester Ultrasound Stratifies Risk of Peripartum Complications in Pregnancies Complicated by Impaired Glucose Tolerance

OBJECTIVE

 The objective of our study was to investigate the effect of impaired glucose metabolism (IGM) and ultrasound (US) findings consistent with hyperglycemia on maternal and neonatal outcomes.

STUDY DESIGN

 This was a retrospective case-control study of singleton, nonanomalous pregnancies with an elevated 1-hour glucose screening test (GST) completed after 23 weeks of gestation. IGM was defined as a 1-hour GST of >130, but less than two abnormal values on 3-hour glucose tolerance test (GTT). Gestational diabetes was defined as two or more abnormal values on 3-hour GTT. Ultrasound evidence of hyperglycemia was defined as abdominal circumference >95th centile and/or polyhydramnios. Individuals with IGM were divided into those with ultrasound evidence of hyperglycemia (impaired glucose metabolism consistent with ultrasound findings [IGM-US]) and those without IGM. Maternal demographics, delivery outcomes (gestational age at delivery, delivery mode, shoulder dystocia, lacerations), postpartum hemorrhage, and neonatal outcome (birth weight centile [BW%], neonatal intensive care unit admission, hypoglycemia, and glucose) were recorded. Composite morbidity was tabulated. Delivery and neonatal outcome variables were compared in individuals with IGM-US, IGM, and gestational diabetes mellitus (GDM). Odds ratios were calculated and adjusted for maternal age, BMI, and gestational weight gain.

RESULTS

 A total of 637 individuals with an abnormal 1-hour GST were included (122 with IGM-US, 280 with IGM, and 235 with GDM). When compared to the IGM group, IGM-US had higher rates of cesarean delivery and BW% > 90th centile at delivery (adjusted odds ratio [aOR]: 1.7 [1.1-2.8] and aOR: 5.9 [2.7-13.0], respectively). Individuals with GDM also demonstrated similar rates with BW% > 90% but not cesarean section(aOR: 3.9 [1.8-8.5] and aOR: 1.4 [0.9-2.1], respectively). The remaining maternal and fetal outcomes were similar.

CONCLUSION

 Women with impaired glucose tolerance should have a third-trimester ultrasound to identify an increased risk of perinatal complications.

KEY POINTS

· Women with elevated blood glucose screening should be evaluated with third-trimester ultrasound to identify risks for perinatal morbidity.. · The third-trimester ultrasound identifies individuals at risk for cesarean section.. · Counseling should be completed with individuals with polyhydramnios or accelerated growth..

Factors associated with higher risk of small-for-gestational-age infants in women treated for gestational diabetes

BACKGROUND

Previously, management of gestational diabetes (GDM) has focused largely on glycaemic control, with a view to reduce the occurrence of large-for-gestational-age (LGA) infants. However, tight glycaemic control in GDM is associated with a higher incidence of small-for-gestational-age (SGA) infants, which has been linked to higher rates of adverse outcomes.

AIM

The aim was to characterise risk factors associated with having an SGA infant in women being treated for GDM.

METHODS

This was a retrospective observational cohort study of 308 women with GDM. Women were split into groups based on their infant's size at delivery (SGA, appropriate-for-gestational-age (AGA) or LGA). Literature review and expert opinion helped to determine several predictors of women with GDM delivering an SGA infant, and statistical analysis was used to produce odds ratios (OR) for these predictors.

RESULTS

The sample included primiparous women with a mean pre-pregnancy body mass index (BMI) of 25.72 (standard deviation: 5.75). Metabolic risk factors associated with delivering an SGA infant included a lower pre-pregnancy BMI (adjusted OR 1.13, P = 0.04, 95% confidence interval (CI): 1.01-1.26), a lower fasting blood glucose level (BGL) (adjusted OR: 3.21, P = 0.01, 95% CI: 1.30-7.93) and growth that was high risk for SGA at baseline ultrasound scan (USS) (adjusted OR: 7.43, P < 0.001, 95% CI: 2.93-18.79).

CONCLUSIONS

The combined clinical picture of lower pre-pregnancy BMI, fasting BGL and baseline USS growth measurements may indicate a need for less aggressive glucose management in women with GDM to prevent SGA infants.

Non-efficacy of early intervention strategy for non-obese patients with early-onset gestational diabetes mellitus: solely based on the short-term outcomes

INTRODUCTION

To verify the effectiveness of intervention in early pregnancy for women with early-onset gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

This study included women with a singleton pregnancy who were diagnosed with early-onset GDM by 20 weeks of gestation according to the International Association of Diabetes and Pregnancy Study Group (IADPSG) threshold. We retrospectively evaluated the pregnancy outcomes in pregnant women with early-onset GDM. In the treatment from early pregnancy group (n=286), patients were diagnosed with early-onset GDM at the Yokohama City University Medical Center (YCU-MC) in 2015-2017 and were treated for GDM from early pregnancy. Concerning the treatment from mid-pregnancy group (n=248), participants were diagnosed with early-onset GDM at five sites, including the YCU-MC in 2018-2019, and were followed up without treatment until the second 75 g oral glucose tolerance test (OGTT) at 24-28 weeks of gestation. Treatment for GDM was given only if the GDM pattern was still present in the second OGTT.

RESULTS

There were no significant differences in maternal backgrounds, including GDM risk factors and gestational weight gain, between the groups. Among the treatment from mid-pregnancy group, the false-positive early GDM was 124/248 (50%). Regarding pregnancy outcome, the rate of large for gestational age (LGA) was 8.8% in the treatment from early pregnancy group and 10% in the treatment from mid-pregnancy group, with no significant difference, whereas small for gestational age (SGA) was significantly higher in the treatment from early pregnancy group (9.4%) than in the treatment from mid-pregnancy group (4.8%) (p=0.046). There were no significant differences in maternal adverse events and neonatal outcomes between the groups. In a subanalysis limited to body mass index >25 kg/m², LGA was significantly lower in the treatment from early pregnancy group than in the treatment from mid-pregnancy group.

CONCLUSIONS

The strategy for diagnosing GDM by IADPSG thresholds in early pregnancy and providing treatment to all patients from early pregnancy did not improve the pregnancy outcomes, but rather increased the SGA rate.

The sFlt-1/PlGF Ratio in Patients Affected by Gestational Diabetes and SARS-CoV-2 Infection

Low values of the ratio of plasmatic soluble blocking factor FMS-like tyrosine Kinase 1 and placental growth factor (sFlt-1/PlGF) are required for an adequate placental angiogenesis and function. It has been shown that patients affected by gestational diabetes (GD) and patients with pneumonia from SARS-CoV-2 are characterized by an increased sFlt-1/PlGF ratio. The aim of the present study was to evaluate the sFlt-1-PlGF ratio in pregnancies complicated by COVID-19 and GD. We compared the plasmatic sFlt-1/PlGF ratio among the following groups of pregnant women: COVID-19, GD patients; COVID-19, non-GD patients; non-COVID-19, GD patients; and non-COVID-19, non-GD controls. We enrolled 62 women in the present study, who were divided as follows: 14 COVID-19, GD patients; 12 COVID-19, non-GD patients; 11 non-COVID-19, GD patients; and 25 non-COVID-19, non-GD controls. The COVID-19, GD patients presented a higher pre-pregnancy BMI, a higher prevalence of hypertensive disorders of pregnancy as a co-morbidity, and an increased need for medication for their diabetes. Neonatal data were similar between the groups. The controls showed a significantly lower sFlt-1/PlGF ratio compared to pregnancies complicated by GD and SARS-CoV-2 infection. The sFlt-1/PlGF ratio was higher in patients affected by both GD and SARS-CoV-2 infection; these subjects were characterized by a greater incidence of obesity and hypertensive disorders of pregnancy.

Flexible treatment of gestational diabetes mellitus adjusted according to intrauterine fetal growth versus treatment according to strict maternal glycemic parameters: a randomized clinical trial

INTRODUCTION

To compare the conventional treatment of gestational diabetes mellitus (GDM) with flexible treatment according to the measurement of fetal abdominal circumference (AC) in daily clinical practice.

RESEARCH DESIGN AND METHODS

Two hundred and sixty pregnant women diagnosed with GDM before week 34 were randomly placed in two groups: a control group, treated according to maternal capillary glycemia, and an experimental group, treated according to ultrasound parameters of fetal growth. The glycemic targets in the control group were blood glucose levels when fasting and 1 hour postprandial (<95/140 mg/dL). In the experimental group, glycemic targets depended on the percentile (p) of fetal AC: if AC p <75th, then blood glucose targets when fasting and at 1 hour postprandial were <120/180 mg/dL; and if AC p ≥75th, then the glycemic targets were <80/120 mg/dL. The follow-up of both groups was scheduled according to the GDM protocol of our diabetes and gestation unit.

RESULTS

The study was completed by 246 pregnant women, 125 in the control group and 121 in the experimental group. In the experimental group, insulin treatment and neonatal hypoglycemia were significantly lower (p=0.018 and p 0.035, respectively). No differences were observed in large and small infants according to gestational age. However, macrosomic infants were less frequent in the experimental group, although this difference did not reach statistical significance. In terms of gestation complications, the type of delivery and its complications and the rest of the neonatal complications analyzed, no significant differences were observed.

CONCLUSIONS

The treatment of flexible GDM according to the measurement of fetal AC is safe for the mother and the fetus and almost halves the number of pregnant women who require insulin treatment, without increasing the number of ultrasound checks or medical visits.

Association between pre-pregnancy body mass index and gestational weight gain and perinatal outcomes in pregnant women diagnosed with gestational diabetes mellitus: The Japan Environment and Children's Study

AIMS/INTRODUCTION

We investigated the association between gestational diabetes mellitus (GDM) and perinatal outcomes stratified by pre-pregnancy body mass index (BMI) and/or gestational weight gain (GWG).

MATERIALS AND METHODS

Data from the national birth cohort in the Japan Environment and Children's Study from 2011 to 2014 (n = 85,228) were used. Japan uses the GDM guidelines of the International Association of Diabetes and Pregnancy Study Groups. The odds ratios (ORs) of perinatal outcomes were compared between women with and those without GDM.

RESULTS

The OR (95% confidence interval) of having a small for gestational age infant in the GDM group with a pre-pregnancy BMI of ≥25.0 kg/m2 and insufficient GWG (<2.75 kg) was 1.78 (1.02-3.12). The OR of having a large for gestational age infant of the same BMI group with excessive GWG (>7.25 kg) was 2.04 (1.56-2.67). The OR of hypertensive disorders of pregnancy was higher in women with a BMI ≥18.5 kg/m2 in the GDM group than in the non-GDM group.

CONCLUSIONS

Large for gestational age and hypertensive disorders of pregnancy were associated with pre-pregnancy BMI and GWG in either normal weight or overweight/obese women, and the relationship was strengthened when GDM was present. Women with GDM and a BMI of ≥25.0 kg/m2 are at risk of having small for gestational age and large for gestational age infants depending on GWG.

Influence of Pre-Pregnancy Underweight Body Mass Index on Fetal Abdominal Circumference, Estimated Weight, and Pregnancy Outcomes in Gestational Diabetes Mellitus

This study aimed to determine the influence of pre-pregnancy body mass index on pregnancy outcomes in gestational diabetes mellitus (GDM), comparing underweight patients with GDM with normal weight patients with GDM. Maternal baseline characteristics, ultrasonographic results, and pregnancy and neonatal outcomes were reviewed in 946 women with GDM with singleton pregnancies. Underweight patients with GDM showed a benign course in most aspects during pregnancy, except for developing a higher risk of giving birth to small for gestational age neonates. Underweight women with GDM required less insulin treatment, had a higher rate of vaginal delivery, and had a lower rate of cesarean delivery. In addition, their neonates were more likely to have fetal abdominal circumference and estimated fetal weight below the 10th percentile both at the time of GDM diagnosis and before delivery. Notably, their risk for preeclampsia and macrosomia were lower. Collectively, our data suggest that underweight women with GDM may require a different approach in terms of diagnosis and management throughout their pregnancy.

Pregnancy in Women With Monogenic Diabetes due to Pathogenic Variants of the Glucokinase Gene: Lessons and Challenges

Heterozygous loss-of-function variants of the glucokinase (GCK) gene are responsible for a subtype of maturity-onset diabetes of the young (MODY). GCK-MODY is characterized by a mild hyperglycemia, mainly due to a higher blood glucose threshold for insulin secretion, and an up-regulated glucose counterregulation. GCK-MODY patients are asymptomatic, are not exposed to diabetes long-term complications, and do not require treatment. The diagnosis of GCK-MODY is made on the discovery of hyperglycemia by systematic screening, or by family screening. The situation is peculiar in GCK-MODY women during pregnancy for three reasons: 1. the degree of maternal hyperglycemia is sufficient to induce pregnancy adverse outcomes, as in pregestational or gestational diabetes; 2. the probability that a fetus inherits the maternal mutation is 50% and; 3. fetal insulin secretion is a major stimulus of fetal growth. Consequently, when the fetus has not inherited the maternal mutation, maternal hyperglycemia will trigger increased fetal insulin secretion and growth, with a high risk of macrosomia. By contrast, when the fetus has inherited the maternal mutation, its insulin secretion is set at the same threshold as the mother's, and no fetal growth excess will occur. Thus, treatment of maternal hyperglycemia is necessary only in the former situation, and will lead to a risk of fetal growth restriction in the latter. It has been recommended that the management of diabetes in GCK-MODY pregnant women should be guided by assessment of fetal growth by serial ultrasounds, and institution of insulin therapy when the abdominal circumference is ≥ 75th percentile, considered as a surrogate for the fetal genotype. This strategy has not been validated in women with in GCK-MODY. Recently, the feasibility of non-invasive fetal genotyping has been demonstrated, that will improve the care of these women. Several challenges persist, including the identification of women with GCK-MODY before or early in pregnancy, and the modalities of insulin therapy. Yet, retrospective observational studies have shown that fetal genotype, not maternal treatment with insulin, is the main determinant of fetal growth and of the risk of macrosomia. Thus, further studies are needed to specify the management of GCK-MODY pregnant women during pregnancy.

Fetal ultrasound scans to guide management of gestational diabetes: Improved neonatal outcomes in routine clinical practice

AIMS

Some guidelines recommend altering glycemic targets in gestational diabetes mellitus (GDM) based on ultrasound measurements of fetal growth, but the impact on outcomes in clinical practice is unknown. The aim of this study was to compare the effects of ultrasound-guided and non-ultrasound-guided management on neonatal outcomes.

METHODS

This was a retrospective, observational study of a random sample of women with GDM and their infants. Outcomes were compared between those who had GDM management tailored according to fetal growth and those who did not.

RESULTS

In the sample of 221 women, 134 had documentation of ultrasound-guided management while 87 did not. There was no significant difference in size-for-gestational age between groups. Fewer neonates in the ultrasound-guided management group were admitted to the Special Care or Intensive Care Nursery (29.1% vs. 48.3%, P = 0.004), had a prolonged hospital stay (3.7% vs. 13.8%, P = 0.006), or had hypoglycemia after birth (42.5% vs. 56.3%, P = 0.045). The reduction in admission rates and prolonged hospital stays remained significant after controlling for confounding variables.

CONCLUSIONS

Ultrasound-guided management was independently associated with improvements in some neonatal outcomes.

Evaluation of fetal cardiac function in pregnancies with well-controlled gestational diabetes

OBJECTIVE

To evaluate fetal ventricular diastolic function in pregnancies of women with gestational diabetes (GD), to determine whether minimal anomalies of glucose metabolism may influence fetal cardiac function.

STUDY DESIGN

Fetal ventricular filling time was measured by transabdominal ultrasound in singleton pregnancies between 34 and 37 weeks of gestation. We used a measurement which consists in the ratio between the diastolic time and the whole cardiac cycle time.

RESULTS

The study included 35 women with a GD and 217 non-diabetic. Right ventricular filling time (RVFT) was significantly lower in the GD group (mean of RVFT = 39.2 ± 4.4 vs 43.6 ± 4.6; p  <  0.01). Likewise, left ventricular filling time (LVFT) was shorter in the GD group compared to the non-GD group, though the difference was not significant (mean of LVFT = 43.6 ± 4.6 vs 44.6 ± 5.5; p  = 0.33).

CONCLUSIONS

Fetal right cardiac function is altered also in pregnancies where gestational diabetes is well controlled.

The role of obesity and gestational diabetes on placental size and fetal oxygenation

INTRODUCTION

Maternal pregestational obesity is a significant risk factor for adverse pregnancy outcomes, such as gestational diabetes. Both these conditions can have an impact on placental development and affect maternal-fetal exchanges, compromising fetal metabolic status. The aim of the study is to investigate the influence of pre-pregnancy BMI on placental size and to evaluate the role of obesity and gestational diabetes mellitus (GDM) on fetal oxygenation in overweight and obese pregnant women.

METHODS

208 normal weight (NW), 57 overweight (OW) and 69 obese (OB) women were studied at elective cesarean section (CS) at term. 10 OW and 24 OB women were affected by GDM. Maternal, fetal and placental data were collected. Respiratory gases and acid-base balance were measured in umbilical venous and arterial blood.

RESULTS

Placental weight and thickness were higher in OB pregnancies. Lower fetal-placental ratios (F/P) were found in GDM pregnancies, both OW and OB. Fetuses from OB mothers were more hypoxic and acidemic compared to NW, particularly when complicated by GDM.

DISCUSSION

In agreement with previous studies, our data show that placentas from OB and GDM pregnancies are heavier and thicker, suggesting that an unbalanced pregestational nutritional status can decrease the placental efficiency in maternal-fetal exchanges. Fetuses from obese women are also hypoxic and acidemic, while fetuses from gestational diabetic mothers are hypoxic, reflecting that an altered pre-pregnancy BMI can affect fetal oxygenation, and GDM can play an additional detrimental role, thus worsening placental function and fetal oxygenation.

Defining Heterogeneity Among Women With Gestational Diabetes Mellitus

Attention to precision medicine in type 2 diabetes (T2D) has provided two favored approaches to subclassifying affected individuals and parsing heterogeneity apparent in this condition: phenotype-based and genotype-based. Gestational diabetes mellitus (GDM) shares phenotypic characteristics with T2D. However, unlike T2D, GDM emerges in the setting of profound pregnancy-related physiologic changes in glucose metabolism. T2D and GDM also share common genetic architecture, but there are likely to be unique genetic influences on pregnancy glycemic regulation that contribute to GDM. In this Perspective, we describe efforts to decipher heterogeneity in T2D and detail how we and others are applying approaches developed for T2D to the study of heterogeneity in GDM. Emerging results reveal the potential of phenotype- and genotype-based subclassification of GDM to deliver the promise of precision medicine to the obstetric population.

Main Fetal Predictors of Adverse Neonatal Outcomes in Pregnancies with Gestational Diabetes Mellitus

The objectives of this study were to (a) assess the utility of fetal anthropometric variables to predict the most relevant adverse neonatal outcomes in a treated population with gestational diabetes mellitus (GDM) beyond the known impact of maternal anthropometric and metabolic parameters and (b) to identify the most important fetal predictors. A total of 189 patients with GDM were included. The fetal predictors included sonographically assessed fetal weight centile (FWC), FWC > 90% and <10%, and fetal abdominal circumference centile (FACC), FACC > 90% and < 10%, at 29 0/7 to 35 6/7 weeks. Neonatal outcomes comprising neonatal weight centile (NWC), large and small for gestational age (LGA, SGA), hypoglycemia, prematurity, hospitalization for neonatal complication, and (emergency) cesarean section were evaluated. Regression analyses were conducted. Fetal variables predicted anthropometric neonatal outcomes, prematurity, cesarean section and emergency cesarean section. These associations were independent of maternal anthropometric and metabolic predictors, with the exception of cesarean section. FWC was the most significant predictor for NWC, LGA and SGA, while FACC was the most significant predictor for prematurity and FACC > 90% for emergency cesarean section. In women with GDM, third-trimester fetal anthropometric parameters have an important role in predicting adverse neonatal outcomes beyond the impact of maternal predictors.

Management of Gestational Diabetes Mellitus

Once a woman is diagnosed with gestational diabetes mellitus (GDM), two strategies are considered for management; life-style modifications and pharmacological therapy. The management of GDM aims to maintain a normoglycemic state and to prevent excessive weight gain in order to reduce maternal and fetal complications. Lifestyle modifications include nutritional therapy and exercise. Calorie restriction with a low glycemic index diet is recommended to avoid postprandial hyperglycemia and to reduce insulin resistance. Blood glucose levels, HbA1c levels, and ketonuria are monitored to analyze the efficacy of conservative management. Pharmacological treatment is initiated if conservative strategies fail to provide expected glucose levels during follow-ups.Insulin has been the first choice for the treatment of diabetes during pregnancy. Recently, metformin has been used more commonly in diabetic pregnant women in cases when insulin cannot be prescribed, after its safety has been proven. However, a high percentage of women, which may be up to 46% may require additional insulin to maintain expected blood glucose levels. The evidence on the long-term safety of other oral anti-diabetics has been lacking yet.Women with diet-controlled GDM can wait for spontaneous labor expectantly in case there are no obstetric indications for birth. However, in women with GDM under insulin therapy or with poor glycemic control, elective induction at term is recommended by authorities.The women who have GDM during pregnancy should be counseled about their increased risks of impaired glucose tolerance, type 2 diabetes mellitus, hypertensive disorders, cardiovascular diseases, and metabolic syndrome.

Guideline No. 393-Diabetes in Pregnancy

OBJECTIVES

This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy.

OUTCOMES

The outcomes evaluated were short and long-term maternal outcomes including pre-eclampsia, Caesarean section, future diabetes and other cardiovascular complications; and fetal outcomes including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia and long-term effects.

EVIDENCE

Published literature was retrieved through searches of PubMed and The Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated. Despite many small randomized controlled trials of glucose-lowering medication treatment in GDM, our understanding of medication management of GDM is incomplete as evidenced by discrepancies among professional society treatment guidelines. The comparative effectiveness of insulin, metformin, and glyburide remains uncertain, particularly with respect to long-term outcomes. Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches. Further research on these topics is likely to improve our understanding of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children.

Non-pharmacological management of gestational diabetes: The role of myo-inositol

Gestational diabetes mellitus (GDM) is the most common metabolic disorder occurring in pregnancy. GDM plays an important role in the current diabetes epidemic: exposure to a high glycemic environment during the early stages of development increases the risk of the fetus to develop type two diabetes mellitus (T2DM) in adult life. Various cardiometabolic risk factors are linked to GDM. A thorough knowledge of the risk factors and genes involved in the development of GDM, along with an understanding of the underlying pathophysiological mechanisms are crucial to properly identify patients at risk of developing this condition. There is growing evidence showing that myo-inositol, combined with an appropriate therapeutic regimen for GDM, can provide additional benefits to the patient. The aim of this review is to analyze the role of inositol isomers - especially myo-inositol (MYO-INS) - in the treatment of patients with GDM.

Fetal biometry for guiding the medical management of women with gestational diabetes mellitus for improving maternal and perinatal health

BACKGROUND

Gestational diabetes mellitus (GDM) is a common medical condition that complicates pregnancy and causes adverse maternal and fetal outcomes. At present, most treatment strategies focus on normalisation of maternal blood glucose values with use of diet, lifestyle modification, exercise, oral anti-hyperglycaemics and insulin. This has been shown to reduce the incidence of adverse outcomes, such as birth trauma and macrosomia. However, this involves intensive monitoring and treatment of all women with GDM. We propose that using medical imaging to identify pregnancies displaying signs of being affected by GDM could help to target management, allowing low-risk women to be spared excessive intervention, and facilitating better resource allocation.

OBJECTIVES

We wanted to address the following question: in women with gestational diabetes, does the use of fetal imaging plus maternal blood glucose concentration to indicate the need for medical management compared with glucose concentration alone reduce the risk of adverse perinatal outcomes?

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 January 2019), ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (both on 29 January 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials, including those published in abstract form only. Studies using a cluster-randomised design and quasi-randomised controlled trials were both eligible for inclusion, but we didn't identify any. Cross-over trials were not eligible for inclusion in our review.We included women carrying singleton pregnancies who were diagnosed with GDM, as defined by the trials' authors. The intervention of interest was the use of fetal biometry on imaging methods in addition to maternal glycaemic values for indicating the use of medical therapy for GDM. The control group was the use of maternal glycaemic values alone for indicating the use of such therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors extracted data and checked them for accuracy.

MAIN RESULTS

Three randomised controlled trials met the inclusion criteria for our systematic review - the studies randomised a total of 524 women.We assessed the three included studies as being at a low to moderate risk of bias; the nature of the intervention made it difficult to achieve blinding of participants and personnel and none of the trial reports contained information about methods of allocation concealment (and were therefore assessed as being at an unclear risk of selection bias).In all studies, the intervention was the use of fetal biometry on ultrasound to identify fetuses displaying signs of fetal macrosomia, and the use of this information to indicate the use of medical anti-hyperglycaemic treatments. Those pregnancies were subject to more stringent blood glucose targets than those without signs of fetal macrosomia.Maternal outcomesThe use of fetal biometry in addition to maternal blood glucose concentration (compared with maternal blood glucose concentration alone) may make little or no difference to the incidence of caesarean delivery (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.10; 2 trials, 428 women; low-certainty evidence). We are unclear about the results for hypertensive disorders of pregnancy (RR 0.80, 95% CI 0.34 to 1.89; 2 trials, 325 women) due to very low-certainty evidence. The included trials did not report on development of type 2 diabetes in the mother or maternal hypoglycaemia.Fetal and neonatal outcomesThe use of fetal biometry may make little or no difference to the incidence of neonatal hypoglycaemia (RR 0.90, 95% CI 0.57 to 1.42; 3 trials, 524 women; low-certainty evidence). Very low-certainty evidence means that we are unclear about the results for large-for-gestational age (RR 0.81, 95% CI 0.38 to 1.74; 3 trials, 524 women); shoulder dystocia (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women); a composite measure of perinatal morbidity or mortality (RR 1.00, 95% CI 0.21 to 4.71; 1 study, 96 women); or perinatal mortality (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women).

AUTHORS' CONCLUSIONS

This review is based on evidence from three trials involving 524 women. The trials did not report some important outcomes of interest to this review, and the majority of our secondary outcomes were also unreported. The available evidence ranged from low- to very low-certainty, with downgrading decisions based on limitations in study design, imprecision and inconsistency.There is insufficient evidence to evaluate the use of fetal biometry (in addition to maternal blood glucose concentration values) to assist in guiding the medical management of GDM, on either maternal or perinatal health outcomes, or the associated costs.More research is required, ideally larger randomised studies which report the maternal and infant short- and long-term outcomes listed in this review, as well as those outcomes relating to financial and resource implications.

Evaluation of Treatment Strategies to Manage Diabetes Mellitus in Pregnancy: Use of Fetal Sonography Compared to Monitoring of Maternal Blood Glucose Alone

Introduction When planning the treatment of women with gestational diabetes, the current standard approach also takes fetal growth development into account. The treatment of pregnant women with type 1 diabetes mellitus (DM) used to be based exclusively on maternal blood glucose values. This study investigated the impact of including fetal growth parameters in the monitoring of pregnant women with type 1 diabetes mellitus. Patients/Method 199 pregnant women with type 1 DM were included in a cohort study. The patient population was divided into two study cohorts. In the mBG cohort (n = 94; investigation period: 1994 - 2005) treatment was monitored using only maternal blood glucose (mBG) values; the aim was to achieve standard target glucose values (mean BG < 5.5 mmol/l, postprandial: at 1 h < 7.7 mmol/l, at 2 h < 6.6 mmol/l). In the fUS collective (n = 101, investigation period: 2006 - 2014) fetal growth parameters were additionally included when monitoring treatment from the 22nd week of gestation, and maternal target glucose values were then individually adjusted to take account of fetal growth. This study aimed to investigate the impact of these two different ways of monitoring treatment on perinatal and peripartum outcomes. Results 91.4% of all patients were normoglycemic at the time of delivery (HbA _1c  < 6.7%); 58.9% of patients achieved strict normoglycemia (HbA _1c  < 5.7%). No differences were found between the two study cohorts (fUS vs. mBG: HbA _1c  < 6.7%: 93.9 vs. 88.4%, n. s.; mean blood glucose (BG): 5.4 ± 0.6 to 6.6 ± 1.1 vs. 5.9 ± 0.7 to 7.4 ± 1.9 mmol/l, n. s.). Patients from the fUS cohort required significantly lower weight-adjusted maximum insulin doses (0.9 ± 0.3 vs. 1.0 ± 0.4 IE/kg bodyweight, p < 0.05). Pregnancy complications occurred significantly less often in the fUS cohort (preeclampsia: 7.1 vs. 20.9%, p = 0.01; premature labor: 4.0 vs. 23.3%, p < 0.001; cervical insufficiency: 0.0 vs. 11.6%, p = 0.001), and there were significantly fewer cases with neonatal hyperbilirubinemia (19.2 vs. 40.7%, p = 0.001). There was no difference in the rates of LGA infants between the two cohorts (21.2 vs. 24.4%, n. s.). Conclusion Using maternal blood glucose values combined with fetal growth parameters to monitor DM treatment allows therapeutic interventions to be individualized and reduces the risk of maternal and infant morbidity. The metabolism of patients in the fUS cohort was significantly more stable and there were fewer variations in glucose values. It is possible that the detected benefits are due to this metabolic stabilization.

The Utility of Lower Glycemic Targets for Treating Gestational Diabetes: A Retrospective Study

OBJECTIVE

In vivo study of glucose homeostasis in pregnancy suggests normal glucose levels are lower than current glycemic targets used in gestational diabetes. After the HAPO study results, our institution began using glycemic targets of fasting 85 mg/dL and 2-hour postprandial of 110 mg/dL. We reviewed our results.

METHODS

A retrospective cohort of GDM patients that delivered at KUMC from January 2007 to May 2017 was reviewed. All patients were diagnosed with the 2-step Carpenter-Coustan thresholds. High targets were compared with low targets. The primary outcome investigated was birthweight > 90% (large for gestational age, LGA).

RESULTS

604 patients were studied, and 34% were treated with low glycemic targets. Our unadjusted results showed that the low-target group had a lower incidence of LGA infants (24.0 vs. 31.8%), higher incidence of neonatal hypoglycemia (20.7 vs. 11.6%), and inductions (39.4 vs. 20.5%). After adjustment for demographic variables, only a higher risk of inductions remained (aOR 2.54 (1.44, 4.49)).

CONCLUSION

Lower glycemic targets did not produce large reductions in fetal overgrowth, but they were associated with a higher rate of inductions. As there were no observed differences in maternal or neonatal outcomes otherwise, aiming for lower glycemic targets in GDM is likely not cost-effective.

Gestational diabetes from A to Z

Gestational diabetes mellitus (GDM) is defined as any degree of hyperglycaemia that is recognized for the first time during pregnancy. This definition includes cases of undiagnosed type 2 diabetes mellitus (T2DM) identified early in pregnancy and true GDM which develops later. GDM constitutes a greater impact on diabetes epidemic as it carries a major risk of developing T2DM to the mother and foetus later in life. In addition, GDM has also been linked with cardiometabolic risk factors such as lipid abnormalities, hypertensive disorders and hyperinsulinemia. These might result in later development of cardiovascular disease and metabolic syndrome. The understanding of the different risk factors, the pathophysiological mechanisms and the genetic factors of GDM, will help us to identify the women at risk, to develop effective preventive measures and to provide adequate management of the disease. Clinical trials have shown that T2DM can be prevented in women with prior GDM, by intensive lifestyle modification and by using pioglitazone and metformin. However, a matter of controversy surrounding both screening and management of GDM continues to emerge, despite several recent well-designed clinical trials tackling these issues. The aim of this manuscript is to critically review GDM in a detailed and comprehensive manner, in order to provide a scientific analysis and updated write-up of different related aspects.

A retrospective study comparing outcomes in a midwestern US population after introduction of IADPSG guidelines for gestational diabetes

OBJECTIVE

More evidence is required to endorse the 1-step approach for gestational diabetes mellitus (GDM) for clinical practice. Since 2010, our department has pragmatically allowed faculty to self-select the guidelines they use to screen and diagnose GDM. We sought to compare the maternal and neonatal outcomes from these two simultaneous cohorts.

STUDY DESIGN

We performed a retrospective cohort study of all singleton pregnancies delivered between October 2011 and -November 2013 at our hospital. Patients were excluded if they had preexisting diabetes, were not screened or screened inappropriately, or their fetus had congenital anomalies. Patients were grouped by their screening strategy, and maternal and neonatal outcomes were analyzed.

RESULTS

The 1-step group had a higher incidence of GDM (21.6% versus 5.0%). Initial results suggested higher rates of neonatal hypoglycemia, phototherapy for hyperbilirubinemia, and a lower rate of gestational HTN. After adjustment, these differences disappeared, but a lower rate of large for gestational age (LGA) infants was discovered (adjusted odds ratios (aOR) 0.78).

CONCLUSION

The picture remains unclear as to whether the 1-step approach is associated with significantly improved outcomes compared with the 2-step approach. We did find a lower risk for a LGA infant in our 1-step cohort, but it is unlikely that the 1-step approach would be cost-effective due to the absence of other improved outcomes.

Neonatal outcomes according to different therapies for gestational diabetes mellitus

OBJECTIVES

To compare different neonatal outcomes according to the different types of treatments used in the management of gestational diabetes mellitus.

METHODS

This was a retrospective cohort study. The study population comprised pregnant women with gestational diabetes treated at a public maternity hospital from July 2010 to August 2014. The study included women aged at least 18 years, with a singleton pregnancy, who met the criteria for gestational diabetes mellitus. Blood glucose levels, fetal abdominal circumference, body mass index and gestational age were considered for treatment decision-making. The evaluated neonatal outcomes were: type of delivery, prematurity, weight in relation to gestational age, Apgar at 1 and 5min, and need for intensive care unit admission.

RESULTS

The sample consisted of 705 pregnant women. The neonatal outcomes were analyzed based on the treatment received. Women treated with metformin were less likely to have children who were small for gestational age (95% CI: 0.09-0.66) and more likely to have a newborn adequate for gestational age (95% CI: 1.12-3.94). Those women treated with insulin had a lower chance of having a preterm child (95% CI: 0.02-0.78). The combined treatment with insulin and metformin resulted in higher chance for a neonate to be born large for gestational age (95% CI: 1.14-11.15) and lower chance to be born preterm (95% CI: 0.01-0.71). The type of treatment did not affect the mode of delivery, Apgar score, and intensive care unit admission.

CONCLUSIONS

The pediatrician in the delivery room can expect different outcomes for diabetic mothers based on the treatment received.

Can Fetal Limb Soft Tissue Measurements in the Third Trimester Predict Neonatal Adiposity?

OBJECTIVES

Neonatal adiposity is associated with chronic metabolic sequelae such as diabetes and obesity. Identifying fetuses at risk for excess neonatal body fat may lead to research aimed at limiting nutritional excess in the prenatal period. We sought to determine whether fetal arm and leg soft tissue measurements at 28 weeks' gestation were predictive of neonatal percent body fat METHODS : In this prospective observational cohort study of singleton term pregnancies, we performed sonography at 28 and 36 weeks' gestation, including soft tissue measurements of the fetal arm and thigh (fractional limb volume and cross-sectional area). We estimated the neonatal body composition (percent body fat) using anthropometric measurements and air displacement plethysmography. We estimated Spearman correlations between sonographic findings and percent body fat and performed modeling to predict neonatal percent body fat using maternal characteristics and sonographic findings.

RESULTS

Our analysis of 44 women yielded a mean maternal age of 30 years, body mass index of 26 kg/m(2), and birth weight of 3382 g. Mean neonatal percent body fat was 8.1% by skin folds at birth and 12.2% by air displacement plethysmography 2 weeks after birth. Fractional thigh volume measurements at 28 weeks yielded the most accurate model for predicting neonatal percent body fat (R(2) = 0.697; P = .001), outperforming models that used abdominal circumference (R(2)= 0.516) and estimated fetal weight (R(2)= 0.489).

CONCLUSIONS

Soft tissue measurements of the fetal thigh at 28 weeks correlated better with neonatal percent body fat than currently used sonographic measurements. After validation in a larger cohort, our models may be useful for prenatal intervention strategies aimed at the prevention of excess fetal fat accretion and, potentially, optimization of long-term metabolic health.

Gestational diabetes in the United States: temporal changes in prevalence rates between 1979 and 2010

OBJECTIVE

To examine age-period-cohort effects on trends in gestational diabetes mellitus (GDM) prevalence in the US, and to evaluate how these trends have affected the rates of stillbirth and large for gestational age (LGA)/macrosomia.

DESIGN

Retrospective cohort study.

SETTING

USA, 1979-2010.

POPULATION

Over 125 million pregnancies (3 337 284 GDM cases) associated with hospitalisations.

METHODS

Trends in GDM prevalence were examined via weighted Poisson models to parse out the extent to which GDM trends can be attributed to maternal age, period of delivery, and maternal birth cohort. Multilevel models were used to assess the contribution of population effects to the rate of GDM. Log-linear Poisson regression models were used to estimate the contributions of the increasing GDM rates to changes in the rates of LGA and stillbirth between 1979-81 and 2008-10.

MAIN OUTCOME MEASURES

Rates and rate ratios (RRs).

RESULTS

Compared with 1979-1980 (0.3%), the rate of GDM has increased to 5.8% in 2008-10, indicating a strong period effect. Substantial age and modest cohort effects were evident. The period effect is partly explained by period trends in body mass index (BMI), race, and maternal smoking. The increasing prevalence of GDM is associated with a 184% (95% CI 180-188%) decline in the rate of LGA/macrosomia and a 0.75% (95% CI 0.74-0.76) increase in the rate of stillbirths for 2008-10, compared with 1979-81.

CONCLUSIONS

The temporal increase in GDM can be attributed to period of pregnancy and age. Increasing BMI appears to partially contribute to the GDM increase in the US.

TWEETABLE ABSTRACT

The increasing prevalence of GDM can be attributed to period of delivery and increasing maternal age.

Diabetes in Pregnancy

OBJECTIVE

This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy.

OUTCOMES

The outcomes evaluated were short- and long-term maternal outcomes, including preeclampsia, Caesarean section, future diabetes, and other cardiovascular complications, and fetal outcomes, including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia, and long-term effects.

EVIDENCE

Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

SUMMARY STATEMENTS

Recommendations It is recognized that the use of different diagnostic thresholds for the "preferred" and "alternative" strategies could cause confusion in certain settings. Despite this, the committee has identified the importance of remaining aligned with the current Canadian Diabetes Association 2013 guidelines as being a priority. It is thus recommended that each care centre strategically align with 1 of the 2 strategies and implement protocols to ensure consistent and uniform reporting of test results.

Ultrasound (in)accuracy: it's in the formulae not in the technique - assessment of accuracy of abdominal circumference measurement in term pregnancies

Introduction: Fetal abdominal circumference (AC) is utilised in calculations for the estimation of fetal weight (EFW) and has been proposed as a method of monitoring diabetic pregnancies. We evaluated true ultrasound accuracy by comparing fetal AC biometry with neonatal anthropometry and compared this with standard ultrasound estimations of fetal weight.

Methods: A prospective observational study was performed at a tertiary referral centre. Women who were having their confinement of a term, singleton gestation either by induction of labour or elective caesarean section from 2009–2011 were approached to participate. An ultrasound was performed within 24 hours of delivery measuring the biometric parameters of AC, head circumference (HC), biparietal diameter and femur length. Following delivery the AC, HC and birthweight were measured on the neonate.

Results: Fifty‐two patients were enrolled in the study with data collected from 50. Mean AC measurement was 35.1 ± 2.1 cm and birth weight was 3596 ± 517 g. A Bland‐Altman plot was used to compare the two AC measurements with the 95% limits of agreement ranging from −2.33–4.69 cm around a mean difference of 1.2 cm. Mean percentage error was 5.0% and 6.2% for the AC and HC measurements respectively, in comparison with percentage errors of 7.0–13.8% for estimation of fetal weight (EFW) from 27 formulae.

Conclusions: Sonographic AC measurement is accurate in term pregnancies, with a percentage error less than HC or EFW. Perceptions of ultrasound inaccuracy may relate to the application of formulae rather than the ultrasound technique itself. Fetal surveillance using serial AC measurement has been proposed, in particular monitoring of diabetic pregnancies and in such a group AC may be easier and faster to obtain and more meaningful than EFW.

Glycemic targets in pregnancies affected by diabetes: historical perspective and future directions

The definition of optimal glycemic control in pregnancies affected by diabetes remains enigmatic. Diabetes phenotypes are heterogeneous. Moreover, fetal macrosomia insidiously occurs even with excellent glycemic control. Current blood glucose (BG) targets (FBG ≤95, 1-h post-prandial <140, 2 h <120 mg/dL) have improved perinatal outcomes, but arguably they have not normalized. The conventional management approach has been to replicate a pattern of glycemia in normal pregnancy. Although these patterns are lower than previously appreciated, a randomized controlled trial (RCT) has never compared current vs. lower glucose targets powered on maternal/fetal outcomes. This paper provides historical context to the current targets by reviewing evidence supporting their evolution. Using lower targets (FBG <90, 1 h <122, 2 h <110, mean BG ≤95 mg/dL) may help normalize outcomes, but phenotypic differences (type 1 vs. type 2 vs. gestational diabetes) might require different glycemic goals. There remains a critical need for well-designed RCTs to confirm optimal glycemic control that minimizes both small for and large for gestational age across pregnancies affected by diabetes.

Ultrasound-guided compared to conventional treatment in gestational diabetes leads to improved birthweight but more insulin treatment: systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of randomized controlled trials assessing ultrasound-guided versus conventional management in women with a broad severity-spectrum of gestational diabetes mellitus.

DESIGN

Systematic review and meta-analysis of trials published until August 2012.

SETTING

PubMed and Web of Science databases.

STUDY SELECTION AND METHODS

Eighteen studies were reviewed in full text. Eligibility criteria were (i) randomized controlled trials comparing metabolic management in women with gestational diabetes mellitus and ultrasound-based vs. the conventional management to assess fetal growth, (ii) representative of the whole spectrum of hyperglycemia and fetal growth, (iii) data on perinatal outcomes. Review Manager 5.0 was used to summarize the results.

RESULTS

Two studies fulfilled inclusion criteria. The ultrasound-guided group had a lower rate of large-for-gestational age newborns (relative risk 0.58, 95% confidence interval 0.34-0.99), macrosomia (relative risk 0.32, 95% confidence interval 0.11-0.95) and abnormal birthweight (small/large-for-gestational age, relative risk 0.64, 95% confidence interval 0.45-0.93) and a higher rate of insulin treatment (relative risk 1.58, 95% confidence interval 1.14-2.20). The number of women with gestational diabetes with a need to treat to prevent an additional newborn with abnormal birthweight was 10.

CONCLUSIONS

In women with a broad severity-spectrum of gestational diabetes mellitus, ultrasound-guided management improves birthweight distribution, but increases the need for insulin treatment. More research is needed in this area because results are derived from a limited number of patients.

Prediction of large for gestational age birth weights in diabetic mothers based on early third-trimester sonography

OBJECTIVES

The purpose of this study was to evaluate the ability of early third-trimester sonography to predict large for gestational age (LGA) birth weights in women with diabetes mellitus.

METHODS

We identified women with nonanomalous singleton gestations and pregestational and gestational diabetes mellitus who underwent sonographic examinations between gestational ages of 28 weeks and 32 weeks 6 days and subsequently delivered at 37 weeks or later. Using a cohort study design, we compared data from women with an estimated fetal weight at or above the 75th percentile (exposed group) with data from those with an estimated fetal weight below the 75th percentile (unexposed group). The primary outcome variable was LGA birth weight, defined as a birth weight of greater than 90% for gestational age.

RESULTS

Eighty-six women met inclusion criteria over a 3-year period: 40 were in the exposed group, and 46 were in the unexposed group. The mean body mass indices ± SD at delivery were similar for both groups: 35.4 ± 8.2 kg/m(2) exposed versus 35.0 ± 8.2 kg/m(2) unexposed (P = .80). There was no difference in the number of women with gestational diabetes mellitus: 40% exposed versus 39% unexposed (P = .90). Neonates whose early third-trimester estimated fetal weight was at or above the 75th percentile were significantly more likely to be LGA at birth compared with neonates whose early third-trimester estimated fetal weight was below the 75th percentile: 65% exposed versus 15% unexposed (P < .001; odds ratio, 10.3; 95% confidence interval, 3.7-29.1). There was no significant difference in cesarean delivery rates: 60% exposed versus 44% unexposed (P = .13)

CONCLUSIONS

Measurements obtained by early third-trimester sonographic fetal biometry are reasonably predictive of fetal LGA birth weights at term.

Diabetes gestacional: um algoritmo de tratamento multidisciplinar

O tratamento do diabetes gestacional é importante para evitar a morbimortalidade materno-fetal. O objetivo deste artigo é descrever o tratamento atualmente disponível para o manejo otimizado da hiperglicemia na gestação e sugerir um algoritmo de tratamento multidisciplinar. A terapia nutricional é a primeira opção de tratamento para as gestantes, e a prática de exercício físico leve a moderado deve ser estimulada na ausência de contraindicações obstétricas. O tratamento medicamentoso está recomendado quando os alvos glicêmicos não são atingidos ou na presença de crescimento fetal excessivo à ultrassonografia. O tratamento tradicional do diabetes gestacional é a insulinoterapia, embora mais recentemente a metformina venha sendo considerada uma opção segura e eficaz. A monitorização do tratamento é realizada com aferição da glicemia capilar e com avaliação da circunferência abdominal fetal por meio de ultrassonografia obstétrica a partir da 28ª semana de gestação.

Reducing the risk of shoulder dystocia and associated brachial plexus injury

Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.

How many sonograms are needed to reliably predict the absence of fetal overgrowth in gestational diabetes mellitus pregnancies?

OBJECTIVE

Serial measurements of the fetal abdominal circumference have been used to guide metabolic management of pregnancies complicated by gestational diabetes mellitus (GDM). A reduction in the number of repeat ultrasound examinations would save resources. Our purpose was to determine the number of serial abdominal circumference measurements per patient necessary to reliably predict the absence of fetal overgrowth.

RESEARCH DESIGN AND METHODS

Women who had GDM were asked to return for repeat ultrasound at 3- to 4-week intervals starting at initiation of care (mean 26.9 ± 5.7 weeks). Maternal risk factors associated with fetal overgrowth were determined.

RESULTS

A total of 4,478 ultrasound examinations were performed on 1,914 subjects (2.3 ± 1.2 per pregnancy). Of the 518 women with fetal abdominal circumference >90th percentile, it was diagnosed in 73.9% with the first ultrasound examination at entry and in 13.1% with the second ultrasound examination. Of the fetuses, 85.9 and 86.9% of the fetuses were born non-large for gestational age (LGA) when abdominal circumference was <90th percentile at 24-27 weeks and 28-32 weeks, respectively, and 88.0% were born non-LGA when both scans showed normal growth. For those women who had no risk factors for fetal overgrowth (risk factors: BMI >30 kg/m², history of macrosomia, and fasting glucose > 100 mg/dl), the accuracy of prediction of a non-LGA neonate was 90.0, 89.5, and 95.2%. The predictive ability did not increase with more than two normal scans.

CONCLUSIONS

The yield of sonographic diagnosis of a large fetus drops markedly after the finding of a fetal abdominal circumference <90th percentile on two sonograms, which excludes with high reliability the risk of a LGA newborn. The ability was enhanced in women who had no risk factors for neonatal macrosomia.

[Obstetrical care in gestational diabetes and management of preterm labor]

OBJECTIVES

Search for data necessary to elaborate recommendations for obstetrical care in gestational diabetes and management of preterm labor.

METHODS

Systematic review of the literature and levels of evidence.

RESULTS

In case of gestational diabetes and in the absence of disease or other risk factor associated, there is no evidence to support a systematic rate of clinical follow up different from other pregnancy. The relevance of ultrasound estimates of fetal weight is limited. No formula is superior to others or to the simple measurement of abdominal circumference for the prediction of macrosomia (EL3). The usefulness of the research septal hypertrophy is not demonstrated (EL4). The systematic application of umbilical Doppler has no proven benefits in the absence of growth restriction or hypertension associated (EL4). Monthly ultrasound monitoring of the fetus can be proposed for diabetics on insulin or poorly controlled. In cases of gestational diabetes controlled by diet, cardiotocography of fetal heart rate has not proven useful. In poorly controlled diabetes and/or on insulin, the registration may be discussed taking into account other risk factors associated (EL4). A weekly recording of fetal heart rate is often recommended in case of type 2 diabetes discovered during pregnancy. In case of preterm labor, calcium channel blockers and oxytocin antagonists can be used without specific precautions. The risk of using beta-adrenergic outweighs the benefit. Administration of corticosteroid can be done under glycemic control, with insulin therapy if necessary. Screening test for gestational diabetes should not be performed within few days after last steroid injection.

Growth of fetal lean mass and fetal fat mass in gestational diabetes

OBJECTIVES

This study was carried out to investigate growth indicators of fetal lean mass and fat mass in the second half of the gestational period in pregnancies complicated by gestational diabetes mellitus (GDM) in comparison to normal control pregnancies.

METHODS

Forty-three control and 171 GDM pregnancies were followed longitudinally by ultrasound examinations, measuring both traditional biometric parameters and six non-traditional parameters for the evaluation of lean and fat mass. A mixed linear model derived from the log-Count function was used to model fetal growth and to make comparisons between groups. Factor analysis was used to evaluate the associations between gestational diabetes and fetal size and fetal fat/lean mass ratios.

RESULTS

A total of 506 scans were obtained in the 214 pregnancies, a mean of 2.4 scans per pregnancy (range 2-5). Maternal age, prepregnancy weight and body mass index were significantly higher in GDM pregnancies. Fetuses of GDM pregnancies showed greater growth, at the same gestational age, for each lean and fat non-traditional parameter, having a significantly greater amount of total tissue mass and a higher fat mass/lean mass ratio, independent of gestational age, in comparison to control pregnancies.

CONCLUSIONS

A non-invasive, repeatable evaluation of fetal body composition in utero could represent a useful method for the early detection of growth abnormalities and for direct estimation of the fetal metabolic status.

Obesity and gestational diabetes

The prevalence of both obesity and gestational diabetes mellitus (GDM) is increasing worldwide. GDM affects about 7% of all pregnancies and is defined as any degree of impaired glucose tolerance during gestation. The presence of obesity has a significant impact on both maternal and fetal complications associated with GDM. These complications can be addressed, at least in part, by good glycaemic control during pregnancy. The significance and impact of obesity in women with GDM are discussed in this article, together with treatment options, the need for long-term risk modification and postpartum follow-up.

Effects of gestational diabetes on fetal oxygen and glucose levels in vivo

OBJECTIVE

Fetal hypoxia and acidemia have been reported in pregestational diabetic pregnancies in relation to poor glycaemic control, but it is still uncertain whether this is the case in apparently well-controlled gestational diabetes.

POPULATION AND METHODS

Maternal arterial and umbilical venous and arterial blood samples were collected from 37 normal (N) and 38 pregnancies complicated by gestational diabetes (GDM) at the time of caesarean section.

MAIN OUTCOME MEASURES

Respiratory gases, acid-base balance, lactate and glucose concentrations were measured.

RESULTS

Both fetal and placental weights were significantly increased in GDM compared to N pregnancies, despite similar gestational age. Maternal biochemical parameters were similar in N and GDM but GDM fetuses were significantly more hypoxic (O2 saturation: N 63.2+/-13.9; GDM 53.8+/-14.6%, P<0.01; O2 content: N 5.5+/-1.4; GDM 4.8+/-1.2 mmol/l, P<0.05). Glucose (N 3.4+/-0.5, GDM 3.9+/-1.2 mmol/l, P<0.05) and lactate (N 1.32+/-0.49; GDM 1.64+/-0.75 mmol/l, P<0.05) concentrations were significantly increased in the umbilical vein in GDM compared to N fetuses. Placental histology was consistent with altered villous morphology.

CONCLUSIONS

Our data indicate that fetuses from gestational diabetic mothers have increased umbilical glucose concentrations despite normal maternal glucose levels and a reduction in oxygen saturation and O2 content together with increased lactate concentration, reflecting altered fetal metabolism. These data suggest that 'good maternal metabolic control' achieved by currently used methods of monitoring glucose control is not sufficient to ensure a normal oxygenation status and metabolic milieu for the fetus in GDM pregnancies.

Treatments for gestational diabetes

BACKGROUND

Gestational diabetes (GDM) affects 3% to 6% of all pregnancies. Women are often intensively managed with increased obstetric monitoring, dietary regulation, and insulin. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of GDM improves perinatal outcome.

OBJECTIVES

To compare the effect of alternative treatment policies for GDM on both maternal and infant outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials comparing alternative management strategies for women with GDM and impaired glucose tolerance in pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors and a member of the Cochrane Pregnancy and Childbirth Group's editorial team extracted and checked data independently. Disagreements were resolved through discussion with the third author.

MAIN RESULTS

Eight randomised controlled trials (1418 women) were included.Caesarean section rate was not significantly different when comparing any specific treatment with routine antenatal care (ANC) including data from five trials with 1255 participants (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.80 to 1.12). However, when comparing oral hypoglycaemics with insulin as treatment for GDM, there was a significant reduction (RR 0.46, 95% CI 0.27 to 0.77, two trials, 90 participants). There was a reduction in the risk of pre-eclampsia with intensive treatment (including dietary advice and insulin) compared to routine ANC (RR 0.65, 95% CI 0.48 to 0.88, one trial, 1000 participants). More women had their labours induced when given specific treatment compared to routine ANC (RR 1.33, 95% CI 1.13 to 1.57, two trials, 1068 participants). The composite outcome of perinatal morbidity (death, shoulder dystocia, bone fracture and nerve palsy) was significantly reduced for those receiving intensive treatment for mild GDM compared to routine ANC (RR 0.32, 95% CI 0.14 to 0.73, one trial, 1030 infants).There was a reduction in the proportion of infants weighing more than 4000 grams (RR 0.46, 95% CI 0.34 to 0.63, one trial, 1030 infants) and the proportion of infants weighing greater than the 90th birth centile (RR 0.55, 95% CI 0.30 to 0.99, three trials, 223 infants) of mothers receiving specific treatment for GDM compared to routine ANC. However, there was no statistically significant difference in this proportion between infants of mothers receiving oral drugs compared to insulin as treatment for GDM.

AUTHORS' CONCLUSIONS

Specific treatment including dietary advice and insulin for mild GDM reduces the risk of maternal and perinatal morbidity. However, it is associated with higher risk of labour induction. More research is needed to assess the impact of different types of intensive treatment, including oral drugs and insulin, on individual short- and long-term infant outcomes.

Management of gestational diabetes mellitus

The incidence of gestational diabetes mellitus (GDM) is on the increase and, if not diagnosed, managed and treated adequately, can have unfavorable maternal and fetal outcomes. Several studies have shown that glycemic values considered as adequate in the past when monitoring GDM failed to contain these adverse outcomes and randomized trials are needed to ascertain whether these targets should be lowered. Dietary restrictions remain the mainstay of GDM management and suitable physical exercise can help too. The use of rapid-acting insulin analogues (lispro and aspart) are novel treatments for improving metabolic control by reducing postprandial glycemia, while long-acting insulin analogues need to be evaluated by further studies for safety in clinical use before they can be prescribed. Numerous studies have found glyburide and metformin safe in women with GDM but more randomized controlled trials are needed, with a long-term follow-up of mother and child, to confirm these results.