Adverse Pregnancy Outcomes Using The International Association of the Diabetes and Pregnancy Study Groups Criteria: Glycemic Thresholds and Associated Risks

Neonatal outcomes according to different glucose threshold values in gestational diabetes: a register-based study

BACKGROUND

Mild hyperglycaemia is associated with increased birth weight but association with other neonatal outcomes is controversial. We aimed to study neonatal outcomes in untreated mild hyperglycaemia using different oral glucose tolerance test (OGTT) thresholds.

METHODS

This register-based study included all (n = 4,939) singleton pregnant women participating a 75 g 2-h OGTT in six delivery hospitals in Finland in 2009. Finnish diagnostic cut-offs for GDM were fasting ≥ 5.3, 1 h ≥ 10.0 or 2-h glucose ≥ 8.6 mmol/L. Women who did not meet these criteria but met the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria (fasting 5.1-5.2 mmol/L and/or 2-h glucose 8.5 mmol/L, n = 509) or the National Institute for Health and Clinical Excellence (NICE) criteria (2-h glucose 7.8-8.5 mmol/L, n = 166) were considered as mild untreated hyperglycaemia. Women who met both the Finnish criteria and the IADPSG or the NICE criteria were considered as treated GDM groups (n = 1292 and n = 612, respectively). Controls were normoglycaemic according to all criteria (fasting glucose < 5.1 mmol/L, 1-h glucose < 10.0 mmol/L and 2-h glucose < 8.5 mmol/L, n = 3031). Untreated mild hyperglycemia groups were compared to controls and treated GDM groups. The primary outcome - a composite of adverse neonatal outcomes, including neonatal hypoglycaemia, hyperbilirubinaemia, birth trauma or perinatal mortality - was analysed using multivariate logistic regression.

RESULTS

The risk for the adverse neonatal outcome in untreated mild hyperglycemia was not increased compared to controls (adjusted odds ratio [aOR]: 1.01, 95% confidence interval [CI]: 0.71-1.44, using the IADPSG criteria; aOR: 1.05, 95% CI: 0.60-1.85, using the NICE criteria). The risk was lower compared to the treated IADPSG (aOR 0.38, 95% CI 0.27-0.53) or the treated NICE group (aOR 0.32, 95% CI 0.18-0.57).

DISCUSSION

The risk of adverse neonatal outcomes was not increased in mild untreated hyperglycaemia compared to normoglycaemic controls and was lower than in the treated GDM groups. The OGTT cut-offs of 5.3 mmol/L at fasting and 8.6 mmol/L at 2 h seem to sufficiently identify clinically relevant GDM, without excluding neonates with a risk of adverse outcomes.

Prevalence of gestational diabetes in the United States and Canada: a systematic review and meta-analysis

BACKGROUND

An understanding of the prevalence of gestational diabetes mellitus among pregnant women is essential at local, national and international level so that appropriate health care interventions can be planned, financed and delivered.

METHODS

A systematic review and meta-analysis of primary research reporting the prevalence of gestational diabetes mellitus in Canada or the United States were carried out according to Meta-analysis of Observational Studies in Epidemiology guidelines. Four electronic databases were systematically searched in June 2023 to identify articles that reported gestational diabetes mellitus prevalence using universal screening in pregnant women from eligible general population samples. Estimates were combined using a random effects model, and the effects of moderator variables analysed.

RESULTS

There were 36 separate samples of women or deliveries (total sample size 1,550,917). Overall mean prevalence of gestational diabetes mellitus was 6.9% (95% CI: 5.7-8.3); 13.7% (95% CI: 10.7-17.3) in studies using a one-step screening strategy, and 5.2% (95% CI: 4.4-6.1) in those using a two-step strategy. Heterogeneity in technical methods between studies produced differences in estimates, as did different diagnostic thresholds used.

CONCLUSIONS

The meta-analysis suggests a slightly higher prevalence of gestational diabetes mellitus in Canada and the United States, compared to Europe, but highlights the need for standardised protocols for estimating gestational diabetes mellitus prevalence.

Body composition and risk of gestational diabetes mellitus: A univariable and multivariable Mendelian randomization study

OBJECTIVE

In this study, we employed a Mendelian randomization (MR) approach to investigate the independent causal associations of six body composition traits with gestational diabetes mellitus (GDM).

METHODS

Genome-wide significant levels (P < 10 × 5-8 ) of single nucleotide polymorphisms associated with body water mass, total protein, whole body fat-free mass, weight, whole body fat mass, and body fat percentage were used as instrumental variables. Data on GDM were obtained from the FinnGen Consortium, and both univariable and multivariable Mendelian randomization were performed. We utilized five different analytical methods including inverse-variance weighted (IVW), MR Egger, weighted median, simple mode, and weighted mode to assess the robustness of the results.

RESULTS

With univariable Mendelian randomization, the risk of GDM increased per 1-standard deviation (SD) increase in weight (ORweight  = 1.297, P = 3.06 × 10-5 ), whole body fat mass (ORwhole body fat mass  = 1.408, P = 1.32 × 10-6 ), and the risk of GDM increased per percent increase in body fat percentage (ORbody fat percentage  = 1.661, P = 1.01 × 10-8 ). Total protein had a protective effect on the risk of GDM (ORtotal protein  = 0.880, P = 0.048). However, there was no significant causal association between increases in body water mass and whole body fat-free mass per SD and the risk of GDM. Causal associations between weight, whole body fat mass, body fat percentage, and total protein with GDM were reduced to null in multivariable Mendelian randomization.

CONCLUSION

The present study furnishes genetic evidence to elucidate the causal relationship between body composition traits and GDM. Additionally, further studies are imperative to establish a causal connection between body composition traits and gestational diabetes mellitus.

Gestational diabetes mellitus and adverse maternal and perinatal outcomes in twin and singleton pregnancies: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the risk of adverse maternal and perinatal complications between twin and singleton pregnancies affected by gestational diabetes mellitus and the respective group without gestational diabetes mellitus (controls).

DATA SOURCES

A literature search was performed using MEDLINE, Embase, and Cochrane from January 1980 to May 2023.

STUDY ELIGIBILITY CRITERIA

Observational studies reporting maternal and perinatal outcomes in singleton and/or twin pregnancies with gestational diabetes mellitus vs controls were included.

METHODS

This was a systematic review and meta-analysis. Pooled estimate risk ratios with 95% confidence intervals were generated to determine the likelihood of adverse pregnancy outcomes between twin and singleton pregnancies with and without gestational diabetes mellitus. Heterogeneity among studies was evaluated in the model and expressed using the I2 statistic. A P value of <.05 was considered statistically significant. The meta-analyses were performed using Review Manager (RevMan Web). Version 5.4. The Cochrane Collaboration, 2020. Meta-regression was used to compare relative risks between singleton and twin pregnancies. The addition of multiple covariates into the models was used to address the lack of adjustments.

RESULTS

Overall, 85 studies in singleton pregnancies and 27 in twin pregnancies were included. In singleton pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.85; 95% confidence interval, 1.69-2.01), induction of labor (relative risk, 1.36; 95% confidence interval, 1.05-1.77), cesarean delivery (relative risk, 1.31; 95% confidence interval, 1.24-1.38), large-for-gestational-age neonate (relative risk, 1.61; 95% confidence interval, 1.46-1.77), preterm birth (relative risk, 1.36; 95% confidence interval, 1.27-1.46), and admission to the neonatal intensive care unit (relative risk, 1.43; 95% confidence interval, 1.38-1.49). In twin pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.69; 95% confidence interval, 1.51-1.90), cesarean delivery (relative risk, 1.10; 95% confidence interval, 1.06-1.13), large-for-gestational-age neonate (relative risk, 1.29; 95% confidence interval, 1.03-1.60), preterm birth (relative risk, 1.19; 95% confidence interval, 1.07-1.32), and admission to the neonatal intensive care unit (relative risk, 1.20; 95% confidence interval, 1.09-1.32) and reduced risks of small-for-gestational-age neonate (relative risk, 0.89; 95% confidence interval, 0.81-0.97) and neonatal death (relative risk, 0.50; 95% confidence interval, 0.39-0.65). When comparing relative risks in singleton vs twin pregnancies, there was sufficient evidence to suggest that twin pregnancies have a lower relative risk of cesarean delivery (P=.003), have sufficient adjustment for confounders, and have lower relative risks of admission to the neonatal intensive care unit (P=.005), stillbirths (P=.002), and neonatal death (P=.001) than singleton pregnancies.

CONCLUSION

In both singleton and twin pregnancies, gestational diabetes mellitus was associated with an increased risk of adverse maternal and perinatal outcomes. In twin pregnancies, gestational diabetes mellitus may have a milder effect on some adverse perinatal outcomes and may be associated with a lower risk of neonatal death.

Self-reported diabetes or hypertension diagnoses and antenatal care among child-bearing women in rural Bangladesh: A cross-sectional study

Health care systems in low- and middle-income countries may not meet the needs of pregnant women where the burden of diabetes and hypertension is rapidly increasing. We asked recently pregnant women about ever having been screened for or diagnosed with hypertension or diabetes and their ANC-seeking experiences in a cross-sectional survey. We used chi-squared tests and logistic regression to test the associations between self-reported coverage of hypertension and diabetes screening, diagnoses, and elements of ANC by age, wealth, educational attainment, and gravidity. Among 4,692 respondents, for hypertension, 97% reported having been screened and 10% of screened women reported a diagnosis. Women 30-39 years of age (aOR 3.02, 95% CI 2.00, 4.56) or in the top wealth quintile (aOR 1.70, 95% CI 1.18, 2.44) were more likely to be diagnosed with hypertension compared to reference groups. Any hypertension diagnosis was associated with reporting four or more antenatal care contacts (44% vs. 35%, p < 0.01), blood pressure measurements (85% vs. 79%, p < 0.01), and urine tests (71% vs. 61%, p < 0.01) conducted during ANC visits. For diabetes, 46% of respondents reported having been screened and 3% of screened women reported a diagnosis. Women 30-39 years of age were more likely to be diagnosed with diabetes (aOR 8.19, 95% CI 1.74, 38.48) compared to the reference group. Any diabetes diagnosis was associated with reporting four or more ANC contacts (48% vs. 36%, p = 0.04) and having blood testing during pregnancy (83% vs. 66%, p < 0.01). However, the frequency and quality of ANC was below the national guidelines among all groups. Focused efforts to ensure that women receive the recommended number of ANC contacts, coupled with improved compliance with ANC guidelines, would improve awareness of hypertension and diabetes among women in Bangladesh.

The Association between Gestational Diabetes Mellitus and Infections in Pregnancy-Systematic Review and Meta-Analysis

We conducted a systematic review and meta-analysis to evaluate the association between gestational diabetes mellitus and infections during pregnancy. We included cross-sectional, case-control, cohort studies and clinical trials, evaluating the frequency of infections in women with and without gestational diabetes mellitus. A search was conducted in Embase, PubMed, and Web of Science electronic databases and by manually searching references, until 23 March 2022, resulting in 16 studies being selected for review, with 111,649 women in the gestational diabetes mellitus group, and 1,429,659 in the controls. Cochrane's Q test of heterogeneity and I² were used to assess heterogeneity. Pooled odds ratio (OR) was calculated. Funnel plots and Egger test were used for assessment of publication bias. The results showed a significant association between gestational diabetes mellitus and infections (pooled-OR 1.3 95% CI [1.2-1.5]). Sub-analyses showed a significant association for urinary tract infections (pooled-OR of 1.2 95% CI [1.1-1.3]), bacterial infections (pooled-OR were 1.2 95% CI [1.1-1.4]), and SARS-CoV-2 (pooled-OR 1.5 95% CI [1.2-2.0]) but not to gingivitis or vaginal candidiasis. The results underscore the significance of acknowledging gestational diabetes mellitus as a risk factor for infections.

Adverse pregnancy outcomes among women in Norway with gestational diabetes using three diagnostic criteria

INTRODUCTION

The aim of this study was to examine the risk of adverse perinatal outcomes in women diagnosed with GDM by the World Health Organization (WHO) 1999 criteria, and in those retrospectively identified by the Norwegian-2017 and WHO-2013 criteria but not by WHO-1999 criteria. We also examine the effect of maternal overweight/obesity and ethnicity.

MATERIAL AND METHODS

We used pooled data from four Norwegian cohorts (2002-2013), encompassing 2970 mother-child pairs. Results from universally offered 75-g oral glucose tolerance tests measuring fasting plasma glucose (FPG) and 2-hour glucose (2HG) were used to assign women into three diagnostic groups: Diagnosed and treated by WHO-1999 (FPG≥7.0 or (2HG ≥7.8 mmol/L), identified by WHO-2013 (FPG ≥5.1 or 2HG ≥8.5 mmol/L), and identified by Norwegian-2017 criteria (FPG ≥5.3 or 2HG ≥9.0 mmol/L). Perinatal outcomes included large-for-gestational-age (LGA) infants, cesarean section, operative vaginal delivery, preterm birth and preeclampsia.

RESULTS

Compared to the non-GDM group, women diagnosed with GDM by either of the three criteria had an increased risk of large-for-gestational-age infants (adjusted odds ratios (OR) 1.7-2.2). Those identified by the WHO-2013 and Norwegian-2017 criteria but not diagnosed and treated by WHO-1999 criteria had an additional increased risk of cesarean section (OR 1.36, 95% CI 1.02,1.83 and 1.44, 95% CI 1.03,2.02, respectively) and operative vaginal delivery (OR 1.35, 95% CI 1.1,1.7 and 1.5, 95% CI 1.1,2.0, respectively). The proportions of LGA neonates and cesarean section were higher for women with GDM in both normal-weight and overweight/obese women. Asians had a lower risk of delivering large-for-gestational-age infants than Europeans applying national birthweight references, but maternal glucose values were similarly positively associated with birthweight in all ethnic groups.

CONCLUSIONS

Women who met the WHO-2013 and Norwegian-2017 criteria, but were not diagnosed by the WHO-1999 criteria and therefore not treated, had an increased risk of LGA, cesarean section and operative vaginal delivery compared to women without GDM.

Treatment of women with mild gestational diabetes mellitus decreases the risk of adverse perinatal outcomes

AIMS

Glycemic thresholds used to diagnose gestational diabetes mellitus (GDM) are a continued subject of debate. Lower glycemic thresholds identify women with milder GDM for whom treatment benefit is unclear. We compared adverse maternal and neonatal outcomes in treated and untreated women with mild hyperglycemia.

METHODS

We reviewed 11 553 patient charts from two tertiary care centers and included singleton pregnancies >32-week gestation. GDM was diagnosed using the one- or two-step 75 g oral glucose tolerance test (OGTT) depending on the center. All OGTT results were reviewed. Women with glycemic values falling between the thresholds of the two tests, referred to as intermediate hyperglycemic (IH), defined as FPG 5.1-5.2 mmol/L, 1 h PG 10.0-10.5 mmol/L, or 2 h PG 8.5-8.9 mmol/L at 75 g OGTT, were untreated at center A and treated at center B.

RESULTS

There were 630 women with IH, 334 were untreated (center A) and 296 who were treated (center B). After adjusting for covariates, untreated IH women had significantly higher rates of gestational hypertension (aOR 6.02, P = 0.002), large for gestational age (LGA) (aOR 3.73, P < 0.001) and birthweights > 4000 g (aOR 3.35, P = 0.001). Our results indicate that treating 11 women with IH would prevent one LGA birth and treating 13 would prevent 1 birthweight > 4000 g.

CONCLUSION

The diagnosis of GDM using the two-step OGTT fails to identify subgroups of women with mild hyperglycemia that would benefit from treatment to lower the risk for adverse maternal and neonatal outcomes. Treatment of women with mild hyperglycemia decreased the risk of LGA and birthweight >4000 g by 3-fold.

The association between offspring birthweight and future risk of maternal diabetes: A population-based study

AIMS

As an indicator of maternal cardiometabolic health, newborn birthweight may be an important predictor of maternal type 2 diabetes mellitus (diabetes). We evaluated the relation between offspring birthweight and onset of maternal diabetes after pregnancy.

METHODS

This retrospective cohort study used linked population-based health databases from Ontario, Canada. We included women aged 16-50 years without pre-pregnancy diabetes, and who had a live birth between 2006 and 2014. We used Cox proportional hazard regression to evaluate the association between age- and sex-standardized offspring birthweight percentile categories and incident maternal diabetes, while adjusting for maternal age, parity, year, ethnicity, gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP). Results were further stratified by the presence of GDM in the index pregnancy.

RESULTS

Of 893,777 eligible participants, 14,329 (1.6%) women were diagnosed with diabetes over a median (IQR) of 4.4 (1.5-7.4) years of follow-up. There was a continuous positive relation between newborn birthweight above the 75th percentile and maternal diabetes. Relative to a birthweight between the 50th and 74.9th percentiles, women whose newborn had a birthweight between the 97th and 100th percentiles had an adjusted hazards ratio (aHR) of diabetes of 2.30 (95% CI 2.16-2.46), including an aHR of 2.01 (95% CI 1.83-2.21) among those with GDM, and 2.59 (2.36-2.84) in those without GDM.

CONCLUSIONS

A higher offspring birthweight signals an increased risk of maternal diabetes, offering another potentially useful way to identify women especially predisposed to diabetes.

Insulin sensitivity, β cell function, and adverse pregnancy outcomes in women with gestational diabetes

BACKGROUND

The potential impact of β cell function and insulin sensitivity on adverse pregnancy outcomes in women with gestational diabetes mellitus (GDM) remains uncertain. We aimed to investigate the association between β cell dysfunction, insulin resistance, and the composite adverse pregnancy outcomes.

METHODS

This observational study included 482 women diagnosed with GDM during pregnancy. Quantitative metrics on β cell function and insulin sensitivity during pregnancy were calculated using traditional equations. The association of β cell dysfunction and insulin resistance with the risk of the composite adverse pregnancy outcomes was investigated using multivariable-adjusted logistic regression models.

RESULTS

Multivariable-adjusted odds ratios (ORs) of adverse pregnancy outcomes across quartiles of homeostatic model assessment for insulin resistance (HOMA-IR) were 1.00, 0.95, 1.34, and 2.25, respectively (P for trend = 0.011). When HOMA-IR was considered as a continuous variable, the multivariable-adjusted OR of adverse pregnancy outcomes was 1.34 (95% confidence interval 1.16-1.56) for each 1-unit increase in HOMA-IR. Multivariable-adjusted ORs of adverse pregnancy outcomes across quartiles of homeostatic model assessment for β cell function (HOMA-β) were 1.00, 0.51, 0.60, and 0.53, respectively (P for trend = 0.068). When HOMA-β was considered as a continuous variable, the multivariable-adjusted OR of adverse pregnancy outcomes was 0.57 (95% CI 0.24-0.90) for each 1-unit increase in HOMA-β. However, other quantitative metrics were not associated with the composite adverse pregnancy outcomes.

CONCLUSIONS

We demonstrated a significant association of β cell function and insulin sensitivity with the risk of adverse pregnancy outcomes. We have provided additional evidence on the early identification of adverse pregnancy outcomes besides the glycemic values.

Lower versus Higher Glycemic Criteria for Diagnosis of Gestational Diabetes

BACKGROUND

Treatment of gestational diabetes improves maternal and infant health, although diagnostic criteria remain unclear.

METHODS

We randomly assigned women at 24 to 32 weeks' gestation in a 1:1 ratio to be evaluated for gestational diabetes with the use of lower or higher glycemic criteria for diagnosis. The lower glycemic criterion was a fasting plasma glucose level of at least 92 mg per deciliter (≥5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥8.5 mmol per liter). The higher glycemic criterion was a fasting plasma glucose level of at least 99 mg per deciliter (≥5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥9.0 mmol per liter). The primary outcome was the birth of an infant who was large for gestational age (defined as a birth weight above the 90th percentile according to Fenton-World Health Organization standards). Secondary outcomes were maternal and infant health.

RESULTS

A total of 4061 women underwent randomization. Gestational diabetes was diagnosed in 310 of 2022 women (15.3%) in the lower-glycemic-criteria group and in 124 of 2039 women (6.1%) in the higher-glycemic-criteria group. Among 2019 infants born to women in the lower-glycemic-criteria group, 178 (8.8%) were large for gestational age, and among 2031 infants born to women in the higher-glycemic-criteria group, 181 (8.9%) were large for gestational age (adjusted relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P = 0.82). Induction of labor, use of health services, use of pharmacologic agents, and neonatal hypoglycemia were more common in the lower-glycemic-criteria group than in the higher-glycemic-criteria group. The results for the other secondary outcomes were similar in the two trial groups, and there were no substantial between-group differences in adverse events. Among the women in both groups who had glucose test results that fell between the lower and higher glycemic criteria, those who were treated for gestational diabetes (195 women), as compared with those who were not (178 women), had maternal and infant health benefits, including fewer large-for-gestational-age infants.

CONCLUSIONS

The use of lower glycemic criteria for the diagnosis of gestational diabetes did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria. (Funded by the Health Research Council of New Zealand and others; GEMS Australian New Zealand Clinical Trials Registry number, ACTRN12615000290594.).

Effect of Different Types of Diagnostic Criteria for Gestational Diabetes Mellitus on Adverse Neonatal Outcomes: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

Evidence supporting various diagnostic criteria for diagnose gestational diabetes mellitus (GDM) are consensus-based, needs for additional evidence related to outcomes. Therefore, the aim of this systematic-review and meta-analysis was to assess the impact of different GDM diagnostic-criteria on the risk of adverse-neonatal-outcomes.

METHODS

Electronic databases including Scopus, PubMed, and Web of Sciences were searched to retrieve English original, population-based studies with the universal GDM screening approach, up to January-2020. GDM diagnostic criteria were classified in seven groups and International Association of the Diabetes and Pregnancy Study Groups (IADPSG) was considered as reference one. We used the Mantel-Haenszel method to calculate the pooled odds of events. The possibility of publication bias was examined by Begg's test.

RESULTS

A total of 55 population-based studies consisting of 1,604,391 pregnant women with GDM and 7,770,855 non-GDM counterparts were included. Results showed that in all diagnostic-criteria subgroups, the risk of adverse neonatal outcomes including macrosomia, hyperbilirubinemia, respiratory distress syndrome, neonatal hypoglycemia, neonatal intensive care unit admission, preterm birth, and birth-trauma were significantly higher than the non-GDM counterparts were significantly higher than non-GDM counterparts. Meta-regression analysis revealed that the magnitude of neonatal risks in all diagnostic-criteria subgroups are similar.

CONCLUSION

Our results showed that the risk of adverse-neonatal-outcome increased among women with GDM, but the magnitude of risk was not different among those women who were diagnosed through more or less intensive strategies. These findings may help health-care-providers and policy-makers to select the most cost-effective approach for the screening of GDM among pregnant women.

Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis

OBJECTIVE

To investigate the association between gestational diabetes mellitus and adverse outcomes of pregnancy after adjustment for at least minimal confounding factors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Web of Science, PubMed, Medline, and Cochrane Database of Systematic Reviews, from 1 January 1990 to 1 November 2021.

REVIEW METHODS

Cohort studies and control arms of trials reporting complications of pregnancy in women with gestational diabetes mellitus were eligible for inclusion. Based on the use of insulin, studies were divided into three subgroups: no insulin use (patients never used insulin during the course of the disease), insulin use (different proportions of patients were treated with insulin), and insulin use not reported. Subgroup analyses were performed based on the status of the country (developed or developing), quality of the study, diagnostic criteria, and screening method. Meta-regression models were applied based on the proportion of patients who had received insulin.

RESULTS

156 studies with 7 506 061 pregnancies were included, and 50 (32.1%) showed a low or medium risk of bias. In studies with no insulin use, when adjusted for confounders, women with gestational diabetes mellitus had increased odds of caesarean section (odds ratio 1.16, 95% confidence interval 1.03 to 1.32), preterm delivery (1.51, 1.26 to 1.80), low one minute Apgar score (1.43, 1.01 to 2.03), macrosomia (1.70, 1.23 to 2.36), and infant born large for gestational age (1.57, 1.25 to 1.97). In studies with insulin use, when adjusted for confounders, the odds of having an infant large for gestational age (odds ratio 1.61, 1.09 to 2.37), or with respiratory distress syndrome (1.57, 1.19 to 2.08) or neonatal jaundice (1.28, 1.02 to 1.62), or requiring admission to the neonatal intensive care unit (2.29, 1.59 to 3.31), were higher in women with gestational diabetes mellitus than in those without diabetes. No clear evidence was found for differences in the odds of instrumental delivery, shoulder dystocia, postpartum haemorrhage, stillbirth, neonatal death, low five minute Apgar score, low birth weight, and small for gestational age between women with and without gestational diabetes mellitus after adjusting for confounders. Country status, adjustment for body mass index, and screening methods significantly contributed to heterogeneity between studies for several adverse outcomes of pregnancy.

CONCLUSIONS

When adjusted for confounders, gestational diabetes mellitus was significantly associated with pregnancy complications. The findings contribute to a more comprehensive understanding of the adverse outcomes of pregnancy related to gestational diabetes mellitus. Future primary studies should routinely consider adjusting for a more complete set of prognostic factors.

REVIEW REGISTRATION

PROSPERO CRD42021265837.

Risk of metformin failure in the treatment of women with gestational diabetes

OBJECTIVES

To estimate the metformin failure rate in women with gestational diabetes.

METHODS

The study was designed as a retrospective cohort of women diagnosed with gestational diabetes by the 75 g 2 h oral glucose tolerance test. Women were placed into two groups: metformin success (107 patients not requiring insulin therapy) or metformin failure (15 patients requiring the addition of, or, transition to insulin). Primary outcome: rate of metformin failure. Secondary outcomes: maternal and neonatal factors.

RESULTS

The failure rate of metformin was 15% (19/122 women) in the study. The failure group was more likely to have 3 abnormal values on a 2-h 75 g oral glucose tolerance test (37% (n=7/19) vs. 15% (n=15/103), p=0.02). Patients who failed had higher average fasting blood glucose levels on the glucose tolerance test as well as on pretreatment fasting finger stick values. Those who failed metformin were diagnosed with gestational diabetes and started on metformin earlier in gestation.

CONCLUSIONS

Overall low rate of metformin failure in treatment of gestational diabetes.

Serum lipid levels in relation to clinical outcomes in pregnant women with gestational diabetes mellitus: an observational cohort study

Background

Research on dyslipidemia during pregnancy in women with gestational diabetes mellitus (GDM) has rarely been conducted in Asia. The present study aimed to evaluate maternal mid-trimester lipid profile in relation to GDM and clinical outcomes in these high-risk populations.

Methods

The medical records of 632 pregnant women in the second trimester were retrospectively analyzed. Maternal fasting serum lipids were assayed for total cholesterol (TC), triglycerides (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), apolipoprotein A1 (Apo A1) and Apo B concentrations during the second trimester. The atherogenic index of plasma (AIP) was calculated as log (TG/HDL). The clinical outcomes were collected by evaluating delivery mode, postpartum hemorrhage, prematurity, macrosomia, birth weight, body length and neonatal Apgar 5 min score.

Results

Levels of TG and AIP were elevated while decreased HDL-C was observed in women with GDM compared with that of the control group. Significant differences were observed in gestational weeks at birth, cesarean section, postpartum hemorrhage, birth weight, body length, prematurity and macrosomia between the two groups. Compared with women with hyperlipidemia, the incidence of GDM and cesarean section was lower in normal lipid group. Women in the hyperlipidemia group had smaller gestational weeks at birth than those in the control group. According to the logistic regression analysis, each unit elevation in AIP increased the risk of GDM by 18.48 times (OR = 18.48, CI: 2.38–143.22). Besides, age (OR = 1.11, CI: 1.06–1.16) and pre-pregnancy BMI (OR = 1.15, CI: 1.07–1.24) were the risk factors of GDM.

Conclusions

These findings suggested that reasonable lipid control in the second trimester might reduce the incidence of GDM and be a potential strategy for improving clinical outcomes in these high-risk women.

Mild Gestational Diabetes and Adverse Pregnancy Outcome: A Systemic Review and Meta-Analysis

Background and Objectives: Mild gestational diabetes (GDM) refers to the gestational hyperglycemia, which does not fulfill the diagnostic criteria for GDM. The results of studies on adverse pregnancy outcomes among women with mild GDM are controversial. Therefore, the aim of this systematic review and meta-analysis was to investigate the impact of mild GDM on the risk of adverse maternal and neonatal outcomes. Methods: A thorough literature search was performed to retrieve articles that investigated adverse maternal and neonatal outcomes in women with mild GDM in comparison with non-GDM counterparts. All populations were classified to three groups based on their diagnostic criteria for mild GDM. Heterogeneous and non-heterogeneous results were analyzed using the fixed/random effects models. Publication bias was assessed using the Harbord test. DerSimonian and Laird, and inverse variance methods were used to calculate the pooled relative risk of events. Subgroup analysis was performed based on mild GDM diagnostic criteria. Quality and risk of bias assessment were performed using standard questionnaires. Results: Seventeen studies involving 11,623 pregnant women with mild GDM and 53,057 non-GDM counterparts contributed to the meta-analysis. For adverse maternal outcomes, the results of meta-analysis showed that the women with mild GDM had a significantly higher risk of cesarean section (pooled RR: 1.3, 95% CI 1.2-1.5), pregnancy-induced hypertension (pooled RR: 1.4, 95% CI 1.1-1.7), preeclampsia (pooled RR: 1.3, 95% CI 1.1-1.5) and shoulder dystocia (pooled RR: 2.7, 95% CI 1.5-5.1) in comparison with the non-GDM population. For adverse neonatal outcomes, the pooled relative risk of macrosomia (pooled RR = 0.4, 95% CI: 1.1-1.7), large for gestational age (pooled RR = 1.7, 95% CI: 1.3-2.3), hypoglycemia (pooled RR = 1.6, 95% CI: 1.1-2.3), hyperbilirubinemia (pooled RR = 1.1, 95% CI: 1-1.3), 5 min Apgar <7 (pooled RR = 1.6, 95% CI: 1.1-2.4), admission to the neonatal intensive care unit (pooled RR = 1.5, 95% CI: 1.1-2.1), respiratory distress syndrome (pooled RR = 3.2, 95% CI: 1.8-5.5), and preterm birth (pooled RR = 1.4, 95% CI: 1.1-1.7) was significantly increased in the mild GDM women as compared with the non-GDM population. However, the adverse events of small for gestational age and neonatal death were not significantly different between the groups. Analysis of composite maternal and neonatal outcomes revealed that the risk of those adverse outcomes in the women with mild GDM in all classifications were significantly higher than the non-GDM population. Also, the meta-regression showed that the magnitude of those increased risks in both composite maternal and neonatal outcomes was similar. Conclusion: The risks of sever adverse neonatal outcomes including small for gestational age and neonatal mortality are not increased with mild GDM. However, the increased risks of most adverse maternal and neonatal outcomes are observed. The risks have similar magnitudes for all mild GDM diagnostic classifications.

Practical use of electronic health records among patients with diabetes in scientific research

Electronic health (medical) records, which are also considered as patients’ information that are routinely collected, provide a great chance for researchers to develop an epidemiological understanding of disease. Electronic health records systems cannot develop without the advance of computer industries. While conducting clinical trials that are always costly, feasible and reasonable analysis of routine patients’ information is more cost-effective and reflective of clinical practice, which is also called real world study. Real world studies can be well supported by big data in healthcare industry. Real world studies become more and more focused and important with the development of evidence-based medicine. These big data will definitely help in making decisions, making policies and guidelines, monitoring of effectiveness and safety on new drugs or technologies. Extracting, cleaning, and analyzing such big data will be a great challenge for clinical researchers. Successful applications and developments of electronic health record in western countries (eg, disease registries, health insurance claims, etc) have provided a clear direction for Chinese researchers. However, it is still at primary stages in China. This review tries to provide a full perspective on how to translate the electronic health records into scientific achievements, for example, among patients with diabetes. As a summary in the end, resource sharing and collaborations are highly recommended among hospitals and healthcare groups.

Resolving the Gestational Diabetes Diagnosis Conundrum: The Need for a Randomized Controlled Trial of Treatment

The diagnosis of and criteria for gestational diabetes mellitus (GDM) continue to divide the scientific and medical community, both between and within countries. Many argue for universal adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and feel that further clinical trials are unjustified and even unethical. However, there are concerns about the large increase in number of women who would be diagnosed with GDM using these criteria and the subsequent impact on health care resources and the individual. This Perspective reviews the origins of the IADPSG consensus and points out some of its less well-known limitations, particularly with respect to identifying women at risk for an adverse pregnancy outcome. It also questions the clinical and cost-effectiveness data often cited to support the IADPSG glycemic thresholds. We present the argument that adoption of diagnostic criteria defining GDM should be based on response to treatment at different diagnostic thresholds of maternal glycemia. This will likely require an international multicenter trial of treatment.

The Impact of Diagnostic Criteria for Gestational Diabetes Mellitus on Adverse Maternal Outcomes: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to examine the impact of different gestational-diabetes (GDM) diagnostic-criteria on the risk of adverse-maternal-outcomes. The search process encompassed PubMed (Medline), Scopus, and Web of Science databases to retrieve original, population-based studies with the universal GDM screening approach, published in English language and with a focus on adverse-maternal-outcomes up to January 2020. According to GDM diagnostic criteria, the studies were classified into seven groups. A total of 49 population-based studies consisting of 1409018 pregnant women with GDM and 7,667,546 non-GDM counterparts were selected for data analysis and knowledge synthesis. Accordingly, the risk of adverse-maternal-outcomes including primary-cesarean, induction of labor, maternal-hemorrhage, and pregnancy-related-hypertension, overall, regardless of GDM diagnostic-criteria and in all diagnostic-criteria subgroups were significantly higher than non-GDM counterparts. However, in meta-regression, the increased risk was not influenced by the GDM diagnostic-classification and the magnitude of the risks among patients, using the IADPSG criteria-classification as the most strict-criteria, was similar to other criteria. In conclusion, a reduction in the diagnostic-threshold increased the prevalence of GDM, but the risk of adverse-maternal-outcome was not different among those women who were diagnosed through more or less intensive strategies. Our review findings can empower health-care-providers to select the most cost-effective approach for the screening of GDM among pregnant women.

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.

Prevalence of gestational diabetes mellitus in Argentina according to the Latin American Diabetes Association (ALAD) and International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria and the associated maternal-neonatal complications

In Argentina, gestational diabetes mellitus (GDM) is diagnosed by the Latin American Diabetes Association (ALAD) diagnostic criterion. In this work, we investigated GDM prevalence according to the ALAD and IADPSG diagnostic criteria, evaluated maternal and fetal outcomes and assessed whether fasting glycemia between 92-99 mg/dL was associated with increased risk of macrosomia and maternal obesity/overweight in an Argentine cohort of pregnant women. GDM prevalence was 9.8% with the ALAD diagnostic criterion and 25% considering the IADPSG criterion. Increased prevalence of maternal obesity/overweight was observed in patients with fasting glycemia over 99 mg/dL. A population of high metabolic risk is identified by the ALAD criterion.

Deleterious effects of gestational diabetes mellitus on the characteristics of the rectus abdominis muscle associated with pregnancy-specific urinary incontinence

AIMS

To evaluate the effects of gestational diabetes mellitus (GDM) on the structural characteristics of the rectus abdominis muscle (RAM) and its indirect effects on pregnancy-specific urinary incontinence (PSUI).

METHODS

A total of 92 pregnant women were divided into four groups, according to their clinical conditions: non-GDM continent, non-GDM associated PSUI, GDM continent and GDM associated PSUI. The muscle morphometry (histochemistry and immunohistochemistry) for the fiber types and collagen fiber distribution, the ultrastructural analysis (transmission electron microscopy), the protein expression of fiber types and calcium signaling (Western blotting), and the content of types I and III collagen fiber (ELISA) in RAM collected at delivery were assessed.

RESULTS

The GDM groups presented a significantly increased number of slow fibers and slow-twitch oxidative fiber expression; decreased fiber area, number of fast fibers, and area of collagen; an increase in central nuclei; ultrastructural alterations with focal lesion areas such as myeloid structures, sarcomere disorganization, and mitochondrial alteration. The PSUI groups presented a considerable decrease in types I and III collagen contents and the localization of collagen fiber.

CONCLUSIONS

Our data reveal that GDM causes morphological, biochemical and physiological changes in the RAM, and this might predispose women to PSUI.

Interventions to prevent women from developing gestational diabetes mellitus: an overview of Cochrane Reviews

BACKGROUND

The prevalence of gestational diabetes mellitus (GDM) is increasing, with approximately 15% of pregnant women affected worldwide, varying by country, ethnicity and diagnostic thresholds. There are associated short- and long-term health risks for women and their babies.

OBJECTIVES

We aimed to summarise the evidence from Cochrane systematic reviews on the effects of interventions for preventing GDM.

METHODS

We searched the Cochrane Database of Systematic Reviews (6 August 2019) with key words 'gestational diabetes' OR 'GDM' to identify reviews pre-specifying GDM as an outcome. We included reviews of interventions in women who were pregnant or planning a pregnancy, irrespective of their GDM risk status. Two overview authors independently assessed eligibility, extracted data and assessed quality of evidence using ROBIS and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm (GRADE moderate- or high-quality evidence with a confidence interval (CI) that did not cross the line of no effect); clear evidence of no effect or equivalence (GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect); possible benefit or harm (low-quality evidence with a CI that did not cross the line of no effect or GRADE moderate- or high-quality evidence with a wide CI); or unknown benefit or harm (GRADE low-quality evidence with a wide CI or very low-quality evidence).

MAIN RESULTS

We included 11 Cochrane Reviews (71 trials, 23,154 women) with data on GDM. Nine additional reviews pre-specified GDM as an outcome, but did not identify GDM data in included trials. Ten of the 11 reviews were judged to be at low risk of bias and one review at unclear risk of bias. Interventions assessed included diet, exercise, a combination of diet and exercise, dietary supplements, pharmaceuticals, and management of other health problems in pregnancy. The quality of evidence ranged from high to very low. Diet Unknown benefit or harm: there was unknown benefit or harm of dietary advice versus standard care, on the risk of GDM: risk ratio (RR) 0.60, 95% CI 0.35 to 1.04; 5 trials; 1279 women; very low-quality evidence. There was unknown benefit or harm of a low glycaemic index diet versus a moderate-high glycaemic index diet on the risk of GDM: RR 0.91, 95% CI 0.63 to 1.31; 4 trials; 912 women; low-quality evidence. Exercise Unknown benefit or harm: there was unknown benefit or harm for exercise interventions versus standard antenatal care on the risk of GDM: RR 1.10, 95% CI 0.66 to 1.84; 3 trials; 826 women; low-quality evidence. Diet and exercise combined Possible benefit: combined diet and exercise interventions during pregnancy versus standard care possibly reduced the risk of GDM: RR 0.85, 95% CI 0.71 to 1.01; 19 trials; 6633 women; moderate-quality evidence. Dietary supplements Clear evidence of no effect: omega-3 fatty acid supplementation versus none in pregnancy had no effect on the risk of GDM: RR 1.02, 95% CI 0.83 to 1.26; 12 trials; 5235 women; high-quality evidence. Possible benefit: myo-inositol supplementation during pregnancy versus control possibly reduced the risk of GDM: RR 0.43, 95% CI 0.29 to 0.64; 3 trials; 502 women; low-quality evidence. Possible benefit: vitamin D supplementation versus placebo or control in pregnancy possibly reduced the risk of GDM: RR 0.51, 95% CI 0.27 to 0.97; 4 trials; 446 women; low-quality evidence. Unknown benefit or harm: there was unknown benefit or harm of probiotic with dietary intervention versus placebo with dietary intervention (RR 0.37, 95% CI 0.15 to 0.89; 1 trial; 114 women; very low-quality evidence), or probiotic with dietary intervention versus control (RR 0.38, 95% CI 0.16 to 0.92; 1 trial; 111 women; very low-quality evidence) on the risk of GDM. There was unknown benefit or harm of vitamin D + calcium supplementation versus placebo (RR 0.33, 95% CI 0.01 to 7.84; 1 trial; 54 women; very low-quality evidence) or vitamin D + calcium + other minerals versus calcium + other minerals (RR 0.42, 95% CI 0.10 to 1.73; 1 trial; 1298 women; very low-quality evidence) on the risk of GDM. Pharmaceutical Possible benefit: metformin versus placebo given to obese pregnant women possibly reduced the risk of GDM: RR 0.85, 95% CI 0.61 to 1.19; 3 trials; 892 women; moderate-quality evidence. Unknown benefit or harm:eight small trials with low- to very low-quality evidence showed unknown benefit or harm for heparin, aspirin, leukocyte immunisation or IgG given to women with a previous stillbirth on the risk of GDM. Management of other health issues Clear evidence of no effect: universal versus risk based screening of pregnant women for thyroid dysfunction had no effect on the risk of GDM: RR 0.93, 95% CI 0.70 to 1.25; 1 trial; 4516 women; moderate-quality evidence. Unknown benefit or harm: there was unknown benefit or harm of using fractional exhaled nitrogen oxide versus a clinical algorithm to adjust asthma therapy on the risk of GDM: RR 0.74, 95% CI 0.31 to 1.77; 1 trial; 210 women; low-quality evidence. There was unknown benefit or harm of pharmacist led multidisciplinary approach to management of maternal asthma versus standard care on the risk of GDM: RR 5.00, 95% CI 0.25 to 99.82; 1 trial; 58 women; low-quality evidence.

AUTHORS' CONCLUSIONS

No interventions to prevent GDM in 11 systematic reviews were of clear benefit or harm. A combination of exercise and diet, supplementation with myo-inositol, supplementation with vitamin D and metformin were of possible benefit in reducing the risk of GDM, but further high-quality evidence is needed. Omega-3-fatty acid supplementation and universal screening for thyroid dysfunction did not alter the risk of GDM. There was insufficient high-quality evidence to establish the effect on the risk of GDM of diet or exercise alone, probiotics, vitamin D with calcium or other vitamins and minerals, interventions in pregnancy after a previous stillbirth, and different asthma management strategies in pregnancy. There is a lack of trials investigating the effect of interventions prior to or between pregnancies on risk of GDM.

Alterations in the structural characteristics of rectus abdominis muscles caused by diabetes and pregnancy: A comparative study of the rat model and women

BACKGROUND AND OBJECTIVE

In the present study, we compared the effect of diabetic pregnancy on the rectus abdominis muscle (RAM) in humans and rats. We hypothesized that our animal model could provide valuable information about alterations in the RAM of women with Gestational Diabetes (GDM).

METHOD

Newborns female rats (n = 10/group) were administered streptozotocin (100 mg/kg body weight) subcutaneously and were mated on reaching adulthood, to develop the mild hyperglycemic pregnant (MHP) rat model. At the end of pregnancy, the mothers were sacrificed, and the RAM tissue was collected. Pregnant women without GDM (non-GDM group; n = 10) and those diagnosed with GDM (GDM group; n = 8) and undergoing treatment were recruited, and RAM samples were obtained at C-section. The RAM architecture and the distribution of the fast and slow fibers and collagen were studied by immunohistochemistry.

RESULTS

No statistically significant differences in the maternal and fetal characters were observed between the groups in both rats and women. However, significant changes in RAM architecture were observed. Diabetes in pregnancy increased the abundance of slow fibers and decreased fast fiber number and area in both rats and women. A decrease in collagen distribution was observed in GDM women; however, a similar change was not observed in the MHP rats.

CONCLUSION

Our results indicated that pregnancy- associated diabetes- induced similar structural adaptations in the RAM of women and rats with slight alterations in fiber type number and area. These findings suggest that the MHP rat model can be used for studying the effects of pregnancy-associated diabetes on the fiber structure of RAM.

Exercise in Pregnant Women with Diabetes

PURPOSE OF REVIEW

Diabetes affects an increasing number of pregnancies. Regular exercise is recommended for pregnant women without diabetes, but whether exercise during pregnancy also benefits women with gestational diabetes (GDM) or preexisting (type 1 or type 2) diabetes or if these women have any specific risks is unclear.

RECENT FINDINGS

Recent evidence suggests that low- to moderate-intensity exercise improves blood glucose and may delay insulin initiation for women with GDM. Exercise is also safe, with no reports of increased maternal or neonatal complications. Few studies evaluated exercise as adjunct therapy for pregnant women with preexisting diabetes, precluding a thorough assessment in this population. Low- to moderate-intensity exercise during pregnancy safely improves glycemic control among women with GDM. More studies are needed to evaluate the impact of exercise in pregnant women with preexisting diabetes. Whether a specific type, volume, or timing of activity is most effective is not known.

The role of altered immune function during the dry period in promoting the development of subclinical ketosis in early lactation

Subclinical ketosis (SCK) may impair white blood cell (WBC) function and thus contribute to the risk of disease postpartum. This preliminary study investigated changes occurring in the immune system before disease onset to elucidate their role in the occurrence of SCK. A group of 13 Holstein dairy cows were housed in tie-stalls and retrospectively divided into 2 groups based on their levels of β-hydroxybutyrate (BHB) measured in plasma between calving day and 35 d from calving (DFC). Levels of BHB <1.4 mmol/L were found in 7 cows (control cows, CTR group) and levels >1.4 mmol/L were found in 6 cows at ≥1 of 6 time points considered (cows with SCK, KET group). From -48 to 35 DFC, body condition score, body weight, dry matter intake, rumination time, and milk yield were measured, and blood samples were collected regularly to assess the hematochemical profile and test the WBC function by ex vivo challenge assays. Data were submitted for ANOVA testing using a mixed model for repeated measurements that included health status and time and their interactions as fixed effects. Compared with CTR cows, KET cows had more pronounced activation of the immune system (higher plasma concentrations of proinflammatory cytokines, myeloperoxidase, and oxidant species, and greater IFN-γ responses to Mycobacterium avium), higher blood concentrations of γ-glutamyl transferase, and lower plasma concentrations of minerals before calving. Higher levels of nonesterified fatty acids, BHB, and glucose were detected in KET cows than in CTR cows during the dry period. The effect observed during the dry period was associated with a reduced dry matter intake, reduced plasma glucose, and increased fat mobilization (further increases in nonesterified fatty acids and BHB) during early lactation. A reduced milk yield was also detected in KET cows compared with CTR. The KET cows had an accentuated acute-phase response after calving (with greater concentrations of positive acute-phase proteins and lower concentrations of retinol than CTR cows) and impaired liver function (higher blood concentrations of glutamate-oxaloacetate transaminase and bilirubin). The WBC of the KET cows, compared with CTR cows, had a reduced response to an ex vivo stimulation assay, with lower production of proinflammatory cytokines and greater production of lactate. These alterations in the WBC could have been driven by the combined actions of metabolites related to the mobilization of lipids and the occurrence of a transient unresponsive state against stimulation aimed at preventing excessive inflammation. The associations identified here in a small number of cows in one herd should be investigated in larger studies.

Interventions to prevent women developing gestational diabetes mellitus: an overview of Cochrane Reviews

This is a protocol for a Cochrane Review (Overview). The objectives are as follows:

To summarise the evidence from Cochrane systematic reviews regarding the effects of interventions to prevent women developing gestational diabetes mellitus (GDM).

The Gut Microbiota in Women Suffering from Gestational Diabetes Mellitus with the Failure of Glycemic Control by Lifestyle Modification

Gestational diabetes mellitus (GDM) is prevalent worldwide, leading to a high risk of significant morbidity for both the mother and offspring with complications. Increasing evidences suggest that gut microbiota plays a role in the pathogenesis of GDM. Lifestyle modification is the cornerstones of GDM treatment. However, a number of patients whose blood glucose is not controlled by lifestyle modification still require exogenous insulin to control blood glucose. No observational study is available about the relationship between the gut microbiota in GDM patients and lifestyle modifications. Thus, we investigated the differences in gut microbiota between GDM patients with successful glycemic control (GDM1) and failure of glycemic control (GDM2) by lifestyle modifications. We sequenced the V3-V4 regions of 16S ribosomal ribonucleic acid (rRNA) gene from stool samples of 52 singleton pregnant women with 24-28 weeks of gestation. Our results showed that Blautia, Eubacterium_hallii_group, and Faecalibacterium in the gut microbiota showed significant differences among the normoglycemic mother, GDM1, and GDM2 groups, respectively. The combined diagnostic performance of Blautia, Eubacterium_hallii_group, and Faecalibacterium in differentiating GDM2 from GDM was considered as the most reasonable identification indicator. Gut bacteria may participate in the pathological development of GDM2 through the peroxisome proliferator-activated receptor (PPAR) signaling pathway. These results indicated that Blautia, Eubacterium_hallii_group, and Faecalibacterium had important characteristic changes in the gut microbiota of women with GDM2.

The post-HAPO situation with gestational diabetes: the bright and dark sides

AIM

In 2010, in light of the data coming from the HAPO study, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed a new detection strategy and diagnostic criteria for gestational diabetes based on a one-step approach with a 75 g OGTT. This review analyzes and discusses the bright and dark sides of their application.

METHODS

The assessment of these recommendations by the international organizations involved in the care of gestational diabetes and a series of observational, retrospective and prospective studies that have been published since 2010 regarding the use of the IADPSG recommendations have been evaluated.

RESULTS

The different international associations involved in the care of pregnancy and of pregnancy complicated by diabetes have not taken an univocal position some of which have accepted them, while others have criticized them. Then, the actual application of the approach recommended by the IADPSG for detecting and diagnosing GDM varies, even at centers that reportedly accept the new diagnostic criteria.

CONCLUSION

So the challenge lies in making every effort to achieve a global standardization of the strategies for detecting, diagnosing and treating GDM.

Association of gestational diabetes mellitus and abnormal vaginal flora with adverse pregnancy outcomes

Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. This study aimed to examine the association between GDM and abnormal vaginal flora, and the association between abnormal vaginal flora and adverse pregnancy outcomes.This was a prospective study of pregnant women who visited Xuanwu Hospital of the Capital Medical University (Beijing, China) between February and October 2015. All women were screened for GDM according to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recommendations. Vaginal secretions were sampled at 28 to 30 and 37 to 40 weeks. Microorganisms were examined.The women were 28.3 ± 2.6 years and their body mass index was 22.8 ± 1.4 kg/m. GDM was associated with higher frequencies of vulvovaginal candidiasis (22.6% vs 9.7%, P < .001), premature rupture of membranes (PROM) (22.6% vs 11.5%, P = .004), premature delivery (16.1% vs 5.5%, P = .02), chorioamnionitis/puerperal infection (19.4% vs 4.5%, P < .001), macrosomia (9.7% vs 4.0%, P = .04), neonatal hypoglycemia (5.4% vs 1.0%, P = .02), and neonatal referral (15.1% vs 6.5%, P = .008). Among healthy women, abnormal flora was associated with PROM (19.4% vs 7.5%, P = .02) and chorioamnionitis/puerperal infection (11.9% vs 0.8%, P < .001). Among women with GDM, abnormal flora was associated with PROM (32.1% vs 10.0%, P < .001), premature delivery (17.7% vs 6.3%, P = .04), and chorioamnionitis/puerperal infection (32.8% vs 2.5%, P < .001).The vaginal infection rate was higher in patients with GDM compared with healthy pregnant women. GDM and abnormal vaginal flora were both associated with adverse pregnancy outcomes. The vaginal Lactobacillus species were different between the 2 groups, which could contribute to the adverse outcomes.

Antenatal dexamethasone before asphyxia promotes cystic neural injury in preterm fetal sheep by inducing hyperglycemia

Antenatal glucocorticoid therapy significantly improves the short-term systemic outcomes of prematurely born infants, but there is limited information available on their impact on neurodevelopmental outcomes in at-risk preterm babies exposed to perinatal asphyxia. Preterm fetal sheep (0.7 of gestation) were exposed to a maternal injection of 12 mg dexamethasone or saline followed 4 h later by asphyxia induced by 25 min of complete umbilical cord occlusion. In a subsequent study, fetuses received titrated glucose infusions followed 4 h later by asphyxia to examine the hypothesis that hyperglycemia mediated the effects of dexamethasone. Post-mortems were performed 7 days after asphyxia for cerebral histology. Maternal dexamethasone before asphyxia was associated with severe, cystic brain injury compared to diffuse injury after saline injection, with increased numbers of seizures, worse recovery of brain activity, and increased arterial glucose levels before, during, and after asphyxia. Glucose infusions before asphyxia replicated these adverse outcomes, with a strong correlation between greater increases in glucose before asphyxia and greater neural injury. These findings strongly suggest that dexamethasone exposure and hyperglycemia can transform diffuse injury into cystic brain injury after asphyxia in preterm fetal sheep.

Impact of new International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria on perinatal outcomes in a regional tertiary hospital in New South Wales, Australia

AIMS

We compared the impact of new gestational diabetes (GDM) diagnostic criteria by IADPSG with previous criteria to ascertain concordance between the two criteria; and whether women discordant for GDM between the old and new criteria had increased pregnancy complications.

METHODS

Oral glucose tolerance tests of pregnant women across time periods using old criteria and new criteria were collected. Maternal data and perinatal outcomes were compared between diagnostic concordant and discordant women.

RESULTS

In total, 666/5178 (12.9%) women were diagnosed and treated for GDM. There was a significant increase in odds of any complication in concordant positive women (OR 3.91 95%CI 2.71-5.63, p<.0001); in women only positive by new GDM criteria (OR 2.06, 95% CI 1.41-2.99, p=.0002); and women only positive by old GDM criteria (OR 2.28, 95% CI 1.42-3.66, p=.0006); compared to concordant negative women. This is mainly due to macrosomia and nursery admissions.

CONCLUSION

This study confirms that women diagnosed with GDM on both old and new criteria have a higher rate of birth complications than women without GDM. Women who have been missed out due to new criteria may still be at risk. Therefore, combination of both old and new criteria may be optimal for identifying high-risk pregnancies.

Application of One-Step IADPSG Versus Two-Step Diagnostic Criteria for Gestational Diabetes in the Real World: Impact on Health Services, Clinical Care, and Outcomes

PURPOSE OF REVIEW

This paper seeks to summarize the impact of the one-step International Association of Diabetes and Pregnancy Study Groups (IADPSG) versus the two-step gestational diabetes mellitus (GDM) criteria with regard to prevalence, outcomes, healthcare delivery, and long-term maternal metabolic risk.

RECENT FINDINGS

Studies demonstrate a 1.03-3.78-fold rise in the prevalence of GDM with IADPSG criteria versus baseline criteria. Women with GDM by IADPSG criteria have more adverse pregnancy outcomes than women with normal glucose tolerance (NGT). Treatment of GDM by IADPSG criteria may be cost effective. Use of the fasting glucose as a screen before the 75-g oral glucose tolerance test to rule out GDM with fasting plasma glucose (FPG) < 4.4 (80 mg/dl) and rule in GDM with FPG ≥ 5.1 mmol/l (92 mg/dl) reduces the need for OGTT by 50% and its cost and inconvenience. The prevalence of postpartum abnormal glucose metabolism is higher for women with GDM diagnosed by IADPSG criteria versus that for women with NGT. Data support the use of IADPSG criteria, if the cost of diagnosis and treatment can be controlled and if lifestyle can be optimized to reduce the risk of future diabetes.

Dietary variables associated with substantial postpartum weight retention at 1-year among women with GDM pregnancy

BACKGROUND

An understanding of the dietary behaviors linked to substantial postpartum weight retention, particularly in women diagnosed with gestational diabetes (GDM), is warranted to focus intervention efforts to prevent future type 2 diabetes. This study evaluates the relationship between dietary food intake at 6-9 weeks postpartum (baseline) and odds of substantial postpartum weight retention (≥ 5 kg) at 1-year in women with GDM.

METHODS

The Study of Women, Infant Feeding and Type 2 Diabetes after GDM pregnancy (SWIFT) is a prospective multi-ethnic cohort (75% minority) of 1035 women (aged 20-45 years) with recent GDM who delivered a singleton, live birth (≥35 weeks gestation) and underwent 2-h 75 g OGTTs, anthropometric measurements and other assessments at 6-9 weeks postpartum (baseline) and annually thereafter. Eight hundred and eighty-eight women without diabetes at baseline completed the 18-item PrimeScreen to assess dietary intake and the 13-item Caffeine Survey to assess beverage intake, and completed 1-year follow-up. Average postpartum weight retention was calculated (1-year postpartum weight minus pre-pregnancy weight). Multivariable logistic regression models that estimated baseline dietary intake and odds of substantial postpartum weight retention (SPPWR ≥5 kg above pre-pregnancy weight) versus not SPPWR adjusted for numerous clinical, sociodemographic and behavioral covariates.

RESULTS

Compared to eating no fried foods, women who reported eating fried foods ≥5 servings/wk. (n = 32) and 2-4 serv/wk. (n = 208), respectively, had a three-fold and two-fold higher odds of SPPWR (OR = 3.38, 95% CI:1.36-8.38, P = 0.009; OR = 1.99, 95% CI:1.30-3.03, P = 0.02), after adjustment for covariates and other foods and soda intake. Soda intake ≥2 serv/wk. versus none was associated with higher odds of SPPWR (OR = 1.95, 95% CI:1.22-3.11, P = 0.005) adjusted for fried foods and covariates, but was attenuated (OR = 1.61,95% CI:0.98-2.66, p = 0.06) after addition of whole eggs and processed meats.

CONCLUSIONS

These findings indicate that interventions should focus on reducing fried foods and soda intake during early postpartum periods to reduce substantial postpartum weight retention in high-risk women with GDM.

TRIAL REGISTRATION

NCT01967030; October 2013, Eunice Kennedy Shriver National Institute of Health and Human Development (NICHD).

The IADPSG diagnostic criteria identify women with increased risk of adverse pregnancy outcomes in Victoria

Controversy remains surrounding International Association of Diabetes and Pregnancy Study Group (IADPSG) diagnostic criteria for gestational diabetes mellitus (GDM), including perceived improvement in perinatal outcomes and health service implications. We compared perinatal outcomes for untreated women meeting IADPSG-only criteria and women without GDM in Victoria. Women meeting IADPSG-only criteria were characterised according to fasting and one hour glucose thresholds and by region of birth. IADPSG criteria identified women with increased risk of adverse perinatal outcomes, particularly women born in Australia compared to Asian regions.

Population-Level Outcomes with a 2-Step Approach for Gestational Diabetes Screening and Diagnosis

OBJECTIVES

To examine outcomes associated with alternative glucose thresholds in a 2-step approach for screening and diagnosing gestational diabetes mellitus (GDM).

METHODS

We studied 178,527 pregnancies between 2008 and 2012 in Alberta, Canada. They were categorized retrospectively as normal 50 g screen (n=144,191); normal 75 g oral glucose tolerance test (OGTT) (n=21,248); abnormal at glucose thresholds suggested by the International Association of Diabetes and Pregnancy Group (IADPSG) (HAPO 1.75, n=4308); abnormal at glucose thresholds associated with an odds ratio of 2.0 for adverse events in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. This latter group, which would have been treated for GDM based on customary care, was further divided into those with 1 (HAPO 2-1 n=5528) or 2 or more abnormal glucose values (HAPO 2-2 n=3252). Main outcomes were large for gestational age (LGA), induced labour and Cesarean-section rates.

RESULTS

LGA rates were 8.2%, 10.5%, 14.2%, 11.8% and 16.5% among normal 50 g, normal 75 g OGTT, HAPO 1.75, HAPO 2-1, and HAPO 2-2 groups, respectively. Labour induction and caesarean-section rates were 29.6% and 36.2% in the IADPSG, 38.2% and 36.8% in the HAPO 2-1 group, and 42.3% and 41.1% in the HAPO 2-2 groups, respectively. Excessive maternal weight (≥91 kg) was associated with a higher risk for all adverse outcomes.

CONCLUSIONS

The 2-step approach effectively identifies pregnancies at low risk for adverse outcomes. Labelling influences induction practice. Any glucose intolerance increases risk for adverse outcomes, and pregnancies with highest (2 or higher) abnormal glucose values remain at greatest risk. Further research is needed to determine whether glycemic thresholds for GDM diagnosis should incorporate information about maternal weight.

Effects of Implementing International Association of Diabetes and Pregnancy Study Groups Gestational Diabetes Screening on Pregnancy Outcomes at a Small Community Teaching Hospital

IN BRIEF Traditional methods of screening for and diagnosing gestational diabetes mellitus (GDM) have been challenged, leading to the development of new screening guidelines by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). This study is a retrospective comparison of pregnancy outcomes based on the Carpenter and Coustan (CC) and IADPSG screening guidelines. It demonstrates that adoption of IADPSG guidelines increased the rate of GDM diagnosis and resulted in more women with diet-controlled GDM. However, a decrease in adverse pregnancy outcomes was not noted. Interestingly, women diagnosed by IADPSG criteria who had diet-controlled GDM had less maternal weight gain than those screened with the CC criteria who did not have GDM but did have an elevated 1-hour oral glucose tolerance test result.

[Clinical audit of screening for gestational diabetes among 848 pregnant women in 23 maternity units of the Pays de la Loire, 2014]

INTRODUCTION

Guidelines for screening for gestational diabetes mellitus (GDM) were published in 2010. An audit of the maternity units of the Pays de la Loire network sought to determine the adherence rate and to study the factors affecting it in order to propose corrective measures to improve it.

METHODS

The perinatal network in Pays de la Loire provided obstetricians of the 23 participating maternity units with a set of criteria to be collected from the files of women giving birth. The methodology of the audit was designed to enable calculation of the adherence rate overall and according to indications (risk factors, hyperglycemia, and macrosomia): adherence, non-adherence, and over-adherence (screening in the absence of an indication). To obtain around 900 pregnancies, the audit was planned to cover a week of deliveries in June 2014.

RESULTS

The analysis included 848 pregnancies and 872 newborns. Risk factors were found for 46.6% of the women (43.2 to 49.9): 13.2% for maternal age≥35years and 30.8% for BMI≥25kg/m². GDM was diagnosed for 14.6% (12.4 to 17.2). The adherence rate for screening was 45.5% (42.2 to 49.9), the non-adherence rate 27.6% (24.7 to 30.7), and the over-adherence rate 26.9% (24.0 to 30.0). Among the factors potentially associated with adherence, we observed only the second-trimester factor (macrosomia); there was no "professional" effect on adherence criteria. No evidence of overmanagement was observed for the pregnancies/deliveries/newborns with overdiagnosis. Oral glucose tolerance tests were performed in accordance with the guidelines (95.9%). Follow-up of women with GDM by specialists was satisfactory (84.6%).

DISCUSSION

This audit showed that adherence to the guidelines was insufficient in the Pays de la Loire network. The reasons for this are numerous: ignorance of the guidelines, in part due to their relative recency, the change in the blood sugar levels defining GDM (perceived as too low), and the absence of strong evidence about these thresholds from publications and practices in other countries, the need to select women for risk factors, and sometimes the late onset of prenatal care at the maternity unit.

CONCLUSION

In view of this audit, the Perinatal Network of Pays de la Loire must work to improve the knowledge and screening practices for GDM among its professionals, by the repeated dissemination of these guidelines and chart review sessions.

Exercise Training and Weight Gain in Obese Pregnant Women: A Randomized Controlled Trial (ETIP Trial)

BACKGROUND

The effectiveness of exercise training for preventing excessive gestational weight gain (GWG) and gestational diabetes mellitus (GDM) is still uncertain. As maternal obesity is associated with both GWG and GDM, there is a special need to assess whether prenatal exercise training programs provided to obese women reduce the risk of adverse pregnancy outcomes. Our primary aim was to assess whether regular supervised exercise training in pregnancy could reduce GWG in women with prepregnancy overweight/obesity. Secondary aims were to examine the effects of exercise in pregnancy on 30 outcomes including GDM incidence, blood pressure, blood measurements, skinfold thickness, and body composition.

METHODS AND FINDINGS

This was a single-center study where we randomized (1:1) 91 pregnant women with a prepregnancy body mass index (BMI) ≥ 28 kg/m2 to exercise training (n = 46) or control (standard maternity care) (n = 45). Assessments were done at baseline (pregnancy week 12-18) and in late pregnancy (week 34-37), as well as at delivery. The exercise group was offered thrice weekly supervised sessions of 35 min of moderate intensity endurance exercise and 25 min of strength training. Seventeen women were lost to follow-up (eight in the exercise group and nine in the control group). Our primary endpoint was GWG from baseline testing to delivery. The principal analyses were done as intention-to-treat analyses, with supplementary per protocol analyses where we assessed outcomes in the women who adhered to the exercise program (n = 19) compared to the control group. Mean GWG from baseline to delivery was 10.5 kg in the exercise group and 9.2 kg in the control group, with a mean difference of 0.92 kg (95% CI -1.35, 3.18; p = 0.43). Among the 30 secondary outcomes in late pregnancy, an apparent reduction was recorded in the incidence of GDM (2009 WHO definition) in the exercise group (2 cases; 6.1%) compared to the control group (9 cases; 27.3%), with an odds ratio of 0.1 (95% CI 0.02, 0.95; p = 0.04). Systolic blood pressure was significantly lower in the exercise group (mean 120.4 mm Hg) compared to the control group (mean 128.1 mm Hg), with a mean difference of -7.73 mm Hg (95% CI -13.23, -2.22; p = 0.006). No significant between-group differences were seen in diastolic blood pressure, blood measurements, skinfold thickness, or body composition in late pregnancy. In per protocol analyses, late pregnancy systolic blood pressure was 115.7 (95% CI 110.0, 121.5) mm Hg in the exercise group (significant between-group difference, p = 0.001), and diastolic blood pressure was 75.1 (95% CI 71.6, 78.7) mm Hg (significant between-group difference, p = 0.02). We had planned to recruit 150 women into the trial; hence, under-recruitment represents a major limitation of our results. Another limitation to our study was the low adherence to the exercise program, with only 50% of the women included in the intention-to-treat analysis adhering as described in the study protocol.

CONCLUSIONS

In this trial we did not observe a reduction in GWG among overweight/obese women who received a supervised exercise training program during their pregnancy. The incidence of GDM in late pregnancy seemed to be lower in the women randomized to exercise training than in the women receiving standard maternity care only. Systolic blood pressure in late pregnancy was also apparently lower in the exercise group than in the control group. These results indicate that supervised exercise training might be beneficial as a part of standard pregnancy care for overweight/obese women.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01243554.

Thiol/disulfide homeostasis in predicting adverse perinatal outcomes at 24-28 weeks of pregnancy in gestational diabetes

OBJECTIVE

The main aim of this study was to investigate thiol/disulfide homeostasis at 24-28 weeks of pregnancy and to evaluate whether it is predictive for adverse perinatal outcomes or not in gestational diabetes mellitus (GDM).

METHODS

A total of 110 pregnant women at 24-28 weeks of pregnancy (74 GDM patients and 36 age- and BMI-matched healthy pregnant women) were enrolled in this prospective case-control study. Thiol/disulfide homeostasis was evaluated with a novel spectrophotometric method to determine if there is an association with adverse perinatal outcomes in GDM, by using logistic regression analysis.

RESULTS

GDM patients, with decreased native thiol levels at 24-28 weeks (OR: 4.890, 95% CI: 1.355-5.764, p = 0.015) and with higher pre-pregnancy BMI (OR: 1.280, 95% CI: 1.072-1.528, p = 0.006), were found to be at increased risk of adverse perinatal outcomes in GDM. There were no statistically significant differences in thiol/disulfide homeostasis between diet- and insulin-treated GDM subgroups. Additionally, 1-h and 2-h glucose levels on 100 g OGTT were found to be predictive for the insulin need in achieving good glycemic control in GDM (OR: 1.022, 95% CI: 1.005-1.038, p = 0.010 and OR: 1.019, 95% CI: 1.004-1.035, p = 0.015).

CONCLUSIONS

GDM patients, with decreased native thiol levels at 24-28 weeks of pregnancy and with higher pre-pregnancy BMI, have an increased risk of possible adverse perinatal outcomes. Also, increased 1-h and 2-h glucose levels on 100 g OGTT can predict the need for insulin treatment for GDM.