Screening for gestational diabetes mellitus

Evolution of Gestational Diabetes Mellitus across Continents in 21st Century

Over the last few decades, several definitions of gestational diabetes mellitus (GDM) have been described. There is currently not enough research to show which way is the best to diagnose GDM. Opinions differ in terms of the optimal screening and diagnostic measures, in part due to the differences in the population risks, the cost-effectiveness considerations, and the lack of an evidence base to support large national screening programs. The basic method for identifying the disease is the measurement of glucose plasma levels which may be determined when fasting, two hours after a meal, or simply at any random time. The currently increasing incidence of diabetes in the whole population, the altering demographics and the presence of lifestyle changes still require better methods of screening for hyperglycemia, especially during pregnancy. The main aim of this review is to focus on the prevalence and modifications to the screening criteria for GDM across all continents in the 21st century. We would like to show the differences in the above issues and correlate them with the geographical situation. Looking at the history of diabetes, we are sure that more than one evolution in GDM diagnosis will occur, due to the development of medicine, appearance of modern technologies, and the dynamic continuation of research.

Cadmium exposure and the risk of GDM: evidence emerging from the systematic review and meta-analysis

Gestational diabetes mellitus (GDM) has become a global concern for its severe adverse effects on both mother and fetus. Recent epidemiological studies reported inconsistent results of the association between cadmium (Cd) exposure and GDM. Therefore, a systematic review and meta- analysis were performed. PubMed, Web of Science, Scopus, Embase, and SpringerLink were searched up to July 2021. Observational studies containing the adjusted relative risks between Cd exposure and GDM were included in the quantitative synthesis. The retrieval comprised 218 articles out of which 11 met our criteria and 9 were included in the meta-analysis, representing a total of 32,392 subjects (2881 GDM). In total, Cd exposure might increase the risk of GDM in some extent (OR = 1.21, 95% CI [0.89, 1.64]), even without statistical significance in high heterogeneity (Q = 28.45, p < 0.05, I² = 71.9%). Filtering two outliers indicated by Galbraith plot yielded a similar risk (OR = 1.19, 95% CI [1.02, 1.39]) with statistical significance. However, the heterogeneity among studies was obviously reduced (Q = 11.75, p = 0.068, I² = 48.9%). Additionally, biological specimen, study design, and diagnostic criteria contributed to the high heterogeneity according to the subgroup analysis. Since some important results do not deny that Cd exposure increases the risk of GDM, high-quality multi-centered large cohort studies are required in the future.

Association between pre-conceptional carbohydrate quality index and the incidence of gestational diabetes: the SUN cohort study

The aim of the study was to investigate the association between pre-gestational carbohydrate quality index (CQI) and the incidence of gestational diabetes mellitus (GDM). Data from the 'Seguimiento Universidad de Navarra' (SUN) cohort were used, which includes 3827 women who notified at least one pregnancy between December 1999 and December 2019. We used a validated semi-quantitative 136-item FFQ to evaluate dietary exposures at baseline and at 10-year follow-up. The CQI was defined by four criteria: glycaemic index, whole-grain/total-grain carbohydrate, dietary fibre intake and solid/total carbohydrate ratio. We fitted generalised estimating equations with repeated measurements of the CQI to assess its relationship with incident GDM. A total of 6869 pregnancies and 202 new cases of incident GDM were identified. The inverse association between the global quality of carbohydrate and the development of GDM was not statistically significant: OR the highest v. the lowest CQI category: 0·67, 95 % CI (0·40, 1·10), Pfor trend = 0·10. Participants at the highest CQI category and with daily carbohydrate amounts ≥50 % of total energy intake had the lowest incidence of GDM (OR = 0·29 (95 % CI (0·09, 0·89)) compared with those with the lowest quality (lowest CQI) and quantity (≤40 %). Further studies are needed to overcome the limitations of our study. Those studies should jointly consider the quality and the quantity of dietary carbohydrates, as the quality might be of importance, especially in women with a higher intake of carbohydrates.

Placental maternally expressed gene 3 differentially methylated region methylation profile is associated with maternal glucose concentration and newborn birthweight

AIMS/INTRODUCTION

Emerging evidence shows that epigenetic modifications occurring during fetal development in response to intrauterine exposures could be one of the mechanisms involved in the early determinants of adult metabolic disorders. This study aimed to investigate whether the placental maternally expressed gene 3 (MEG3) deoxyribonucleic acid (DNA) methylation profile is associated with maternal gestational diabetes mellitus status and newborn birthweight.

MATERIALS AND METHODS

Samples for measurement were collected from 23 women with gestational diabetes mellitus and 23 healthy controls. MEG3 gene expression and DNA methylation levels were assessed using quantitative real-time polymerase chain reaction and MethylTargetTM, respectively. Pearson correlation analyses were used to examine associations between placental DNA methylation levels and clinical variables of interest. The associated results were adjusted by multivariate linear regression for maternal age, body mass index, height, gestational age and newborn sex as confounders.

RESULTS

We found that the DNA methylation levels in the MEG3 differentially methylated region were significantly different between the gestational diabetes mellitus and control groups on the maternal side of the placenta (40.64 ± 2.15 vs 38.33 ± 2.92; P = 0.004). Furthermore, the mean MEG3 DNA methylation levels were correlated positively with maternal fasting glucose concentrations (R = 0.603, P < 0.001) and newborn birthweight (R = 0.568, P < 0.001).

CONCLUSIONS

The placental DNA methylation status in the MEG3 differentially methylated region was correlated with maternal glucose concentrations and newborn birthweight. These epigenetic adaptations might contribute to late-onset obesity, underlining the adverse intrauterine environment.

Functional genetic variants in the 3'UTR of PTPRD associated with the risk of gestational diabetes mellitus

A previous study revealed that protein tyrosine phosphatase receptor type D (PTPRD) is highly associated with diabetes mellitus, particularly for type 2 diabetes, through a genome-wide association study. However, the influence of the human polymorphism in the 3'-untranslated region (3'-UTR) of PTPRD on gestational diabetes mellitus (GDM) has remained to be defined. The present study focused on the functional polymorphism located in the 3'-UTR of PTPRD and whether it is associated with the susceptibility to develop GDM. A total of 1,100 pregnant female patients aged between 28 and 36 years within gestational weeks 24-28 were recruited. The participants enrolled in the study comprised 500 cases of GDM and 600 normal controls. Based on the screening results, the single nucleotide polymorphism (SNP) rs56407701 exhibited the most significant difference and may increase the susceptibility to GDM. A prediction of target microRNAs (miRNAs/miRs) using the miRNA SNP database indicated that SNP rs56407701 may be bound by miR-450a, causing the suppression of PTPRD expression in subjects with the GC or CC genotype. In conclusion, The CC genotype of PTPRD rs56407701, which may be bound by miR-450a, may increase the susceptibility of Chinese Han females to GDM during pregnancy. The present study provided a theoretical basis for the SNP rs56407701 being a source of GDM susceptibility loci.

Trends in National Canadian Guideline Recommendations for the Screening and Diagnosis of Gestational Diabetes Mellitus over the Years: A Scoping Review

Canada's largest national obstetric and diabetology organizations have recommended various algorithms for the screening of gestational diabetes mellitus (GDM) over the years. Though uniformity across recommendations from clinical practice guidelines (CPGs) is desirable, historically, national guidelines from Diabetes Canada (DC) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) have differed. Lack of consensus has led to variation in screening approaches, rendering precise ascertainment of GDM prevalence challenging. To highlight the reason and level of disparity in Canada, we conducted a scoping review of CPGs released by DC and the SOGC over the last thirty years and distributed a survey on screening practices among Canadian physicians. Earlier CPGs were based on expert opinion, leading to different recommendations from these organizations. However, as a result of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, disparities between DC and the SOGC no longer exist and many Canadian physicians have adopted their recent recommendations. Given that Canadian guidelines now recommend two different screening programs (one step vs. two step), lack of consensus on a single diagnostic threshold continues to exist, resulting in differing estimates of GDM prevalence. Our scoping review highlights these disparities and provides a step forward towards reaching a consensus on one unified threshold.

Gestational Diabetes Mellitus in Southeast Asia: A Scoping Review

A rapid increase in the prevalence of gestational diabetes mellitus (GDM) has been associated with various factors such as urbanization, lifestyle changes, adverse hyperglycemic intrauterine environment, and the resulting epigenetic changes. Despite this, the burden of GDM has not been well-assessed in Southeast Asia. We comprehensively reviewed published Southeast Asian studies to identify the current research trend in GDM in this region. Joanna Briggs Institute’s methodology was used to guide the scoping review. The synthesis of literature findings demonstrates almost comparable clinical evidence in terms of risk factors and complications, challenges presented in diagnosing GDM, and its disease management, given the similarities of the underlying population characteristics in Southeast Asia. Evidence suggests that a large proportion of GDM risk in women may be preventable by lifestyle modifications. However, the GDM burden across countries is expected to rise, given the heterogeneity in screening approaches and diagnostic criteria, mainly influenced by economic status. There is an urgent need for concerted efforts by government and nongovernmental sectors to implement national programs to prevent, manage, and monitor the disease.

Maternal Arsenic Exposure and Gestational Diabetes: A Systematic Review and Meta-Analysis

Gestational diabetes mellitus (GDM) is a metabolic complication associated with adverse outcomes for mother and fetus. Arsenic (As) exposure has been suggested as a possible risk factor for its development. The aim of this meta-analysis was to provide a comprehensive overview of published evidence on the association between As and GDM. The systematic search from PubMed, MEDLINE, and Scopus was limited to full-length manuscripts published in peer-reviewed journals up to April 2020, identifying fifty articles. Ten studies met the inclusion criteria, nine for quantitative synthesis with a total of n = 1984 GDM cases. The overall pooled risk was 1.56 (95% Confidence Interval - CI = 1.23, 1.99) with moderate heterogeneity (χ² = 21.95; I²% = 64). Several differences among the included studies that may account for heterogeneity were investigated. Stratification for exposure indicator confirmed a positive association for studies assessing urine As. A slightly higher risk was detected pooling studies based in Asia rather than in North America. Stratification for GDM diagnostic criteria showed higher risks when diagnosis was made according to the Canadian Diabetes Association (CDA-SOGC) or World Health Organization (WHO) criteria, whereas a lower risk was observed when adopting the American Diabetes Association (ADA) criteria. These results provide additional evidence for a possible association between As exposure and GDM, although the data need to be interpreted with caution due to heterogeneity.

Utility of ultrasound assessment in management of pregnancies with preterm prelabor rupture of membranes

OBJECTIVES

To evaluate the utility of ultrasound markers in the management of pregnancies complicated by preterm prelabor rupture of membranes (PPROM) between 23 + 0 and 33 + 6 weeks' gestation, and to assess the ability of ultrasound markers to predict adverse neonatal outcomes.

METHODS

This was a retrospective cohort study of all patients with PPROM between 23 + 0 and 33 + 6 weeks' gestation and latency period (PPROM to delivery) > 48 h, who delivered before 34 weeks' gestation at a tertiary referral center between 2005 and 2017. All patients underwent a non-stress test daily and an ultrasound scan twice a week for assessment of amniotic fluid volume, biophysical profile (BPP) and umbilical artery (UA) pulsatility index (PI). In patients with suspected fetal growth restriction, fetal middle cerebral artery (MCA)-PI was also assessed and the cerebroplacental ratio (CPR) calculated. The last ultrasound examination performed prior to delivery was analyzed. We compared the characteristics and outcomes between women who were delivered owing to clinical suspicion of chorioamnionitis and those who were not delivered for this indication. The primary objective was to evaluate the utility of ultrasound in the management of patients with PPROM. The secondary objective was to assess the diagnostic performance of ultrasound markers (BPP score < 6, oligohydramnios, UA-PI > 95^th percentile, MCA-PI < 5^th percentile, CPR < 5^th percentile) for the prediction of composite adverse neonatal outcome, which was defined as the presence of one or more of: perinatal death, respiratory distress syndrome, periventricular leukomalacia, intraventricular hemorrhage Grade 3 or 4, necrotizing enterocolitis, hypoxic ischemic encephalopathy, neonatal sepsis or neonatal seizures.

RESULTS

A total of 504 women were included in the study, comprising 120 with suspected chorioamnionitis and 384 without. Women with suspected chorioamnionitis, compared with those without, were less likely to be nulliparous (34.2% vs 45.3%; P = 0.03) and more likely to have fever (50.8% vs 2.6%; P < 0.001) and be delivered by Cesarean section (69.2% vs 42.4%; P < 0.001), mainly owing to a history of previous Cesarean section (18.3% vs 9.1%; P = 0.005) and to having non-reassuring fetal heart rate tracings (32.5% vs 14.6%; P < 0.001). No significant differences were found between the two groups with regard to the median amniotic fluid volume, overall BPP score, BPP score < 6, MCA-PI or CPR. Median UA-PI was slightly higher in the suspected-chorioamnionitis group, yet the incidence of UA-PI > 95^th percentile was similar between the two groups. There was a higher incidence of composite adverse neonatal outcome in the group with suspected chorioamnionitis than in the group without (78.3% vs 64.3%, respectively; P = 0.004). However, on logistic regression analysis, none of the ultrasound markers evaluated was found to be associated with chorioamnionitis or composite adverse neonatal outcome, and they all had a poor diagnostic performance for the prediction of chorioamnionitis and composite adverse neonatal outcome.

CONCLUSIONS

Commonly used ultrasound markers in pregnancies complicated by PPROM were similar between women delivered for suspected chorioamnionitis and those delivered for other indications, and performed poorly in predicting composite adverse neonatal outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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.

No. 239-Obesity in Pregnancy

OBJECTIVE

To review the evidence and provide recommendations for the counselling and management of obese parturients.

OUTCOMES

Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.

RECOMMENDATIONS

Long-term endocrine outcome of small for gestational age infants born to mothers with and without gestational diabetes mellitus

Small for gestational age (SGA) infants and infants born to mothers with gestational diabetes mellitus (GDM) are at an increased risk for significant morbidity and mortality, mainly metabolic disorders. We aimed to question the long-term endocrine morbidity of SGA infants born to mothers with GDM compared to SGA infants born to non- diabetic mothers. A population-based cohort study was performed to assess the risk for endocrine morbidity among children born SGA to mothers with and without GDM. The main outcome evaluated was endocrine morbidity of the offspring up to the age of 18 years, predefined in a set of ICD-9 codes. Endocrine morbidity included thyroid disease, insulin and non-insulin dependent diabetes mellitus, hypoglycemia, childhood obesity, parathyroid hormone disease, adrenal disease, and sex hormone disease. All SGA infants born between the years 1991 and 2014 and discharged alive from the hospital were included in the study. Multiple pregnancies, infants with congenital malformations or chromosomal abnormalities and mothers lacking prenatal care were excluded from the analysis. Kaplan-Meier survival curve was constructed to compare cumulative endocrine morbidity. A Cox proportional hazards model was conducted to control for confounders. During the study period, 9312 newborn infants met the inclusion criteria, of them 259 SGA infants were born to mothers with GDM and 9053 SGA infants were born to mother without GDM. No significant differences in long-term endocrine morbidity were noted between the groups (0.8% in children born to mothers with GDM vs. 0.5% in children born to non-diabetic mothers, p = .62). Likewise, the Kaplan-Meier survival curve did not demonstrate a significantly higher cumulative incidence of endocrine morbidity in offspring of women with GDM (log rank test p=.67). In a Cox regression model, while controlling for ethnicity, hypertensive disorders, preterm birth, and maternal age, delivery of an SGA neonate to mother with GDM was not associated with long-term endocrine morbidity of the offspring (adjusted HR 1.2, 95% confidence interval 0.27-5.00, p=.82). SGA infants born to mothers with GDM are not at an increased risk for long-term endocrine morbidity as compared with SGA infants born to non-diabetic mothers.

Association between inflammatory potential of diet and odds of gestational diabetes mellitus among Iranian women

Background: The possible relationship between diet-related inflammation and the risk of gestational diabetes mellitus (GDM) requires further investigation, especially in non-Western populations. We examined the association between dietary inflammatory index (DII) scores and GDM in a case-control study conducted in Iran. Methods: This study included 122 GDM cases and 266 controls hospitalized for acute non-neoplastic diseases. Cases were pregnant women aged 18-40 years, who visited major general hospitals in different regions of Tehran. Pregnant women were screened for gestational diabetes between the 24th and 28th week of gestation with a 50-g, 1-hour glucose challenge test (GCT). Cases were diagnosed positive for GDM. Controls were pregnant women who had normal GCT test. DII scores were computed from dietary intake assessed by a previously validated 147-item food frequency questionnaire. Logistic regression models adjusted age, gestational age, energy, exercise, BMI, smoking exposure, family history of diabetes, and history of multivitamin intake were used to estimate odds ratios (ORs) and 95% confidence intervals (CI). Results: Subjects with higher DII scores (i.e. indicating a more proinflammatory diet) had a higher odd of GDM with the DII being used as both a continuous (OR = 1.20; 95% CI = 0.94-1.54) and as categorical (ORtertile 3vs1 = 2.10; 95% CI = 1.02-4.34, p-trend = .03). Conclusions: These results indicate that a proinflammatory diet, as evidenced by higher DII scores, is associated with increased odds of GDM among Iranian women.

Twice-Daily vs 4-Times-Daily Glucose Testing in Women With Gestational Diabetes Mellitus: A Pilot Study

OBJECTIVES

In women with gestational diabetes mellitus (GDM), glycemic control is typically assessed by capillary blood glucose (BG) self-monitoring. Currently, the standard method of monitoring is by 4-times-daily self-measurements. The goal of our study was to determine whether twice-daily capillary BG testing is comparable with 4-times-daily testing in women with GDM.

METHODS

Thirty-two women with GDM completed initial dietary counselling and recorded consecutive fasting and 2-h postprandial BG over a 14-day period. We randomly selected 2 of 4 BG measurements on each given day and compared mean (95% confidence interval [CI]) twice-daily vs 4-times-daily BG measurements using paired t tests and Bland-Altman plots. The proportion of 14-day BG measurements above glycemic targets was also compared between twice-daily vs 4-times-daily testing for fasting and postprandial readings.

RESULTS

Comparing twice-daily vs 4-times-daily mean BG, there was a small difference for fasting BG (0.09 mmol/L; 95% CI, 0.03 to 0.14), but not for 2-h postbreakfast (-0.05 mmol/L; 95% CI, -0.17 to 0.06), 2-h postlunch (-0.03 mmol/L; 95% CI, -0.13 to 0.08) or 2-h postdinner (0.05 mmol/L; 95% CI, -0.09 to 0.19) BG. Bland-Altman plots showed general agreement and minimal bias between twice-daily vs 4-times-daily BG, whether fasting or postprandial. There was no significant difference in the proportion of 14-day BG measurements above glycemic targets comparing twice-daily vs 4-times-daily testing in the fasting or postprandial states.

CONCLUSIONS

Twice-daily BG testing appears to generate 14-day average values similar to 4-times-daily BG testing. In women with GDM, whose BG is in target range, twice-daily BG monitoring may reduce inconvenience and cost.

Diabetes distress is associated with adverse pregnancy outcomes in women with gestational diabetes: a prospective cohort study

BACKGROUND

Around 12% of pregnant women develop gestational diabetes mellitus (GDM), which is associated with increased health risks for both mother and child and pre- and postpartum depression. Little is known about the relationship of GDM with diabetes-specific emotional distress (diabetes distress). The aims of this study are to assess the prevalence of diabetes distress in GDM and its association with adverse pregnancy outcomes.

METHODS

A prospective cohort study was carried out in an Amsterdam based teaching hospital with an ethnic diverse population. Women diagnosed with GDM completed a set of questionnaires at three time points. Questionnaires consisted of Problem Areas in Diabetes Scale 5 (PAID-5) for diabetes distress (T0-T1), Patient Health Questionnaire 9 (PHQ-9) for depressive symptoms (T0-T2), and questions to assess adverse pregnancy outcomes (T2). Adverse pregnancy outcomes (collected via self-report and if feasible from the medical records) were defined as hypertension, pre-eclampsia, caesarean section, severe perineal tearing, postpartum hemorrhage, postpartum depression, shoulder dystocia, neonatal hospitalization, macrosomia, jaundice, hypoglycemia and other (among which low heart rate, fever, hypoxia). Adverse pregnancy outcomes were dichotomized into none and 1 or more. Additional information was collected from the medical charts. Missing data were imputed via predictive mean matching and a multivariable logistic regression analysis was performed with diabetes distress, depressive symptoms, socioeconomic status, parity and ethnicity as predictors and age, HbA1c, and BMI as covariates.

RESULTS

A total of 100 women were included, mean age 32.5 (4.1), mean BMI 26.7 (4.8), 71% were of non-Dutch ethnic background. Elevated diabetes distress (PAID score ≥ 8) was reported by 36% of the women. Multivariable logistic regression analyses revealed that both high diabetes distress (OR 4.70, p = .02) and parity (OR 0.21, p = .02) but not antepartum depressive symptoms were related to adverse pregnancy outcomes.

CONCLUSIONS

Diabetes distress is likely in women with GDM and our findings suggest an association between both diabetes distress, parity and adverse pregnancy outcomes in women with GDM. This warrants replication and further research into the underlying mechanisms explaining the impact of diabetes distress in GDM and potential interventions to reduce distress.

Maternal urinary phthalate metabolites in relation to gestational diabetes and glucose intolerance during pregnancy

BACKGROUND

Phthalates are common plasticizer chemicals that have been linked to glucose intolerance in the general population, but there is only limited research on their association with gestational diabetes (GDM).

OBJECTIVE

We evaluated the association between 11 urinary phthalate metabolites and GDM, impaired glucose tolerance (IGT), and continuous blood glucose concentration during pregnancy in The Infant Development and Environment Study (TIDES). Based on prior study results, our primary analyses focused on monoethyl phthalate (MEP) in relation to our outcomes of interest.

STUDY DESIGN

We used multi-variable logistic regression to examine the odds of GDM and IGT in relation to an interquartile-range (IQR) increase in natural log (ln)-transformed, specific gravity (SG)-adjusted first trimester (T1) and average of T1 and third trimester (T3) ("T1T3avg") phthalate metabolite concentrations. We fit linear regression models to examine the percent change in blood glucose per IQR increase in ln-transformed, SG-adjusted T1 and T1T3avg phthalates. In sensitivity analyses, we examined interactions between exposure and race. We adjusted for maternal age, maternal body mass index, study center, race/ethnicity, parity, and gestational age at glucose testing.

RESULTS

In our sample of 705 pregnant women, we observed 60 cases of GDM, 90 cases of IGT, and an average GLT blood glucose of 113.6 ± 27.7 mg/dL. In our primary analysis, T1T3avg MEP was positively associated with GDM ([OR (95% CI) per IQR increase] T1T3avg MEP: 1.61 (1.10, 2.36)). In secondary analyses, most other phthalates were not found to be related to study outcomes, though some associations were noted. Sensitivity analyses indicated possible strong race-specific associations in Asians, though these results are based on a small sample size (n = 35).

CONCLUSION

In alignment with our a priori selection, we documented an association between T1T3avg MEP and GDM. Additional phthalate metabolites were also found to be linked to glucose intolerance, with possible stronger associations in certain racial/ethnic subgroups. Given the prevalence of phthalate exposures and the growing evidence of associations with metabolic outcomes, future studies should continue to examine this question in diverse cohorts of pregnant women, particularly in those who may be at higher risk for GDM and IGT.

Association between maternal urinary speciated arsenic concentrations and gestational diabetes in a cohort of Canadian women

BACKGROUND

Epidemiological and toxicological evidence suggests that maternal total arsenic (As) levels are associated with an elevated risk of gestational diabetes (GDM). Uncertainty remains regarding the metabolic toxicity of specific arsenic species, comprised of both organic and inorganic sources of arsenic exposure.

OBJECTIVES

We assessed associations between speciated As and GDM using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study.

METHODS

Concentrations of speciated As [(inorganic (trivalent, pentavalent)), methylated arsenic species metabolites (monomethylarsonic acid (MMA), dimethylarsinic acid (DMA)), and organic (arsenobetaine)] were measured in first trimester maternal urine samples. GDM cases were identified in accordance with Canadian guidelines. Multivariable regression models were used to estimate associations between speciated As and GDM, evaluate potential interaction between speciated As exposures, and assess fetal sex-specific findings.

RESULTS

Among 1243 women who had a live, singleton birth and no previous history of diabetes, 4% met the diagnostic criteria for GDM. Our analyses focused on DMA and arsenobetaine as these were the subtypes with detectable concentrations in at least 40% of samples. Compared to women in the lowest tertile of DMA (<1.49 μg As/L), women with concentrations exceeding 3.52 μg As/L (3rd tertile) experienced an increased risk of GDM (aOR = 3.86; 95% CI: 1.18, 12.57) (p-value for trend across tertiles = 0.04). When restricted to women carrying male infants, the magnitude of this association increased (aOR 3rd tertile = 4.71; 95% CI: 1.05, 21.10).

CONCLUSIONS

These results suggest a positive relation between DMA and GDM; potential differences in risk by fetal sex requires further investigation.

Perspectives on diagnostic strategies for hyperglycemia in pregnancy - Dealing with the barriers and challenges in South Asia

Estimates indicate that south Asia accounts for over two fifths of the global burden of hyperglycemia in pregnancy (HIP) and the ongoing nutritional and epidemiological transition may make the situation worse. Given their higher risk, all women of south Asian decent require to be tested for HIP. With approximately 37 million births annually in the region requires that 37 million women be tested annually; thereby placing a huge burden on the fragile inadequately resourced health systems in the region with poor awareness and lack of trained manpower. Recommendation for testing must therefore be pragmatic, feasible, convenient and cost effective. Diabetes in pregnancy study group India (DIPSI) has proposed a simple testing protocol that is endorsed by the Indian National Guideline on GDM, and by the FIGO guideline on HIP for use in South Asia. This testing protocol has received widespread support in the region. Despite the many challenges it is encouraging to note that in the four large countries in the region - Bangladesh, India, Pakistan and Sri Lanka which account for over 80% of the estimated burden of HIP in south Asia, large scale credible programs have been initiated to address the identified barriers.

Early diabetes screening in pregnancy

The present literature review was conducted to evaluate early diabetes screening in pregnancy. The review focuses on the various guidelines for early screening, the target populations for screening, and the assessment of various early screening targets and strategies. The advantages and disadvantages of each screening method are highlighted. The review emphasizes that there are no validated criteria for selecting high-risk pregnant women for early screening. The different early screening modalities, including fasting plasma glucose, random plasma glucose, postload glucose, and hemoglobin A1c, lack concordance and have not been validated for the early diagnosis of diabetes in pregnancy. Moreover, the benefit of early screening by earlier initiation of treatment has not been shown. Until a randomized controlled trial demonstrates benefit to screening and validates a particular screening method, it is not possible to provide evidence to support any single strategy for early diabetes screening in pregnancy.

Gestational diabetes and risk of cardiovascular disease up to 25 years after pregnancy: a retrospective cohort study

AIMS

The risk of cardiovascular disease in women with gestational diabetes is poorly understood. We sought to determine whether gestational diabetes increases the risk of cardiovascular disease more than two decades after pregnancy.

METHODS

We carried out a retrospective cohort study of 1,070,667 women who delivered infants in hospitals within Quebec, Canada, between 1989 and 2013. We followed 67,356 women with gestational diabetes and 1,003,311 without gestational diabetes for a maximum of 25.2 years after the index delivery. The main outcome measures were hospitalization for ischemic heart disease, myocardial infarction, coronary angioplasty, coronary artery bypass graft, and other cardiovascular disorders. We used Cox regression to estimate hazard ratios (HR) and 95% confidence intervals (CI) comparing women with gestational diabetes to no gestational diabetes, adjusted for age, parity, socioeconomic deprivation, time period, and preeclampsia.

RESULTS

Women with gestational diabetes had a higher cumulative incidence of hospitalization for cardiovascular disease 25 years after delivery (190.8 per 1000 women) compared with no gestational diabetes (117.8 per 1000 women). Gestational diabetes was associated with a higher risk of ischemic heart disease (HR 1.23, 95% CI 1.12-1.36), myocardial infarction (HR 2.14, 95% CI 1.15-2.47), coronary angioplasty (HR 2.23, 95% CI 1.87-2.65), and coronary artery bypass graft (HR 3.16, 95% CI 2.24-4.47).

CONCLUSIONS

In this population of pregnant women, gestational diabetes was associated with an increased risk of heart disease 25 years after delivery. Women with gestational diabetes may merit closer monitoring for cardiovascular disease prevention after pregnancy.

Obesity in pregnancy: a comparison of four national guidelines

BACKGROUND

Obesity in pregnancy has become one of the most important challenges in obstetrical care given its prevalence and potential adverse impact on both mother and fetus. The primary objective of this descriptive review is to identify common themes and distinctions within the current recommendations for maternal obesity in the most updated version of four published national guidelines.

METHODS

We reviewed the following guidelines for obesity in pregnancy: American College of Obstetricians and Gynecologists (ACOG) 2015, Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) 2013, Royal College of Obstetrics and Gynecology (RCOG) 2010, and Society of Obstetrics and Gynecologists of Canada (SOGC) 2010.

RESULTS

There were no major contradictions between the guidelines, however, variations did exist. Recognition of overweight and obese populations prenatally was uniformly emphasized, so that appropriate nutrition and exercise counseling could be provided prior to pregnancy. Obesity in pregnancy was consistently defined as a body mass index of 30 kg/m² or more, and weight gain recommendations were in line with the Institute of Medicine guidelines. Counseling patients regarding the specific maternal and fetal complications in pregnancy, delivery, and postpartum which are associated with obesity was consistently emphasized. Most guidelines recommended early screening for gestational diabetes, however, specific details were not provided. All guidelines stressed the importance of available resources in clinics and the operating room specific to the obese population. Disparities were found regarding recommendations for high-dose folic acid, vitamin D supplementation, and low-dose aspirin. Thromboprophylaxis is a matter of debate, with most guidelines recommending use on an individual patient basis.

CONCLUSIONS

In general, the guidelines emphasized the importance of counseling women regarding the risks associated with obesity in pregnancy, and stressed the necessity of screening for these adverse outcomes. Initiatives to develop common terminology and reporting of outcomes in women's health are important for the development of cohesive and uniform recommendations for patient care. Disparities existed with respect to management strategies and where the further research and systematic reviews should be targeted, to allow clinicians to provide an appropriate obstetrical care pathway for obese women.

Associations between maternal triclosan concentrations in early pregnancy and gestational diabetes mellitus, impaired glucose tolerance, gestational weight gain and fetal markers of metabolic function

BACKGROUND

Triclosan is a phenolic biocide used in a multitude of consumer products and in health care settings. It is widely detected in the American and Canadian populations and has been shown in animal models to act as an endocrine disrupting agent. However, there has been little examination to date of the effects of triclosan exposure in pregnancy on perinatal metabolic outcomes in human populations.

METHODS

Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a Canadian pregnancy cohort, we measured associations of first-trimester urinary triclosan concentrations with total gestational weight gain, gestational diabetes mellitus and impaired glucose tolerance in pregnancy, and fetal markers of metabolic function. Leptin and adiponectin were measured in plasma from umbilical cord blood samples in term neonates and categorized into low (< 10th percentile), intermediate (10th-90th percentile) and high (> 90th percentile) levels. Triclosan concentrations were grouped into quartiles and associations with study outcomes were examined using logistic regression models with adjustment for maternal age, race/ethnicity, pre-pregnancy BMI, education and urinary specific gravity. Restricted cubic spline analysis was performed to help assess linearity and shape of any dose-response relationships. All analyses for leptin and adiponectin levels were performed on the entire cohort as well as stratified by fetal sex.

RESULTS

Triclosan measures were available for 1795 MIREC participants with a live born singleton birth. Regression analyses showed a non-significant inverse association between triclosan concentrations and leptin levels above the 90th percentile that was restricted to female fetuses (OR for highest quartile of triclosan compared to lowest quartile = 0.4 (95% CI 0.2-1.1), p-value for trend across quartiles = 0.02). Triclosan concentrations in the second quartile were associated with elevated odds of adiponectin below the 10th percentile in male fetuses (OR for Q2 compared to Q1 = 2.5, 95% CI 1.1-5.9, p-value for trend across quartiles = 0.93). No significant linear associations between triclosan concentrations and leptin or adiponectin levels in overall or sex-specific analyses were observed from restricted cubic spline analyses. No significant associations were observed in adjusted analyses between triclosan concentrations and gestational diabetes mellitus, impaired glucose tolerance or gestational weight gain.

CONCLUSIONS

This study does not support an association between triclosan concentrations in pregnancy and fetal metabolic markers, glucose disorders of pregnancy, or excessive gestational weight gain.

Gestational diabetes and the long-term risk of cataract surgery: A longitudinal cohort study

AIMS

We assessed the long-term risk of cataract following a pregnancy complicated by gestational diabetes.

METHODS

We carried out a longitudinal cohort study of 1,108,541 women who delivered infants between 1989-2013 in Quebec, Canada, with follow-up extending up to 25years later. The cohort included 71,862 women with gestational diabetes and 5247 with cataracts. We used Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of gestational diabetes with subsequent risk of cataract, adjusted for age, parity, socioeconomic status, time period, comorbidity, and type 2 diabetes.

RESULTS

Women with gestational diabetes had an elevated incidence of cataract (22.6 per 1000) compared with no gestational diabetes (15.1 per 1000), with 1.15 times the risk (95% CI 1.04-1.28). Women with gestational diabetes who subsequently developed type 2 diabetes had a higher risk of cataract compared with no gestational and type 2 diabetes (HR 3.62, 95% CI 3.01-4.35), but women with gestational diabetes who did not develop type 2 diabetes continued to be at risk (HR 1.12, 95% CI 1.00-1.25).

CONCLUSIONS

Gestational diabetes may be an independent risk factor for cataract later in life, although risks are greatest for women who subsequently develop type 2 diabetes.

Genome-wide DNA methylation variation in maternal and cord blood of gestational diabetes population

AIMS

Gestational diabetes mellitus (GDM) has always been a concerning issue for pregnant women. In recent studies, GDM was found to be related to epigenetic modifications, which would alter gene expressions, thus affecting the patients' and their offspring's health, leading to a higher probability of developing metabolic syndromes and diabetes later in life.

METHODS

In this study, we collected both maternal and cord blood samples from 16 pregnant women and their newborns, including eight exposed to GDM. GDM was diagnosed via a 75g oral glucose tolerance test (OGTT) at 24-28weeks of pregnancy. DNA methylation was measured at 841,573 CpG sites via the Infinium HumanMethylationEPIC BeadChip. An Ingenuity Pathway Analysis was conducted afterwards to identify genes and pathways epigenetically affected by GDM.

RESULTS

We identified the top 200 loci and their corresponding genes in the maternal blood group (n=151) and cord blood group (n=167), both of which were methylated differently in the GDM and unexposed group. Metabolic disease-related pathways and molecules, such as interleukin-6 and interleukin-10 were identified in both groups. These results suggested that GDM has epigenetic effects on both mother and their offspring, which might result in future metabolic syndromes or diabetes.

CONCLUSIONS

The high-throughput platform enabled us to analyze methylation sites throughout the genome and identify the most promising genes and pathways associated with GDM.

Prepregnancy Body Mass Index as a Significant Predictor of Total Gestational Weight Gain and Birth Weight

Purpose: We aimed to describe adherence to gestational weight gain (GWG) recommendations and identify determinants of excessive GWG in a sample of women from Quebec, Canada.

Methods: Data were collected from the multi-centre 3D (Design, Develop, Discover) pregnancy cohort study, which included women who delivered between May 2010 and August 2012 at 9 obstetrical hospitals in Quebec, Canada. GWG was calculated for 1145 women and compared to the 2009 Institute of Medicine (IOM) recommendations.

Results: Overall, 51% of participants exceeded the recommendations. Approximately 68% of women with obesity gained weight in excess of the IOM recommendations. The corresponding numbers were 75%, 44%, and 27% in overweight, normal weight, and underweight women, respectively. A prepregnancy BMI of 25 kg/m2 or more was the only significant predictor of exceeding GWG recommendations (OR 3.35, 95% CI 2.44–4.64) in a multivariate model. Birth weight was positively associated with GWG. GWG and prepregnancy BMI could explain 3.13% and 2.46% of the variance in birth weight, respectively.

Conclusion: About half of women exceeded GWG recommendations, and this was correlated with infant birth weight. This reinforces the need to develop and evaluate strategies, including nutritional interventions, for pregnant women to achieve optimal GWG.

Obstetric Outcome in Obese Saudi Pregnant Women: A Cohort Prospective Study at a Teaching Hospital

Objective:

The objective of this study was to compare obstetrical outcome in obese women with a body mass index (BMI) ≥29.9 kg/m² and women with a normal BMI of 20–24.9 kg/m².

Methods:

This is a prospective cohort study of 300 Saudi females aged between 20 and 35 years in their first trimester of pregnancy and 300 nonobese pregnant controls attending the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Patients with a preexisting disease were excluded from the study.

Results:

A significantly higher proportion of obstetrical complications were seen among women with higher BMI compared with those with a normal BMI. The specific complications seen in obese women were gestational hypertension/preeclampsia, antepartum hemorrhage, gestational diabetes, postpartum hemorrhage, cesarean delivery, macrosomia, shoulder dystocia, birth asphyxia, neonatal intensive care admission, premature birth, wound complications and thromboembolism.

Conclusion:

Obesity in pregnancy is associated with higher fetomaternal morbidities and a comprehensive plan should be implemented to provide a better outcome for both women and their infants.

Maternal Dietary Patterns and Gestational Diabetes Risk: A Case-Control Study

BACKGROUND

Maternal dietary patterns play an important role in the progress of gestational diabetes mellitus (GDM). The aim of the present study was to explore this association.

METHOD

A total of 388 pregnant women (122 case and 266 control) were included. Dietary intake were collected using a food frequency questionnaire (FFQ). GDM was diagnosed using a 100-gram, 3-hour oral glucose tolerance test. Dietary pattern was identified by factor analysis. To investigate the relation between each of the independent variables with gestational diabetes, the odds ratio (OR) was calculated.

RESULTS

Western dietary pattern was high in sweets, jams, mayonnaise, soft drinks, salty snacks, solid fat, high-fat dairy products, potatoes, organ meat, eggs, red meat, processed foods, tea, and coffee. The prudent dietary pattern was characterized by higher intake of liquid oils, legumes, nuts and seeds, fruits and dried fruits, fish and poultry whole, and refined grains. Western dietary pattern was associated with increased risk of gestational diabetes mellitus before and after adjustment for confounders (OR = 1.97, 95% CI: 1.27-3.04, OR = 1.68, 95% CI: 1.04-2.27). However, no significant association was found for a prudent pattern.

CONCLUSION

These findings suggest that the Western dietary pattern was associated with an increased risk of GDM.

Expressions of VEGF-A and VEGFR-2 in placentae from GDM pregnancies

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy, and has important health implications for mother and child. Changes in the fetoplacental vessels may predict those in the vasculature of the developing fetus, as these have been implicated in the pathogenesis of human GDM. This study aimed to determine the differences in the localization and expression level of VEGFA and VEGFR2 between placentas of women with GDM and placentas of normal pregnancies, which is the first step in elucidating the possible roles of VEGFA and VEGFR2 in the altered uteroplacental function resulting from maternal hyperglycaemia and ultimately in the manifestation of GDM.

METHODS

The expressions of VEGFA and VEGFR2 mRNA and protein in 20 samples from each group were analyzed by real-time PCR, immunohistochemistry and Western blot. The placental blood barrier and angiogenesis were observed by the transmission electron microscopy (TEM) in10 GDM samples and ten controls.

RESULTS

The expression levels of VEGFA and VEGFR2 mRNA and protein were significantly decreased in the GDM group (P < 0.05 or 0.01). Immunohistochemical analysis showed the reduced expression of VEGFA and VEGFR2 protein in GDM-affected placental tissues, and the degenerative alterations of the terminal villi vascular.

CONCLUSION

The expressions of VEGFA and VEGFR-2 mRNAs and protein were reduced in GDM-affected placental tissues, suggesting that maternal GDM affects the pathophysiological function of placentas.

Up-regulation of miR-98 and unraveling regulatory mechanisms in gestational diabetes mellitus

MiR-98 expression was up-regulated in kidney in response to early diabetic nephropathy in mouse and down-regulated in muscle in type 2 diabetes in human. However, the expression prolife and functional role of miR-98 in human gestational diabetes mellitus (GDM) remained unclear. Here, we investigated its expression and function in placental tissues from GDM patients and the possible molecular mechanisms. The results showed that miR-98 was up-regulated in placentas from GDM patients compared with normal placentas. MiR-98 over-expression increased global DNA methylational level and miR-98 knockdown reduced global DNA methylational level. Further investigation revealed that miR-98 could inhibit Mecp2 expression by binding the 3'-untranslated region (UTR) of methyl CpG binding protein 2 (Mecp2), and then led to the expression dysregulation of canonical transient receptor potential 3 (Trpc3), a glucose uptake related gene. More importantly, in vivo analysis found that the expression level of Mecp2 and Trpc3 in placental tissues from GDM patients, relative to the increase of miR-98, was diminished, especially for GDM patients over the age of 35 years. Collectively, up-regulation of miR-98 in the placental tissues of human GDM is linked to the global DNA methylation via targeting Mecp2, which may imply a novel regulatory mechanism in GDM.

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.

Vitamin D Status and Gestational Diabetes: Effect of Smoking Status during Pregnancy

BACKGROUND

Vitamin D status, as measured by serum 25-hydroxyvitamin D (25(OH)D), has been shown in some studies to be inversely associated with gestational diabetes risk. Recently, it has been suggested that maternal smoking status may modify this relationship. We explored the association between 25(OH)D concentration and gestational diabetes and determined if there was an interaction between smoking and 25(OH)D.

METHODS

A nested case-control study was conducted in Halifax, Nova Scotia and Quebec City, Quebec. Women were recruited before 20 weeks gestation and 25(OH)D was measured. Cases were women who developed gestational diabetes and controls were frequency matched to cases on study site, gestational age at blood draw, and season and year of blood draw. Logistic regression models estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI). Models were tested for multiplicative and additive interaction, which was estimated by relative excess risk due to interaction (RERI).

RESULTS

The study included 395 gestational diabetes cases and 1925 controls. Women who smoked during pregnancy and had 25(OH)D concentrations <30 nmol/L had an aOR = 3.73 [95% CI 1.95, 7.14] compared to non-smokers with 25(OH)D concentrations ≥50 nmol/L. Additive interaction was detected between smoking status and 25(OH)D [RERI = 2.44, 95% CI 0.03, 4.85].

CONCLUSION

Our study supports the inverse association of vitamin D status with gestational diabetes risk, particularly among women who smoke during pregnancy. More research is needed to confirm this finding and, if confirmed, to determine the mechanism by which the combined effect of smoking and low vitamin D status increases the risk of developing gestational diabetes.

Exposure to organophosphorus and organochlorine pesticides, perfluoroalkyl substances, and polychlorinated biphenyls in pregnancy and the association with impaired glucose tolerance and gestational diabetes mellitus: The MIREC Study

BACKGROUND

Studies report increases in rates of gestational diabetes mellitus (GDM) over recent decades. Environmental chemicals may increase the risk of diabetes through impacts on glucose metabolism, mitochondrial dysfunction, and endocrine-disrupting mechanisms including effects on pancreatic β-cell function and adiponectin release.

OBJECTIVES

To determine the associations between pesticides, perfluoroalkyl substances (PFASs) and polychlorinated biphenyls (PCBs) measured in early pregnancy and impaired glucose tolerance (IGT) and GDM in a Canadian birth cohort.

METHODS

Women enrolled in the Maternal-Infant Research on Environmental Chemicals (MIREC) Study were included if they had a singleton delivery and did not have pre-existing diabetes. Exposure variables included three organophosphorus (OP) pesticide metabolites detected in first-trimester urine samples, as well as three organochlorine (OC) pesticides, three PFASs, and four PCBs in first-trimester blood samples. Gestational IGT and GDM were assessed by chart review in accordance with published guidelines. Adjusted logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CI) for the association between quartiles of environmental chemicals and both gestational IGT and GDM.

RESULTS

Of the 2001 women recruited into the MIREC cohort, 1274 met the inclusion criteria and had outcome and biomonitoring data available. Significantly lower odds of GDM were observed in the third and fourth quartiles of dimethylphosphate (DMP) and in the fourth quartile of dimethylthiophosphate (DMTP) in adjusted analyses (DMP Q3: OR=0.2, 95% CI=0.1-0.7; DMP Q4: OR=0.3, 95% CI=0.1-0.8; DMTP: OR=0.3, 95% CI=0.1-0.9). Significantly elevated odds of gestational IGT was observed in the second quartile of perfluorohexane sulfonate (PFHxS) (OR=3.5, 95% CI=1.4-8.9). No evidence of associations with GDM or IGT during pregnancy was observed for PCBs or OC pesticides.

CONCLUSIONS

We did not find consistent evidence for any positive associations between the chemicals we examined and GDM or IGT during pregnancy. We observed statistical evidence of inverse relationships between urine concentrations of DMP and DMTP with GDM. We cannot rule out the influence of residual confounding due to unmeasured protective factors, such as nutritional benefits from fruit and vegetable consumption, also associated with pesticide exposure, on the observed inverse associations between maternal OP pesticide metabolites and GDM. These findings require further investigation.

A Ten-Year Review of Antenatal Complications and Pregnancy Outcomes Among HIV-Positive Pregnant Women

OBJECTIVE

To review the incidence of antenatal complications among a cohort of HIV-positive pregnant women over a 10-year period.

METHODS

A retrospective review was performed of all HIV-positive pregnant women receiving multidisciplinary prenatal care at an urban tertiary care centre from March 2000 to March 2010. Collected data included the presence of additional infectious or medical conditions, genetic screening information, and the presence or absence of antenatal complications.

RESULTS

One hundred and forty-two singleton pregnancies during the study period were identified. Almost 95% of women were taking combination antiretroviral therapy during pregnancy, and greater than 90% had viral loads less than 1000 copies/ml at delivery. The presence of co-infections was low. Forty-one women (29%) had other medical comorbidities. Genetic screening occurred in 104 pregnancies (73%); 4% were abnormal screens. Rates of any hypertension, gestational diabetes, and fetal growth restriction were all low. Thirty-two percent of women were colonized with group B streptococcus.

CONCLUSION

This study adds strength to the argument that good outcomes can be achieved for HIV-positive pregnant women with good access to both prenatal and HIV care, and appropriate management. Women with HIV should be optimally cared for in advance of and during pregnancy in order to maximize the likelihood of good pregnancy outcomes.

Rankings of iron, vitamin D, and calcium intakes in relation to maternal characteristics of pregnant Canadian women

Iron, vitamin D, and calcium intakes in the prenatal period are important determinants of maternal and fetal health. The objective of this study was to examine iron, vitamin D, and calcium intakes from diet and supplements in relation to maternal characteristics. Data were collected in a subsample of 1186 pregnant women from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a cohort study including pregnant women recruited from 10 Canadian sites between 2008 and 2011. A food frequency questionnaire was administered to obtain rankings of iron, calcium, and vitamin D intake (16-21 weeks of pregnancy). Intakes from supplements were obtained from a separate questionnaire (6-13 weeks of pregnancy). Women were divided into 2 groups according to the median total intake of each nutrient. Supplement intake was an important contributor to total iron intake (median 74%, interquartile range (IQR) 0%-81%) and total vitamin D intake (median 60%, IQR 0%-73%), while the opposite was observed for calcium (median 18%, IQR 0%-27%). Being born outside of Canada was significantly associated with lower total intakes of iron, vitamin D, and calcium (p ≤ 0.01 for all). Consistent positive indicators of supplement use (iron, vitamin D, and calcium) were maternal age over 30 years and holding a university degree. In conclusion, among Canadian women, the probability of having lower iron, vitamin D, and calcium intakes is higher among those born outside Canada; supplement intake is a major contributor to total iron and vitamin D intakes; and higher education level and age over 30 years are associated with supplement intake.

Glycosylated hemoglobin values in nondiabetic pregnant women in the third trimester and adverse fetal outcomes: An observational study

Objective:

The objective of the study is to estimate the level of glycosylated hemoglobin (HbA1c) for a safe fetal outcome and to estimate the relation between this level and various adverse fetal outcomes. Materials and

Methodology:

Primigravidas who are diagnosed as not having gestational diabetes mellitus as per the glucose challenge test done at 24 weeks with a cutoff value up to 140 mg/dl are followed up at 30–34 weeks for the estimation of HbA1c in the blood and further till the time of delivery and postnatal period for the fetal outcomes. Data were collected based on detailed patient interview, clinical examination, and laboratory investigations. Data were analyzed to obtain the mean value of HbA1c in the third trimester. Fetal outcomes were analyzed with the HbA1c value using Chi-square test.

Results:

The HbA1c values in the third trimester of pregnancy in this study ranged from 4.5% to 6%.

Discussion:

Unfavorable outcomes were found the least in the 4.5%–5%. The average plasma blood glucose corresponding to HbA1c value of 5% is 101 mg/dl. The majority of the newborn were admitted for observation for transient tachypnea (49.5%) and hyperbilirubinemia (16.5%) requiring phototherapy, hypocalcemia requiring calcium supplements (12.6%), hypoglycemia requiring glucose (7.8%), and persistent tachypnea of newborn (5.8%) and all the outcomes correlated significantly with HbA1c values.

Conclusion:

Hence, HbA1c can be utilized for the monitoring of glycemic level and as screening test.

GESTATIONAL DIABETES. OBSTETRICAL PERSPECTIVE

This review discusses current international recommendations for GDM diagnosis and management and argues whether it would be worth considering first, universal screening for GDM in our country, second, updating of management guidelines and third, organized follow-up of women diagnosed with GDM and adoption of lifestyle interventions after delivery that could reduce the onset and prevalence of type 2 DM.

The association between physical activity and maternal and neonatal outcomes: a prospective cohort

Some evidence, but not enough to be conclusive, suggests that physical activity in pregnancy reduces the risk of perinatal complications. Our objective was to examine if physical activity in the year before pregnancy and in the first half of pregnancy is associated with maternal and neonatal outcomes. Associations between physical activity and maternal and neonatal outcomes were examined in a prospective cohort (n = 1,749) in Halifax, Canada. The Kaiser Physical Activity Survey, completed at approximately 20 weeks' gestation, requested information regarding physical activity during the year before the pregnancy and the first 20 weeks of pregnancy. Outcomes were assessed by medical chart review. Multiple logistic regression was used to estimate odds ratios (OR) with 95 % confidence intervals (CI). Women with prepregnancy physical activity levels in the middle and highest tertiles were more likely to have high gestational weight gain relative to women in the lowest tertile [OR (CI): 1.40 (1.06-1.85) and 1.57 (1.18-2.09), respectively]. Higher physical activity in the first half of pregnancy decreased the odds of delivering a macrosomic infant (p trend = 0.005). Associations were not observed between total physical activity and gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth, and low birth weight. Physical activity before, but not in the first half of pregnancy, is associated with high gestational weight gain. Physical activity in the first half of pregnancy may reduce the occurrence of macrosomia without affecting preterm birth or low birth weight.

Evaluation of the Families SHARE workbook: an educational tool outlining disease risk and healthy guidelines to reduce risk of heart disease, diabetes, breast cancer and colorectal cancer

BACKGROUND

Common diseases such as heart disease, diabetes, and cancer are etiologically complex with multiple risk factors (e.g., environment, genetic, lifestyle). These risk factors tend to cluster in families, making families an important social context for intervention and lifestyle-focused disease prevention. The Families Sharing Health Assessment and Risk Evaluation (SHARE) workbook was designed as an educational tool outlining family health history based risk of heart disease, type 2 diabetes, breast cancer, and colorectal cancer. The current paper describes the steps taken to develop and evaluate the workbook employing a user-centered design approach.

METHODS

The workbook was developed in four steps, culminating in an evaluation focusing on understanding and usability of the tool. The evaluation was based on two Phases of data collected from a sample of mothers of young children in the Washington, D.C., area. A baseline assessment and follow-up approximately two weeks after receipt of the workbook were conducted, as well as focus groups with participants. The design of the workbook was refined in response to participant feedback from the first evaluation Phase and subsequently re-evaluated with a new sample.

RESULTS

After incorporating user-based feedback and revising the workbook, Phase 2 evaluation results indicated that understanding of the workbook components improved for all sections (from 6.26 to 6.81 on a 7-point scale). In addition, 100% of users were able to use the algorithm to assess their disease risk and over 60% used the algorithm to assess family members' disease risk. At follow-up, confidence to increase fruit, vegetable and fiber intake improved significantly, as well.

CONCLUSIONS

The Families SHARE workbook was developed and evaluated resulting in a family health history tool that is both understandable and usable by key stakeholders. This educational tool will be used in intervention studies assessing the effectiveness of family genomics health educators who use the Families SHARE workbook to disseminate family risk information and encourage risk reducing behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01498276 . Registered 21 December 2011.

Exposure to phthalates, bisphenol A and metals in pregnancy and the association with impaired glucose tolerance and gestational diabetes mellitus: The MIREC study

BACKGROUND

Studies from several countries report increases in rates of gestational diabetes mellitus (GDM) over recent decades. Exposure to environmental chemicals could contribute to this trend.

OBJECTIVES

To determine the associations between plasticisers and metals measured in early pregnancy with impaired glucose tolerance (IGT) and GDM in a Canadian pregnancy cohort.

METHODS

Women enrolled in the Maternal-Infant Research on Environmental Chemicals (MIREC) Study were included if they had a singleton delivery and did not have pre-existing diabetes. Eleven phthalate metabolites and total bisphenol A (BPA) were measured in first-trimester urine samples, and four metals (lead, cadmium, mercury and arsenic) were measured in first-trimester blood samples. IGT and GDM were assessed in accordance with standard guidelines by chart review. Chemical concentrations were grouped by quartiles, and associations with outcomes were examined using logistic regression with adjustment for maternal age, race, pre-pregnancy BMI, and education. Restricted cubic spline analysis was performed to help assess linearity and nature of any dose-response relationships.

RESULTS

Of 2001 women recruited into the MIREC cohort, 1274 met the inclusion criteria and had outcome data and biomonitoring data measured for at least one of the chemicals we examined. Elevated odds of GDM were observed in the highest quartile of arsenic exposure (OR = 3.7, 95% CI = 1.4-9.6) in the adjusted analyses. A significant dose-response relationship was observed in a cubic spline model between arsenic and odds of GDM (p < 0.01). No statistically significant associations were observed between phthalates or BPA or other metals with IGT or GDM.

CONCLUSIONS

Our findings add to the growing body of evidence supporting the role of maternal arsenic exposure as a risk factor for gestational diabetes.

Sexually dimorphic adaptations in basal maternal stress physiology during pregnancy and implications for fetal development

There is clear evidence of reciprocal exchange of information between the mother and fetus during pregnancy but the majority of research in this area has focussed on the fetus as a recipient of signals from the mother. Specifically, physiological signals produced by the maternal stress systems in response to the environment may carry valuable information about the state of the external world. Prenatal stress produces sex-specific adaptations within fetal physiology that have pervasive and long-lasting effects on development. Little is known, however, about the effects of sex-specific fetal signals on maternal adaptations to pregnancy. The current prospective study examined sexually dimorphic adaptations within maternal stress physiology, including the hypothalamic-adrenal-pituitary (HPA) axis and the autonomic nervous system (ANS) and associations with fetal growth. Using diurnal suites of saliva collected in early and late pregnancy, we demonstrate that basal cortisol and salivary alpha-amylase (sAA) differ by fetal sex. Women carrying female fetuses displayed greater autonomic arousal and flatter (but more elevated) diurnal cortisol patterns compared to women carrying males. Women with flatter daytime cortisol trajectories and more blunted sAA awakening responses also had infants with lower birth weight. These maternal adaptations are consistent with sexually dimorphic fetal developmental/evolutionary adaptation strategies that favor growth for males and conservation of resources for females. The findings provide new evidence to suggest that the fetus contributes to maternal HPA axis and ANS regulation during pregnancy and that these systems also contribute to the regulation of fetal growth.

Severe burn injury in late pregnancy: a case report and literature review

The management of serious burn injuries during pregnancy is an unsolved clinical problem because of the low incidence of this disease. Although it has been documented that the effect of burns on fetal and maternal survival is detrimental, there have been conflicting reports among the different burn centers regarding the mortality of burned pregnant women and the management of burn patients during pregnancy. We report a case of severe burn in late pregnancy treated at our burn center. Additionally, we searched and summarized the literature concerning the management of pregnant patients to provide useful information for their treatment.

Frequency of gestational diabetes mellitus and the associated risk factors

Objective:

This prospective study was undertaken to assess the frequency of gestational diabetes mellitus (GDM) and the associated risk factors during pregnancy.

Methods:

The sample consisted of 650 pregnant women who had no known risk factors for GDM and were followed-up at the Outpatient Clinic for Pregnant Women, Corum State Hospital between March 2009 and June 2010. The data were expressed as percentage, arithmetic mean, standard deviation and chi-square test.

Results:

Of the 650 pregnant women, 45 were diagnosed with GDM during the study period (6.9%). A statistically significant correlation between GDM and advanced age, family history, and body mass index was found, while no significant correlations existed between GDM and the frequency of pregnancy, number of pregnancy, parity, and number of live births.

Conclusion:

Advanced age, high body mass index and family history of diabetes mellitus emerged as risk factors for GDM in our study.

Using estimated fetal weight from ultrasonography at 18 to 22 weeks to predict gestational diabetes mellitus and newborn macrosomia

OBJECTIVES

To determine if fetal macrosomia in the second trimester predicts the onset of gestational diabetes mellitus (GDM) or large for gestational age (LGA) birth weight.

METHODS

We performed a case-control study using data from the Diabetes in Pregnancy Clinic in our tertiary care hospital. Cases were women with GDM requiring insulin (n = 65) or controlled with diet (n = 65). Control subjects were women who screened negative for GDM at 24 to 28 weeks' gestation (n = 131). Estimated fetal weight (EFW) was determined by ultrasound at 18 to 22 weeks.

RESULTS

Estimated fetal weight that was one standard deviation (70 g) higher at 18 to 22 weeks was not associated with subsequent GDM (adjusted OR [aOR] 1.00, 95% confidence intervals 0.61 to 1.66), but was associated with a 231 g (95% CI 128 g to 334 g) increase in birth weight and increased odds of LGA (aOR 4.02, 95% CI 1.76 to 9.19) after adjusting for gestational age at the time of estimating fetal weight, maternal age, parity, BMI and GDM treatment.

CONCLUSION

EFW at 18 to 22 weeks did not predict the onset of GDM, but did predict LGA.