Diagnosis and Management of Gestational Diabetes Mellitus: An Overview of National and International Guidelines

Gestational diabetes mellitus management according to ultrasound fetal growth versus strict glycemic treatment in singleton pregnancies: A systematic review and meta-analysis of clinical trials

AIM

The objective of this meta-analysis was to evaluate obstetric outcomes in gestational diabetes mellitus (GDM) patients treated with flexible management based on intrauterine ultrasound fetal growth (FMIUFG) or strict maternal glycemic adjustment (SMGA).

METHODS

We performed a comprehensive systematic review of electronic databases for randomized clinical trials (RCTs) comparing obstetrics outcomes of singleton GDM patients managed according to FMIUFG or SMGA. The review protocol was registered in PROSPERO (CRD497888). Searches were conducted in PubMed, Embase, Cochrane, and LILACS. Primary outcomes were gestational age at delivery and birth weight. Random-effect model meta-analyses were used to minimize the effects of uncertainty associated with inter-study variability. Results are reported as standardized mean differences (SMDs) or as odds ratios (ORs) and their 95% confidence interval (CI). Heterogeneity between studies was estimated using the I2 statistic. The Cochrane Risk of Bias Scale was used to assess the quality of studies. There were five RCTs with low to moderate risk of bias, including 450 patients managed according to the FMIUFSG and 381 according to the SMGA.

RESULTS

The macrosomia (birthweight >4000 g) rate was lower in pregnancies managed according to FMIUFG than SMGA adjustments (OR: 0.34; 95%CI: 0.16, 0.71). There were no significant differences in hypertensive disorder, cesarean section, neonatal intensive care unit admission, and large newborn for gestational age rates.

CONCLUSIONS

The macrosomia rate was lower in women managed with the FMIUFG. There were no significant differences in other obstetric and neonate outcomes.

Current status of screening and management of gestational diabetes in early pregnancy: a questionnaire survey in Japan

Our aim is to investigate the obstetric practices in Japan regarding the screening and management of gestational diabetes mellitus (GDM) diagnosed before 20 weeks of gestation (early-GDM). A web-based questionnaire survey was administered to 991 teaching hospitals between November 2021 and February 2022, and 602 responses were received (a response rate of 61%). Screening tests for all pregnant women in the first trimester were conducted in 553 (92%) hospitals, and nearly all of these hospitals (535/553 [97%]) adhered to an individual protocol, predominantly relying on random plasma glucose measurements (488/535 [91%]). A quarter (139 [26%]) implemented a risk profile assessment for GDM screening, taking into account factors such as previous gestational diabetes, prior macrosomia, and family history of diabetes. A small number (23 [4%]) targeted only women at high risk of GDM using the risk profile assessment. The majority of hospitals (501 [94%]) employed a 75 g oral glucose tolerance test as a diagnostic measure, and glycemic control for early-GDM was established in most hospitals (429 [80%]). Of the 535 hospitals that maintained an individual management protocol, 356 [67%] facilitated dietary management, self-monitoring of blood glucose, and insulin administration if needed to meet glycemic targets. Our survey revealed a widespread adoption of universal screening and subsequent treatment for early-GDM in Japan.

Long-Term Impact on Offspring (5 to 11 Years of Age) of Metformin Use in Pregnancy in Mothers With Diabetes: A Systematic Review and Meta-Analysis

OBJECTIVE

Data are scant on the impact of metformin use in gestational diabetes mellitus/diabetes in pregnancy on long-term outcomes in children and mothers beyond 5 years of childbirth. This systematic review and meta-analysis aimed to evaluate the long-term impact of metformin use in pregnancy on children and their mothers.

METHODS

Electronic databases were searched for studies evaluating metformin compared with insulin for managing gestational diabetes mellitus/diabetes in pregnancy. The primary outcome was the change in body mass index (BMI) in children at the ages of 5 to 11 years. The secondary outcomes were alterations in other anthropometric measures, obesity, and changes in the levels of lipids and adipocytokines in children and mothers.

RESULTS

Children at the age of 9 years born to mothers who were treated with metformin during pregnancy had similar BMI (mean difference [MD], 1.09 kg/m2 [95% confidence interval {CI}, -0.44 to 2.62]; P = .16; I2 = 16%), waist circumference-to-height ratio (MD, 0.13 [95% CI, -0.05 to 0.30]; P = .16; I2 = 94%), dual-energy X-ray absorptiometry (DXA) total fat mass (MD, 0.68 kg [95% CI, -2.39 to 3.79]; P = .66; I2 = 70%), DXA total fat percent (MD, 0.04% [95% CI, -3.44 to 3.51]; P = .98; I2 = 56%), DXA total fat-free mass (MD, 0.81 kg [95% CI, -0.96 to 2.58]; P = .37; I2 = 55%), magnetic resonance imaging visceral adipose tissue volume (MD, 80.97 cm3 [95% CI, -136.47 to 298.41]; P = .47; I2 = 78%), and magnetic resonance spectroscopy liver fat percentage (MD, 0.27% [95% CI, -1.26 to 1.79]; P = .73; I2 = 0%) to those born to mothers who were treated with insulin. Serum adiponectin, leptin, alanine aminotransferase, and ferritin were comparable among groups. In children between the ages of 9 and 11 years, the occurrence of obesity, diabetes, or challenges in motor and social development were comparable between the 2 groups. After 9 years of childbirth, BMI and the risk of developing diabetes were similar between the 2 groups of women.

CONCLUSION

Metformin use in pregnancy did not show any adverse effects compared with insulin on long-term outcomes in children and their mothers.

Integrated care of diabetes during pregnancy: a Qatari nationwide cohort

Background

Diabetes in pregnancy (DIP) is associated with adverse fetal and maternal outcomes. DIP is classified as either pre-existing or new-onset diabetes mellitus (DM), which is classified into gestational DM (GDM) and newly detected type 2 (N-T2D). All pregnant women in Qatar who are not known to have pre-existing DM are offered screening for DIP during the first antenatal care visit and after 24 weeks gestation. The study aims to report the DIP screening rates, the prevalence of DIP, and the impact of the universal screening program on adverse pregnancy outcomes.

Methods

This retrospective study included all women who gave birth in Hamad Medical Corporation (HMC) hospitals between 2019 and 2022. New-onset DIP was defined using the WHO-2013 criteria. The primary outcomes were the screening rates and the prevalence of DIP in Qatar. The secondary outcomes were the difference in preterm delivery, C-section, macrosomia, large for gestational age (LGA), small for gestational age (SGA), and intra-uterine fetal death (IUFD) between women with or without GDM.

Findings

We included 94,422 women who gave birth to 96,017 neonates (85.7%) out of 112,080 neonates born nationwide. The number of women with pre-existing diabetes was 2496 women. Of 91,926 eligible women, 77,372 (84.2%) were screened for DIP. The prevalence of GDM is 31.6% (95% CI: 31.3-32.0%); N-T2D is 2.2% (95% CI: 2.1-2.3%), and pre-existing Type 2 DM and Type 1 DM was 2.6% (95% CI: 0.8-3.0%) and 0.2% (0.19-0.25), respectively. Compared to the non-GDM group, women with GDM were older (30.8 ± 5.3 versus 29.7 ± 5.2 years, p < 0.001). After adjusting for age, women with GDM had lower risk of IUFD and SGA (0.63 [95% CI 0.50-0.80, p < 0.001], 0.88 [95% CI 0.84-0.92, p < 0.001] respectively) but higher risk of C-section and LFD (1.07 [95% CI 1.04-1.10, p < 0.001], 1.09 [95% CI 1.01-1.15, p = 0.01], respectively, compared to women with no-GDM.

Interpretation

Of the women eligible for screening, 84.2% were screened by the DIP program in Qatar. The prevalence of DIP in Qatar is 36.9%. Integrated care is critical for the screening and management of diabetes during pregnancy.

Fundings

The authors did not receive any funding for this project.

Factors Affecting Mode of Birth in Women With Preexisting Diabetes and Gestational Diabetes: A Retrospective Cohort at a Tertiary Referral Center

Women with preexisting diabetes and gestational diabetes mellitus (GDM) are at higher risk for adverse maternal and neonatal outcomes. However, there is no consensus on a uniform approach regarding mode of birth (MOB) for all forms of diabetes. The aim of the study is to compare MOB in women with preexisting diabetes and GDM and possible factors influencing it. A retrospective cohort study of women with GDM and preexisting diabetes between 2015 and 2021 at a tertiary referral center was conducted. One thousand three hundred eighty-five singleton pregnancies were included. One thousand twenty-two (74.4%) women had a vaginal birth (VB) and 351 (25.6%) a caesarean section. Preexisting diabetes was significantly associated with caesarean section compared to GDM (OR 2.43). Five hundred fifty-one (40.1%) women underwent induction of labor, and 122 (22.1%) women had a secondary caesarean after IOL. Women induced due to spontaneous rupture of membrane (SROM) achieved the highest rate of VB at 93%. The lowest rates of VB occurred if indication for induction was for preeclampsia or hypertension. IOL was significantly less successful in preexisting diabetes with a VB achieved in 56.4% for type 1 diabetes and 52.6% of type 2 diabetes compared to GDM (78.2% in GDM; 81.2% in IGDM; OR 3.25, 95% CI 1.70-6.19, p < 0.001). The rate of VB was higher who were induced preterm compared to women with term IOL (n = 240 (81.9%) vs. n = 199 (73.2%); p < 0.05). Parity, previous VB and SROM favored VB after IOL, whereas preexisting diabetes, hypertension, and IOL after 40 + 0 weeks are independent risk factors for caesarean delivery.

Relationship between gut microbiota and the pathogenesis of gestational diabetes mellitus: a systematic review

Introduction

Gestational diabetes mellitus (GDM) is a form of gestational diabetes mellitus characterized by insulin resistance and abnormal function of pancreatic beta cells. In recent years, genomic association studies have revealed risk and susceptibility genes associated with genetic susceptibility to GDM. However, genetic predisposition cannot explain the rising global incidence of GDM, which may be related to the increased influence of environmental factors, especially the gut microbiome. Studies have shown that gut microbiota is closely related to the occurrence and development of GDM. This paper reviews the relationship between gut microbiota and the pathological mechanism of GDM, in order to better understand the role of gut microbiota in GDM, and to provide a theoretical basis for clinical application of gut microbiota in the treatment of related diseases.

Methods

The current research results on the interaction between GDM and gut microbiota were collected and analyzed through literature review. Keywords such as "GDM", "gut microbiota" and "insulin resistance" were used for literature search, and the methodology, findings and potential impact on the pathophysiology of GDM were systematically evaluated.

Results

It was found that the composition and diversity of gut microbiota were significantly associated with the occurrence and development of GDM. Specifically, the abundance of certain gut bacteria is associated with an increased risk of GDM, while other changes in the microbiome may be associated with improved insulin sensitivity. In addition, alterations in the gut microbiota may affect blood glucose control through a variety of mechanisms, including the production of short-chain fatty acids, activation of inflammatory pathways, and metabolism of the B vitamin group.

Discussion

The results of this paper highlight the importance of gut microbiota in the pathogenesis of GDM. The regulation of the gut microbiota may provide new directions for the treatment of GDM, including improving insulin sensitivity and blood sugar control through the use of probiotics and prebiotics. However, more research is needed to confirm the generality and exact mechanisms of these findings and to explore potential clinical applications of the gut microbiota in the management of gestational diabetes. In addition, future studies should consider the interaction between environmental and genetic factors and how together they affect the risk of GDM.

Adverse pregnancy outcomes in gestational diabetes mellitus: a systematic review and meta-analysis protocol

INTRODUCTION

Gestational diabetes mellitus (GDM) is associated with adverse pregnancy outcomes, including adverse outcomes for both the mother and the fetus. Different diagnostic criteria are used for GDM, and it is not clear how these affect the reported prevalence of adverse pregnancy outcomes. This protocol is for a systematic review to describe and compare the prevalence of adverse pregnancy outcomes in GDM using the different diagnostic criteria applied in various countries/regions of the world.

METHODS AND ANALYSIS

A systematic review and meta-analysis will be carried out. A comprehensive search of observational studies that report the outcomes of interest to this review from 2010 to 2021 will be conducted. We will search the major electronic databases such as PubMed, Scopus, CINHAL and Google Scholar, and screen references of included studies for additional studies. Meta-analyses will be performed, if there is low heterogeneity, and pooled estimates per outcome reported. We will use the bias-adjusted inverse variance heterogeneity model and random effects models, depending on the heterogeneity observed, to pool prevalence estimates and perform subgroup analyses by region, by age group, by diagnostic criteria and by GDM screening method if sufficient data are available. We will also compare the prevalence of adverse outcomes by diagnostic method and report prevalence ratios. We will report 95% confidence estimates for all estimates.

ETHICS AND DISSEMINATION

Ethical approval is not required as the review uses published data. Findings will be published in peer-reviewed journals and presented at conferences.

PROSPERO REGISTRATION NUMBER

CRD42020155061.

Simple and Fast Prediction of Gestational Diabetes Mellitus Based on Machine Learning and Near-Infrared Spectra of Serum: A Proof of Concept Study at Different Stages of Pregnancy

Gestational diabetes mellitus (GDM) is a hyperglycemic state that is typically diagnosed by an oral glucose tolerance test (OGTT), which is unpleasant, time-consuming, has low reproducibility, and results are tardy. The machine learning (ML) predictive models that have been proposed to improve GDM diagnosis are usually based on instrumental methods that take hours to produce a result. Near-infrared (NIR) spectroscopy is a simple, fast, and low-cost analytical technique that has never been assessed for the prediction of GDM. This study aims to develop ML predictive models for GDM based on NIR spectroscopy, and to evaluate their potential as early detection or alternative screening tools according to their predictive power and duration of analysis. Serum samples from the first trimester (before GDM diagnosis) and the second trimester (at the time of GDM diagnosis) of pregnancy were analyzed by NIR spectroscopy. Four spectral ranges were considered, and 80 mathematical pretreatments were tested for each. NIR data-based models were built with single- and multi-block ML techniques. Every model was subjected to double cross-validation. The best models for first and second trimester achieved areas under the receiver operating characteristic curve of 0.5768 ± 0.0635 and 0.8836 ± 0.0259, respectively. This is the first study reporting NIR-spectroscopy-based methods for the prediction of GDM. The developed methods allow for prediction of GDM from 10 µL of serum in only 32 min. They are simple, fast, and have a great potential for application in clinical practice, especially as alternative screening tools to the OGTT for GDM diagnosis.

Antenatal Care: A Comparative Review of Guidelines

Importance

Antenatal care plays a crucial role in safely monitoring and ensuring the well-being of both the mother and the fetus during pregnancy, ultimately leading to the best possible perinatal outcomes.

Objective

The aim of this study was to review and compare the most recently published guidelines on antenatal care.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Public Health Agency of Canada, the World Health Organization, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists regarding antenatal care was conducted.

Results

There is a consensus among the reviewed guidelines regarding the necessary appointments during the antenatal period, the proper timing for induction of labor, the number and frequency of laboratory examinations for the assessment of mother's well-being, and management strategies for common physiological problems during pregnancy, such as nausea and vomiting, heartburn, pelvic pain, leg cramps, and symptomatic vaginal discharge. In addition, special consideration should be given for mental health issues and timely referral to a specialist, reassurance of complete maternal vaccination, counseling for safe use of medical agents, and advice for cessation of substance, alcohol, and tobacco use during pregnancy. Controversy surrounds clinical evaluation during the antenatal period, particularly when it comes to the routine use of an oral glucose tolerance test and symphysis-fundal height measurement for assessing fetal growth, whereas routine cardiotocography and fetal movement counting are suggested practices only by Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Of note, recommendations on nutritional interventions and supplementation are offered only by Public Health Agency of Canada and World Health Organization, with some minor discrepancies in the optimal dosage.

Conclusions

Antenatal care remains a critical factor in achieving positive outcomes, but there are variations depending on the socioeconomic status of each country. Therefore, the establishment of consistent international protocols for optimal antenatal care is of utmost importance. This can help provide safe guidance for healthcare providers and, consequently, improve both maternal and fetal outcomes.

Quality assessment of videos on social media platforms related to gestational diabetes mellitus in China: A cross-section study

Purpose

This study aimed to systematically evaluate the quality of content and information in videos related to gestational diabetes mellitus on Chinese social media platforms.

Methods

The videos on various platforms, TikTok, Bilibili, and Weibo, were searched with the keyword "gestational diabetes mellitus" in Chinese, and the first 50 videos with a comprehensive ranking on each platform were included for subsequent analysis. Characteristic information of video was collected, such as their duration, number of days online, number of likes, comments, and number of shares. DISCREN, JAMA (The Journal of the American Medical Association) Benchmark Criteria, and GQS (Global Quality Scores) were used to assess the quality of all videos. Finally, the correlation analysis was performed among video features, video sources, DISCERN scores, and JAMA scores.

Results

Ultimately, 135 videos were included in this study. The mean DISCERN total score was 31.84 ± 7.85, the mean JAMA score was 2.33 ± 0.72, and the mean GQS was 2.00 ± 0.40. Most of the videos (52.6%) were uploaded by independent medical professionals, and videos uploaded by professionals had the shortest duration and time online (P < 0.001). The source of the video was associated with numbers of "likes", "comments", and "shares" for JAMA scores (P < 0.001), but there was no correlation with DISCERN scores. Generally, videos on TikTok with the shortest duration received the most numbers of "likes", "comments", and "shares", but the overall quality of videos on Weibo was higher.

Conclusion

Although the majority of the videos were uploaded by independent medical professionals, the overall quality appeared to be poor. Therefore, more efforts and actions should be taken to improve the quality of videos related to gestational diabetes mellitus.

Postnatal Care: A Comparative Review of Guidelines

Importance

Postnatal care refers to the ongoing health care provision of both the mother and her offspring and contributes to the timely identification and effective management of complications in the postpartum period, to secure maternal and infant short- and long-term well-being.

Objective

The aim of this study was to review and compare the most recently published influential guidelines on postnatal care practices.

Evidence Acquisition

A comparative review of guidelines from the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Care Excellence, and the Public Health Agency of Canada regarding postnatal care was conducted.

Results

There is a consensus among the reviewed guidelines regarding the importance of health care provision in the postpartum period, including home visits and midwifery services, the use of telemedicine for the facilitation of communication with the patient, and the appropriate preparation for discharge, as well as the discharge criteria. All medical societies also agree on the clinical aspects that should be evaluated at each postnatal visit, although discrepancies exist with regard to the contact schedule. In addition, there is consistency regarding the management of postpartum infections, perineal pain, fecal and urinary incontinence, and physical activity guidance. Mental health issues should be addressed at each postnatal visit, according to all guidelines, but there is disagreement regarding routine screening for depression. As for the optimal interpregnancy interval, the American College of Obstetricians and Gynecologists recommends avoiding pregnancy for at least 6 months postpartum, whereas the National Institute for Health and Care Excellence recommends a 12-month interval. There is no common pathway regarding the recommended contraceptive methods, the nutrition guidance, and the postpartum management of pregnancy complications. Of note, the World Health Organization alone provides recommendations concerning the prevention of specific infections during the postnatal period.

Conclusions

Postnatal care remains a relatively underserved aspect of maternity care, although the puerperium is a critical period for the establishment of motherhood and the transition to primary care. Thus, the development of consistent international protocols for the optimal care and support of women during the postnatal period seems of insurmountable importance to safely guide clinical practice and subsequently reduce maternal and neonatal morbidity.

Antepartum Fetal Surveillance and Optimal Timing of Delivery in Diabetic Women: A Narrative Review

Antepartum fetal surveillance (AFS) is essential for pregnant women with diabetes to mitigate the risk of stillbirth. However, there is still no universal consensus on the optimal testing method, testing frequency, and delivery timing. This review aims to comprehensively analyze the evidence concerning AFS and the most advantageous timing for delivery in both gestational and pregestational diabetes mellitus cases. This review's methodology involved an extensive literature search encompassing international diabetes guidelines and scientific databases, including PubMed, MEDLINE, Google Scholar, and Scopus. The review process meticulously identified and utilized pertinent articles for analysis. Within the scope of this review, a thorough examination revealed five prominent international guidelines predominantly addressing gestational diabetes. These guidelines discuss the utility and timing of fetal well-being assessments and recommendations for optimal pregnancy resolution timing. However, the scarcity of clinical trials directly focused on this subject led to a reliance on observational studies as the basis for most recommendations. Glucose control, maternal comorbidities, and the medical management received are crucial in making decisions regarding AFS and determining the appropriate delivery timing.

Preferred lifestyle intervention characteristics and behaviour change needs of postpartum women following cardiometabolic pregnancy complications

BACKGROUND

Women with cardiometabolic pregnancy complications are at increased risk of future diabetes and heart disease which can be reduced through lifestyle management postpartum.

OBJECTIVES

This study aimed to explore preferred intervention characteristics and behaviour change needs of women with or without prior cardiometabolic pregnancy complications for engaging in postpartum lifestyle interventions.

DESIGN

Quantitative cross-sectional study.

METHODS

Online survey.

RESULTS

Overall, 473 women were included, 207 (gestational diabetes (n = 105), gestational hypertension (n = 39), preeclampsia (n = 35), preterm birth (n = 65) and small for gestational age (n = 23)) with and 266 without prior cardiometabolic pregnancy complications. Women with and without complications had similar intervention preferences, with delivery ideally by a healthcare professional with expertise in women's health, occurring during maternal child health nurse visits or online, commencing 7 weeks to 3 months post birth, with 15- to 30-min monthly sessions, lasting 1 year and including monitoring of progress and social support. Women with prior complications preferred intervention content on women's health, mental health, exercise, mother's diet and their children's health and needed to know more about how to change behaviour, have more time to do it and feel they want to do it enough to participate. There were significant differences between groups, with more women with prior cardiometabolic pregnancy complications wanting content on women's health (87.9% vs 80.8%, p = 0.037), mother's diet (72.5% vs 60.5%, p = 0.007), preventing diabetes or heart disease (43.5% vs 27.4%, p < 0.001) and exercise after birth (78.3% vs 68.0%, p = 0.014), having someone to monitor their progress (69.6% vs 58.6%, p = 0.014), needing the necessary materials (47.3% vs 37.6%, p = 0.033), triggers to prompt them (44.0% vs 31.6%, p = 0.006) and feeling they want to do it enough (73.4%, 63.2%, p = 0.018).

CONCLUSION

These unique preferences should be considered in future postpartum lifestyle interventions to enhance engagement, improve health and reduce risk of future cardiometabolic disease in these high-risk women.

Telomere Length in Patients with Gestational Diabetes Mellitus and Normoglycemic Pregnant Women: a Systematic Review and Meta-analysis

We performed a systematic review and meta-analysis of studies assessing telomere length in blood leukocytes or mononuclear cells in women with gestational diabetes mellitus (GDM) and normoglycemic pregnant women (NPW) and their infants. The review protocol was registered in PROSPERO (CRD42022300950). Searches were conducted in PubMed, Embase, LILACS, CNKI, and Wang Fang, from inception through November 2022. The primary outcomes were maternal and offspring telomere length. The Newcastle-Ottawa Scale was used to assess the quality of included studies. Random-effect meta-analyses were applied to estimate standardized mean differences (SMDs) and their 95% confidence interval (CI). The meta-analysis of four studies showed no significant maternal telomere length difference (SMD = -0.80, 95% CI: -1.66, 0.05) in women with GDM compared to NPW. In the sensibility analysis omitting one study with a small sample of women, the telomere length becomes significantly reduced in women with GDM (SMD = -1.10, 95% CI: -2.18, -0.02). GDM patients had increased glucose (SMD = 0.28, 95% CI: 0.09, 0.46) and glycosylated hemoglobin than NPW (SMD = 0.62, 95% CI: 0.23, 1.01) while total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides did not display differences between women with and without GDM. There was no significant difference in cord blood telomere length in offspring from women with GDM and NPW (SMD = 0.11, 95% CI: -0.52, 0.30). Cord blood insulin levels (SMD = 0.59, 95% CI: 0.33, 0.85) and birthweight (SMD = 0.59, 95% CI: 0.39, 0.79) were higher in offspring from pregnant women with GDM than in those from NPW. There were no significant differences in maternal and offspring telomere length between pregnancies with and without GDM.

Prediction of Gestational Diabetes Mellitus in the First Trimester of Pregnancy Based on Maternal Variables and Pregnancy Biomarkers

Gestational diabetes mellitus (GDM) is a significant health concern with adverse outcomes for both pregnant women and their offspring. Recognizing the need for early intervention, this study aimed to develop an early prediction model for GDM risk assessment during the first trimester. Utilizing a prospective cohort of 4917 pregnant women from the Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece, the study sought to combine maternal characteristics, obstetric and medical history, and early pregnancy-specific biomarker concentrations into a predictive tool. The primary objective was to create a series of predictive models that could accurately identify women at high risk for developing GDM, thereby facilitating early and targeted interventions. To this end, maternal age, body mass index (BMI), obstetric and medical history, and biomarker concentrations were analyzed and incorporated into five distinct prediction models. The study's findings revealed that the models varied in effectiveness, with the most comprehensive model combining maternal characteristics, obstetric and medical history, and biomarkers showing the highest potential for early GDM prediction. The current research provides a foundation for future studies to refine and expand upon the predictive models, aiming for even earlier and more accurate detection methods.

Correlation between PAPP-A serum levels in the first trimester of pregnancy with the occurrence of gestational diabetes, a multicenter cohort study

OBJECTIVE

This study aimed to investigate the association between first-trimester Pregnancy-associated plasma protein A (PAPP-A) levels and subsequent gestational diabetes mellitus (GDM) development.

METHOD

The study was conducted on 5854 pregnant women who attended routine prenatal care. Maternal biomarkers, including PAPP-A and free beta hCG, were measured for all women in a referral laboratory and converted to MoM values. Pregnant women were divided into two groups, based on the serum concentration of PAPP-A, (PAPP-A > 0.4 (normal) and PAPP-A < 0.4 (low)). Data on the screening test for GDM and pregnancy outcomes were collected and analyzed with appropriate tests.

RESULT

Of the 5854 pregnant women, 889 (15.19%) developed GDM. The maternal PAPP-A MoM concentrations were significantly lower in GDM cases compared to controls. Indeed, gestational age at delivery and birth weight were significantly lower (p < 0.001) in PAPP-A MoM < 0.4, and the rate of intrauterine growth restriction (IUGR) was significantly higher (p < 0.001). ROC analysis revealed that the sensitivity and specificity of MoM concentration for predicting GDM were 53.3% and 51.9%, respectively.

CONCLUSION

Lower maternal PAPP-A in early pregnancy can lead to glucose intolerance and increase the risk of subsequent GDM development. In addition, decreased serum concentration of PAPP-A is significantly correlated to lower birth weight and IUGR.

Clinical practice guidelines on physical activity and exercise for pregnant women with gestational diabetes mellitus: A systematic review

AIM

This review aimed to appraise clinical guidelines about exercise for women with gestational diabetes mellitus and summarize consensus and inconsistent recommendations.

BACKGROUND

Exercise is an effective non-pharmacological therapeutic for gestational diabetes mellitus, but the variety of relevant clinical practice guidelines is confusing for healthcare professionals.

DESIGN

This is a systematic review of clinical practice guidelines.

DATA SOURCES

Websites of guideline development institutions, eight literature databases and organizations of obstetricians, gynaecologists, midwives, and medical sports associations were searched for guidelines published from January 2011 to October 2021.

REVIEW METHODS

Two reviewers independently extracted recommendations. Four reviewers assessed guideline quality using the AGREE II instrument independently.

RESULTS

Fifteen guidelines were included. All women with diabetes are recommended to exercise during pregnancy. The consistent recommendations were for pre-exercise screening, for 30 min per exercise session on 5 days of the week or every day after meals, exercise at moderate intensity, using aerobic and resistance exercise, and walking. The main non-consistent recommendations included warning signs for women on insulin during exercise, minimum duration per session, intensity assessment, duration and frequency of sessions for strengthening and flexibility exercise and detailed physical activity giving birth.

CONCLUSIONS

Guidelines strongly support pregnant women with diabetes to exercise regularly. Research is needed to make non-consistent recommendations clear.

Association between eating habits during adolescence and gestational diabetes: data from the Japan environment and children's study

Purpose

It is difficult to change pre-pregnancy eating habits, yet establishing healthy eating habits before pregnancy is important for preventing gestational diabetes mellitus (GDM). This study aimed to examine whether the weight-loss behavior of avoiding between-meal and midnight snacking in teenagers is associated with a reduction in the risk of subsequent GDM.

Methods

We used a dataset (jecs-an-20,180,131) from a nationwide, prospective birth cohort study, the Japan Environment and Children's Study (JECS). We included 89,227 (85.7% of the total) mother-infant pairs with live births. Participants in their second or third trimester were asked to report their weight-loss behavior during their teenage years. The prevalence of GDM was investigated. Differences in maternal characteristics were examined using chi-square tests. Crude and adjusted logistic regression models were constructed to assess the associations of various maternal characteristics with the weight-loss behavior of avoiding between-meal and midnight snacking during teenage years.

Results

A total of 2,066 (2.3%) participants had GDM. Weight-loss behavior in teenagers was associated with a decreased risk of GDM. Among participants with normal weight or overweight prior to pregnancy, the adjusted odds ratios were 0.79 (95% confidence interval, 0.70-0.89) and 0.82 (95% confidence interval, 0.69-0.98), respectively.

Conclusions

The results suggest that teenage weight-loss behaviors, such as avoiding between-meal and midnight snacking, are associated with a decreased risk of developing GDM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01294-2.

Magnesium Status, Genetic Variants of Magnesium-Related Ion Channel Transient Receptor Potential Membrane Melastatin 6 (TRPM6) and the Risk of Gestational Diabetes Mellitus in Chinese Pregnant Women: A Nested Case-Control Study

SCOPE

Magnesium plays an important role in regulating glucose metabolism. The study attempts to explore association between magnesium status and single nucleotide polymorphisms (SNPs) of gene involved in magnesium absorption-transient receptor potential membrane melastatin 6 (TRPM6) and gestational diabetes mellitus (GDM) risk METHODS AND RESULTS: A nested case-control study including 170 GDM cases and matched 340 controls is conducted based on Tongji Birth Cohort. Dietary, serum, and urine magnesium are evaluated before the diagnosis of GDM. Compared to the lowest tertile, women in the highest tertile of serum magnesium are at a lower risk of GDM (adjusted odds ratio [aOR] 0.42, 95% confidence intervals [CI] 0.21-0.84). Serum magnesium is inversely associated with insulin and homeostatic model assessment of insulin resistance (β = -0.05, p = 0.002; β = -0.04, p = 0.001, respectively). The aOR for GDM in carriers of the CT or CC genotypes of TRPM6 rs2274924 compared with carriers of the TT genotype is 2.76 (95% CI 1.78-4.26). Dietary magnesium is positively associated with serum magnesium (β = 0.02, p = 0.004), but not with GDM risk.

CONCLUSION

Serum magnesium and the TRPM6 rs2274924 polymorphism are associated with the risk of GDM.

Comparison of machine learning and conventional logistic regression-based prediction models for gestational diabetes in an ethnically diverse population; the Monash GDM Machine learning model

BACKGROUND

Early identification of pregnant women at high risk of developing gestational diabetes (GDM) is desirable as effective lifestyle interventions are available to prevent GDM and to reduce associated adverse outcomes. Personalised probability of developing GDM during pregnancy can be determined using a risk prediction model. These models extend from traditional statistics to machine learning methods; however, accuracy remains sub-optimal.

OBJECTIVE

We aimed to compare multiple machine learning algorithms to develop GDM risk prediction models, then to determine the optimal model for predicting GDM.

METHODS

A supervised machine learning predictive analysis was performed on data from routine antenatal care at a large health service network from January 2016 to June 2021. Predictor set 1 were sourced from the existing, internationally validated Monash GDM model: GDM history, body mass index, ethnicity, age, family history of diabetes, and past poor obstetric history. New models with different predictors were developed, considering statistical principles with inclusion of more robust continuous and derivative variables. A randomly selected 80% dataset was used for model development, with 20% for validation. Performance measures, including calibration and discrimination metrics, were assessed. Decision curve analysis was performed.

RESULTS

Upon internal validation, the machine learning and logistic regression model's area under the curve (AUC) ranged from 71% to 93% across the different algorithms, with the best being the CatBoost Classifier (CBC). Based on the default cut-off point of 0.32, the performance of CBC on predictor set 4 was: Accuracy (85%), Precision (90%), Recall (78%), F1-score (84%), Sensitivity (81%), Specificity (90%), positive predictive value (92%), negative predictive value (78%), and Brier Score (0.39).

CONCLUSIONS

In this study, machine learning approaches achieved the best predictive performance over traditional statistical methods, increasing from 75 to 93%. The CatBoost classifier method achieved the best with the model including continuous variables.

Trimester-specific reference intervals for hemoglobin A1c in non-diabetic pregnancy in a Chinese population

BACKGROUND

Physiological glycated hemoglobin (HbA1c) values in each trimester are not well defined. This study aimed to determine trimester-specific reference intervals for HbA1c levels in non-diabetic pregnant women in China.

METHODS

In this cross-sectional study, 5,042 Chinese pregnant women from 6 to 41 weeks of gestation were screened. An inclusion of 4,134 non-diabetic women was made to determine the reference intervals, they were divided into three trimesters: trimester 1 (T1), 6 weeks to 13 weeks + 6 days, trimester 2 (T2), 14 weeks to 27 weeks + 6 days, and trimester 3 (T3), 28 weeks to 41 weeks + 6 days. A total of 4,134 women (T1 n = 760, T2 n = 1,953, and T3 n = 1,421) provided blood samples which were analyzed for HbA1c concentrations. HbA1c was measured using high-performance liquid chromatography. The median and percentile (2.5th to 97.5th) for the HbA1c reference intervals were calculated for each trimester.

RESULTS

In total, 8,732 HbA1c measurements were taken. Reference intervals for HbA1c expressed as median and percentile (2.5th to 97.5th) for each trimester were: T1: 4.7 (4.0-5.5%), T2: 4.5 (3.9-5.3%), and T3: 4.8 (4.1-5.7%) respectively. The HbA1c levels were significantly lower in the second trimester compared to those in the first trimester (p < 0.0001), and higher in the third trimester compared to the second trimester (p < 0.0001).

CONCLUSIONS

The reference intervals for HbA1c levels were 3.9-5.7% with upper limits of 5.5% in the first trimester, 5.3% in the second trimester, and 5.7% in the third trimester. These findings highlight the importance of considering trimester-specific reference intervals for HbA1c in non-diabetic pregnant women to promote maternal and fetal health.

A Prediction Model of Gestational Diabetes Mellitus Based on OGTT in Early Pregnancy: A Prospective Cohort Study

CONTEXT

Gestational diabetes mellitus (GDM) is a common obstetric complication. Although early intervention could prevent the development of GDM, there was no consensus on early identification for women at high risk of GDM.

OBJECTIVE

To develop a reliable prediction model of GDM in early pregnancy.

METHODS

In this prospective cohort study, between May 30, 2021, and August 13, 2022, a total of 721 women were included from Women's Hospital, Zhejiang University School of Medicine. Participants were asked to complete an oral glucose tolerance test (OGTT) during gestational weeks 7 through 14 for early prediction of GDM, and at weeks 24 through 28 for GDM diagnosis. Using OGTT results and baseline characteristics, logistic regression analysis was used to construct the prediction model. Receiver operating characteristic (ROC) curve, Hosmer-Lemeshow test, decision clinical analysis, and a nomogram were used for model performances assessment and visualization. Internal and external validation was performed to testify the stability of this model.

RESULTS

According to the International Association of Diabetes and Pregnancy Study Groups criteria in early OGTT, the mean (SD) age was 30.5 ± 3.7 years in low-risk participants and 31.0 ± 3.9 years in high-risk participants. The area under ROC curve (AUC) of the existing criteria at weeks 7 through 14 varied from 0.705 to 0.724. Based on maternal age, prepregnancy body mass index, and results of early OGTT, the AUC of our prediction model was 0.8720, which was validated by both internal (AUC 0.8541) and external (AUC 0.8241) confirmation.

CONCLUSIONS

The existing diagnostic criteria were unsatisfactory for early prediction of GDM. By combining early OGTT, we provided an effective prediction model of GDM in the first trimester.

Early Gestational Blood Markers to Predict Preeclampsia Complicating Gestational Diabetes Mellitus

Objective

Gestational diabetes mellitus (GDM) and preeclampsia (PE) are common pregnancy complications that share some common risk factors. GDM patients are also at high risk for PE. There are no sensitive markers for prediction, especially for the occurrence of PE in GDM patients. This study investigated plasma proteins for the prediction of PE in GDM patients.

Methods

A total of 10 PE, 10 GDM, and 5 PE complicated with GDM cases, as well as 10 pregnant controls without obvious complications, were included in the nested cohort. The proteomics in the plasma collected at 12-20 weeks of gestational age (GA) were analyzed by liquid chromatography‒mass spectrometry/mass spectrometry. Some potential markers, such as soluble transferrin receptor (sTfR), ceruloplasmin (CP), apolipoprotein E (ApoE) and inositol 1,4,5-trisphosphate receptor 1 (ITPR1), were validated using enzyme-linked immunosorbent assays.

Results

Functional analysis of the plasma showed that proteasome activation, pancreatic secretion, and fatty acid degradation were activated in the GDM group, and renin secretion-, lysosome-, and proteasome pathways involving iron transport and lipid metabolism were enriched in the PE group, distinguishing PE complicating GDM.

Conclusion

Through proteomics analysis of plasma in early pregnancy, PE complicating GDM may have a unique mechanism from that of PE alone. Plasma sTfR, CP and ApoE levels have potential clinical applications in early screening.

Evaluating the Impact of Fetal Sex on Gestational Diabetes Mellitus Following Interaction with Maternal Characteristics

Fetal-sex-specific changes to placental immunity and metabolism occur in response to obesity. Few studies have determined if fetal sex interacts with maternal characteristics to alter risk of gestational diabetes mellitus (GDM). Among 43,727 singleton pregnancies, we examined the association between male fetal sex and GDM using log-binomial logistic regression to calculate relative risks (RR) and 95% confidence intervals (CI). Interactions were examined between fetal sex and maternal characteristics on the risk of GDM by calculating relative excess risk due to interaction. After adjusting for body mass index, race/ethnicity, maternal age, education, and gravidity, male fetal sex was not associated with GDM (RRadj. 0.95, 95% CI 0.93, 1.04). We found a positive interaction between male fetal sex and obesity (p = 0.04). Nonobese women with male fetuses were less likely to develop GDM, but in the presence of obesity, an opposite trend was observed. There was a positive interaction between male fetal sex and GDM on the risk of preterm delivery < 37-weeks gestation (p = 0.0006). In response to underlying maternal obesity, fetal sex may modify the risk of GDM. In addition, male fetal sex may increase the occurrence of preterm birth among women with GDM.

Differential effects of diet and physical activity interventions in pregnancy to prevent gestational diabetes mellitus and reduce gestational weight gain by level of maternal adiposity: a protocol for an individual patient data (IPD) meta-analysis of randomised controlled trials

INTRODUCTION

Women and their infants are at increased risk of complications if gestational diabetes mellitus (GDM) or excessive gestational weight gain (GWG) occurs in pregnancy. Weight management interventions in pregnancy, consisting of diet and physical activity components are targeted based on maternal body mass index (BMI). However, the relative effectiveness of interventions targeted based on alternative measures of adiposity to BMI is unclear. This individual patient data (IPD) meta-analysis aims to explore whether interventions are more effective at preventing GDM and reducing GWG in women according to their level of adiposity.

METHODS

The International Weight Management in Pregnancy Collaborative Network has a living database of IPD from randomised trials of diet and/or physical activity interventions in pregnancy. This IPD meta-analysis will use IPD from trials identified from systematic literature searches up until March 2021, where maternal adiposity measures (eg, waist circumference) were collected prior to 20 weeks' gestation. A two-stage random effects IPD meta-analysis approach will be taken for each outcome (GDM and GWG) to understand the effect of early pregnancy adiposity measures on the effect of weight management interventions for GDM prevention and GWG reduction. Summary intervention effects with 95% CIs) will be derived along with treatment covariate interactions. Between-study heterogeneity will be summarised by I² and tau² statistics. Potential sources of bias will be evaluated, and the nature of any missing data will be explored and appropriate imputation methods adopted.

ETHICS AND DISSEMINATION

Ethics approval is not required. The study is registered on the International Prospective Register of Systematic Reviews (CRD42021282036). Results will be submitted to peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021282036.

Effect of Gestational Weight Gain during the First Half of Pregnancy on the Incidence of GDM, Results from a Pregnant Cohort in Northern Greece

The aim of this study was to evaluate the effect of gestational weight gain (GWG) up to 23⁺⁶ weeks of gestation on the incidence of Gestational Diabetes Mellitus (GDM). A pregnant cohort of 5948 women in Northern Greece was recruited. Anthropometric features before and during pregnancy were recorded, the GWG by 23⁺⁶ weeks was calculated and a Generalized Linear Regression Model (GLM) with subgroup analyses based on weight status were computed. GDM was diagnosed in 5.5% of women. GLM results showed that GDM likelihood increased with maternal age (MA) and pre-pregnancy BMI (aOR: 1.08, 95%CI: [1.06, 1.11] and aOR: 1.09, 95%CI: [1.09, 1.11], respectively). Ιn the normal pre-pregnancy weight group, when the extra weight gain was >8 kgs, the odds of GDM increased (OR: 2.13, 95%CI: [0.98, 4.21], p = 0.03). Women with pre-pregnancy level 2 clinical obesity (OB2 pre) (BMI > 35 and <40 kg/m²) that shifted to OB3 category (BMI ≥ 40 kg/m²) had an increased GDM likelihood (OR: 4.85, 95%CI: [1.50, 15.95]). Women of higher MA may require stricter monitoring for GDM from early pregnancy, while in obese women, recommended GWG may need to be re-evaluated, since refraining from any weight gain may have a preventive effect for GDM.

Pre-Pregnancy Adherence to Mediterranean Diet and Risk of Gestational Diabetes Mellitus: A Prospective Cohort Study in Greece

Gestational Diabetes Mellitus (GDM) is a growing epidemic affecting pregnant women and their offspring. This study aimed to identify the relationship between adherence to a Mediterranean diet (MD) before conception and the risk of GDM in a contemporary Greek pregnant cohort. A prospective cohort of pregnant women was recruited at the routine first trimester visit. Nutritional intake was evaluated using a population specific validated food frequency questionnaire (FFQ). Pre-pregnancy adherence to MD was derived using two different scoring systems, the Mediterranean diet index score (MDS), and a modified version. Adjusted odds ratios (aOR) were computed using multiple logistic regression models for each score derived. Of 743 participating women, 112 (15.1%) developed GDM. The MDS index showed that scoring 5-9 points (high adherence) was associated with a lower GDM incidence (aOR: 0.57 95% CI (0.32, 0.90), p = 0.02), while the modified MDS index showed no significant association for any level of adherence. Pre-pregnancy consumption of "meat and derivatives" and "fatty meat and processed meat" was associated with a higher risk of GDM, with both scoring systems (p = 0.008, p = 0.004, respectively). A higher adherence to a MD pre-pregnancy, especially with less meat consumption, may have a protective effect on the occurrence of GDM.

Predictors for pharmacological therapy and perinatal outcomes with metformin treatment in women with gestational diabetes

BACKGROUND

The prevalence of gestational diabetes mellitus (GDM) has been increasing in Australia and worldwide. The study aims were to examine, in comparison with dietary intervention, perinatal outcomes for women with gestational diabetes who were attending a single hospital clinic and to identify predictors for their pharmacological GDM treatment.

METHODS

A prospective, observational study of women with GDM, treated with "Diet, N= 50", "Metformin, N = 35", "Metformin and Insulin, N = 46" or "Insulin, N = 20".

FINDINGS

The mean BMI for the whole cohort was 25.8 ± 4.7 kg/m². The Metformin group, compared to the Diet group, had OR=3.1 (95% CI:1.13 to 8.25) for caesarean section birth (LSCS) compared to normal vaginal birth mode with no longer such a significant association after controlling for the number of their elective LSCS. The insulin treated group had the highest number of small for gestational age neonates (20%, p<0.05) with neonatal hypoglycaemia (25%, p< 0.05). Fasting glucose value on oral GTT (glucose tolerance test) was the strongest predictor for a pharmacological intervention requirement with OR = 2.77 (95CI%: 1.16 to 6.61), followed by timing of OGTT with OR=0.90 (95% CI: 0.83 to 0.97) and previous pregnancy loss with OR=0.28 (95% CI:0.10 to 0.74).

INTERPRETATION

These data suggest that metformin may be a safe alternative treatment to insulin treatment in GDM. Raised fasting glucose on oral GTT was the strongest indicator that GDM women with BMI < 35 kg/m² may require pharmacological therapy. Further studies are needed to identify the most effective and safe management of gestational diabetes within the public hospital setting.

AUSTRALIAN NEW ZEALAND CLINICAL TRIAL REGISTRY ANZCTR TRIAL ID

ACTRN12620000397910.

Finding the best method for screening for gestational diabetes mellitus: fetal thymic-thoracic ratio or fetal thymus transverse diameter

OBJECTIVE

The aim of this study was to compare the efficiency of fetal thymic-thoracic ratio and fetal thymus transverse diameter measurements in gestational diabetes mellitus.

METHODS

Fetal thymic-thoracic ratio and fetal thymus transverse diameter were assessed in 360 pregnant women. Patients were examined in two groups: 180 gestational diabetes mellitus (study group) and 180 healthy pregnant women (control group).

RESULTS

There were no statistically significant differences between the cases with gestational diabetes mellitus and the control group in terms of fetal thymus transverse diameter; however, the fetal thymic-thoracic ratio was found to be significantly lower in cases with gestational diabetes mellitus compared to that in the control group (p<0.001).

CONCLUSION

The fetal thymic-thoracic ratio is superior to the fetal thymus transverse diameter in evaluating the fetal thymus size.

Obesity in Pregnancy: A Comprehensive Review of Influential Guidelines

Importance

Obesity is one of the most common clinical entities complicating pregnancies and is associated with short- and long-term consequences for both the mother and the offspring.

Objective

The aim of this study were to review and compare the most recently published influential guidelines on the management of maternal obesity in the preconceptional, antenatal, intrapartum, and postpartum period.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynecologists of Canada, the Royal College of Obstetricians and Gynecologists, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on obesity in pregnancy was carried out.

Results

There is an overall agreement among the reviewed guidelines regarding the importance of prepregnancy weight loss with behavioral modification, optimization of gestational weight gain, and screening for comorbidities in improving pregnancy outcomes of obese women. Women with previous bariatric surgery should be screened for nutritional deficiencies and have a closer antenatal surveillance, according to all guidelines. In addition, folic acid supplementation is recommended for 1 to 3 months before conception and during the first trimester, but several discrepancies were identified with regard to other vitamins, iodine, calcium, and iron supplementation. All medical societies recommend early screening for gestational diabetes mellitus and early anesthetic assessment in obese women and suggest the use of aspirin for the prevention of preeclampsia when additional risk factors are present, although the optimal dosage is controversial. The International Federation of Gynecology and Obstetrics, Society of Obstetricians and Gynecologists of Canada, Royal College of Obstetricians and Gynecologists, and Royal Australian and New Zealand College of Obstetricians and Gynecologists point out that specific equipment and adequate resources must be readily available in all health care facilities managing obese pregnant women. Moreover, thromboprophylaxis and prophylactic antibiotics are indicated in case of cesarean delivery, and intrapartum fetal monitoring is justified during active labor in obese patients. However, there are no consistent protocols regarding the fetal surveillance, the monitoring of multiple gestations, the timing and mode of delivery, and the postpartum follow-up, although weight loss and breastfeeding are unanimously supported.

Conclusions

Obesity in pregnancy is a significant contributor to maternal and perinatal morbidity with a constantly rising global prevalence among reproductive-aged women. Thus, the development of uniform international protocols for the effective management of obese women is of paramount importance to safely guide clinical practice and subsequently improve pregnancy outcomes.

Influence of Maternal Diabetes on the Risk of Neurodevelopmental Disorders in Offspring in the Prenatal and Postnatal Periods

BACKGROUND

This study aimed to evaluate the influence of maternal diabetes in the risk of neurodevelopmental disorders in offspring in the prenatal and postnatal periods.

METHODS

This cohort study included singleton gestational diabetes mellitus (GDM) pregnancies >22 weeks' gestation with live newborns between 1991 and 2008. The control group was randomly selected and matched (1:2) for maternal age, weeks of gestation and birth year. Cox regression models estimated the effect of GDM on the risk of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and maternal type 2 diabetes mellitus (T2DM). Moreover, interaction between maternal T2DM and GDM-ADHD relationship was evaluated.

RESULTS

Children (n=3,123) were included (1,073 GDM; 2,050 control group). The median follow-up was 18.2 years (interquartile range, 14.2 to 22.3) (n=323 with ADHD, n=36 with ASD, and n=275 from women who developed T2DM). GDM exposure was associated with ADHD (hazard ratio [HR]crude, 1.67; 95% confidence interval [CI], 1.33 to 2.07) (HRadjusted, 1.64; 95% CI, 1.31 to 2.05). This association remained significant regardless of the treatment (diet or insulin) and diagnosis after 26 weeks of gestation. Children of mothers who developed T2DM presented higher rates of ADHD (14.2 vs. 10%, P=0.029). However, no interaction was found when T2DM was included in the GDM and ADHD models (P>0.05). GDM was not associated with an increased risk of ASD (HRadjusted, 1.46; 95% CI, 0.74 to 2.84).

CONCLUSION

Prenatal exposure to GDM increases the risk of ADHD in offspring, regardless of GDM treatment complexity. However, postnatal exposure to maternal T2DM was not related to the development of ADHD.

Establishing the Optimal Time for Induction of Labor in Women with Diet-Controlled Gestational Diabetes Mellitus: A Single-Center Observational Study

To determine the optimal week for labor induction in women with diet-controlled gestational diabetes mellitus by comparing differences in perinatal and neonatal outcomes of labor induction to expectant management at different gestational weeks. Methods: This was a retrospective analysis of a prospectively recruited cohort of 797 singleton pregnancies complicated by diet-controlled gestational diabetes mellitus that were diagnosed, treated, and delivered after 37 weeks in a tertiary, university-affiliated perinatal center between January 2016 and December 2021. Results: The incidence of neonatal complications was highest when delivery occurred at 37 weeks, whereas fetal macrosomia occurred mostly at 41 weeks (20.7%); the frequency of large for gestational age infants did not differ between the groups. Conversely, the best neonatal outcomes were observed at 40 weeks due to the lowest number of neonates requiring phototherapy for neonatal jaundice (1.7%) and the smallest proportion of neonates experiencing composite adverse neonatal outcomes defined as neonatal hypoglycemia, phototherapy, clavicle fracture, or umbilical artery pH < 7.15 (10.4%). Compared with expectant management, the risk for neonatal hypoglycemia was increased for induction at 39 weeks (adjusted odds ratio 12.29, 95% confidence interval 1.35−111.75, p = 0.026) and that for fetal macrosomia was decreased for induction at 40 weeks (adjusted odds ratio 0.11, 95% confidence interval 0.01−0.92, p = 0.041), after adjusting for maternal pre-pregnancy body mass index, nulliparity, and mean pregnancy A1c. Conclusions: The lowest rate of neonatal complications was observed at 40 weeks. Labor induction at 40 weeks prevented fetal macrosomia.

Cultural and Digital Health Literacy Appropriateness of App- and Web-Based Systems Designed for Pregnant Women With Gestational Diabetes Mellitus: Scoping Review

BACKGROUND

The prevalence of women diagnosed with gestational diabetes mellitus (GDM) is increasing dramatically. Mobile technologies to enhance patient self-management offer many advantages for women diagnosed with GDM. However, to our knowledge, although mobile health (mHealth) and telemedicine systems for GDM management exist, evidence on their cultural and digital health literacy appropriateness levels is limited.

OBJECTIVE

This review aimed to search and assess the literature on mHealth and telemedicine systems designed for women diagnosed with GDM. Our assessment of these technologies focused on their cultural and digital health literacy appropriateness as well as the systems' effectiveness in improving glycemic control and maternal and infant outcomes.

METHODS

We conducted a scoping review using a framework adapted from Arksey and O'Malley. Four electronic databases were searched for relevant studies: PubMed, MEDLINE (EBSCO), Web of Science, and Scopus. The databases were searched between January 2010 and January 2022. The inclusion criteria were pregnant women diagnosed with GDM, use of telemedicine for monitoring and management, and vulnerable or disadvantaged patients. We used terms related to mobile apps and telemedicine: GDM, vulnerable populations, periphery, cultural appropriateness, and digital health literacy. Studies were screened and selected independently by 2 authors. We extracted the study data on a Microsoft Excel charting table and categorized them into final themes. The results were categorized according to the cultural and digital health literacy features presented.

RESULTS

We identified 17 studies that reported on 12 telemedicine and mHealth app interventions. We assessed the studies in three domains: cultural appropriateness, digital health literacy, and maternal and infant outcomes. In the literature, we found that existing digital technologies may improve glycemic control and diabetes self-management. However, there is a lack of assessment of cultural and digital health literacy appropriateness for pregnant women diagnosed with GDM. Considerations in app design regarding cultural appropriateness were found in only 12% (2/17) of the studies, and only 25% (3/12) of the interventions scored ≥3 out of 5 in our assessment of digital health literacy.

CONCLUSIONS

mHealth and telemedicine can be an effective platform to improve the clinical management of women with GDM. Although studies published on the use of mHealth and telemedicine systems exist, there is a limited body of knowledge on the digital health literacy and cultural appropriateness of the systems designed for women diagnosed with GDM. In addition, as our study was restricted to the English language, relevant studies may have been excluded. Further research is needed to evaluate, design, and implement better tailored apps regarding cultural and digital literacy appropriateness for enhancing pregnant women's self-management as well as the effectiveness of these apps in improving maternal and infant health outcomes.

Investigation and management of stillbirth: a descriptive review of major guidelines

Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.

Inositol Nutritional Supplementation for the Prevention of Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This study was aimed at assessing the efficacy and safety of inositol nutritional supplementation during pregnancy for the prevention of GDM. PubMed, Embase, MEDLINE, and Cochrane library were systematically searched for randomized controlled trails (RCTs) in this field until May 2022. Primary outcomes were the incidence for GDM and plasma glucose levels by oral glucose tolerance test (OGTT). Pooled results were expressed as relative risk (RR) or mean difference (MD) with a 95% confidence interval (95% CI). Seven RCTs with 1321 participants were included in this study. Compared with the control group, 4 g myo-inositol (MI) supplementation per day significantly decreased the incidence of GDM (RR = 0.30, 95% CI (0.18, 0.49), p < 0.00001). It significantly decreased the plasma glucose levels of OGTT regarding fasting-glucose OGTT (MD = −4.20, 95% CI (−5.87, −2.54), p < 0.00001), 1-h OGTT (MD = −8.75, 95% CI (−12.42, −5.08), p < 0.00001), and 2-h OGTT (MD = −8.59, 95% CI (−11.81, −5.83), p < 0.00001). It also decreased the need of insulin treatment, and reduced the incidence of preterm delivery and neonatal hypoglycemia. However, no difference was observed between 1.1 g MI per day plus 27.6 mg D-chiro-inositol (DCI) per day and the control group regarding all evaluated results. In conclusion, 4 g MI nutritional supplementation per day during early pregnancy may reduce GDM incidence and severity, therefore may be a practical and safe approach for the prevention of GDM.

Preterm Labor: A Comprehensive Review of Guidelines on Diagnosis, Management, Prediction and Prevention

Importance

Preterm labor (PTL) is one of the most common and serious pregnancy complications associated with significant perinatal morbidity and mortality, as well as long-term neurologic impairment in the offspring.

Objective

The aim of this study was to review and compare the most recently published major guidelines on diagnosis, management, prediction, and prevention of this severe complication of pregnancy.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence (NICE), the World Health Organization, the American College of Obstetricians and Gynecologists, the New South Wales Government, and the European Association of Perinatal Medicine (EAPM) on PTL was carried out.

Results

There is a consensus among the reviewed guidelines that the diagnosis of PTL is based on clinical criteria, physical examination, measurement of cervical length (CL) with transvaginal ultrasound (TVUS) and use of biomarkers, although there is disagreement on the first-line diagnostic test. The NICE and the EAPM are in favor of TVUS CL measurement, whereas the New South Wales Government mentions that fetal fibronectin testing is the mainstay for PTL diagnosis. Moreover, there is consistency among the guidelines regarding the importance of treating PTL up to 34 weeks of gestation, to delay delivery for 48 hours, for the administration of antenatal corticosteroids, magnesium sulfate, and in utero transfer to higher care facility, although several discrepancies exist regarding the tocolytic drugs of choice and the administration of corticosteroids and magnesium sulfate after 34 and 30 gestational weeks, respectively. Routine cesarean delivery in case of PTL is unanimously not recommended. Finally, the NICE, the American College of Obstetricians and Gynecologists, and the EAPM highlight the significance of screening for PTL by TVUS CL measurement between 16 and 24 weeks of gestation and suggest the use of either vaginal progesterone or cervical cerclage for the prevention of PTL, based on specific indications. Cervical pessary is not recommended as a preventive measure.

Conclusions

Preterm labor is a significant contributor of perinatal morbidity and mortality with a substantial impact on health care systems. Thus, it seems of paramount importance to develop consistent international practice protocols for timely diagnosis and effective management of this major obstetric complication and subsequently improve pregnancy outcomes.

A Review of the Associations Between Obstructive Sleep Apnea and Gestational Diabetes Mellitus and Possible Mechanisms of Disease

Obstructive sleep apnea (OSA) usually leads to the occurrence of diabetes. Gestational diabetes mellitus (GDM) is a common gestational complication associated with adverse maternal and fetal outcomes. Increasing studies suggest that women with OSA during pregnancy may be at a significantly greater risk of developing GDM. It is crucial to explore the association between OSA and GDM and the mechanisms underlying this association. In this review, we presented a comprehensive literature review of the following: the association between OSA and GDM, the possible mechanisms of this association, and the effects of continuous positive airway pressure (CPAP) on OSA with GDM. The results showed that most authors suggested that there was an association between OSA and GDM. The intermittent hypoxemia (IH) and reduction of slow-wave sleep (SWS) may be the key to this association. IH induces the products of oxidative stress and inflammation as well as dysregulation of the hypothalamic-pituitary-adrenal, which lead to diabetes. In addition, SWS reduction in OSA enhances the inflammation by increasing the inflammatory cytokines, increases the sympathetic activation, and causes changes in leptin level, which result in the development of GDM. Additionally, whether CPAP is beneficial to GDM remains still unclear.

Thyroid Disease in Pregnancy: A Descriptive Review of Guidelines

Importance

Thyroid disorders represent one of the most frequent complications of pregnancy associated with adverse obstetric, fetal, and neonatal outcomes, especially in case of delayed diagnosis and suboptimal management.

Objective

The aim of this study was to review and compare the recommendations of the most recently published guidelines on the diagnosis and management of these common conditions.

Evidence Acquisition

A descriptive review of guidelines from the Endocrine Society, the European Thyroid Association, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American Thyroid Association, and the American College of Obstetricians and Gynecologists on thyroid disease in pregnancy was carried out.

Results

There is an overall consensus regarding the diagnosis of overt and subclinical hypothyroidism and hyperthyroidism in pregnancy using the pregnancy-specific reference ranges and the definition of postpartum thyroiditis. The reviewed guidelines unanimously discourage universal screening for thyroid function abnormalities before and during pregnancy and support targeted screening of high-risk patients by measuring serum thyroid-stimulating hormone levels. Moreover, they all highlight the need of treating overt hypothyroidism and hyperthyroidism, not only during pregnancy, but also before conception, suggesting similar management policies and treatment targets. There is also agreement regarding the management of gestational transient hyperthyroidism with hyperemesis gravidarum, suspected fetal thyrotoxicosis, postpartum thyroiditis, and thyroid malignancy. Scanning or treating with radioactive iodine is contraindicated during pregnancy and breastfeeding. On the other hand, there is controversy on the management of subclinical thyroid disease, thyroid function surveillance protocols, and iodine nutrition recommendations. Of note, the American College of Obstetricians and Gynecologists makes some specific recommendations on the treatment of thyroid storm and thyrotoxic heart failure in pregnant women, whereas the American Thyroid Association makes a special reference to the management of women with thyroid cancer.

Conclusions

As the disorders of the thyroid gland affect a significant proportion of pregnant women, it is of paramount importance to develop uniform international evidence-based protocols for their accurate diagnosis and optimal management, in order to safely guide clinical practice and eventually improve perinatal outcomes.

Trends in hospitalizations and emergency department visits among women with hyperglycemia in pregnancy between 2008 and 2017 in Taiwan

INTRODUCTION

We investigated health service utilization, including hospitalizations and emergency department visits, for women with hyperglycemia in pregnancy between 2008 and 2017 in Taiwan.

METHODS

Data from the Health and Welfare Data Science Center were used to conduct this nationwide population-based study. We identified pregnant women and the date of childbirth according to Birth Certificate Applications from 2007 to 2018. The study population was divided into four groups: known DM, newly diagnosed DM, GDM, and no DM/GDM. To assess quality of healthcare during the gestation period, trends in 30-day readmission rate, number of emergency department visits/hospitalizations per 100 childbirths, and length of hospital stay from 2008 to 2017 were examined.

RESULTS

A total of 1830511 childbirths and 990569 hospitalizations were identified for analyses. Between 2008 and 2017, women with hyperglycemia in pregnancy (known DM, newly diagnosed DM, and GDM) had a higher rate of hospitalization, a longer length of hospital stay, and higher rates of various maternal and fetal outcomes, compared with women with no DM/GDM. Nevertheless, the differences between women with GDM and those with no DM/GDM in the aforementioned outcome measures were modest. Women with GDM had a modest decrease in the 30-day readmission rate (p for trend 0.046) with no significant difference in the number of emergency department visits during the study period.

DISCUSSION

Our findings provide evidence of the quality of healthcare for women with GDM between 2008 and 2017 in Taiwan.

The Relationship Between Pre-Operative Glycosylated Haemoglobin and Opioid Consumption After Caesarean Section in Women With Gestational Diabetes Mellitus

INTRODUCTION

Women with Gestational diabetes mellitus (GDM) had a higher need and consumption of analgesics than women without GDM. The preoperative level of HbA1c was associated with the postoperative consumption for analgesics in diabetic patients. This prospective observational study go further to investigate the relationship between the pre-operative HbA1c and the post-operative consumption for analgesics in women with GDM.

METHODS

Women with GDM and a singleton pregnancy undergoing elective cesarean section under combined spinal-epidural anaesthesia were divided into two groups based on pre-operative HbA1c: group HbA1c < 6% and group HbA1c ≥ 6%. Analgesics consumption, number of patient-controlled analgesia (PCA) compression, and pain scores in 6 hours and 24 hours post-operation were compared between the two groups. Then Pearson's correlation coefficient and a stepwise multivariate linear regression were performed to investigate possible independentpredictors of post-operative 24-hour sufentanil consumption.

RESULTS

Analgesics consumption was significantly lower (18.8 ± 0.4 vs 23.2 ± 4.3; 82.7 ± 2.4 vs 115.8 ± 17.4, P < 0.001), and number of PCA compressions was significantly less frequent (1 [1-2] vs 3 [1-5]; 5 [3-7] vs 7 [3-15], P < 0.001), and in group HbA1c < 6% than in group HbA1c ≥ 6% in 6 hours and 24 hours post-operation.The univariate analysis showed that sufentanil consumption at 24 hours post-operation was significantly related to pre-operative HbA1c (r = 0.338, P < 0.001) and parity (r = 0.184, P = 0.03) and was related to blood glucose management methods (r = 0.172, P = 0.043). Multivariate linear regression analysis showed that HbA1c was the independent factor related to post-operative 24-hour sufentanil consumption (adjusted r2 = 0.246, P < 0.001).

CONCLUSIONS

This study demonstrated that in pregnant women with GDM, the pre-operative HbA1c is independently related to the need for and consumption of analgesics in 24 hours after CS.

Every Mother and Every Fetus Matters: A Positive Pregnant Test = Multiple Offerings of Reproductive Risk Screening for personal, family, and specific obstetrical-fetal conditions

Structured OBJECTIVE: The requirement and need for a focused 'pregnant person -centered' antenatal care process with time for informed consent and shared decision making are important for optimal antenatal care. This commentary focuses on the evidenced -based screening test options and timing as part of the overall 'pregnant person-centered' preconception and antenatal care journey.

METHODS

A structured quality improvement (QI) review (Squire 2.0) was undertaken to examine the appropriate reproductive screening process in the periods of preconception and during pregnancy.

RESULTS

First, evaluated the broader antenatal care structure which, second, enabled the directed reproductive risk screening processes to be offered within an informed consent process. Four international pre-conception and antenatal evidenced-based consensus would routinely offer specific gestational age reproductive risk screening elements: totaling 21 screening elements (preconception 3; 1st trimester 9; 2nd trimester 3; 3rd trimester 4; intrapartum 1; postpartum 1).

CONCLUSION

The best evidenced-based opportunity for comprehensive and collaborative antenatal care with appropriate screening elements requires: single national access healthcare system; expert evidenced-based guideline creation; collaborative maternity care providers based for risk assessment, triage, and management; pregnant person (women) centered care model of maternity care; clearly identified evidenced-based gestational age directed screening elements; international pre-conception and antenatal guideline consensus.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines

Importance

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons.

Objective

The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out.

Results

There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring.

Conclusions

The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Impact of the Gestational Diabetes Diagnostic Criteria during the Pandemic: An Observational Study

OBJECTIVE

To analyze the effect of applying alternative diagnostic criteria for gestational diabetes mellitus (GDM) during the COVID-19 pandemic on GDM prevalence and obstetrical and perinatal outcomes, in comparison to usual diagnostic approaches.

METHODS

Data from women referred to GDM diagnosis from 1 September to 30 November 2019 were retrospectively collected (2019-group). The same data from the same period in 2020 were prospectively collected (2020-group). In both cases, a two-step diagnostic approach was used, the first step being a screening test (1 h 50 goral glucose tolerance test, OGTT). In 2019 it was followed by a 100 gr OGTT for diagnosis. In 2020, this was replaced by a blood test for the measurement of plasma glucose and HbA1c, according to alternative GDM diagnostic criteria during the COVID-19 pandemic.

RESULTS

From 237 women in the 2019 group, 40 (16.9%) were diagnosed with GDM, while from 255 women in the 2020 group, 37 (14.5%) had GDM (p = 0.470). More women in the 2020 group, in comparison to the 2019 group, were nulligravid (41.9% vs. 47.2%, p = 0.013), had a personal history of GDM (11.4% vs. 4.6%, p = 0.013) and had macrosomia in previous pregnancies (10.2% vs. 2.1%, p = 0.001). Obstetrical and perinatal outcomes were similar when comparing women with GDM to non-GDM women in the 2019 and 2020 groups and between GDM women and non-GDM women.

CONCLUSION

In a Spanish population, GDM prevalence during the COVID-19 pandemic using the alternative diagnostic criteria was similar to that found in 2019 using the usual diagnostic criteria. Despite women referred for GDM diagnosis during the pandemic having more GDM risk factors, obstetrical and perinatal outcomes were comparable to those observed before the pandemic.