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Blankstein AR, Sigurdson SM, Frehlich L, Raizman Z, Donovan LE, Lemieux P, Pylypjuk C, Benham JL, Yamamoto JM. Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis. Obstet Gynecol 2024:00006250-990000000-01125. [PMID: 39088826 DOI: 10.1097/aog.0000000000005682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/23/2024] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes. DATA SOURCES MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022. METHODS OF STUDY SELECTION Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model. TABULATION, INTEGRATION, AND RESULTS From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2=82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2=82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2=0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2=0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2=87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2=0%). CONCLUSION Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022303112.
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Affiliation(s)
- Anna R Blankstein
- Department of Medicine, the Department of Obstetrics, Gynecology and Reproductive Sciences, and the Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, the Department of Community Health Sciences, the Department of Medicine, the Department of Obstetrics and Gynecology, the Alberta Children's Hospital Research Institute, the O'Brien Institute for Public Health, and the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, and the Department of Medicine, Université Laval, Quebec City, Quebec, Canada; and Stanford Lifestyle Medicine, Stanford University, Redwood City, California
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McEwen I, Huybrechts KF, Straub L, Hernández-Díaz S. Patterns of paternal medication dispensation around the time of conception. Paediatr Perinat Epidemiol 2024; 38:461-466. [PMID: 38949455 DOI: 10.1111/ppe.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 05/22/2024] [Accepted: 05/25/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Past research on the safety of prenatal exposure to medications has focused on maternal use during gestation, with limited research into the potential effects of paternal use during the spermatogenic period preceding conception. Knowing the most common medications used by fathers around the time of conception can inform research priorities in this field. OBJECTIVES To identify the most common medications dispensed to fathers in the preconception period. METHODS Within the MarketScan research database of commercially insured individuals in the United States from 2011 to 2020, we identified pregnancies, estimated the date of conception, linked each pregnancy to the father using family enrolment information and required minimum enrolment period and prescription benefits. Then, we described the use of prescription medications by the father during the 90 days before conception based on pharmacy dispensation claims. RESULTS Of 4,437,550 pregnancies, 51.6% were linked with a father. Among the 1,413,762 pregnancies connected with a father that also met the inclusion criteria, the most common classes of medications dispensed were psychotropics (8.66%), antibiotics (7.21%), and analgesics (6.82%). The most frequently dispensed medications were amoxicillin (3.75%), azithromycin (3.15%), fluticasone (2.70%) and acetaminophen/hydrocodone (2.70%). Some fathers filled prescriptions for medications associated with foetal embryopathy when used by the mother, including mycophenolate (0.04%), methotrexate (0.03%) and isotretinoin (0.02%). CONCLUSIONS More than a third of fathers filled at least one prescription medication in the preconception period, and several of them are known to be embryotoxic, emphasizing the necessity for further investigation into the potential teratogenicity of paternal exposure.
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Affiliation(s)
- Isobel McEwen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Chiu YH, Huybrechts KF, Patorno E, Yland JJ, Cesta CE, Bateman BT, Seely EW, Hernán MA, Hernández-Díaz S. Metformin Use in the First Trimester of Pregnancy and Risk for Nonlive Birth and Congenital Malformations: Emulating a Target Trial Using Real-World Data. Ann Intern Med 2024; 177:862-870. [PMID: 38885505 DOI: 10.7326/m23-2038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Metformin is a first-line pharmacotherapy for type 2 diabetes, but there is limited evidence about its safety in early pregnancy. OBJECTIVE To evaluate the teratogenicity of metformin use in the first trimester of pregnancy. DESIGN In an observational cohort of pregnant women with pregestational type 2 diabetes receiving metformin monotherapy before the last menstrual period (LMP), a target trial with 2 treatment strategies was emulated: insulin monotherapy (discontinue metformin treatment and initiate insulin within 90 days of LMP) or insulin plus metformin (continue metformin and initiate insulin within 90 days of LMP). SETTING U.S. Medicaid health care administration database (2000 to 2018). PARTICIPANTS 12 489 pregnant women who met the eligibility criteria. MEASUREMENTS The risk and risk ratio of nonlive births, live births with congenital malformations, and congenital malformations among live births were estimated using standardization to adjust for covariates. RESULTS A total of 850 women were in the insulin monotherapy group and 1557 in the insulin plus metformin group. The estimated risk for nonlive birth was 32.7% under insulin monotherapy (reference) and 34.3% under insulin plus metformin (risk ratio, 1.02 [95% CI, 1.01 to 1.04]). The estimated risk for live birth with congenital malformations was 8.0% (CI, 5.7% to 10.2%) under insulin monotherapy and 5.7% (CI, 4.5% to 7.3%) under insulin plus metformin (risk ratio, 0.72 [CI, 0.51 to 1.09]). LIMITATION Possible residual confounding by glycemic control and body mass index. CONCLUSION Compared with switching to insulin monotherapy, continuing metformin and adding insulin in early pregnancy resulted in little to no increased risk for nonlive birth among women receiving metformin before pregnancy. Under conventional statistical criteria, anything between a 49% decrease and a 9% increase in risk for congenital malformations was highly compatible with our data. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Yu-Han Chiu
- CAUSALab and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Y.-H.C., S.H.)
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (K.F.H., E.P.)
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (K.F.H., E.P.)
| | - Jennifer J Yland
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts (J.J.Y.)
| | - Carolyn E Cesta
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (C.E.C.)
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California (B.T.B.)
| | - Ellen W Seely
- Endocrinology, Diabetes and Hypertension Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (E.W.S.)
| | - Miguel A Hernán
- CAUSALab, Department of Epidemiology, and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (M.A.H.)
| | - Sonia Hernández-Díaz
- CAUSALab and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Y.-H.C., S.H.)
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Cesta CE, Hernández-Díaz S, Huybrechts KF, Bateman BT, Vine S, Seely EW, Patorno E. Achieving comparability in glycemic control between antidiabetic treatment strategies in pregnancy when using real world data. Pharmacoepidemiol Drug Saf 2023; 32:1350-1359. [PMID: 37461243 PMCID: PMC10792121 DOI: 10.1002/pds.5665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/13/2023] [Accepted: 07/04/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE Healthcare utilization databases often lack information on glycemic control, a key confounder when studying the safety of antidiabetic treatments, since patients with worse control are channeled to second-line agents, in particular insulin, versus first-line agents such as metformin. We evaluated whether adjustment for measured characteristics attains balance in glycemic control when comparing antidiabetic treatment strategies in pregnant women with pregestational type 2 diabetes (T2DM). METHODS In a US insurance claims database, we identified 3360 women with T2DM pregnant between 2004 and 2015, of whom a subset of 996 had data on hemoglobin A1c (HbA1c ) levels. We selected insulin only as the comparator group and used propensity score (PS)-matching on comorbidities and proxies of diabetes severity, but not on HbA1c , to adjust for confounding. We used standardized differences (st.diff) to assess balance in claims-based covariates and mean HbA1c (% ± SD) in the subset. RESULTS There were imbalances in claims-based covariates before PS-matching, with smaller differences when both treatment strategies included insulin. After PS-matching, balance was achieved in most claims-based covariates (st.diff <0.1). Mean HbA1c was similar before and after PS-matching when both treatments included insulin (e.g., 7.1 ± 1.5 vs. 7.7 ± 1.8 and 7.1 ± 1.5 vs. 7.5 ± 1.7, respectively, for metformin + insulin vs. insulin only). Differences in mean HbA1c remained after PS-matching when non-insulin treatments were compared to treatments including insulin (e.g., 6.3 ± 1.1 vs. 7.6 ± 1.7 for metformin only vs. insulin only). CONCLUSIONS Balance in both claims-based characteristics and glycemic control was attained after restricting the population to women with T2DM and comparing treatment strategies indicated for patients with similar diabetes severity. When comparing treatment strategies with versus without insulin, differences in glycemic control persisted after PS-matching even when balance was attained for other measured characteristics.
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Affiliation(s)
- Carolyn E Cesta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
- Centre for Pharmacoepidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| | - Seanna Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Ellen W Seely
- Endocrinology, Diabetes and Hypertension Division, Brigham and Women’s Hospital and Harvard Medical School
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
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Zhao L, Chang Q, Cong Z, Zhang Y, Liu Z, Zhao Y. Effects of dietary polyphenols on maternal and fetal outcomes in maternal diabetes. Food Funct 2023; 14:8692-8710. [PMID: 37724008 DOI: 10.1039/d3fo02048g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
The incidences of short-term or long-term adverse maternal and fetal outcomes caused by maternal diabetes are increasing. Due to toxicity or side effects, economic pressures, and other problems associated with injections or oral hypoglycemic drugs, many researchers have investigated natural treatment methods. Polyphenols can protect against chronic pathologies by regulating numerous physiological processes and provide many health benefits. Moreover, polyphenols have anti-diabetic properties and can be used to treat diabetic complications. Diets rich in polyphenols are beneficial to pregnant women with diabetes. Here, we review the epidemiological and experimental evidence on the impact of dietary polyphenols on maternal and fetal outcomes in pregnant women with diabetes, and the effects of polyphenols on biological changes and possible mechanisms. Previous data (mainly from in vitro and animal experiments) showed that polyphenols can alleviate gestational diabetes mellitus and diabetic embryopathy by reducing maternal hyperglycemia and insulin resistance, alleviating inflammation and oxidative stress, and regulating related signaling pathways. Although polyphenols have shown many health benefits, further research is needed to better understand the complex interactions between polyphenols and maternal diabetes.
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Affiliation(s)
- Lu Zhao
- Liaoning Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Qing Chang
- Liaoning Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China.
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhangzhao Cong
- Department of Teaching Affairs, China Medical University, Shenyang, China
| | - Yalin Zhang
- Liaoning Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Zhuxi Liu
- Liaoning Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Yuhong Zhao
- Liaoning Key Laboratory of Precision Medical Research on Major Chronic Disease, Shengjing Hospital of China Medical University, Shenyang, China.
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China
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Raets L, Ingelbrecht A, Benhalima K. Management of type 2 diabetes in pregnancy: a narrative review. Front Endocrinol (Lausanne) 2023; 14:1193271. [PMID: 37547311 PMCID: PMC10402739 DOI: 10.3389/fendo.2023.1193271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
The prevalence of type 2 diabetes (T2DM) at reproductive age is rising. Women with T2DM have a similarly high risk for pregnancy complications as pregnant women with type 1 diabetes. To reduce adverse pregnancy and neonatal outcomes, such as preeclampsia and preterm delivery, a multi-target approach is necessary. Tight glycemic control together with appropriate gestational weight gain, lifestyle measures, and if necessary, antihypertensive treatment and low-dose aspirin is advised. This narrative review discusses the latest evidence on preconception care, management of diabetes-related complications, lifestyle counselling, recommendations on gestational weight gain, pharmacologic treatment and early postpartum management of T2DM.
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Affiliation(s)
- Lore Raets
- Department of Endocrinology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | | | - Katrien Benhalima
- Department of Endocrinology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
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Sanchez Ortiz S, Huerta C, Llorente-García A, Ortega P, Astasio P, Cea-Soriano L. A Validation Study on the Frequency and Natural History of Miscarriages Using the Spanish Primary Care Database BIFAP. Healthcare (Basel) 2021; 9:healthcare9050596. [PMID: 34069788 PMCID: PMC8157258 DOI: 10.3390/healthcare9050596] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: There is a major gap of knowledge towards the natural history of miscarriages in electronic medical records. We aimed to calculate the frequency of miscarriages using data from BIFAP database. (2) Methods: We identified all pregnancy losses and carried out a multistep validation exercise. Potential cases with positive predictive values (PPV) of miscarriage confirmation <85% or those confirming other pregnancy loss were excluded. Kaplan–Meier figures and incidence rates (IRs) of miscarriage with 95% confidence intervals (CIs) expressed by 1000 person-weeks were calculated. Stratifying analysis by age, specific high-risk groups, and drug exposure within the pre-pregnancy period were performed restricted to women with recording last menstrual period (LMP). (3) Results: Women with confirmed miscarriage (N = 18,070), tended to be older, with higher frequency of comorbidities and drug utilization. Restricting to women with LPM recorded, IR of miscarriage was 10.89 (CI 95% 10.68–11.10) per 1000 women-weeks, with a median follow-up of 10 weeks (IQR: 8–12). The IR according to age was: 2.71 (CI 95% 2.59–2.84) in those aged <30 years compared to 9.11 (CI 95% 8.55–9.70) in women aged ≥40 years. Advanced maternal age (Hazard Ratio (HR, 95% confidence interval) CI 95%: 3.34 (3.08–3.62)), use of antihypertensives (1.49 (1.21–1.84), and use of drugs classified as D or X during pregnancy (1.17 (1.07–1.29)) showed to be positive predictors associated with increased risk of miscarriages. (4) Conclusion: BIFAP database can be used to identify women suffering from miscarriages, which will serve to further study risk factors associated with miscarriages with special attention to drug utilization.
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Affiliation(s)
- Sara Sanchez Ortiz
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (S.S.O.); (C.H.); (P.O.); (P.A.)
| | - Consuelo Huerta
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (S.S.O.); (C.H.); (P.O.); (P.A.)
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), 28040 Madrid, Spain;
| | - Ana Llorente-García
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), 28040 Madrid, Spain;
| | - Paloma Ortega
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (S.S.O.); (C.H.); (P.O.); (P.A.)
| | - Paloma Astasio
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (S.S.O.); (C.H.); (P.O.); (P.A.)
| | - Lucía Cea-Soriano
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (S.S.O.); (C.H.); (P.O.); (P.A.)
- Correspondence: ; Tel.: +34-91-531-3404
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Peppa M, Minassian C, Mangtani P, Thomas SL. The identification and validity of congenital malformation diagnoses in UK electronic health records: A systematic review. Pharmacoepidemiol Drug Saf 2021; 30:875-898. [PMID: 33881794 DOI: 10.1002/pds.5251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 04/15/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE To describe the methods used to identify and validate congenital malformation diagnoses recorded in UK electronic health records, and the results of validation studies. METHODS Medline and Embase were searched for publications between 1987 and 2019 that involved identifying congenital malformations from UK electronic health records using diagnostic codes. The methods and code-lists used to identify congenital malformations, and the methods and results of validations, were examined. RESULTS We retrieved 54 eligible studies; 36 identified congenital malformations from primary care data and 18 from secondary care data alone or in combination with birth and/or death records. Identification in secondary care data relied on codes from the 'Q' chapter for congenital malformations in ICD-10. In contrast, studies using primary care data frequently used additional codes outside of the 'P' chapter for congenital malformation diagnoses in Read, although the exact codes used were not always clear. Eight studies validated diagnoses identified in primary care data. The positive predictive value was highest (80%-100%) for congenital malformations overall, major malformations, and heart defects although the validity of the reference standard used was often uncertain. It was lowest for neural tube defects (71%) and developmental hip dysplasia (56%). CONCLUSIONS Studies identifying congenital malformations from primary care data provided limited details about the methods used. The few validation studies were limited to diagnoses recorded in primary care. Further assessments of all measures of validity in both data sources and of other malformation subgroups are needed, using robust reference standards and adhering to reporting guidelines.
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Affiliation(s)
- Maria Peppa
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline Minassian
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Punam Mangtani
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sara L Thomas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Maggio L. Medications for Pregnant Women With Obesity: Special Considerations. Clin Obstet Gynecol 2021; 64:214-225. [PMID: 33306496 DOI: 10.1097/grf.0000000000000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pregnant women with obesity are at increased risk of a multitude of complications of pregnancy and adverse perinatal outcomes. The risk of some of these complications, such as neural tube defects or preeclampsia, may be mitigated by some medications. Other complications, such as diabetes, venous thromboembolism, and infections, require treatment with medications. Given the changes in pharmacokinetics and pharmacodynamics during pregnancy, which is further enhanced by obesity, the optimal medication and its dose is often researched. This chapter further explores the different complications and common medications that women with obesity are likely to require.
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Affiliation(s)
- Lindsay Maggio
- Division of Maternal Fetal Medicine, Nemours Children's Hospital, Orlando, Florida
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Ford E, Curlewis K, Squires E, Griffiths LJ, Stewart R, Jones KH. The Potential of Research Drawing on Clinical Free Text to Bring Benefits to Patients in the United Kingdom: A Systematic Review of the Literature. Front Digit Health 2021; 3:606599. [PMID: 34713089 PMCID: PMC8521813 DOI: 10.3389/fdgth.2021.606599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The analysis of clinical free text from patient records for research has potential to contribute to the medical evidence base but access to clinical free text is frequently denied by data custodians who perceive that the privacy risks of data-sharing are too high. Engagement activities with patients and regulators, where views on the sharing of clinical free text data for research have been discussed, have identified that stakeholders would like to understand the potential clinical benefits that could be achieved if access to free text for clinical research were improved. We aimed to systematically review all UK research studies which used clinical free text and report direct or potential benefits to patients, synthesizing possible benefits into an easy to communicate taxonomy for public engagement and policy discussions. Methods: We conducted a systematic search for articles which reported primary research using clinical free text, drawn from UK health record databases, which reported a benefit or potential benefit for patients, actionable in a clinical environment or health service, and not solely methods development or data quality improvement. We screened eligible papers and thematically analyzed information about clinical benefits reported in the paper to create a taxonomy of benefits. Results: We identified 43 papers and derived five themes of benefits: health-care quality or services improvement, observational risk factor-outcome research, drug prescribing safety, case-finding for clinical trials, and development of clinical decision support. Five papers compared study quality with and without free text and found an improvement of accuracy when free text was included in analytical models. Conclusions: Findings will help stakeholders weigh the potential benefits of free text research against perceived risks to patient privacy. The taxonomy can be used to aid public and policy discussions, and identified studies could form a public-facing repository which will help the health-care text analysis research community better communicate the impact of their work.
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Affiliation(s)
- Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Keegan Curlewis
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Emma Squires
- Swansea Medical School, University of Swansea, Swansea, United Kingdom
| | - Lucy J. Griffiths
- Swansea Medical School, University of Swansea, Swansea, United Kingdom
| | - Robert Stewart
- King's College London, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Kerina H. Jones
- Swansea Medical School, University of Swansea, Swansea, United Kingdom
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Abstract
PURPOSE OF REVIEW Fetuses of diabetic mothers are at increased risk for congenital malformations. Research in recent decades using animal and embryonic stem cell models has revealed many embryonic developmental processes that are disturbed by maternal diabetes. The aim of this review is to give clinicians a better understanding of the reasons for rigorous glycemic control in early pregnancy, and to provide background to guide future research. RECENT FINDINGS Mouse models of diabetic pregnancy have revealed mechanisms for altered expression of tissue-specific genes that lead to malformations that are more common in diabetic pregnancies, such as neural tube defects (NTDs) and congenital heart defects (CHDs), and how altered gene expression causes apoptosis that leads to malformations. Embryos express the glucose transporter, GLUT2, which confers susceptibility to malformation, due to high rates of glucose uptake during maternal hyperglycemia and subsequent oxidative stress; however, the teleological function of GLUT2 for mammalian embryos may be to transport the amino sugar glucosamine (GlcN) from maternal circulation to be used as substrate for glycosylation reactions and to promote embryo cell growth. Malformations in diabetic pregnancy may be not only due to excess glucose uptake but also due to insufficient GlcN uptake. Avoiding maternal hyperglycemia during early pregnancy should prevent excess glucose uptake via GLUT2 into embryo cells, and also permit sufficient GLUT2-mediated GlcN uptake.
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Affiliation(s)
- Mary R Loeken
- Section on Islet Cell and Regenerative Biology, Department of Medicine, Joslin Diabetes Center and Harvard Medical School, One Joslin Place, Boston, MA, 02215, USA.
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Jones KH, Ford EM, Lea N, Griffiths LJ, Hassan L, Heys S, Squires E, Nenadic G. Toward the Development of Data Governance Standards for Using Clinical Free-Text Data in Health Research: Position Paper. J Med Internet Res 2020; 22:e16760. [PMID: 32597785 PMCID: PMC7367542 DOI: 10.2196/16760] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/06/2020] [Accepted: 03/23/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Clinical free-text data (eg, outpatient letters or nursing notes) represent a vast, untapped source of rich information that, if more accessible for research, would clarify and supplement information coded in structured data fields. Data usually need to be deidentified or anonymized before they can be reused for research, but there is a lack of established guidelines to govern effective deidentification and use of free-text information and avoid damaging data utility as a by-product. OBJECTIVE This study aimed to develop recommendations for the creation of data governance standards to integrate with existing frameworks for personal data use, to enable free-text data to be used safely for research for patient and public benefit. METHODS We outlined data protection legislation and regulations relating to the United Kingdom for context and conducted a rapid literature review and UK-based case studies to explore data governance models used in working with free-text data. We also engaged with stakeholders, including text-mining researchers and the general public, to explore perceived barriers and solutions in working with clinical free-text. RESULTS We proposed a set of recommendations, including the need for authoritative guidance on data governance for the reuse of free-text data, to ensure public transparency in data flows and uses, to treat deidentified free-text data as potentially identifiable with use limited to accredited data safe havens, and to commit to a culture of continuous improvement to understand the relationships between the efficacy of deidentification and reidentification risks, so this can be communicated to all stakeholders. CONCLUSIONS By drawing together the findings of a combination of activities, we present a position paper to contribute to the development of data governance standards for the reuse of clinical free-text data for secondary purposes. While working in accordance with existing data governance frameworks, there is a need for further work to take forward the recommendations we have proposed, with commitment and investment, to assure and expand the safe reuse of clinical free-text data for public benefit.
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Affiliation(s)
- Kerina H Jones
- Population Data Science, Medical School, Swansea University, Swansea, United Kingdom
| | | | - Nathan Lea
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Lucy J Griffiths
- Population Data Science, Medical School, Swansea University, Swansea, United Kingdom
| | - Lamiece Hassan
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Sharon Heys
- Population Data Science, Medical School, Swansea University, Swansea, United Kingdom
| | - Emma Squires
- Population Data Science, Medical School, Swansea University, Swansea, United Kingdom
| | - Goran Nenadic
- Department of Computer Science, University of Manchester & The Alan Turing Institute, Manchester, United Kingdom
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Benhalima K, Mathiesen ER, Paldanius PM, Mathieu C. The need for appropriate registration of pregnancy outcomes under newer oral glucose-lowering therapies. Diabetes Obes Metab 2018; 20:2477-2480. [PMID: 29806119 DOI: 10.1111/dom.13386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/24/2018] [Accepted: 05/24/2018] [Indexed: 11/26/2022]
Abstract
Because of the increase in type 2 diabetes (T2DM) in young adults, women of childbearing age are frequently treated with newer glucose-lowering therapies, and an increase in unintentional exposure to therapies unapproved for use during pregnancy is expected. The clinician is left with the dilemma of deciding between discontinuation of a novel agent that is providing excellent glycaemic control, while switching to other agents may cause deterioration of glycaemia, and continued use of novel agents that may have uncertain effects on the unborn child. For T2DM, pregnancy data are collected only via spontaneous reporting systems. Therefore, we evaluated the available data on pregnancy outcomes under newer glucose-lowering agents in pharmaceutical safety databases. We found that data on pregnancy outcomes with new glucose-lowering agents in T2DM are scarce, with a high risk of bias towards negative outcomes, limiting their usefulness in robustly assessing safety. Because of the lack of information at present, these agents are not recommended for use during pregnancy or when planning pregnancy. To better guide clinical practice, structured systems of assessing pregnancy outcomes in women receiving these novel agents are urgently needed.
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Affiliation(s)
- Katrien Benhalima
- Department of Endocrinology, UZ Gasthuisberg KU Leuven, Leuven, Belgium
| | - Elisabeth R Mathiesen
- Department of Endocrinology, Center for Pregnant Women with Diabetes, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg KU Leuven, Leuven, Belgium
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