Influence of gestational diabetes mellitus on neonatal weight outcome in twin pregnancies

Greater risk of type 2 diabetes progression in multifetal gestations with gestational diabetes: the impact of obesity

BACKGROUND

The relationship between gestational diabetes mellitus and adverse outcomes in multifetal pregnancies is complex and controversial. Moreover, limited research has focused on the risk of gestational diabetes mellitus progression to type 2 diabetes mellitus specifically in multifetal pregnancies, resulting in conflicting results from existing studies.

OBJECTIVE

This study aimed to assess the risk of gestational diabetes mellitus progression to type 2 diabetes mellitus between singleton and multifetal pregnancies in a large cohort of parturients with a 5-year follow-up.

STUDY DESIGN

A retrospective study was conducted on a prospective cohort of pregnant individuals with pregnancies between January 1, 2017, and December 31, 2020, followed up to 5 years after delivery. Glucose levels during pregnancy were obtained from the Meuhedet Health Maintenance Organization laboratory system and cross-linked with the Israeli National Diabetes Registry. The cohort was divided into 4 groups: singleton pregnancy without gestational diabetes mellitus, singleton pregnancy with gestational diabetes mellitus, multifetal pregnancy without gestational diabetes mellitus, and multifetal pregnancy with gestational diabetes mellitus. Gestational diabetes mellitus was defined according to the American Diabetes Association criteria using the 2-step strategy. Univariate analyses, followed by survival analysis that included Kaplan-Meier hazard curves and Cox proportional-hazards models, were used to assess differences between groups and calculate the adjusted hazard ratios with 95% confidence intervals for progression to type 2 diabetes mellitus.

RESULTS

Among 88,611 parturients, 61,891 cases met the inclusion criteria. The prevalence of type 2 diabetes mellitus was 6.5% in the singleton pregnancy with gestational diabetes mellitus group and 9.4% in the multifetal pregnancy with gestational diabetes mellitus group. Parturients with gestational diabetes mellitus, regardless of plurality, were older and had higher fasting plasma glucose levels in the first trimester of pregnancy. The rates of increased body mass index, hypertension, and earlier gestational age at delivery were significantly higher in the gestational diabetes mellitus group among patients with singleton pregnancies but not among patients with multifetal pregnancies. Survival analysis demonstrated that gestational diabetes mellitus was associated with adjusted hazard ratios of type 2 diabetes mellitus of 4.62 (95% confidence interval, 3.69-5.78) in singleton pregnancies and 9.26 (95% confidence interval, 2.67-32.01) in multifetal pregnancies (P<.001 for both). Stratified analysis based on obesity status revealed that, in parturients without obesity, gestational diabetes mellitus in singleton pregnancies increased the risk of type 2 diabetes mellitus by 10.24 (95% confidence interval, 6.79-15.44; P<.001) compared with a nonsignificant risk in multifetal pregnancies (adjusted hazard ratio, 9.15; 95% confidence interval, 0.92-90.22; P=.059). Among parturients with obesity, gestational diabetes mellitus was associated with an increased risk of type 2 diabetes mellitus for both singleton and multifetal pregnancies (adjusted hazard ratio, 3.66; [95% confidence interval, 2.81-4.67; P<.001] and 9.31 [95% confidence interval, 2.12-40.76; P=.003], respectively).

CONCLUSION

Compared with gestational diabetes mellitus in singleton pregnancies, gestational diabetes mellitus in multifetal pregnancies doubles the risk of progression to type 2 diabetes mellitus. This effect is primarily observed in patients with obesity. Our findings underscore the importance of providing special attention and postpartum follow-up for patients with multifetal pregnancies and gestational diabetes mellitus, especially those with obesity, to enable early diagnosis and intervention for type 2 diabetes mellitus.

Gestational diabetes in twin pregnancies-a pathology requiring treatment or a benign physiological adaptation?

There is level-1 evidence that screening for and treating gestational diabetes in singleton pregnancies reduce maternal and neonatal morbidity. However, similar data for gestational diabetes in twin pregnancies are currently lacking. Consequently, the current approach for the diagnosis and management of gestational diabetes in twin pregnancies is based on the same diagnostic criteria and glycemic targets used in singleton pregnancies. However, twin pregnancies have unique physiological characteristics, and many of the typical gestational diabetes-related complications are less relevant for twin pregnancies. These differences raise the question of whether the greater increase in insulin resistance observed in twin pregnancies (which is often diagnosed as diet-treated gestational diabetes) should be considered physiological and potentially beneficial in which case alternative criteria should be used for the diagnosis of gestational diabetes in twin pregnancies. In this review, we summarize the most up-to-date evidence on the epidemiology, pathophysiology, and clinical consequences of gestational diabetes in twin pregnancies and review the available data on twin-specific screening and diagnostic criteria for gestational diabetes. Although twin pregnancies are associated with a higher incidence of diet-treated gestational diabetes, diet-treated gestational diabetes in twin pregnancies is less likely to be associated with adverse outcomes and accelerated fetal growth than in singleton pregnancies and may reduce the risk for intrauterine growth restriction. In addition, there is currently no evidence that treatment of diet-treated gestational diabetes in twin pregnancies improves outcomes, whereas preliminary data suggest that strict glycemic control in such cases might increase the risk for intrauterine growth restriction. Overall, these findings provide support to the hypothesis that the greater transient increase in insulin resistance observed in twin pregnancies is merely a physiological exaggeration of the normal increase in insulin resistance observed in singleton pregnancies (that is meant to support 2 fetuses) rather than a pathology that requires treatment. These data illustrate the need to develop twin-specific screening and diagnostic criteria for gestational diabetes to avoid overdiagnosis of gestational diabetes and to reduce the risks associated with overtreatment of diet-treated gestational diabetes in twin pregnancies. Although data on twin-specific screening and diagnostic criteria are presently scarce, preliminary data suggest that the optimal screening and diagnostic criteria in twin pregnancies are higher than those currently used in singleton pregnancies.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY ELIGIBILITY CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Different subtypes of gestational diabetes mellitus are associated with distinct perinatal outcomes in twin pregnancies

AIMS

To determine whether different gestational diabetes mellitus (GDM) subtypes are associated with distinct perinatal outcomes in twin pregnancies.

MATERIALS

This retrospective cohort study enrolled women with twin pregnancies who gave birth at a tertiary hospital between January 2017 and December 2022. GDM was diagnosed by the IADPSG diagnostic criteria. Three subtypes of GDM were defined as only abnormal fasting glucose (OAFG) values, only abnormal post-load glucose (OAPG) values and abnormal combined fasting and post-load glucose (ACFPG) values. Logistic regression or generalized estimation equation models were used to test the correlation of subtypes of GDM and perinatal outcomes.

RESULTS

GDM with OAPG had a slightly higher risk for preterm delivery (PTD) at <37 gestational weeks (aOR 1.22, 95 %CI 1.01-1.47) and neonatalintensivecareunit (NICU) admission (aOR 1.31, 95 %CI 1.09-1.57). GDM with ACFPG were associated with PTD at <37 gestational weeks (aOR 1.42, 95 %CI 1.06-1.89) and PTD at <34 gestational weeks (aOR 1.65, 95 % CI 1.14-2.39). GDM with OAFG had a lower risk of being small-for-gestational age (SGA) (aOR 0.48, 95 % CI 0.26-0.92).

CONCLUSIONS

Different subtypes of GDM are associated with distinct perinatal outcomes. Only abnormal fasting glucose levels may be responsible for reduced the risk of SGA neonates.

Gestational Diabetes Mellitus Does Not Worsen Obstetrical and Neonatal Outcomes of Twin Pregnancy

The specific effects of gestational diabetes mellitus (GDM) on twin pregnancy outcomes, which are at high risk per se, are unclear. The present study analyzes outcomes of twin pregnancies complicated by GDM (n = 227) by comparing them with GDM singleton pregnancies (n = 1060) and with twin pregnancies without GDM (n = 1008), all followed up at Sant'Anna Hospital, Turin (Italy), between January 2010 and March 2020. The prevalence of GDM among twin pregnancies (n = 1235) was 18.4%. Compared to GDM singletons, GDM twins had higher rates of preeclampsia (aOR 2.0; 95% CI 1.2-3.8), cesarean section (aOR 7.5; 95% CI 5.2-10.8), and neonatal hypoglycemia (aOR 2.5; 95% CI 1.1-5.3). They had a higher incidence of abnormal 2 h OGTT values (aOR 7.1; 95% CI: 3.2-15.7) and were less likely to require insulin therapy (aOR 0.5; 95% CI: 0.3-0.7). In comparison with twin pregnancies without GDM, women with GDM twins were significantly older (35.0 vs. 33.0 years; p < 0.001) and had higher BMI (23.0 versus 22.0 kg/m²; p < 0.001); they had a higher incidence of LGA newborns (aOR 5.3; 95% CI 1.7-14.8), and lower incidence of low APGAR scores (0.5; 95% CI 0.3-0.9). Overall, GDM does not worsen outcomes of twin pregnancy, which is per se at high risk for adverse outcomes.

Impact of Gestational Diabetes and Hypertension Disorders of Pregnancy on Neonatal Outcomes in Twin Pregnancies Based on Chorionicity

OBJECTIVES

The objective of this study was to investigate the impact of the co-existence of gestational diabetes (GDM) and hypertension disorders of pregnancy (HDP) on neonatal outcomes in twin pregnancies based on chorionicity.

METHODS

A retrospective study of 1398 women with twin pregnancies was performed between January 2016 and December 2021. The effects of GDM and HDP on neonatal outcomes were assessed by logistic regression models. An additional stratified analysis was conducted to estimate the effects based on chorionicity (monochorionic (MC) and dichorionic (DC)).

RESULTS

The incidence of the co-existence of GDM and HDP was 3.8%. The presence of GDM increased the likelihood of HDP only in women with MC twin pregnancies (OR, 2.13; 95% CI 1.08-4.19). After adjustments, co-existence of GDM and HDP was positively associated with gestational age (β, 1.06; 95% CI 0.43-1.69) and birthweight (β, 174.90; 95% CI 8.91-340.89) in MC twin pregnancies, while no associations were found between co-existence of GDM and HDP and neonatal outcomes in DC twin pregnancies. However, HDP was negatively associated with birthweight (β, -156.97; 95% CI (-257.92, -56.02)) and positively associated with small-for-gestational-age (SGA) (OR, 2.03; 95% CI 1.02-4.03) and discordant twins (OR, 2.83; 95% CI 1.78-4.48) in DC twin pregnant women without GDM.

CONCLUSIONS

Our results suggested that GDM leads to an increased risk of HDP only in MC twin pregnancies, but GDM seemed to attenuate the adverse effects of HDP on perinatal outcomes in both MC and DC twin pregnancies. Further investigation is needed to explain these intriguing findings.

Comparing the course and delivery outcomes of Japanese twin pregnancies with and without gestational diabetes mellitus: a single-center retrospective analysis

Singleton pregnant women with gestational diabetes mellitus (GDM) are at an increased risk of adverse maternal and neonatal outcomes. Multiple pregnancies are associated with increased risks of perinatal complications; however, the impact of GDM on maternal and neonatal outcomes in multiple pregnancies is unknown, and there are currently few reports on GDM status in twin pregnancies. This study aimed to compare the background and perinatal outcomes between Japanese twin pregnancies with and without GDM at a perinatal center in Japan. Additionally, the clinical course of GDM was investigated. In this retrospective cohort study, women with twin pregnancies underwent GDM screening at Yokohama City University Medical Center from January 2011 to December 2016. Overall, 307 twin pregnancies were divided into GDM (47 cases, 15.3%) and non-GDM (260 cases, 84.7%) groups. GDM-associated pregnancy complications, GDM status, and pregnancy outcomes were ascertained. Women with GDM were older and had a higher pre-pregnancy body mass index than those without GDM. Glycemic control was good in all patients, and there was no difference in delivery outcomes between the two groups. Gestational weight gain was lower in pregnant women with GDM (+8.0 kg) than in those without GDM (+11.8 kg), suggesting the impact of strict nutritional guidance on twin pregnancies with GDM. In conclusion, twin pregnancies with GDM did not have different delivery outcomes compared to those without GDM. To manage twin pregnancies with GDM, this study suggests that it is important to monitor patients' weight and blood glucose levels.

The effect of maternal gestational diabetes on maternal and neonatal outcomes in twin pregnancies: a systematic review and meta-analysis

Diabetes and twin pregnancies are known risk factors for poor perinatal and neonatal outcomes. However, the effects of these two entities occurring together are still unclear. PubMed, Scopus and Google Scholar databases were searched in a systematic manner to identify observational studies among twin pregnancies, which documented the association of gestational diabetes with maternal and neonatal outcomes. All the analysis was done using STATA software. The meta-analysis included 21 studies, of which majority were retrospective data based. Mothers with gestational diabetes had higher risks of hypertensive disorder in pregnancy, caesarean section, large for gestational age baby, NICU admission and neonatal hypoglycaemia compared to mothers without gestational diabetes. Diabetic mothers were at reduced risk of small for gestational age baby and low APGAR score. No statistically significant differences in the risk of low birth weight, mean birth weight, prematurity and neonatal death were noted. This meta-analysis observed increased risks of detrimental maternal, neonatal and perinatal outcomes in twin pregnancies complicated by gestational diabetes, underscoring the need for the early detection and management of gestational diabetes.

Perinatal outcomes among twin pregnancies with gestational diabetes mellitus: A nine-year retrospective cohort study

Objective

To compare the outcomes between gestational diabetes mellitus (GDM) vs. non-GDM twin gestations.

Methods

A retrospective cohort study of 2,151 twin pregnancies was performed in a tertiary hospital in Foshan, China, 2012–2020. Pregnancy and neonatal outcomes were compared between women with vs. without GDM using 1:1 propensity score matching (PSM) and multivariable logistic models. For neonatal outcomes, generalized estimating equation (GEE) approach was used to address the intertwin correlation.

Results

Of the 2,151 participants, 472 women (21.9%) were diagnosed with GDM. Women with GDM were older and more likely to be overweight or obese, and more likely have chronic hypertension, assisted pregnancies and dichorionic twins. In the PSM cohort of 942 pregnancies, there was no statistical difference when comparing GDM twin pregnancies and non-GDM in any of the perinatal outcomes, especially in terms of preterm birth (PTB) <37 weeks (P = 0.715), large for gestational age (LGA) (P = 0.521) and neonatal respiratory distress (NRDS) (P = 0.206). In the entire cohort, no significant adjusted ORs for these outcomes were obtained from logistic regression models adjusted for confounders (aOR for PTB < 37 weeks: 1.25, 95% CI: 0.98–1.58; aOR for LGA: 1.26, 95% CI: 0.88–1.82; and aOR for NRDS, 1.05, 95% CI: 0.68–1.64).

Conclusion

Twin pregnancies with GDM and adequate prenatal care have comparable perinatal outcomes to those without.

Gestational diabetes in twin pregnancy: A predictor of adverse fetomaternal outcomes?

AIM

To compare fetomaternal outcomes between GDM pregnant women with twin versus singleton pregnancies and then between women with GDM versus non-GDM twin pregnancies.

METHODS

We performed a retrospective study including GDM pregnant women with both twin and singleton pregnancies followed in our tertiary center between 2011 and 2018. The fetomaternal characteristics of each group were compared. We then compared women with GDM twin pregnancy followed at our institution between 2011 and 2018 to non-GDM twin pregnant women giving childbirth in 2018.

RESULTS

A total of 1127 GDM pregnant women were evaluated: 42 with twin pregnancy and 1085 with singleton pregnancy. Preeclampsia (14.3% vs. 3.3%, p < 0.001) and cesarean delivery (76.2% vs. 36.9%, p < 0.001) were more frequent among women with twin pregnancy. Neonatal morbidity was also more common among neonates delivered from twin pregnant women, including preterm labor (73.8% vs. 7.8%, p < 0.001), hypoglycemia (6% vs. 4.8%, p = 0.043), hyperbilirubinemia (33.3% vs. 9.0%, p < 0.001), RDS (28.6% vs. 2.7%, p < 0.001), admission in NICU (32.1% vs. 4.5%, p < 0.001) and SGA (19.0% vs. 11.0%, p = 0.001). Overall there were no significant differences in fetomaternal morbidity parameters between GDM (n = 42) versus non-GDM (n = 83) twin pregnancies, although SGA infants were more frequent in the latter group (33.9% vs. 19.0%, p = 0.014).

CONCLUSIONS

In GDM pregnant women, twin pregnancy seems to be associated with an increased prevalence of neonatal morbidity when compared to singleton pregnancy. On the other hand, in twin pregnancy, diagnosis of GDM does not seem to be associated with poorer fetomaternal outcomes. GDM seems to be protective for the occurrence of SGA neonates in twin pregnancies.

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

OBJECTIVE

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

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

REVIEW REGISTRATION

PROSPERO CRD42021265837.

Gestational Diabetes Mellitus and Preeclampsia: Correlation and Influencing Factors

Gestational diabetes mellitus (GDM) and preeclampsia (PE) are common pregnancy complications with similar risk factors and pathophysiological changes. Evidence from previous studies suggests that the incidence of PE is significantly increased in women with GDM, but whether GDM is independently related to the occurrence of PE has remained controversial. GDM complicated by PE further increases perinatal adverse events with greater impact on the future maternal and offspring health. Identify factors associated with PE in women with GDM women, specifically those that are controllable, is important for improving pregnancy outcomes. This paper provides the findings of a review on the correlation between GDM and PE, factors associated with PE in women with GDM, possible mechanisms, and predictive markers. Most studies concluded that GDM is independently associated with PE in singleton pregnancy, and optimizing the treatment and management of GDM can reduce the incidence of PE, which is very helpful to improve pregnancy outcomes.

Perinatal outcomes of twin pregnancies with preterm premature rupture of the membranes at 24-34 weeks' gestation

To describe the perinatal outcomes of twin pregnancies with preterm premature rupture of membranes (PPROM) before 34 weeks’ gestation and identify factors associated with discharge without severe or moderate-severe neonatal morbidity. This study was conducted as a retrospective analysis of twin pregnancies with PPROM occurring at 24 0/7 to 33 6/7 weeks’ gestation. Perinatal outcomes were assessed by gestational age (GA) at PPROM and compared between PPROM and non PPROM twins. Factors associated with discharge without severe or moderate-severe neonatal morbidity were identified using logistic regression analysis. Of the 180 pregnancies (360 foetuses), only 17 (9.4%) women remained pregnant 7 days after PPROM. There were 10 (2.8%) cases of prenatal or neonatal death; 303 (84.2%) and 177 (49.2%) neonates were discharged without severe or moderate-severe morbidity, respectively. As GA at PPROM increased, the adverse obstetric and neonatal outcomes decreased, especially after 32 weeks. There was no significant difference in general neonatal outcomes between PPROM and non PPROM twins. The GA at PPROM and latency period were both significantly associated with discharge without severe or moderate-severe neonatal morbidity. Pregnancy complications and 5-min Apgar score < 7 increased severe neonatal morbidity. As GA at PPROM increased, the risk of adverse perinatal outcomes decreased. GA at PPROM and latency period were significantly associated with discharge without severe or moderate-severe neonatal morbidity.

Gestational diabetes and fetal growth in twin compared with singleton pregnancies

BACKGROUND

Gestational diabetes mellitus is associated with accelerated fetal growth in singleton pregnancies but may affect twin pregnancies differently because of the slower growth of twin fetuses during the third trimester of pregnancy and their greater predisposition to fetal growth restriction.

OBJECTIVE

This study aimed to evaluate the association of gestational diabetes mellitus with longitudinal fetal growth in twin pregnancies and to compare this association with that observed in singleton pregnancies.

STUDY DESIGN

This was a retrospective cohort study of all women with a singleton or twin pregnancy who were followed up at a single tertiary referral center between January 2011 and April 2020. Data on estimated fetal weight and individual fetal biometric indices were extracted from ultrasound examinations of eligible women. Generalized linear models were used to model and compare the change in fetal weight and individual biometric indices as a function of gestational age between women with and without gestational diabetes mellitus in twin pregnancies and between women with and without gestational diabetes mellitus in singleton pregnancies. The primary outcome was estimated fetal weight as a function of gestational age. The secondary outcomes were longitudinal growth of individual fetal biometric indices and the rate of small for gestational age and large for gestational age at birth.

RESULTS

A total of 26,651 women (94,437 ultrasound examinations) were included in the analysis: 1881 with a twin pregnancy and 24,770 with a singleton pregnancy. The rate of gestational diabetes mellitus in the twin and singleton groups was 9.6% (n=180) and 7.6% (n=1893), respectively. The estimated fetal weight in singleton pregnancies with gestational diabetes mellitus was significantly higher than that in pregnancies without gestational diabetes mellitus (P<.001) starting at approximately 30 weeks of gestation. The differences remained similar after adjusting for maternal age, chronic hypertension, nulliparity, and neonatal sex (P<.001). In twin pregnancies, fetal growth was similar between pregnancies with and without gestational diabetes mellitus (P=.105 and P=.483 for unadjusted and adjusted models, respectively). The findings were similar to the association of gestational diabetes mellitus with the risk of large for gestational fetuses and the growth of each biometric index. When stratified by type of gestational diabetes mellitus treatment, twin pregnancies with gestational diabetes mellitus was associated with accelerated fetal growth only in the subgroup of women with medically treated gestational diabetes mellitus (P<.001), which represented 12% (n=21) of the twin pregnancy group with gestational diabetes mellitus.

CONCLUSION

In contrast to singleton pregnancies, twin pregnancies with gestational diabetes mellitus is less likely to be associated with accelerated fetal growth. This finding has raised the question of whether the diagnostic criteria for gestational diabetes mellitus and the blood glucose targets in women diagnosed with gestational diabetes mellitus should be individualized for twin pregnancies.

Risk factors and adverse maternal and perinatal outcomes for women with dichorionic twin pregnancies complicated by gestational diabetes mellitus: A retrospective cross-sectional study

AIMS/INTRODUCTION

The association between gestational diabetes mellitus (GDM) and adverse maternal and perinatal outcomes in twin pregnancies remains unclear. This study was undertaken to highlight risk factors for GDM in women with dichorionic (DC) twins, and to determine the association between GDM DC twins and adverse maternal and perinatal outcomes in a large homogeneous Taiwanese population.

MATERIALS AND METHODS

A retrospective cross-sectional study was carried out on 645 women with DC twins, excluding pregnancies complicated by one or both fetuses with demise (n = 22) or congenital anomalies (n = 9), who gave birth after 28 complete gestational weeks between 1 January 2001 and 31 December 2018. Univariable and multiple logistic regression analyses were carried out.

RESULTS

Maternal age >34 years (adjusted odds ratio 2.52; 95% confidence interval 1.25-5.07) and pre-pregnancy body mass index >24.9 kg/m2 (adjusted odds ratio 2.83, 95% confidence interval 1.47-5.46) were independent risk factors for GDM in women with DC twins. Newborns from women with GDM DC twins were more likely to be admitted to the neonatal intensive care unit (adjusted odds ratio 1.70, 95% confidence interval 1.06-2.72) than newborns from women with non-GDM DC twins. Other pregnancy and neonatal outcomes were similar between the two groups.

CONCLUSIONS

Advanced maternal age and pre-pregnancy overweight or obesity are risk factors for GDM in women with DC twins. Except for a nearly twofold increased risk of neonatal intensive care unit admission of newborns, the pregnancy and neonatal outcomes for women with GDM DC twins are similar to those for women with non-GDM DC twins.

Perinatal outcomes in twin pregnancies complicated by gestational diabetes

BACKGROUND

Gestational diabetes in singleton pregnancies increases the risk for large for gestational age infants, hypertensive disorders of pregnancy, and neonatal morbidity. Compared with singleton gestations, twin gestations are at increased risk for fetal growth abnormalities, hypertensive disorders, and neonatal morbidity. Whether gestational diabetes further increases the risk for these outcomes is unclear.

OBJECTIVE

We sought to determine the relationship between gestational diabetes and the risk for preeclampsia, fetal growth abnormalities, and neonatal intensive care unit admissions in a large cohort of women with twin pregnancies.

STUDY DESIGN

We used a retrospective cohort of all twin gestations that were delivered at our institution from 1998 to 2013. We excluded pregnancies delivered before 24 weeks' gestation, monochorionic-monoamniotic twins, and patients with preexisting diabetes for a final cohort of 2573 twin deliveries. Gestational diabetes was defined as 2 abnormal values on a 100 g, 3-hour glucose challenge test as defined by the Carpenter-Coustan criteria or a 1-hour value of 200 mg/dL after a 50 g glucose test. Multivariable Poisson regression models were used to estimate the associations between gestational diabetes and preeclampsia, small for gestational age infants, large for gestational age infants, and admission to the neonatal intensive care unit after adjusting for prepregnancy body mass index, maternal race, maternal age, parity, use of in vitro fertilization, prepregnancy smoking status, and chronic hypertension as confounders.

RESULTS

The unadjusted incidence of gestational diabetes was 6.5% (n=167). Women with gestational diabetes were more likely to be aged 35 years or older, living with obesity, and have conceived via in vitro fertilization than women without gestational diabetes. Preeclampsia was more common among women with twin pregnancies complicated by gestational diabetes (31%) than among women with twin pregnancies without gestational diabetes (18%) (adjusted risk ratio, 1.5; 95% confidence interval, 1.1-2.1). A diagnosis of small for gestational age infant was less common among women with gestational diabetes (17%) than among women without gestational diabetes (24%), although the results were imprecise (adjusted risk ratio, 0.8; 95% confidence interval, 0.5-1.1). There was no association between gestational diabetes and the incidence of large for gestational age neonates or neonatal intensive care unit admissions. Among women with gestational diabetes who reached 35 weeks' gestation, 62% (n=60) required medical management.

CONCLUSION

Gestational diabetes is a risk factor for preeclampsia among women with twin pregnancies. Close blood pressure monitoring and patient education are critical for this high-risk group. The association between gestational diabetes and neonatal outcomes among women with twin pregnancies is less precise, although it may reduce the incidence of small for gestational age infants. Prospective studies to determine if glycemic control decreases the risk for preeclampsia in twin pregnancies with gestational diabetes are needed.

Trends in Prevalence of Diabetes among Twin Pregnancies and Perinatal Outcomes in Catalonia between 2006 and 2015: The DIAGESTCAT Study

The aims of our study were to evaluate the trends in the prevalence of diabetes among twin pregnancies in Catalonia, Spain between 2006 and 2015, to assess the influence of diabetes on perinatal outcomes of twin gestations and to ascertain the interaction between twin pregnancies and glycaemic status. A population-based study was conducted using the Spanish Minimum Basic Data Set. Cases of gestational diabetes mellitus (GDM) and pre-existing diabetes were identified using ICD-9-CM codes. Data from 743,762 singleton and 15,956 twin deliveries between 2006 and 2015 in Catalonia was analysed. Among twin pregnancies, 1088 (6.82%) were diagnosed with GDM and 83 (0.52%) had pre-existing diabetes. The prevalence of GDM among twin pregnancies increased from 6.01% in 2006 to 8.48% in 2015 (p < 0.001) and the prevalence of pre-existing diabetes remained stable (from 0.46% to 0.27%, p = 0.416). The risk of pre-eclampsia was higher in pre-existing diabetes (15.66%, p = 0.015) and GDM (11.39%, p < 0.001) than in normoglycaemic twin pregnancies (7.55%). Pre-existing diabetes increased the risk of prematurity (69.62% vs. 51.84%, p = 0.002) and large-for-gestational-age (LGA) infants (20.9% vs. 11.6%, p = 0.001) in twin gestations. An attenuating effect on several adverse perinatal outcomes was found between twin pregnancies and the presence of GDM and pre-existing diabetes. As a result, unlike in singleton pregnancies, diabetes did not increase the risk of all perinatal outcomes in twins and the effect of pre-existing diabetes on pre-eclampsia and LGA appeared to be attenuated. In conclusion, prevalence of GDM among twin pregnancies increased over the study period. Diabetes was associated with a higher risk of pre-eclampsia, prematurity and LGA in twin gestations. However, the impact of both, pre-existing diabetes and GDM, on twin pregnancy outcomes was attenuated when compared with its impact on singleton gestations.

The effect of sleep impairment on gestational diabetes mellitus: a systematic review and meta-analysis of cohort studies

OBJECTIVE

This systematic review and meta-analysis evaluated the influence of sleep duration or impairment (poor sleep quality, snoring, and obstructive sleep apnea [OSA]) on gestational diabetes mellitus (GDM) risk.

METHODS

PubMed, Embase, EBSCO, and WOS databases were searched up to March 4th, 2019. Cohort studies were included and relative risk (RR) with 95% confidence interval (CI) were used as the measure of effects. Heterogeneity was assessed by the Chi-squared and I² tests. Subgroup analyses, sensitivity analysis, and dose-response analysis were performed. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 16 studies with 2,551,017 pregnant women and 142,103 GDM cases were included in this study. Both short and long sleep duration were associated with increased risk of GDM. There was a U-shaped relationship between sleep duration and GDM risk (P_{-nonlinearity} < 0.001), and pregnant women with 8 h of sleep presented lower GDM risk. Poor sleep quality, snoring and OSA also increased the subsequent risk of GDM.

CONCLUSIONS

Pregnant women should be made aware of the benefits of proper sleep, and those with poor sleep quality, snoring, and OSA should be screened for GDM.

Maternal dietary patterns and risk of gestational diabetes mellitus in twin pregnancies: a longitudinal twin pregnancies birth cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) is correlated with an increased risk of adverse perinatal outcomes for both the mother and offspring. Previous research has reported correlations between maternal dietary patterns and GDM, but such evidence for twin pregnancies is lacking. This study aimed to identify maternal dietary patterns in the second trimester and investigate their relationships with the risk of GDM among women who were pregnant with twins in China.

METHODS

A longitudinal twin pregnancies birth cohort study of women who were pregnant with twins in China was conducted. Maternal dietary intake in the second trimester was recorded by using a food frequency questionnaire prior to the diagnosis of GDM among participants from the prospective twin pregnancies birth cohort in Chongqing City. GDM was diagnosed with a 75 g 2-h oral glucose tolerance test at 23-26 weeks of gestation. Dietary patterns were identified by principal components analysis, and the correlations between dietary pattern and GDM were examined using multivariable logistic regression analyses.

RESULTS

Of the 324 participants, 101 (31.2%) were diagnosed with GDM. Four dietary patterns were identified: a vegetable-based pattern, a poultry-and-fruit-based pattern, a sweet-based pattern and a plant-protein-based pattern. Multivariate analysis showed that none of the dietary patterns were correlated with the risk of GDM among women who were pregnant with twins, but the sweet-based dietary pattern, which was associated with a higher GDM risk for quartile 4 versus quartile 1 (OR 2.69; 95% CI: 1.09, 6.66) among non-overweight women (prepregnancy BMI < 24.0).

CONCLUSION

Dietary patterns were not correlated with later GDM risk among women who were pregnant with twins in western China, whereas a high intake of sweets was associated with a higher risk for GDM among women who were not overweight prior to pregnancy.

TRIAL REGISTRATION

ChiCTR-OOC-16008203. Retrospectively registered on 1 April 2016.

Maternal diabetes mellitus and risk of neonatal respiratory distress syndrome: a meta-analysis

AIM

The relationship between maternal diabetes mellitus (DM) and neonatal respiratory distress syndrome (RDS) has long been recognized, but the conclusions of this relationship were non-consistent. We conducted this meta-analysis to explore the association between maternal DM and the risk of neonatal RDS.

METHODS

We searched PubMed and Web of Science databases for cohort or case-control studies related to the association of maternal DM and neonatal RDS risk up to 25 August 2018. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by the use of random effect model. Meta-regression was used to explore potential sources of between-study heterogeneity.

RESULTS

A total of 24 studies from 23 available articles were included in this meta-analysis. For the association between maternal DM and the risk of neonatal RDS, the pooled OR was 1.47 (95% CI 1.24-1.74), especially for cohort studies (1.39, 95% CI 1.17-1.65). The pooled OR of the risk of neonatal RDS was 1.57 (95% CI 1.28-1.93) for gestational diabetes mellitus (GDM) and 2.66 (95% CI 2.06-3.44) for pre-gestational diabetes mellitus (PGDM).

CONCLUSIONS

This meta-analysis suggests that maternal DM, including GDM and PGDM, is linked to an increased risk of neonatal RDS.

Hypertensive disorders of pregnancy in twin gestations complicated by gestational diabetes. J Matern Fetal Neonatal Med 2019;34:720-724. [PMID: 31096815 DOI: 10.1080/14767058.2019.1614160]

Objective: Gestational diabetes (GDM) in singleton pregnancies is known to be associated with an increased risk for hypertensive disorders of pregnancy. The data are mixed regarding the effect of GDM on the risk for hypertensive disorders of pregnancy in twin gestations. The objective of our study was to assess the rate of hypertensive disorders of pregnancy in twin gestations complicated by GDM.Methods: This is a secondary analysis of a multicenter randomized trial in which twin gestations were assigned to weekly intramuscular injections of progesterone in order to reduce the rate of preterm birth. We included all twin pregnancies with and without GDM. Women with pregestational diabetes, chronic hypertension, twin pregnancies complicated by twin to twin transfusion syndrome and congenital fetal anomalies were excluded. Our primary outcome was the rate of hypertensive disorders in twin pregnancies complicated by GDM. Our secondary outcomes included the rate of cesarean section, number of neonates who were small for gestational age, Apgar scores, and a composite adverse neonatal outcome. Logistic regression analysis was used to control for confounding variables.Results: Six hundred fourteen twin pregnancies were included, 570 (93%) without GDM and 44 (7%) with GDM. The group with GDM had a significantly higher prepregnancy body mass index (BMI) and maternal age, and were more likely to have undergone in vitro fertilization (IVF). The rate of hypertensive disorders of pregnancy in the GDM group was significantly higher when compared to the non-GDM group (31.8 versus 17.9%, p = .033, RR 1.78 [95% CI = 1.11-2.84]); however, after adjusting for maternal age, IVF treatment and prepregnancy BMI, this association lost its statistical significance (aRR = 1.36 [95% CI = 0.83-2.21]). The cesarean section rate was higher in the GDM group as compared to the non-GDM group and after adjusting for confounders, the rate of cesarean section was still higher in the GDM group (77.3 versus 61.1%, p = .003, aRR = 1.27 [95% CI = 1.06-1.50]). Neonates born to women in the GDM group were more likely to experience the adverse composite outcome (26.4 versus 8.2%, p = 0.02, RR = 1.81 [95% CI = 1.09-2.99]).Conclusion: In this prospective cohort of twin pregnancies, the rate of hypertensive disorders of pregnancy did not differ between women with and without gestational diabetes after adjusting for maternal age, IVF treatment, race, and prepregnancy BMI. To better target complications associated with GDM in twin gestations, large prospective studies evaluating the effect of GDM on outcomes specifically in twin pregnancies are warranted.

Does Gestational Diabetes Cause Additional Risk in Twin Pregnancy?

It has been suggested that the risk of adverse perinatal outcomes in twin pregnancies is exacerbated by concomitant gestational diabetes mellitus (GDM). This study aimed to assess the risk incurred by twin pregnancy and by a diagnosis of GDM, separately, on the development of poor perinatal outcomes. A retrospective cohort study was conducted on all pregnant women at a tertiary center between 2016 and 2017. The impact of GDM and twin pregnancies on perinatal outcomes — birth weight above the 90th centile for gestational age, cesarean delivery, clinical neonatal hypoglycemia, and premature delivery (before 37 weeks’ gestation) — was assessed using univariate and multivariate analyses. Overall, 13,527 women were eligible for the study; 11,915 were uncomplicated singleton pregnancies; 1379 of these had GDM; 194 were twin pregnancies, and 39 of these had GDM. Univariate analyses showed that twin pregnancies were associated with a higher risk of all perinatal outcomes except macrosomia. In the multivariate analyses, twin pregnancy was a much higher predictor of cesarean delivery (OR 8.40, 95% CI [6.25, 11.49], p < .0001) and preterm birth (OR 58.82, 95% CI [31.25, 125], p < .0001) compared to GDM but GDM was a higher predictor of neonatal hypoglycemia (OR 4.87, 95% CI [3.74, 6.29], p < .0001). Twin pregnancy is more strongly associated with all adverse perinatal outcomes except macrosomia. GDM does not increase risk of adverse perinatal outcomes except for neonatal hypoglycemia.

Gestational diabetes mellitus is associated with adverse outcomes in twin pregnancies

BACKGROUND

Among singleton pregnancies, gestational diabetes mellitus is associated with adverse outcomes. In twin pregnancies, this association may be attenuated, given the higher rate of prematurity and the a priori increased risk of some of these complications.

OBJECTIVE

Our aim was to test the hypothesis that gestational diabetes mellitus is less likely to be associated with adverse pregnancy outcomes in twin compared with singleton gestations.

METHODS

This retrospective cohort study comprised all twin and singleton live births in Ontario, Canada, 2012-2016. Pregnancy outcomes were compared between women with vs without gestational diabetes mellitus, analyzed separately for twin and singleton births. Adjusted risk ratios and 95% confidence intervals were generated using modified Poisson regression, adjusting for maternal age, nulliparity, smoking, race, body mass index, preexisting hypertension, and assisted reproductive technology.

RESULTS

A total of 270,843 women with singleton (n = 266,942) and twin (n = 3901) pregnancies met the inclusion criteria. In both the twin and singleton groups, gestational diabetes mellitus was associated with (adjusted risk ratio, [95% confidence interval]) cesarean delivery (1.11 [1.02-1.21] and 1.20 [1.17-1.23], respectively) and preterm birth at <37^0/7 weeks (1.21 [1.08-1.37] and 1.48 [1.39-1.57]) and at <34^0/7 weeks (1.45 [1.03-2.04] and 1.25 [1.06-1.47]). In singletons, but not twins, gestational diabetes mellitus was associated with gestational hypertension (1.66 [1.55-1.77]) and preeclampsia. With respect to neonatal outcomes, gestational diabetes mellitus was associated with birthweight greater than the 90th percentile in both twins and singletons, with the risk being 2-fold higher in twins (2.53 [1.52-4.23] vs 1.18 [1.13-1.23], respectively, P = .004). Gestational diabetes mellitus was associated with jaundice in both twins (1.56 [1.10-2.21]) and singletons (1.49 [1.37-1.62) but was associated with the following complications only in singletons: neonatal intensive care unit admission (1.44 [1.38-1.50]), respiratory morbidity (1.09 [1.02-1.16]), and neonatal hypoglycemia (3.20 [3.01-3.40]).

CONCLUSION

In contrast to singleton pregnancies, gestational diabetes mellitus in twins was not associated with hypertensive complications and certain neonatal morbidities. Still, the current study highlights that gestational diabetes mellitus is associated with some adverse pregnancy outcomes including accelerated fetal growth also in twin pregnancies.

Incidence and risk factors for gestational diabetes mellitus in twin versus singleton pregnancies

OBJECTIVE

To compare the incidence and risk factors for gestational diabetes mellitus (GDM) between women with twin and singleton pregnancies.

METHODS

Retrospective study of all women who had a twin or singleton birth in Ontario (2012-2016). Risk ratios (RR) and 95% CIs for GDM (stratified by type of treatment) were adjusted for relevant confounding variables. Multivariable Poisson regression analysis was used to identify risk factors for GDM in twin and singleton gestations.

RESULTS

Of 270,843 women who met inclusion criteria, 266,942 (98.6%) and 3901 (1.4%) had a singleton and a twin pregnancy, respectively. Women with twins had a significantly higher risk for overall GDM (aRR = 1.13, 95% CI 1.01-1.28) and diet-treated GDM (aRR = 1.20, 95% CI 1.01-1.42) while the association with insulin-treated GDM was not significant (aRR = 1.07, 95% CI 0.89-1.28). Maternal age ≥ 35 years, non-Caucasian ethnicity and BMI > 30 kg/m² were independent risk factors for GDM among women with twins and singletons, and the magnitude of the association of these factors with GDM was similar.

CONCLUSIONS

Women with twins are at increased risk of GDM, mainly due to a higher rate of diet-treated GDM. Despite higher baseline risk of GDM in women with twins, the effect of known risk factors for GDM is similar to that observed in singletons.

Outcomes of twin pregnancies complicated by gestational diabetes: a meta-analysis of observational studies

OBJECTIVE

Gestational diabetes mellitus (GDM) in singleton pregnancy is associated with large for gestational age neonates and adverse perinatal outcomes; however, the impact of GDM in twin pregnancy is unclear. Thus, the aim of this study is to assess the perinatal outcomes of twin pregnancies complicated by GDM by performing a meta-analysis of observational studies.

STUDY DESIGN

Studies investigating GDM in twin pregnancy were identified through an online search of three databases: Medline, Embase and Web of Science. Selection criteria comprised full paper observational studies (retrospective or prospective) published in English that examined GDM in twin pregnancy compared with non-GDM twin pregnancy and reported on birth weight and/or adverse perinatal outcomes. Random-effects models with inverse-variance weighting were used to calculate standardized mean differences and unadjusted odds ratios. Sensitivity analyses were carried out to determine the impact of possible maternal confounders (body mass index and age) and GDM diagnostic criteria on perinatal outcomes.

RESULTS

Thirteen observational studies were included. GDM twins were born at the same gestation as non-GDM twins, with marginally lower birth weight. There was no difference in the incidence of large or small for gestational age neonates. Although there was no correlation between GDM in twin pregnancy and respiratory distress, neonatal hypoglycemic or low Apgar score, GDM twins had a higher rate of neonatal intensive care unit admission (OR 1.49; 95% confidence interval: 1.10, 2.02; P<0.01).

CONCLUSION

Identification and subsequent treatment of GDM in twin pregnancy demonstrates a similar risk of adverse perinatal outcomes compared with non-GDM twin pregnancies.

Three patients presenting with severe macrosomia and congenital hypertrophic cardiomyopathy: a case series

Background

Macrosomia and hypertrophic cardiomyopathy are two features often associated in neonates of diabetic mothers. We report the cases of three patients with severe macrosomia and critical hypertrophic cardiomyopathy without severely unbalanced maternal diabetes. Only three patients with those two features and no uncontrolled maternal diabetes have been previously reported.

Case presentation

The first patient was a 39-week-old girl, the second patient was a 39-week-old girl, and the third patient was a 41-week-old boy. The two French girls and the French boy had severe macrosomia and hypertrophic cardiomyopathy, leading to the death of the boy. The outcome of the two girls was favorable, with a standardization of growth curves and ventricular hypertrophy. Their mothers presented with high body mass index but no severe documented maternal diabetes; glycemic imbalance was only suspected on postnatal analyses. There was no hydramnios during pregnancy and no other environmental factor, especially toxic exposure. Their parents are from Mayotte, Guadeloupe, and Guinea-Conakry. The usual genetics causes, Beckwith–Wiedemann syndrome, and chromosomal copy number variation, were also excluded.

Conclusions

This report suggests the implication of other factors in addition to glycemic disorders, including genetic factors, in the occurrence of macrosomia and severe hypertrophic cardiomyopathy in neonates. These three original observations indicate that gynecologists and neonatologists should pay attention to neonates from mothers with a high body mass index and when maternal diabetes is not documented.

Electronic supplementary material

The online version of this article (doi:10.1186/s13256-017-1231-5) contains supplementary material, which is available to authorized users.

Twin pregnancies complicated by gestational diabetes mellitus: a single centre cohort study

AIMS

In women with a twin pregnancy, to determine the incidence of, risk factors for and outcomes of women with gestational diabetes mellitus, and assess how these have changed with a change in gestational diabetes screening.

METHODS

Retrospective cohort study of women with a twin pregnancy attending an Australian tertiary hospital, 2002-2013. Information on gestational diabetes status, gestational diabetes risk factors and pregnancy outcomes was ascertained. Pregnancy outcomes included hypertensive disorders, twin birthweight centile and a composite adverse pregnancy outcome. Analysis was stratified pre/post screening protocol change (epoch 1: 2002-2009, epoch 2: 2010-2013) and by gestational diabetes status.

RESULTS

Gestational diabetes was diagnosed in 86/982 (8.8%) women, increasing from 4.4% to 14.7% between epochs (P = 0.0001). The proportion of women with hypertensive disorders increased (11.7% vs. 13.4%, P = 0.009), but the proportion of infant's birthweight > 90th centile decreased (11.0% vs. 7.6%, P = 0.02) between epochs. Overall, 33.6% of women had ≥ 1 risk factors for gestational diabetes. Three-quarters (73.7%) of women overall had an adverse pregnancy outcome, with a slightly higher proportion in women with gestational diabetes compared with those with no gestational diabetes (79.7% vs. 73.1%, P = 0.06). The rate of the adverse pregnancy outcome did not change by epoch, after adjusting for maternal and pregnancy risk factors (adjusted odds ratio = 0.96, 95% confidence interval 0.73-1.26).

CONCLUSIONS

Almost 1 in 10 women with a twin pregnancy were diagnosed with gestational diabetes, with the incidence of gestational diabetes increasing threefold with a new screening protocol. The pregnancy outcomes of women with a twin pregnancy did not change with increased detection and treatment for gestational diabetes.

Does gestational diabetes affect fetal growth and pregnancy outcome in twin pregnancies?

BACKGROUND

Women with twin pregnancies are at increased risk for fetal growth restriction, which might be attributed to the limited maternal resources that are being shared by >1 fetus. Based on that, it may be hypothesized that the fetal effects of gestational diabetes mellitus (GDM) with respect to accelerated fetal growth may be less pronounced in twin gestations or alternatively may even have a beneficial role in decreasing the risk of fetal growth restriction in these pregnancies. However, available data are conflicting and are limited by the fact that many of the complications associated with GDM are less relevant for twin gestations, and that all women with GDM included in previous studies were monitored and treated to control maternal blood glucose levels.

OBJECTIVE

We sought to assess the impact of GDM and milder degrees of glucose intolerance on fetal growth and pregnancy outcome in twin pregnancies.

STUDY DESIGN

This was a retrospective cohort study of all women with twin pregnancies who underwent screening for GDM in a single tertiary referral center from October 2003 through December 2014. The diagnosis of GDM during the study period was based on the 2008 Canadian Diabetes Association (CDA) guidelines, which involve universal screening with a 50-g glucose challenge test (GCT) followed by a diagnostic 2-hour 75-g oral glucose tolerance test (OGTT). Fetal growth and pregnancy outcome were compared among 4 groups of women with increasing degree of glucose intolerance: (1) GCT-NEGATIVE, negative 50-g GCT; (2) OGTT-NEGATIVE, positive 50-g GCT followed by a negative 75-g OGTT; (3) GDM-IADPSG, positive 50-g GCT followed by a positive 75-g OGTT according to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria but not the 2008 CDA criteria-because these women were not considered to have GDM during the study period they were not subjected to any form of treatment; and (4) GDM-CDA, positive 50-g GCT followed by a positive 75-g OGTT according to the 2008 CDA criteria.

RESULTS

Overall 1393 women were eligible for the study: 1021 (73.3%) in the GCT-NEGATIVE group, 184 (13.2%) in the OGTT-NEGATIVE group, 99 (7.1%) in the GDM-IADPSG group, and 89 (6.4%) in the GDM-CDA group. There was a continuous relationship between the degree of glucose intolerance and fetal growth as reflected by a right shift of the distribution curve of birthweight percentiles and a greater likelihood of high birthweight percentile: OGTT-NEGATIVE = odds ratio (OR), 1.5; 95% confidence interval (CI), 1.07-2.2; GDM-IADPSG = OR, 1.7; 95% CI, 1.1-2.6; and GDM-CDA = OR, 1.9, 95% CI, 1.3-3.1 (using the GCT-NEGATIVE group as reference). Fetuses of women with glucose intolerance were more likely to experience asymmetric growth as reflected by an elevated abdominal circumference to head circumference ratio.

CONCLUSION

GDM and milder degrees of glucose intolerance in twin pregnancies are associated with an increased risk of asymmetric overgrowth in a manner that is related to the degree of glucose intolerance.

Outcomes of singleton and twin pregnancies complicated by pre-existing diabetes and gestational diabetes: A population-based study in Alberta, Canada, 2005-11

BACKGROUND

We assessed the prevalence and pregnancy outcomes of pre-existing diabetes mellitus (pre-DM) and gestational diabetes mellitus (GDM) in Alberta, Canada, 2005-11.

METHODS

327 198 singleton and 5552 twin pregnancies resulting in live births or stillbirths were included. The odds ratios of adverse outcomes were evaluated comparing pre-DM with no diabetes and GDM with no diabetes, controlling for maternal characteristics.

RESULTS

Diabetes complicated 6.3% of pregnancies, with 88% being GDM. In singleton pregnancies, pre-DM and GDM were associated with increased risks of pre-eclampsia (adjusted odds ratio [aOR] = 3.38 and 1.83, respectively), cesarean delivery (aOR 2.53, 1.55), spontaneous preterm (aOR 4.20, 1.71), and labor-induced preterm (aOR 3.82, 2.00) in the mother, and macrosomia (aOR 2.11, 1.30), shoulder dystocia (aOR 1.54, 1.32), congenital anomalies (aOR 1.61, 1.20), and neonatal intensive care unit (NICU) admissions (aOR 3.81, 1.60) in the infants. In addition, pre-DM was associated with an increased likelihood of stillbirth (aOR 3.73) and neonatal death (aOR 2.00) compared with non-diabetic pregnancies. In twin pregnancies, pre-DM was associated with increased risks of spontaneous (aOR 3.54) and labor-induced (aOR 3.57) preterm births, large for gestational age (LGA) infants (aOR 3.73), congenital anomalies (aOR 3.05) and NICU admissions (aOR 2.91); GDM was associated with an increased risk of pre-eclampsia (aOR 1.54), cesarean delivery (aOR 1.57), and LGA infants (aOR 1.63).

CONCLUSIONS

Pre-existing diabetes confers higher risks than GDM. Diabetes is associated with adverse outcomes in singleton and twin pregnancies, and the increased risks are generally similar or less in twins, probably due to their higher "baseline" risks and closer clinical monitoring.

Associations between body mass index and maternal weight gain on the delivery of LGA infants in Chinese women with gestational diabetes mellitus

BACKGROUND

Women with gestational diabetes mellitus (GDM) are at increased risk for maternal and fetal complications including delivery of large for gestational age (LGA) infants. Maternal body mass index (BMI) and excessive weight gain during pregnancy are associated with delivery of LGA infants. However, whether maternal BMI and weight gain are associated with LGA infants in women with GDM is unclear.

BASIC PROCEDURES

Data on 1049 pregnant women who developed GDM were collected from a university teaching hospital in China and retrospectively analyzed. Data included maternal BMI, weight gain, incidence of LGA and gestational week at diagnosis.

MAIN FINDINGS

The incidence of LGA infants was significantly associated with maternal BMI (p=0.0002) in women with GDM. The odds of delivery of LGA for obese or overweight pregnant women are 3.8 or 2 times more than normal weight pregnant women. The incidence of LGA infants was also significantly associated with maternal weight gain in women with GDM. The odds ratio of delivery of LGA for pregnant women with excessive weight gain was 3.3 times more than pregnant women with normal weight gain. The effect of weight gain was not significantly different between different maternal BMI.

PRINCIPAL CONCLUSION

The incidence of delivery of LGA infants in Chinese women with GDM who were overweight or obese is higher than Caucasians, Hispanic, and Asian-Americans. The effects of maternal BMI and weight gain on the delivery of LGA infants by women with GDM are additive.

Utilization of International Association of Diabetes and Pregnancy Study Groups criteria vs. a two-step approach to screening for gestational diabetes mellitus in Chinese women with twin pregnancies

AIM

To evaluate prevalence and pregnancy outcomes using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and screening protocol vs. a standard two-step screening approach for gestational diabetes mellitus in Chinese twin pregnancies.

METHODS

A retrospective cohort study for pregnancies during 2007-2013 was performed in a tertiary hospital in Shanghai, China. Data were abstracted from the medical records of twin pregnancies delivered at the hospital. During the period 2007-2011, this hospital used a two-step approach with a 50 g screening with a cut-off value of ≥ 7.8 mmol/l followed by a 100 g diagnostic oral glucose tolerance test (OGTT) utilizing Carpenter-Coustan criteria. In 2012-2013, the hospital switched to the IADPSG protocol of universal 75 g OGTT.

RESULTS

Among 1461 twin pregnancies, 643 were screened utilizing IADPSG criteria and 818 using the two-step protocol. Gestational diabetes mellitus was diagnosed more frequently in the IADPSG group than in the two-step group [20.4% and 7.0%, respectively; adjusted odds ratio (aOR) = 3.22; 95% confidence interval (CI) = 2.30-4.52]. During the IADPSG period, the incidence of pre-eclampsia was 38% lower in non-gestational diabetes mellitus affected pregnancies compared with the two-step period (aOR = 0.62; 95% CI = 0.44-0.87). We observed no significant differences in most perinatal outcomes between the two groups.

CONCLUSION

Compared with a standard two-step approach to screening and diagnosis, the IADPSG screening method resulted in a three-fold increase in the incidence of gestational diabetes mellitus in twin pregnancies, with a 38% lower risk of pre-eclampsia but no significant difference in most perinatal outcomes in non-gestational diabetes mellitus affected pregnancies.