1
|
Barak O, Yoles I, Wainstock T, Gadassi N, Schiller T, Vaisbuch E. The association between an oral glucose tolerance test performed at term pregnancy and obstetric outcomes. Obstet Med 2022; 15:185-189. [PMID: 36262815 PMCID: PMC9574452 DOI: 10.1177/1753495x211055634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 10/07/2021] [Indexed: 09/03/2023] Open
Abstract
Aims Assessing the value of oral glucose tolerance test performed at term pregnancy in identifying obstetric complications. Methods Retrospective cohort study of women with a normal 50 g glucose challenge test who also had an oral glucose tolerance test at term (defined as at or after 37 weeks of gestation). Comparison between the pathological and normal oral glucose tolerance test groups was performed. Results The mean glucose in the glucose challenge test of women in the normal oral glucose tolerance test (n = 256) group was lower than that in the pathological oral glucose tolerance test (N = 16) group (105 ± 17 mg/dl (5.8 ± 0.9 mmol/l) vs 117 ± 13 mg/dl (6.5 ± 0.7 mmol/l), p = 0.007). Relevant obstetrical complications did not differ significantly between the groups. Of note, in the pathological oral glucose tolerance test group only one woman delivered a macrosomic infant. Conclusions A pathological oral glucose tolerance test performed at term was unable to identify women at risk for impaired glucose metabolism-related obstetric complications and is therefore of limited clinical value and seems to be unjustified.
Collapse
Affiliation(s)
- Oren Barak
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Israel
- Faculty of Medicine, Hebrew University of Jeruslem, Israel
| | - Israel Yoles
- Clalit Health Services, the Central District, Israel
| | | | - Noa Gadassi
- Faculty of Medicine, Hebrew University of Jeruslem, Israel
- Department of Neonatology, Kaplan Medical Center, Israel
| | - Tal Schiller
- Faculty of Medicine, Hebrew University of Jeruslem, Israel
- Diabetes, Endocrinology and Metabolism, Kaplan Medical Center, Israel
| | - Edi Vaisbuch
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Israel
- Faculty of Medicine, Hebrew University of Jeruslem, Israel
| |
Collapse
|
3
|
Powe CE, Hivert MF, Udler MS. Defining Heterogeneity Among Women With Gestational Diabetes Mellitus. Diabetes 2020; 69:2064-2074. [PMID: 32843565 PMCID: PMC7506831 DOI: 10.2337/dbi20-0004] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/29/2020] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Camille E Powe
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
| | - Marie-France Hivert
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Boston, MA
| | - Miriam S Udler
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
Ott R, Stupin JH, Loui A, Eilers E, Melchior K, Rancourt RC, Schellong K, Ziska T, Dudenhausen JW, Henrich W, Plagemann A. Maternal overweight is not an independent risk factor for increased birth weight, leptin and insulin in newborns of gestational diabetic women: observations from the prospective 'EaCH' cohort study. BMC Pregnancy Childbirth 2018; 18:250. [PMID: 29925339 PMCID: PMC6011392 DOI: 10.1186/s12884-018-1889-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 06/10/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Both gestational diabetes mellitus (GDM) as well as overweight/obesity during pregnancy are risk factors for detrimental anthropometric and hormonal neonatal outcomes, identified to 'program' adverse health predispositions later on. While overweight/obesity are major determinants of GDM, independent effects on critical birth outcomes remain unclear. Thus, the aim of the present study was to evaluate, in women with GDM, the relative/independent impact of overweight/obesity vs. altered glucose metabolism on newborn parameters. METHODS The prospective observational 'Early CHARITÉ (EaCH)' cohort study primarily focuses on early developmental origins of unfavorable health outcomes through pre- and/or early postnatal exposure to a 'diabetogenic/adipogenic' environment. It includes 205 mother-child dyads, recruited between 2007 and 2010, from women with treated GDM and delivery at the Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, Germany. Recruitment, therapy, metabolite/hormone analyses, and data evaluation were performed according to standardized guidelines and protocols. This report specifically aimed to identify maternal anthropometric and metabolic determinants of anthropometric and critical hormonal birth outcomes in 'EaCH'. RESULTS Group comparisons, Spearman's correlations and unadjusted linear regression analyses initially confirmed that increased maternal prepregnancy body-mass-index (BMI) is a significant factor for elevated birth weight, cord-blood insulin and leptin (all P < 0.05). However, consideration of and adjustment for maternal glucose during late pregnancy showed that no maternal anthropometric parameter (weight, BMI, gestational weight gain) remained significant (all n.s.). In contrast, even after adjustment for maternal anthropometrics, third trimester glucose values (fasting and postprandial glucose at 32nd and 36th weeks' gestation, HbA1c in 3rd trimester and at delivery), were clearly positively associated with critical birth outcomes (all P < 0.05). CONCLUSIONS Neither overweight/obesity nor gestational weight gain appear to be independent determinants of increased birth weight, insulin and leptin. Rather, 3rd trimester glycemia seems to be crucial for respective neonatal outcomes. Thus, gestational care and future research studies should greatly consider late pregnancy glucose in overweight/obese women with or without GDM, for evaluation of critical causes and interventional strategies against 'perinatal programming of diabesity' in the offspring.
Collapse
Affiliation(s)
- Raffael Ott
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Division of ‘Experimental Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Jens H. Stupin
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Andrea Loui
- Department of Neonatology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Elisabeth Eilers
- Department of Neonatology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Kerstin Melchior
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Division of ‘Experimental Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Rebecca C. Rancourt
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Division of ‘Experimental Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Karen Schellong
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Division of ‘Experimental Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Thomas Ziska
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Division of ‘Experimental Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Joachim W. Dudenhausen
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Wolfgang Henrich
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Andreas Plagemann
- Clinic of Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Division of ‘Experimental Obstetrics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| |
Collapse
|
5
|
Carlson NS, Leslie SL, Dunn A. Antepartum Care of Women Who Are Obese During Pregnancy: Systematic Review of the Current Evidence. J Midwifery Womens Health 2018; 63:259-272. [PMID: 29758115 PMCID: PMC6363119 DOI: 10.1111/jmwh.12758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/13/2018] [Accepted: 03/15/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Nearly 40% of US women of childbearing age are obese. Obesity during pregnancy is associated with multiple risks for both the woman and fetus, yet clinicians often feel unprepared to provide optimal antepartum care for this group of women. We collected and reviewed current evidence concerning antepartum care of women who are obese during pregnancy. METHODS We conducted a systematic review using PRISMA guidelines. Current evidence relating to the pregnancy care of women with a prepregnancy body mass index of 30kg/m2 or higher was identified using MEDLINE databases via PubMed, Embase, and Web of Science Core Collection between January 2012 and February 2018. RESULTS A total of 354 records were located after database searches, of which 63 met inclusion criteria. Topic areas for of included studies were: pregnancy risk and outcomes related to obesity, communication between women and health care providers, gestational weight gain and activity/diet, diabetic disorders, hypertensive disorders, obstructive sleep apnea, mental health, pregnancy imaging and measurement, late antepartum care, and preparation for labor and birth. DISCUSSION Midwives and other health care providers can provide better antepartum care to women who are obese during pregnancy by incorporating evidence from the most current clinical investigations.
Collapse
|
6
|
Brown J, Alwan NA, West J, Brown S, McKinlay CJD, Farrar D, Crowther CA. Lifestyle interventions for the treatment of women with gestational diabetes. Cochrane Database Syst Rev 2017; 5:CD011970. [PMID: 28472859 PMCID: PMC6481373 DOI: 10.1002/14651858.cd011970.pub2] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gestational diabetes (GDM) is glucose intolerance, first recognised in pregnancy and usually resolving after birth. GDM is associated with both short- and long-term adverse effects for the mother and her infant. Lifestyle interventions are the primary therapeutic strategy for many women with GDM. OBJECTIVES To evaluate the effects of combined lifestyle interventions with or without pharmacotherapy in treating women with gestational diabetes. SEARCH METHODS We searched the Pregnancy and Childbirth Group's Trials Register (14 May 2016), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (14th May 2016) and reference lists of retrieved studies. SELECTION CRITERIA We included only randomised controlled trials comparing a lifestyle intervention with usual care or another intervention for the treatment of pregnant women with GDM. Quasi-randomised trials were excluded. Cross-over trials were not eligible for inclusion. Women with pre-existing type 1 or type 2 diabetes were excluded. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by the Cochrane Collaboration. All selection of studies, data extraction was conducted independently by two review authors. MAIN RESULTS Fifteen trials (in 45 reports) are included in this review (4501 women, 3768 infants). None of the trials were funded by a conditional grant from a pharmaceutical company. The lifestyle interventions included a wide variety of components such as education, diet, exercise and self-monitoring of blood glucose. The control group included usual antenatal care or diet alone. Using GRADE methodology, the quality of the evidence ranged from high to very low quality. The main reasons for downgrading evidence were inconsistency and risk of bias. We summarised the following data from the important outcomes of this review. Lifestyle intervention versus control groupFor the mother:There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of hypertensive disorders of pregnancy (pre-eclampsia) (average risk ratio (RR) 0.70; 95% confidence interval (CI) 0.40 to 1.22; four trials, 2796 women; I2 = 79%, Tau2 = 0.23; low-quality evidence); caesarean section (average RR 0.90; 95% CI 0.78 to 1.05; 10 trials, 3545 women; I2 = 48%, Tau2 = 0.02; low-quality evidence); development of type 2 diabetes (up to a maximum of 10 years follow-up) (RR 0.98, 95% CI 0.54 to 1.76; two trials, 486 women; I2 = 16%; low-quality evidence); perineal trauma/tearing (RR 1.04, 95% CI 0.93 to 1.18; one trial, n = 1000 women; moderate-quality evidence) or induction of labour (average RR 1.20, 95% CI 0.99 to 1.46; four trials, n = 2699 women; I2 = 37%; high-quality evidence).More women in the lifestyle intervention group had met postpartum weight goals one year after birth than in the control group (RR 1.75, 95% CI 1.05 to 2.90; 156 women; one trial, low-quality evidence). Lifestyle interventions were associated with a decrease in the risk of postnatal depression compared with the control group (RR 0.49, 95% CI 0.31 to 0.78; one trial, n = 573 women; low-quality evidence).For the infant/child/adult:Lifestyle interventions were associated with a reduction in the risk of being born large-for-gestational age (LGA) (RR 0.60, 95% CI 0.50 to 0.71; six trials, 2994 infants; I2 = 4%; moderate-quality evidence). Birthweight and the incidence of macrosomia were lower in the lifestyle intervention group.Exposure to the lifestyle intervention was associated with decreased neonatal fat mass compared with the control group (mean difference (MD) -37.30 g, 95% CI -63.97 to -10.63; one trial, 958 infants; low-quality evidence). In childhood, there was no clear evidence of a difference between groups for body mass index (BMI) ≥ 85th percentile (RR 0.91, 95% CI 0.75 to 1.11; three trials, 767 children; I2 = 4%; moderate-quality evidence).There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of perinatal death (RR 0.09, 95% CI 0.01 to 1.70; two trials, 1988 infants; low-quality evidence). Of 1988 infants, only five events were reported in total in the control group and there were no events in the lifestyle group. There was no clear evidence of a difference between lifestyle intervention and control groups for a composite of serious infant outcome/s (average RR 0.57, 95% CI 0.21 to 1.55; two trials, 1930 infants; I2 = 82%, Tau2 = 0.44; very low-quality evidence) or neonatal hypoglycaemia (average RR 0.99, 95% CI 0.65 to 1.52; six trials, 3000 infants; I2 = 48%, Tau2 = 0.12; moderate-quality evidence). Diabetes and adiposity in adulthood and neurosensory disability in later childhoodwere not prespecified or reported as outcomes for any of the trials included in this review. AUTHORS' CONCLUSIONS Lifestyle interventions are the primary therapeutic strategy for women with GDM. Women receiving lifestyle interventions were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born LGA and decreased neonatal adiposity. Long-term maternal and childhood/adulthood outcomes were poorly reported.The value of lifestyle interventions in low-and middle-income countries or for different ethnicities remains unclear. The longer-term benefits or harms of lifestyle interventions remains unclear due to limited reporting.The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy. Lifestyle interventions are useful as the primary therapeutic strategy and most commonly include healthy eating, physical activity and self-monitoring of blood glucose concentrations.Future research could focus on which specific interventions are most useful (as the sole intervention without pharmacological treatment), which health professionals should give them and the optimal format for providing the information. Evaluation of long-term outcomes for the mother and her child should be a priority when planning future trials. There has been no in-depth exploration of the costs 'saved' from reduction in risk of LGA/macrosomia and potential longer-term risks for the infants.
Collapse
Affiliation(s)
- Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Nisreen A Alwan
- Faculty of Medicine, University of SouthamptonAcademic Unit of Primary Care and Population SciencesSouthampton General HospitalSouthamptonHampshireUKSO16 6YD
| | - Jane West
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation TrustBradfordUK
| | - Stephen Brown
- Auckland University of TechnologySchool of Interprofessional Health Studies90 Akoranga DriveAucklandNew Zealand0627
| | | | - Diane Farrar
- Bradford Institute for Health ResearchMaternal and Child HealthBradford Royal InfirmaryDuckworth LaneBradfordUKBD9 6RJ
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | | |
Collapse
|
7
|
Ma RCW, Schmidt MI, Tam WH, McIntyre HD, Catalano PM. Clinical management of pregnancy in the obese mother: before conception, during pregnancy, and post partum. Lancet Diabetes Endocrinol 2016; 4:1037-1049. [PMID: 27743977 PMCID: PMC6691730 DOI: 10.1016/s2213-8587(16)30278-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 08/15/2016] [Accepted: 08/18/2016] [Indexed: 12/21/2022]
Abstract
The global epidemic of obesity has led to an increasing number of obese women of reproductive age. Obesity is associated with reduced fertility, and pregnancies complicated by maternal obesity are associated with adverse outcomes, including increased risk of gestational diabetes, pre-eclampsia, preterm birth, instrumental and caesarean births, infections, and post-partum haemorrhage. The medical and obstetric management of obese women is focused on identifying, addressing, and preventing some of these associated complications, and is a daunting challenge given the high percentage of patients with obesity and few therapeutic options proven to improve outcomes in this population. The UK's National Institute for Health and Care Excellence guidelines and the American College of Obstetricians and Gynecologists recommend that all pregnant women follow a healthy diet, and consider at least half an hour of moderate physical activity per day during pregnancy. However, although obese women are often directed to seek the advice of a nutritionist and to limit gestational weight gain, guidelines for the management of pregnancy and delivery in this high-risk group are lacking. The post-partum period represents an important opportunity to optimise maternal health before the next pregnancy. As many of the physiological changes of pregnancy associated with maternal obesity are present from early pregnancy onward, reducing maternal obesity before conception is probably the best strategy to decrease the health burden associated with maternal obesity.
Collapse
Affiliation(s)
- Ronald Ching Wan Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| | | | - Wing Hung Tam
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Harold David McIntyre
- Mater Clinical School and Mater Research, The University of Queensland, Brisbane, QLD, Australia
| | - Patrick M Catalano
- Center for Reproductive Health, Case Western Reserve University and MetroHealth Medical Center, Cleveland, OH, USA.
| |
Collapse
|