A prospective controlled study of neonatal morbidities in infants born at 36 weeks or more gestation to Women with diet-controlled gestational diabetes (GDM-class Al)

Development and internal validation of a clinical score to predict neonatal hypoglycaemia in women with gestational diabetes

INTRODUCTION

Gestational diabetes (GD) is a risk factor for neonatal hypoglycaemia (NH), but other factors can increase this risk.

OBJECTIVES

To create a score to predict NH in women with GD.

METHODS

Retrospective study of women with GD with a live singleton birth between 2012 and 2017 from the Portuguese GD registry. Pregnancies with and without NH were compared. A logistic regression was used to study NH predictors. Variables independently associated with NH were used to score derivation. The model's internal validation was performed by a bootstrapping. The association between the score and NH was assessed by logistic regression.

RESULTS

We studied 10216 pregnancies, 410 (4.0%) with NH. The model's AUC was 0.628 (95%CI: 0.599-0.657). Optimism-corrected c-index: 0.626. Points were assigned to variables associated with NH in proportion to the model's lowest regression coefficient: insulin-treatment 1, preeclampsia 3, preterm delivery 2, male sex 1, and small-for-gestational-age 2, or large-for-gestational-age 3. NH prevalence by score category 0-1, 2, 3, 4, and ≥5 was 2.3%, 3.0%, 4.5%, 6.0%, 7.4%, and 11.5%, respectively. Per point, the OR for NH was 1.35 (95% CI: 1.27-1.42). A score of 2, 3, 4, 5 or ≥6 (versus ≤1) had a OR for NH of 1.67 (1.29-2.15), 2.24 (1.65-3.04), 2.83 (2.02-3.98), 3.08 (1.83-5.16), and 6.84 (4.34-10.77), respectively.

CONCLUSION

Per each score point, women with GD had 35% higher risk of NH. Those with ≥6 points had 6.8-fold higher risk of NH compared to a score ≤1. Our score may be useful for identifying women at a higher risk of NH.

Low Protein Diets for Pregnant Women and Its Association with Insulin Secretion and Resistance

Gestational diabetes mellitus (GDM) complicates 3.5% of pregnancies in England and Wales and continues to show an increase in incidence each year. GDM can lead to diabetes postpartum, it is associated with an increased perinatal risk, and an increase in neonatal mortality. This review article looks at different studies regarding protein diets and their potential effects on GDM. We aimed to determine if a certain protein diet could potentially help protect against GDM using. We found that while a few studies have shown that increasing proteins in the diet of pregnant women, specifically that from poultry, whey, fish, nuts and legumes, may reduce the risk of GDM, there is certainly room for further research on the topic.

Increased Proportion of Hematopoietic Stem and Progenitor Cell Population in Cord Blood of Neonates Born to Mothers with Gestational Diabetes Mellitus

We assessed the hematopoietic stem and progenitor cell (HSPC) population in the cord blood of neonates born to mothers with gestational diabetes mellitus (GDM) in a hypothesis generating pilot study, due to that, neonatal polycythemia may be the consequence of GDM pregnancy. Forty-five pregnant women with GDM (last trimester mean HbA1C = 33.9 mmol/mol) and 42 (nondiabetic) control pregnant women were enrolled after their routine 75 g oral glucose tolerance test (OGTT) between the 24th and 28th gestational week (with expected differences in their mean routine clinical characteristics: plasma glucose at OGTT: 0′ = 5.07 vs. 4.62 mM, 120′ = 8.9 vs. 5.76 mM, age = 35.07 vs. 31.66 years, prepregnancy body mass index = 27.9 vs. 23.9 kg/m², GDM vs. control, respectively) on a voluntary basis after signing the informed consent. EDTA-treated cord blood samples were analyzed by flow cytometry and the software Kaluza1.2 using CD45 and CD34-specific fluorescent antibodies to identify the HSPC population (CD34⁺ cells within the CD45^dim blast gate). The proportion of CD34⁺CD45^dim HSPCs among the nucleated cells was significantly (P < 0.05, statistical power = 60.8%) higher in the cord blood samples of neonates born to mothers with GDM (median 0.38%) compared to neonates born to nondiabetic mothers (median 0.32%) and according to treatment types (P < 0.05) median: control 0.32%, GDM-diet only 0.37%, GDM-on insulin 0.45%; control versus GDM on insulin (P < 0.05). The increased proportion of circulating CD34⁺CD45^dim cells in the cord blood may possibly be related to altered fetal stem cell mobilization in GDM pregnancy, yet these results should be interpreted only as preliminary due to the small sample sizes.

Sex of the baby and risk of gestational diabetes mellitus in the mother: a systematic review and meta-analysis

AIMS/HYPOTHESIS

It has recently emerged that carrying a male fetus may be associated with poorer maternal beta cell function and an increased risk of gestational diabetes mellitus (GDM). Recognising that the overall impact of fetal sex on maternal glucose metabolism is likely to be subtle, we sought to perform a systematic review and meta-analysis of observational studies to obtain a robust estimate of the incremental maternal risk of GDM associated with the sex of the baby.

METHODS

We searched PubMed and EMBASE to identify observational studies published between 1 January 1950 and 4 April 2015 that reported data on fetal sex and the prevalence of GDM. Two independent reviewers extracted the data and pooled estimates of the RR were calculated by a random-effects model. We considered male fetus as the exposure and prevalence of GDM as the outcome of interest.

RESULTS

We identified 320 studies through electronic searches and nine studies through manual searches. Twenty studies met the inclusion criteria, yielding data on 2,402,643 women. Pooled analysis of these studies demonstrated an increased risk of GDM in women carrying a male fetus compared with women carrying a female fetus (RR 1.04; 95% CI 1.02, 1.06). This result was confirmed in a sensitivity analysis including only studies that applied a stringent definition of GDM (RR 1.03; 95% CI 1.01, 1.06) (I(2) = 0%, p = 0.66).

CONCLUSIONS/INTERPRETATION

Pregnant women carrying a boy have a 4% higher relative risk of GDM than those carrying a girl. The fetus thus may have previously unsuspected effects on maternal glucose metabolism in pregnancy.

[Gestational diabetes mellitus: importance of blood glucose monitoring]

Gestational diabetes mellitus (GDM) is common during pregnancy, and is frequently associated with maternal and perinatal complications. Intensive treatment of hyperglycaemia during pregnancy has been shown to reduce perinatal morbidity. In women with pregestational type 1 or 2 diabetes, hyperglycaemia during labour and delivery is an important factor in the development of neonatal hypoglycaemia. There are no generally accepted recommendations for women with GDM. Recent studies evaluating patients with GDM show that peripartum glucose control can be achieved in these women without the need for insulin use in the majority of cases. Hyperglycaemia during labour is not related with treatment established during pregnancy but rather with non-compliance of endocrinological follow-up. Factors such as ethnic origin, neonatal hypoxaemia, and large for gestational age seem to play an important role in the development of neonatal hypoglycaemia.

A prospective evaluation of neonatal hypoglycaemia in infants of women with gestational diabetes mellitus

OBJECTIVE

To analyse first-day-of-life glucose levels in infants of women with gestational diabetes (GDM) and the influence of maternal, gestational and peripartum factors on the development of neonatal hypoglycaemia.

STUDY DESIGN

Prospective cohort study including newborns of GDM mothers. Capillary blood glucose (CBG) was measured serially on the first day of life. CBG values were defined as normal (≥ 2.5 mmol/l), mild hypoglycaemia (2.2-2.4 mmol/l), moderate hypoglycaemia (1.6-2.1 mmol/l) and severe hypoglycaemia (<1.6 mmol/l).

RESULTS

One hundred and ninety infants were included: 23 (12.1%) presented mild, 20 (10.5%) moderate and only 5 (2.6%) severe hypoglycaemia. Hypoglycaemic infants were more frequently large-for-gestational-age (29.3% vs 11.3%, p=0.003), had lower umbilical cord pH (7.28 vs 7.31, p=0.03) and their mothers had more frequently been hyperglycaemic during labour (18.8% vs 8.5%, p=0.04). In multivariate analysis Pakistani origin (OR: 2.94; 95% CI: 1.14-7.55) and umbilical cord venous pH (OR: 0.04, 95% CI: 0.261-0.99) were significantly and independently associated with hypoglycaemia.

CONCLUSIONS

Mild and moderate neonatal hypoglycaemias were common although severe episodes were unusual in infants of women with GDM. Hypoglycaemia is mainly influenced by ethnicity and cord blood pH, although maternal peripartum glycaemic control and large-for-gestational-age condition may also play a role.

Altered transitional circulation in infants of diabetic mothers with strict antenatal obstetric management: a functional echocardiography study

OBJECTIVE

Infants born to diabetic mothers (IDMs) even with good glycemic control are at risk for neonatal morbidity. Many of these problems occur during neonatal transition. We assessed (i) systemic and pulmonary blood flow in IDMs compared with controls and (ii) directional blood flow changes within fetal shunts during the first few days of life.

STUDY DESIGN

In this prospective observational cohort study, we evaluated right (RVO) and left ventricular output, superior vena cava flow, atrial and ductal shunts, and tricuspid regurgitation in 32 IDMs and 18 controls using serial echocardiography after birth and 48 h of life in both groups and at 24 and 72 h in IDMs only.

RESULT

IDMs had lower RVO after birth and 48 h of life. IDMs also had less left to right atrial shunt and more right to left ductal shunt after birth compared with controls. In all, 15 of the 32 IDMs were admitted to the neonatal intensive care unit and 11 had respiratory symptoms.

CONCLUSION

Persistence of fetal shunts and decreased RVO in IDMs suggest that even those with good gestational control have impaired transitional hemodynamics.

Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes

BACKGROUND

Infants born to diabetic women are at higher risk for hypoglycaemia related to hyperinsulinism in response to maternal hyperglycaemia during pregnancy. As such, recommendations to prevent neonatal hypoglycaemia include infant feeding in the early postpartum period. The present study aimed to examine the effect of early breastfeeding and type of nutrition used for the first feed (human milk or formula) on glucose levels in infants born to women with gestational diabetes.

METHODS

The prospective pilot study of 84 infants born to gestational diabetic women examined the glycaemic levels of infants who were breastfed in the delivery room compared to glycaemic levels of those who were not. The study also compared the glycaemic levels of infants who breastfed with those who received formula for their first feed.

RESULTS

Infants who were breastfed in the delivery room had a significantly lower rate of borderline hypoglycaemia than those who were not breastfed in the early postpartum period (10% versus 28%; Fisher's exact test., P = 0.05,). Likewise, infants breastfed in the delivery room had significantly higher mean blood glucose level compared to infants who were not breastfed in the delivery room (3.17 versus 2.86 mmol L(-1), P = 0.03). Additionally, breastfed infants had a significantly higher mean blood glucose level compared to those who were formula fed for their first feed (3.20 versus 2.68 mmol L(-1), P = 0.002).

CONCLUSIONS

Early breastfeeding may facilitate glycaemic stability in infants born to women with gestational diabetes.