Pregnancy outcomes for women with pre‐pregnancy diabetes mellitus in Australian populations, rural and metropolitan: A review

Dietary patterns during pregnancy and maternal and birth outcomes in women with type 1 diabetes: the Environmental Determinants of Islet Autoimmunity (ENDIA) study

AIMS/HYPOTHESIS

Dietary patterns characterised by high intakes of vegetables may lower the risk of pre-eclampsia and premature birth in the general population. The effect of dietary patterns in women with type 1 diabetes, who have an increased risk of complications in pregnancy, is not known. The aim of this study was to investigate the relationship between dietary patterns and physical activity during pregnancy and maternal complications and birth outcomes in women with type 1 diabetes. We also compared dietary patterns in women with and without type 1 diabetes.

METHODS

Diet was assessed in the third trimester using a validated food frequency questionnaire in participants followed prospectively in the multi-centre Environmental Determinants of Islet Autoimmunity (ENDIA) study. Dietary patterns were characterised by principal component analysis. The Pregnancy Physical Activity Questionnaire was completed in each trimester. Data for maternal and birth outcomes were collected prospectively.

RESULTS

Questionnaires were completed by 973 participants during 1124 pregnancies. Women with type 1 diabetes (n=615 pregnancies with dietary data) were more likely to have a 'fresh food' dietary pattern than women without type 1 diabetes (OR 1.19, 95% CI 1.07, 1.31; p=0.001). In women with type 1 diabetes, an increase equivalent to a change from quartile 1 to 3 in 'fresh food' dietary pattern score was associated with a lower risk of pre-eclampsia (OR 0.37, 95% CI 0.17, 0.78; p=0.01) and premature birth (OR 0.35, 95% CI 0.20, 0.62, p<0.001). These associations were mediated in part by BMI and HbA1c. The 'processed food' dietary pattern was associated with an increased birthweight (β coefficient 56.8 g, 95% CI 2.8, 110.8; p=0.04). Physical activity did not relate to outcomes.

CONCLUSIONS/INTERPRETATION

A dietary pattern higher in fresh foods during pregnancy was associated with sizeable reductions in risk of pre-eclampsia and premature birth in women with type 1 diabetes.

Risk for fetal malformations and unfavorable neonatal outcomes in early-onset gestational diabetes mellitus

BACKGROUND

Early-onset gestational diabetes mellitus (GDM) is diagnosed before the 24th gestational week. Since early GDM is associated with first trimester hyperglycemia, many clinicians treat these women as having pre-GDM. However, whether early GDM increases the risk for unfavorable pregnancy outcomes and particularly for fetal malformations to a greater extent than late-onset GDM were not studied sufficiently. We aimed to examine the effect of early-onset GDM on unfavorable pregnancy outcomes.

METHODS

A retrospective cohort study of women with GDM delivering singletons during 2005-2018 was conducted. Women were divided into GDM diagnosed at the first (Trimester1; up to 13.6 weeks; N = 117), the second (Trimester2; up to 23.6 weeks; N = 126), and the third trimester (Trimester3; N = 2334). The primary outcomes were neonatal malformations and a composite of large-for-age newborns, hypoglycemia and hyperbilirubinemia treated with phototherapy. Comparisons were made between early- (Trimester1 + Trimester2-groups) and late-onset GDM (Trimester3-group), and between the three trimesters.

RESULTS

Fetal malformations were low and comparable between the trimester1, trimester2, trimester3 groups (2 (1.7%), 3 (2.4%), and 110 (4.7%), respectively). The composite neonatal complications was similar between the groups (68 (58%), 58 (46%), and 1087 (47%), respectively). In early-onset, the rates of neonatal hypoglycemia and shoulder dystocia were higher than in the late-onset GDM group (OR 95% CI 3.5 [2.0-6.1] and 10.3 [2.4-44.6], respectively). Macrosomia was higher in trimester1 compared with trimester2 and trimester3 cohorts (OR 95% CI 5.3 [1.7-16.9] and 2.8 [1.5-5.2], respectively).

CONCLUSIONS

The risk for fetal malformations was low and comparable between the first, second and third trimester GDM. Since the risks for macrosomia, shoulder dystocia, and neonatal hypoglycemia are higher in early-onset GDM, these women should undergo strict glycemic control, intensive monitoring, and careful neonatal evaluation.

Prevalence of diabetic retinopathy in women with pregestational diabetes during pregnancy and the postpartum

BACKGROUND

Diabetic retinopathy (DR) may be affected by pregnancy. The majority of prevalence data regarding DR in pregnancy predate the advent of contemporary guidelines for diabetes management during pregnancy. This study reports DR prevalence and associated risk factors in women with pregestational diabetes during pregnancy and the postpartum in Australia.

METHODS

A total of 172 pregnant women with type 1 (T1DM) or type 2 diabetes diagnosed pre-pregnancy were prospectively recruited from two obstetrics hospitals in Melbourne (November 2017-March 2020). Eye examinations were scheduled in each trimester, at 3-, 6-, and 12-months postpartum. DR severity was graded from two-field fundus photographs by an independent grader utilising the Airlie House Classification. Sight-threatening DR (STDR) was defined as the presence of diabetic macular oedema or proliferative DR.

RESULTS

Overall, 146 (84.9%) women had at least one eye examination during pregnancy. The mean age was 33.8 years (range 19-51), median diabetes duration was 7.0 years (IQR 3.0-17.0), 71 women (48.6%) had T1DM. DR and STDR prevalence during pregnancy per 100 eyes was 24.3 (95% CI 19.7-29.6) and 9.0 (95% CI 6.1-12.9); while prevalence in the postpartum was 22.2 (95% CI 16.5-29.3) and 10.0 (95% CI 5.4-17.9), respectively. T1DM, longer diabetes duration, higher HbA1c in early pregnancy, and pre-existing nephropathy were significant risk factors.

CONCLUSIONS

The prevalence of DR in pregnant women was similar to the non-pregnant diabetic population in Australia. One in nine participants had STDR during pregnancy and the postpartum, highlighting the need to optimise DR management guidelines in pregnancy given the significant risk of vision loss.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review

AIM

The aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes.

METHODS

Eight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high-income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools.

RESULTS

Three articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias.

CONCLUSION

There is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high-income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

A Scoping Review of Breastfeeding in Women with Chronic Diseases

Background: Approximately 10-20% of mothers have a chronic disease. Studies on breastfeeding in women with chronic disease span multiple disciplines, and these have not been collated to synthesize knowledge and identify gaps. The objective of this review was to summarize published literature on breastfeeding in women with chronic disease. Methods: We conducted a scoping review of original research and systematic reviews identified in Medline, EMBASE, and CINAHL (1990-2019) and by hand searching on women with chronic diseases reporting on at least one breastfeeding-related topic. Conference abstracts, case-studies, and studies on pregnancy-induced conditions or lactation pharmacology were excluded. Content analysis and narrative synthesis were used to analyze findings. Results: We identified 128 articles that were predominantly quantitative (80.5%), conducted in Europe or North America (65.6%), analyzed sample sizes of <200 (57.0%), and published from 2010 onward (68.8%). Diabetes (42.2%), multiple sclerosis (MS; 19.5%), and epilepsy (13.3%) were the most common diseases studied. Breastfeeding was a primary focus in approximately half (53.1%) of the articles, though definitions were infrequently reported (32.8%). The most-studied topics were breastfeeding duration/exclusivity (55.7%), reasons for feeding behavior (19.1%), and knowledge and attitudes about breastfeeding (18.3%). Less studied topics (<10% of articles each) included milk expression behaviors, breastfeeding difficulties, and feeding supports. Conclusions: Existing literature focuses primarily on diabetes or MS, and breastfeeding behaviors and outcomes. Further research examining a broader range of chronic diseases, with large sample sizes, and sufficient breastfeeding measurement detail can improve our understanding of breastfeeding disparities in this population.

Markers for undiagnosed type 2 diabetes mellitus during pregnancy-A population-based retrospective cohort study

BACKGROUND

To examine possible markers for undiagnosed type 2 diabetes in early-onset gestational diabetes mellitus (GDM).

METHODS

A population-based retrospective cohort study of women with GDM diagnosed prior to the 24th week, who delivered between 2005 and 2018, was conducted. The results of the 50-g glucose challenge test, 100-g oral glucose tolerance test, and the first available glycosylated hemoglobin (HbA1c) were examined as markers for type 2 diabetes diagnosed 6 to 12 weeks post pregnancy, which is suggestive of pregestational diabetes. This was done by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for each marker. These markers and additional ones were evaluated for independency by stepwise multivariate logistic regression.

RESULTS

Of 69 417 pregnancies, 3321 (5%) pregnancies were with GDM. Of them, in 261 (8%) women GDM was diagnosed prior to the 24th week, and 219 (84%) women had available data for analysis. Among them, 11 (5%) women had type 2 diabetes post pregnancy. Elevated HbA1c was the most accurate marker for undiagnosed type 2 diabetes (AUC 91% with 95% CI [81%-100%]) and the only independent marker for undiagnosed type 2 diabetes in multivariate analysis (odds ratio [OR] 19; 95% CI [3.2-109], C statistic = 88%). Using the ROC curve, a cutoff of 5.8% predicted type 2 diabetes with 89% sensitivity, 86% specificity, 99.4% negative predictive value, and 23% positive predictive value.

CONCLUSIONS

Early-onset GDM with HbA1c ≥ 5.8% should be managed as type 2 diabetes. Definitive diagnosis should be done after delivery.

Adherence to clinical evaluations in women with pre-existing diabetes during pregnancy: A call to action from an Italian real-life investigation

AIMS

Women with pre-existing diabetes should plan for optimal care of the disease before, during and after pregnancy. The aim of this study was to assess the quality of diabetes mellitus monitoring and care before, during and after pregnancy in a large cohort of women.

METHODS

1913 diabetic women resident in the Lombardy Region (Italy) who experienced at least a birth between 2011 and 2015 and exhibited signs of diabetes ≥2 years before delivery were identified using the healthcare utilization database. Antidiabetic care was defined via outpatient examinations (i.e., assessments of glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine, and dilated eye exams) and use of antidiabetic drugs. Differences in adherence to recommendations before, during and after pregnancy were assessed by the non-parametric McNemar's test among the whole cohort and among the subgroup with type 1 diabetes.

RESULTS

Adherence to recommendations was very poor before pregnancy, ranging from 13% to 42% for dilated eye and serum creatinine exam, respectively. During pregnancy, a significant portion of women increased adherence to all recommendations (e.g., glycated haemoglobin from 20% to 47%, p-value < 0.001), with the exception of lipid profile control. After pregnancy, adherence dropped to pre-pregnancy levels. A similar trend was observed in the use of antidiabetic drugs. Although women with type 1 diabetes showed better adherence across all periods, the same patterns emerged.

CONCLUSIONS

Besides an improvement in the indicators of clinical adherence during pregnancy, the management of diabetes among pregnant women remains sub-optimal both before and after the birth.