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Greco E, Calanducci M, Nicolaides KH, Barry EVH, Huda MSB, Iliodromiti S. Gestational diabetes mellitus and adverse maternal and perinatal outcomes in twin and singleton pregnancies: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:213-225. [PMID: 37595821 DOI: 10.1016/j.ajog.2023.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/10/2023] [Accepted: 08/10/2023] [Indexed: 08/20/2023]
Abstract
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.
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Affiliation(s)
- Elena Greco
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom.
| | - Maria Calanducci
- The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; The Harris Birthright Research Centre, King's College, London, United Kingdom
| | - Kypros H Nicolaides
- The Harris Birthright Research Centre, King's College, London, United Kingdom
| | - Eleanor V H Barry
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Mohammed S B Huda
- The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Stamatina Iliodromiti
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
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Wen L, Chen Y, Liu T, Wang Y, Baker PN, Qi H, Wang L. Different subtypes of gestational diabetes mellitus are associated with distinct perinatal outcomes in twin pregnancies. Diabetes Res Clin Pract 2023; 204:110920. [PMID: 37742804 DOI: 10.1016/j.diabres.2023.110920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/07/2023] [Accepted: 09/21/2023] [Indexed: 09/26/2023]
Abstract
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.
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Affiliation(s)
- Li Wen
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China; Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing 401147, China
| | - Ya Chen
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China; Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing 401147, China
| | - Taihang Liu
- School of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China
| | - Yingxiong Wang
- School of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Hongbo Qi
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China; Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing 401147, China; State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Lan Wang
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China; Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Chongqing 401147, China.
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Luo J, Geng X, Zhou J, Liang S, Zheng W, Li G. Characteristics of the oral glucose tolerance test in women with different pre-pregnancy body mass index and the effect of gestational diabetes mellitus on twin pregnancy outcomes. Clinics (Sao Paulo) 2023; 78:100272. [PMID: 37604047 PMCID: PMC10445444 DOI: 10.1016/j.clinsp.2023.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the mid-pregnancy blood glucose levels of women with singleton or twin pregnancies. METHOD The relationship between blood glucose levels and Gestational Diabetes Mellitus (GDM) was studied in women with different pre-pregnancy Body Mass Index (BMI), and the effect of GDM on twin pregnancy outcomes was analyzed. Women with twin (n = 1,985) and singleton (n = 1,985) pregnancies were categorized into underweight (BMI < 18.5 kg/m2, n = 597), normal weight (BMI: 18.5-23.9 kg/m2, n = 2,575), and overweight/obese (BMI ≥ 24 kg/m2, n = 798) groups. RESULTS The incidence of GDM was 21.01% in women with twin pregnancies. Among the women with GDM in twin pregnancies, 38.37% had at least two abnormal blood glucose levels. The incidence of these parameters increased with preconception BMI, and the incidence of twin pregnancies was higher than that of singleton pregnancies (p < 0.001). In the normal weight and overweight/obese group, the oral glucose tolerance test glucose level and incidence of GDM were higher in women with twin than singleton pregnancies (p < 0.05). For twin pregnancies, the prevalence of selective fetal growth restriction was higher and anemia was lower in the GDM group than in the non-GDM group (all p < 0.05). CONCLUSION Therefore, a greater emphasis should be placed on BMI before conception, and well-controlled GDM does not increase adverse pregnancy outcomes for twin pregnancies.
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Affiliation(s)
- Jinying Luo
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, PR China; Beijing Maternal and Child Health Care Hospital, PR China; Department of Obstetrics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, PR China
| | - Xiaoyan Geng
- Department of Obstetrics and Gynecology, Xicheng Women and Children's Health Hospital, PR China
| | - Jinfu Zhou
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, PR China
| | - Shengnan Liang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, PR China; Beijing Maternal and Child Health Care Hospital, PR China
| | - Wei Zheng
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, PR China; Beijing Maternal and Child Health Care Hospital, PR China
| | - Guanghui Li
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, PR China; Beijing Maternal and Child Health Care Hospital, PR China.
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Wang Y, Zhu X. The effect of maternal gestational diabetes on maternal and neonatal outcomes in twin pregnancies: a systematic review and meta-analysis. J OBSTET GYNAECOL 2022; 42:2592-2602. [PMID: 36017972 DOI: 10.1080/01443615.2022.2112558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Yuejuan Wang
- Department of Obstetrics, Shaoxing People's Hospital, Shaoxing, China
| | - Xuhui Zhu
- Department of Emergency, ZhuJi Maternity and Child Care Hospital, Zhuji, China
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Abstract
Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.
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Affiliation(s)
- Arianne Sweeting
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jencia Wong
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Helen R Murphy
- Diabetes in Pregnancy Team, Cambridge University Hospitals, Cambridge, UK
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
- Division of Women’s Health, Kings College London, London, UK
| | - Glynis P Ross
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Lin D, Fan D, Li P, Chen G, Rao J, Zhou Z, Zhang H, Luo X, Ma H, Feng J, Lu D, Wang L, Lan S, Luo C, Guo X, Liu Z. Perinatal outcomes among twin pregnancies with gestational diabetes mellitus: A nine-year retrospective cohort study. Front Public Health 2022; 10:946186. [PMID: 35958858 PMCID: PMC9358001 DOI: 10.3389/fpubh.2022.946186] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/06/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Dongxin Lin
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Dazhi Fan
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Pengsheng Li
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Gengdong Chen
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Jiaming Rao
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Zixing Zhou
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Huishan Zhang
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Xin Luo
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Huiting Ma
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Jingping Feng
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Demei Lu
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Lijuan Wang
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Shiyan Lan
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Caihong Luo
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
| | - Xiaoling Guo
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- *Correspondence: Xiaoling Guo
| | - Zhengping Liu
- Foshan Institute of Fetal Medicine, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Department of Obstetrics, Southern Medical University Affiliated Maternal and Child Health Hospital of Foshan, Foshan, China
- Zhengping Liu
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[Effects of gestational weight on the association between serum high sensitivity C reaction protein and gestational diabetes mellitus among twin gestations: A cohort study]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54. [PMID: 35701118 PMCID: PMC9197712 DOI: 10.19723/j.issn.1671-167x.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the association between serum high sensitivity C-reaction protein (hsCRP) in early pregnancy and gestational diabetes mellitus (GDM) among twin pregnant women, and to explore the effects of the pre-pregnant body mass index (BMI) and gestational weight gain (GWG) status on such association. METHODS Twin pregnant women with pre-pregnant BMI greater than or equal to 18.5 kg/m2 were recruited at Department of Obstetrics and Gynecology of Peking University Third Hospital from March 2017 to December 2020. Serum samples collected in early pregnancy were analyzed for hsCRP using particle-enhanced immunoturbidimetric method. In the following visits, the information about GWG and GDM were prospectively collected in every trimester. The association effect between hsCRP tertiles and GDM were estimated using Logistic regression, and further converted into risk ratio (RR). Cochran-Mantel-Haenszel test and mediation analysis were used to explore the effects of BMI and GWG status on the association. RESULTS Among the included 570 twin pregnant women, 31.6% deve-loped GDM, 26.1% were pre-pregnant overweight or obesity, and 49.5% with GWG out of referenced range. After adjustment for confounding factors, risk of developing GDM in twin gestations with the middle tertile and highest tertile of serum hsCRP in early pregnancy were 1.42 fold (95%CI: 1.02-1.89) and 1.54 fold (95%CI: 1.12-2.02), respectively, compared with the lowest tertile of serum hsCRP, and there existed significantly linear trend (P=0.022). Findings from mediation analysis illustrated that pre-pregnant BMI had partial mediating effect on the association, and BMI accounted for 23.84% (P < 0.001) of the increasing GDM risks with elevated hsCRP. Joint analysis with hsCRP and GWG found that those who were with GWG out of referenced range accompanied with the higher hsCRP tertiles (>1.21 mg/L) had significantly 2.31 fold increased risk according to those who were with GWG in the referenced range accompanied with the lowest hsCRP tertile (≤1.21 mg/L, P < 0.01). CONCLUSION Elevated hsCRP in early pregnancy significantly increased GDM risk among twin pregnant women. The hsCRP-GDM association was dependent on GWG status, and pre-pregnant BMI had partial mediating effect on such association. It is suggested that twin pregnant women should consider systemic inflammation and gestational weight at the same time to reduce GDM risk.
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Obstetric and neonatal outcomes of gestational diabetes mellitus in twin pregnancies according to changes in its diagnostic criteria from National Diabetes Data Group criteria to Carpenter and Coustan criteria: a retrospective cohort study. BMC Pregnancy Childbirth 2022; 22:9. [PMID: 34979991 PMCID: PMC8722060 DOI: 10.1186/s12884-021-04361-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare obstetric and neonatal outcomes in twin pregnancies with or without gestational diabetes mellitus (GDM) before and after changes in GDM diagnostic criteria. METHODS This was a retrospective cohort study of 1,764 twin pregnancies including 130 women with GDM (GDM group) and 1,634 women without GDM (non-GDM group). Patients with pregestational diabetes, unknown GDM status, and fetal death at < 24 gestational weeks were excluded. Obstetric and neonatal outcomes were compared between the two groups by two periods: period 1 (1995-2005) and period 2 (2005-2018) when National Diabetes Data Group criteria and Carpenter and Coustan criteria were used for diagnosis of GDM, respectively. RESULTS The incidence of GDM in twin pregnancies increased from 4.0% in period 1 to 9.3% in period 2. Composite obstetric complications rate was significantly higher in the GDM group than that in the non-GDM group during period 1 (72.0% vs. 45.5%, P = 0.009). However, it became comparable during period 2 (60.0% vs. 57.4%, P = 0.601). Interaction between GDM and period indicated a significant differential effect of GDM by period on the rate of composite obstetric complications. The rate of composite neonatal complications was similar between the two groups during both periods. The interaction between GDM and period was not significant. CONCLUSION After changes of GDM diagnostic criteria, the incidence of GDM increased more than twice, and the rate of composite obstetric complications decreased, but the rate of composite neonatal complications did not change significantly.
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Gupta S, Gupte S, Gupta S, Bamrah P, Gupta K. Evaluation of treatment strategies and pregnancy outcome among GDM twin versus GDM singleton pregnancy. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-00990-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Hung T, Hsieh T, Shaw SW, Kok Seong C, Chen S. Risk factors and adverse maternal and perinatal outcomes for women with dichorionic twin pregnancies complicated by gestational diabetes mellitus: A retrospective cross-sectional study. J Diabetes Investig 2021; 12:1083-1091. [PMID: 33064935 PMCID: PMC8169347 DOI: 10.1111/jdi.13441] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 10/01/2020] [Accepted: 10/12/2020] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Tai‐Ho Hung
- Department of Obstetrics and GynecologyTaipei Chang Gung Memorial HospitalTaipeiTaiwan
- Department of Obstetrics and GynecologyKeelung Chang Gung Memorial HospitalKeelungTaiwan
- Department of MedicineCollege of MedicineChang Gung UniversityTaoyuanTaiwan
| | - T’sang‐T’ang Hsieh
- Department of Obstetrics and GynecologyTaipei Chang Gung Memorial HospitalTaipeiTaiwan
| | - Steven W Shaw
- Department of Obstetrics and GynecologyTaipei Chang Gung Memorial HospitalTaipeiTaiwan
- Department of MedicineCollege of MedicineChang Gung UniversityTaoyuanTaiwan
| | - Chan Kok Seong
- Department of Obstetrics and GynecologySabah Women and Children HospitalSabahMalaysia
| | - Szu‐Fu Chen
- Department of Physical Medicine and RehabilitationCheng Hsin General HospitalTaipeiTaiwan
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Gortazar L, Flores-Le Roux JA, Benaiges D, Sarsanedas E, Navarro H, Payà A, Mañé L, Pedro-Botet J, Goday A. Trends in Prevalence of Diabetes among Twin Pregnancies and Perinatal Outcomes in Catalonia between 2006 and 2015: The DIAGESTCAT Study. J Clin Med 2021; 10:1937. [PMID: 33946383 PMCID: PMC8125732 DOI: 10.3390/jcm10091937] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Lucia Gortazar
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
| | - Juana Antonia Flores-Le Roux
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
- Institut Hospital del Mar d’Investigacions Mèdiques, 08003 Barcelona, Spain
| | - David Benaiges
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
- Institut Hospital del Mar d’Investigacions Mèdiques, 08003 Barcelona, Spain
- Consorci Sanitari de l’Alt Penedès Garraf, 08720 Vilafranca del Penedès, Spain
| | - Eugènia Sarsanedas
- Health Information Management Department, Hospital del Mar, 08003 Barcelona, Spain;
| | - Humberto Navarro
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
| | - Antonio Payà
- Department of Gynecology and Obstetrics, Hospital del Mar, 08003 Barcelona, Spain;
| | - Laura Mañé
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
| | - Juan Pedro-Botet
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
- Institut Hospital del Mar d’Investigacions Mèdiques, 08003 Barcelona, Spain
| | - Albert Goday
- Department of Endocrinology and Nutrition, Hospital del Mar, Passeig Marítim, 25-29, 08003 Barcelona, Spain; (L.G.); (J.A.F.-L.R.); (H.N.); (L.M.); (J.P.-B.); (A.G.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08139 Barcelona, Spain
- Institut Hospital del Mar d’Investigacions Mèdiques, 08003 Barcelona, Spain
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12
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Alkaabi J, Almazrouei R, Zoubeidi T, Alkaabi FM, Alkendi FR, Almiri AE, Sharma C, Souid AK, Ali N, Ahmed LA. Burden, associated risk factors and adverse outcomes of gestational diabetes mellitus in twin pregnancies in Al Ain, UAE. BMC Pregnancy Childbirth 2020; 20:612. [PMID: 33046000 PMCID: PMC7552445 DOI: 10.1186/s12884-020-03289-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background Gestational diabetes mellitus (GDM) in singleton pregnancies represent a high-risk scenario. The incidence, associated factors and outcomes of GDM in twin pregnancies is not known in the UAE. Methods This was five years retrospective analysis of hospital records of twin pregnancies in the city of Al Ain, Abu Dhabi, UAE. Relevant data with regards to the pregnancy, maternal and birth outcomes and incidence of GDM was extracted from two major hospitals in the city. Regression models assessed the relationship between socio-demographic and pregnancy-related variables and GDM, and the associations between GDM and maternal and fetal outcomes at birth. Results A total of 404 women and their neonates were part of this study. The study population had a mean age of 30.1 (SD: 5.3), overweight or obese (66.5%) and were majority multiparous (66.6%). High incidence of GDM in twin pregnancies (27.0%). While there were no statistical differences in outcomes of the neonates, GDM mothers were older (OR: 1.09, 95% CI: 1.06–1.4) and heavier (aOR: 1.02, 95% CI: 1.00 -1.04). They were also likely to have had GDM in their previous pregnancies (aOR: 7.37, 95% CI: 2.76–19.73). The prognosis of mothers with twin pregnancies and GDM lead to an independent and increased odds of cesarean section (aOR: 2.34, 95% CI: 1.03–5.30) and hospitalization during pregnancy (aOR: 1.60, 95% CI: 1.16–2.20). Conclusion More than a quarter of women with twin pregnancies were diagnosed with GDM. GDM was associated with some adverse pregnancy outcomes but not fetal outcomes in this population. More studies are needed to further investigate these associations and the management of GDM in twin pregnancies.
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Affiliation(s)
- Juma Alkaabi
- Department of Internal Medicine, College of Medicine, and Health Sciences, Emirates University, PO Box 17666, Al Ain, United Arab Emirates.
| | - Raya Almazrouei
- Division of Endocrinology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Taoufik Zoubeidi
- Departments of Statistics, College of Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Fatema M Alkaabi
- Division of Endocrinology, Al Ain Hospital, Al Ain, United Arab Emirates
| | | | - Amel Eisa Almiri
- Internal Medicine Department, Tawam Hospital, Al Ain, United Arab Emirates
| | - Charu Sharma
- Department of Internal Medicine, College of Medicine, and Health Sciences, Emirates University, PO Box 17666, Al Ain, United Arab Emirates
| | - Abdul-Kader Souid
- Department of Pediatrics, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Nasloon Ali
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Luai A Ahmed
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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Abstract
AbstractIt 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.
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Ooi S, Wong VW. Twin Pregnancy With Gestational Diabetes Mellitus: A Double Whammy? Diabetes Care 2018; 41:e15-e16. [PMID: 29208653 DOI: 10.2337/dc17-2227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/04/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Sara Ooi
- Women's and Child Health, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Vincent W Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
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Cozzolino M, Serena C, Maggio L, Rambaldi MP, Simeone S, Mello G, Pasquini L, Di Tommaso M, Mecacci F. Analysis of the main risk factors for gestational diabetes diagnosed with International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria in multiple pregnancies. J Endocrinol Invest 2017; 40:937-943. [PMID: 28324453 DOI: 10.1007/s40618-017-0646-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/17/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The aim is to investigate the proportion of multiple pregnancies with gestational diabetes mellitus (GDM) diagnosed using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and to identify the impact of age, body mass index (BMI), and mode of conception on incidence of GDM. MATERIALS AND METHODS This is a single center, retrospective cohort study on 656 multiple pregnancies screened for GDM with 75-g, 2-h oral glucose tolerance test at 24-28 weeks of gestation, between January 2010 and January 2016. The diagnosis of gestational diabetes mellitus (GDM) was reached through the IADPSG. RESULTS The incidence of GDM in our population was 15.1%. When patients who conceived through heterologous assisted reproduction technology were compared with those who conceived spontaneously, there was a significant difference for GDM (31.1 vs 13.6%, p < 0.001, OR 2.86). A similar finding was also observed comparing egg donation IVF/ICSI patients with homologous IVF/ICSI patients (31.1 vs 14.8%, p = 0.006, OR 2.59). Incidence of GDM was significantly higher in obese than in non-obese patients (42.5 vs 14.8%, p < 0.001, OR 4.88) and in women over 35 compared to younger patients (18.4 vs 11.1%, p = 0.01, OR 1.81). Logistic regression comparing the diabetes onset with conception mode gave a p = 0.07. The calculation of the Chi-square and odds ratio for single mode of conception showed that homologous vs conceived spontaneously p = 0.90, OR 0.97, heterologous vs homologous p = 0.01 with OR 2.46, and heterologous vs conceived spontaneously p = 0.01 with OR 2.39. Logistic regression showed that age and BMI are risk factors for developing GDM, respectively, p = 0.03 with OR 1.4 and p < 0.01 and OR 1.09. DISCUSSION The contribution our study can make is improved counseling about GDM risks for couples with multiple pregnancies. Our data support the role of age, BMI, and mode of conception as risk factors for GDM in multiple pregnancies.
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Affiliation(s)
- M Cozzolino
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy.
| | - C Serena
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - L Maggio
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - M P Rambaldi
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - S Simeone
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - G Mello
- Department of Sciences for the Health of Women and Children, Careggi Hospital, University of Florence, Florence, Italy
| | - L Pasquini
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
| | - M Di Tommaso
- Department of Sciences for the Health of Women and Children, Careggi Hospital, University of Florence, Florence, Italy
| | - F Mecacci
- Department of Sciences for the Health of Women and Children, Careggi Hospital, Florence, Italy
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Outcomes of twin pregnancies complicated by gestational diabetes: a meta-analysis of observational studies. J Perinatol 2017; 37:360-368. [PMID: 28079866 DOI: 10.1038/jp.2016.254] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/23/2016] [Accepted: 12/07/2016] [Indexed: 11/09/2022]
Abstract
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.
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Simões T, Queirós A, Valdoleiros S, Marujo AT, Felix N, Blickstein I. Concurrence of gestational diabetes and pre-gravid obesity (“diabesity”) in twin gestations. J Matern Fetal Neonatal Med 2016; 30:1813-1815. [DOI: 10.1080/14767058.2016.1226797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Teresinha Simões
- Department of Maternal–Fetal Medicine Maternity Dr. Alfredo da Costa, Centro Hospitalar Lisboa Central and Universidade Nova de Lisboa, Lisbon, Portugal,
| | - Alexandra Queirós
- Department of Maternal–Fetal Medicine Maternity Dr. Alfredo da Costa, Centro Hospitalar Lisboa Central and Universidade Nova de Lisboa, Lisbon, Portugal,
| | - Sandra Valdoleiros
- Department of Maternal–Fetal Medicine Maternity Dr. Alfredo da Costa, Centro Hospitalar Lisboa Central and Universidade Nova de Lisboa, Lisbon, Portugal,
| | - Ana Teresa Marujo
- Department of Maternal–Fetal Medicine Maternity Dr. Alfredo da Costa, Centro Hospitalar Lisboa Central and Universidade Nova de Lisboa, Lisbon, Portugal,
| | - Nisa Felix
- Department of Maternal–Fetal Medicine Maternity Dr. Alfredo da Costa, Centro Hospitalar Lisboa Central and Universidade Nova de Lisboa, Lisbon, Portugal,
| | - Isaac Blickstein
- Department of Maternal–Fetal Medicine Maternity Dr. Alfredo da Costa, Centro Hospitalar Lisboa Central and Universidade Nova de Lisboa, Lisbon, Portugal,
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel, and
- The Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
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