Evaluating the therapeutic approach in pregnancies complicated by borderline glucose intolerance: a randomized clinical trial

Pregnancy outcomes of women with untreated 'mild' gestational diabetes (gestational diabetes by the WHO 2013 but not by the WHO-1999 diagnostic criteria) - A population-based cohort study

AIMS

We compared pregnancy outcomes of untreated 'mild' GDM (GDM by WHO 2013 but not by WHO-1999) to normal glucose tolerant women (NGT).

METHODS

In a universal screening program 4333 pregnant women had a 3-point 75 g OGTT in Hungary in 2009-2013. By WHO-2013 untreated NGT was diagnosed in n = 3303, 'mild' GDM in n = 336 cases.

RESULTS

'Mild' GDM women were older (mean difference, SE: 1.4, 0.3 yrs), had higher fasting (1.0, 0.02), 60-minute (1.0, 0.09), and 120-minute (0.4, 0.06 mmol/l) blood glucose, and blood pressure (2.6, 0.5/2.0, 0.5 mmHg). Weight gain was similar in both groups (-0.3, 0.3 kg). GDM newborns were heavier (142, 50 g) and were more frequently macrosomic (>4000 g, OR 1.85, 95 %CI 1.35-2.54). Hypertension during pregnancy was more prevalent in the GDM group (OR 1.55, 95 %CI 1.05-2.28), as well as induced (OR 1.38, 95 %CI 1.10-1.74) and instrumental delivery (OR 1.34, 95 %CI 1.07-1.68), and acute caesarean section (OR 1.32, 95 %CI 1.04-1.64). Most of these differences substantially attenuated or became non-significant after adjustment for pre-pregnancy BMI.

CONCLUSIONS

Pregnancy outcomes of 'mild' GDM were worse compared to normal glucose tolerant women however these differences were explained by the pre-pregnancy BMI difference between groups.

Impact of gestational diabetes mellitus treatment on medium/long-term outcomes after pregnancy: A systematic review and meta-analysis

AIM

We aimed to evaluate the effect of gestational diabetes mellitus (GDM) treatment on medium/long-term outcomes both the mother and offspring.

METHODS

We performed a systematic review on randomized clinical trials addressing specific treatment of women with GDM versus usual care and its impact on maternal and offspring outcomes at medium/long-term. MEDLINE, EMBASE and CENTRAL were searched from inception to 8 October 2021.

OUTCOME VARIABLES

maternal (diabetes, metabolic syndrome, 12 secondary); offspring (diabetes, impaired fasting glucose, impaired glucose tolerance, high body mass index, 15 secondary). Risk of bias was assessed with Cochrane tool and aggregation performed with Revman 5.4.

RESULTS

We included five studies (1140 women, 767 offspring) with follow-up ranging 4-16 years after delivery. GDM treatment likely does not reduce risk of maternal diabetes (RR 1.00; [95% CI 0.82-1.23]) and may not reduce that of metabolic syndrome (RR 0.93; [95% CI 0.71-1.22]). We obtained very uncertain evidence that treatment may increase maternal HDL-cholesterol. Findings showed that GDM treatment may not have an impact on infants' outcomes (RRs 0.79; [95% CI 0.39-1.69] for impaired fasting glucose; RR 0.91; [95% CI 0.74-1.12] for body mass index >85th centile and 0.89; [95% CI 0.65-1.22] for body mass index >95th centile respectively).

CONCLUSIONS

With current evidence is uncertain if specific treatment of women with GDM has an impact on medium/long-term metabolic outcomes either in the mother or in the offspring. These results add evidence to the recommendation of systematically reevaluating mother and offspring after delivery.

REGISTRATION

OSF, DOI 10.17605/OSF.IO/KFN79.

Lifestyle intervention during pregnancy in patients with gestational diabetes mellitus and the risk of neonatal hypoglycemia: A systematic review and meta-analysis

Objective

Neonatal hypoglycemia is a severe adverse consequence of infants born to mothers with gestational diabetes mellitus (GDM), which can lead to neonatal mortality, permanent neurological consequences, and epilepsy. This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to explore the effect of lifestyle intervention during pregnancy in women with GDM on the risk of neonatal hypoglycemia.

Methods

PubMed, Web of Science, Cochrane Library, CINAHL, and SPORTDiscus databases were searched by 1st April 2022. Data were pooled as the risk ratio (RR) with 95% CIs of neonatal hypoglycemia. Random-effects, subgroup analyses, meta-regression analysis, and leave-one-out analysis were conducted, involving 18 RCTs.

Results

Prenatal lifestyle intervention could significantly reduce the risk of neonatal hypoglycemia (RR: 0.73, 95% CI: 0.54-0.98, P = 0.037). Subgroup analysis further demonstrated that the reduced risk of neonatal hypoglycemia was observed only when subjects were younger than 30 years, initiated before the third trimester, and with dietary intervention. Meta-regression analysis revealed that the risk of neonatal hypoglycemia post lifestyle intervention was lower in mothers with lower fasting glucose levels at trial entry.

Conclusion

We found that prenatal lifestyle intervention in women with GDM significantly reduced the risk of neonatal hypoglycemia. Only lifestyle intervention before the third trimester of pregnancy, or dietary intervention only could effectively reduce the risk of neonatal hypoglycemia. Future studies are required to explore the best pattern of lifestyle intervention and to determine the proper diagnostic criteria of GDM in the first/second trimester of pregnancy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#myprospero, PROSPERO, identifier: CRD42021272985.

Gestational Diabetes Mellitus among Pregnant Women Delivering in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction

Gestational diabetes mellitus is increasing globally leading to significant maternal and foetal morbidity. This study aimed to find out the prevalence of gestational diabetes mellitus among pregnant women delivering in a tertiary care hospital.

Methods

A descriptive cross-sectional study on a total of 3034 pregnant women was conducted in a tertiary care hospital from 14th April 2017 to 13th April 2018 with ethical approval from Research and Institutional Review Committee (Reference number: 061-077/078) of the hospital. Pregnant women who met the eligibility criteria were included in the study. Convenience sampling was done. Data were analysed using the Statistical Package for the Social Sciences version 24.0 and Microsoft Excel. Point estimate at 99% Confidence Interval was calculated along with frequency and percentage for binary data.

Results

Among 3034 patients who delivered in the tertiary centre, the prevalence of gestational diabetes mellitus was found to be 104 (3.42%) (2.57-4.26 at 99% Confidence Interval). The majority of women were of maternal age >30 years in 69 (66.34%). Out of which 48 (46.15%) women had family history of diabetes mellitus. Thirty-eight (36.53%) patients required a caesarean section. The most common obstetric complication was polyhydramnios in 35 (35.57%).

Conclusions

The prevalence of gestational diabetes was lower when compared to other studies done in similar settings. The majority of women were of higher maternal age, had family history of diabetes mellitus and were also obese.

Keywords

diabetes mellitus; gestational diabetes; pregnancy in diabetes.

Liposomal ferric pyrophosphate and ascorbic acid supplementation in pregnant women with iron deficiency anaemia: haematochemical, obstetric, neonatal and psychological outcomes in a prospective observational study

This study aimed to determine the effects of liposomal iron pyrophosphate/ascorbic acid on clinical and psychological outcomes in pregnant women. Women at the 11th-13th weeks of gestation with iron deficiency anaemia assuming Sideremil™ from April 2018 to May 2019 were recruited. Haematochemical, obstetric, neonatal and psychological outcomes were investigated at the enrolment, 21-23 weeks of gestation, 30-32 weeks of gestation and after 6 weeks from childbirth. Results showed significant positive effects on haemoglobin, ferritin, sideremia and transferrin levels, compared to baseline data. A significant improvement of anxiety and depression levels was also observed. Regarding the quality of life, all the domains significantly improved, especially the Physical Role domain. Our results indicate that Sideremil^™ may be a valid treatment for iron deficiency anaemia in pregnant women, since it significantly improves haematological and mental health outcomes. However, further studies are needed to confirm these results.

Mild Gestational Diabetes and Adverse Pregnancy Outcome: A Systemic Review and Meta-Analysis

Background and Objectives: Mild gestational diabetes (GDM) refers to the gestational hyperglycemia, which does not fulfill the diagnostic criteria for GDM. The results of studies on adverse pregnancy outcomes among women with mild GDM are controversial. Therefore, the aim of this systematic review and meta-analysis was to investigate the impact of mild GDM on the risk of adverse maternal and neonatal outcomes. Methods: A thorough literature search was performed to retrieve articles that investigated adverse maternal and neonatal outcomes in women with mild GDM in comparison with non-GDM counterparts. All populations were classified to three groups based on their diagnostic criteria for mild GDM. Heterogeneous and non-heterogeneous results were analyzed using the fixed/random effects models. Publication bias was assessed using the Harbord test. DerSimonian and Laird, and inverse variance methods were used to calculate the pooled relative risk of events. Subgroup analysis was performed based on mild GDM diagnostic criteria. Quality and risk of bias assessment were performed using standard questionnaires. Results: Seventeen studies involving 11,623 pregnant women with mild GDM and 53,057 non-GDM counterparts contributed to the meta-analysis. For adverse maternal outcomes, the results of meta-analysis showed that the women with mild GDM had a significantly higher risk of cesarean section (pooled RR: 1.3, 95% CI 1.2-1.5), pregnancy-induced hypertension (pooled RR: 1.4, 95% CI 1.1-1.7), preeclampsia (pooled RR: 1.3, 95% CI 1.1-1.5) and shoulder dystocia (pooled RR: 2.7, 95% CI 1.5-5.1) in comparison with the non-GDM population. For adverse neonatal outcomes, the pooled relative risk of macrosomia (pooled RR = 0.4, 95% CI: 1.1-1.7), large for gestational age (pooled RR = 1.7, 95% CI: 1.3-2.3), hypoglycemia (pooled RR = 1.6, 95% CI: 1.1-2.3), hyperbilirubinemia (pooled RR = 1.1, 95% CI: 1-1.3), 5 min Apgar <7 (pooled RR = 1.6, 95% CI: 1.1-2.4), admission to the neonatal intensive care unit (pooled RR = 1.5, 95% CI: 1.1-2.1), respiratory distress syndrome (pooled RR = 3.2, 95% CI: 1.8-5.5), and preterm birth (pooled RR = 1.4, 95% CI: 1.1-1.7) was significantly increased in the mild GDM women as compared with the non-GDM population. However, the adverse events of small for gestational age and neonatal death were not significantly different between the groups. Analysis of composite maternal and neonatal outcomes revealed that the risk of those adverse outcomes in the women with mild GDM in all classifications were significantly higher than the non-GDM population. Also, the meta-regression showed that the magnitude of those increased risks in both composite maternal and neonatal outcomes was similar. Conclusion: The risks of sever adverse neonatal outcomes including small for gestational age and neonatal mortality are not increased with mild GDM. However, the increased risks of most adverse maternal and neonatal outcomes are observed. The risks have similar magnitudes for all mild GDM diagnostic classifications.

A Randomized Controlled Trial to Evaluate the Effects of a Smartphone Application-Based Lifestyle Coaching Program on Gestational Weight Gain, Glycemic Control, and Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: The SMART-GDM Study

OBJECTIVE

SMART-GDM examined whether Habits-GDM, a smartphone application (app) coaching program, can prevent excessive gestational weight gain (EGWG) and improve glycemic control and maternal and neonatal outcomes in gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

In this randomized controlled trial, women diagnosed with GDM between 12 and 30 weeks were randomly assigned to usual care (control) or to additional support from Habits-GDM that integrated dietary, physical activity, weight, and glucose monitoring (intervention). The primary outcome was the proportion of participants with EGWG. Secondary outcomes included absolute gestational weight gain (GWG), glycemic control, and maternal, delivery, and neonatal outcomes.

RESULTS

In total, 340 women were randomized (170 intervention, 170 control; mean ± SD age 32.0 ± 4.2 years; mean BMI 25.6 ± 5.6 kg/m²). There were no statistically significant differences in the proportions of women with EGWG, absolute GWG, or maternal and delivery outcomes between experimental groups. Average glucose readings were lower in the intervention group (mean difference -0.15 mmol/L [95% CI -0.26; -0.03], P = 0.011) as were the proportions of glucose above targets (premeal: 17.9% vs. 23.3%, odds ratio 0.68 [95% CI 0.53; 0.87], P = 0.003; 2-h postmeal: 19.9% vs. 50%, 0.54 [0.42; 0.70], P < 0.001). When regarded as a composite (although not prespecified), the overall neonatal complications (including birth trauma, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress, neonatal intensive care unit admission, and perinatal death) were significantly lower in the intervention group (38.1% vs. 53.7%, 0.53 [0.34; 0.84], P = 0.006).

CONCLUSIONS

When added to usual care, Habits-GDM resulted in better maternal glycemic control and composite neonatal outcomes (nonprespecified) but did not reduce EGWG among women with GDM.

Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map

The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).

The Effect of Mild Gestational Diabetes Mellitus Treatment on Adverse Pregnancy Outcomes: A Systemic Review and Meta-Analysis

OBJECTIVES

It is uncertain whether the treatment of mild gestational diabetes mellitus (GDM) improves pregnancy outcomes. The aim of this systemic review and meta-analysis was to investigate the effect of mild GDM treatment on adverse pregnancy outcomes.

METHODS

A comprehensive literature search was conducted on the databases of PubMed, Scopus, and Google Scholar to retrieve studies that compared interventions for the treatment of mild GDM with usual antenatal care. The fixed/random effects models were used for the analysis of heterogeneous and non-heterogeneous results. Publication bias was assessed using the Harbord test. Also, the DerSimonian and Laird, and inverse variance methods were used to calculate the pooled odds ratio of events. The quality assessment of the included studies was performed using the Modified Newcastle-Ottawa Quality Assessment scale and the CONSORT checklist. In addition, the risk of bias was evaluated using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

The systematic review and meta-analysis involved ten studies consisting of 3317 pregnant women who received treatment for mild GDM and 4407 untreated counterparts. Accordingly, the treatment of mild GDM significantly reduced the risk of macrosomia (OR = 0.3; 95%CI = 0.3-0.4), large for gestational age (OR = 0.4; 95%CI = 0.3-0.5), shoulder dystocia (OR = 0.3; 95%CI = 0.2-0.6), caesarean-section (OR = 0.8; 95%CI = 0.7-0.9), preeclampsia (OR = 0.4; 95%CI = 0.3-0.6), elevated cord C-peptide (OR = 0.7; 95%CI = 0.6-0.9), and respiratory distress syndrome (OR = 0.7; 95%CI = 0.5-0.9) compared to untreated counterparts. Moreover, the risk of induced labor significantly increased in the treated group compared to the untreated group (OR = 1.3; 95%CI = 1.0-1.6). However, no statistically significant difference was observed between the groups in terms of small for gestational age, hypoglycemia, hyperbilirubinemia, birth trauma, admission to the neonatal intensive care unit, and preterm birth. Sensitivity analysis based on the exclusion of secondary analysis data was all highly consistent with the main data analysis.

CONCLUSION

Treatment of mild GDM reduced the risk of selected important maternal outcomes including preeclampsia, macrosomia, large for gestational age, cesarean section, and shoulder dystocia without increasing the risk of small for gestational age. Nevertheless, the treatment could not reduce the risk of neonatal metabolic abnormalities or several complications in newborn.

Iron Deficiency Anemia in Pregnancy: Novel Approaches for an Old Problem

Iron needs increase exponentially during pregnancy to meet the increased demands of the fetoplacental unit, to expand maternal erythrocyte mass, and to compensate for iron loss at delivery. In more than 80% of countries in the world, the prevalence of anemia in pregnancy is > 20% and could be considered a major public health problem. The global prevalence of anemia in pregnancy is estimated to be approximately 41.8%. Undiagnosed and untreated iron deficiency anemia (IDA) can have a great impact on maternal and fetal health. Indeed, chronic iron deficiency can affect the general wellbeing of the mother and leads to fatigue and reduced working capacity. Given the significant adverse impact on maternal-fetal outcomes, early recognition and treatment of this clinical condition is fundamental. Therefore, the laboratory assays are recommended from the first trimester to evaluate the iron status. Oral iron supplementation is the first line of treatment in cases of mild anemia. However, considering the numerous gastrointestinal side effects that often lead to poor compliance, other therapeutic strategies should be evaluated. This review aims to provide an overview of the current evidence about the management of IDA in pregnancy and available treatment options.

High maternal early-pregnancy blood glucose levels are associated with altered fetal growth and increased risk of adverse birth outcomes

AIMS/HYPOTHESIS

The study aimed to assess the associations of maternal early-pregnancy blood glucose levels with fetal growth throughout pregnancy and the risks of adverse birth outcomes.

METHODS

In a population-based prospective cohort study among 6116 pregnant women, maternal non-fasting glucose levels were measured in blood plasma at a median 13.2 weeks of gestation (95% range 9.6-17.6). We measured fetal growth by ultrasound in each pregnancy period. We obtained information about birth outcomes from medical records and maternal sociodemographic and lifestyle factors from questionnaires.

RESULTS

Higher maternal early-pregnancy non-fasting glucose levels were associated with altered fetal growth patterns, characterised by decreased fetal growth rates in mid-pregnancy and increased fetal growth rates from late pregnancy onwards, resulting in an increased length and weight at birth (p ≤0.05 for all). A weaker association of maternal early-pregnancy non-fasting glucose levels with fetal head circumference growth rates was present. Higher maternal early-pregnancy non-fasting glucose levels were also associated with an increased risk of delivering a large-for-gestational-age infant, but decreased risk of delivering a small-for-gestational-age infant (OR 1.28 [95% CI 1.16, 1.41], OR 0.88 [95% CI 0.79, 0.98] per mmol/l increase in maternal early-pregnancy non-fasting glucose levels, respectively). These associations were not explained by maternal sociodemographic factors, lifestyle factors or BMI. Maternal early-pregnancy non-fasting glucose levels were not associated with preterm birth or delivery complications.

CONCLUSIONS/INTERPRETATION

Higher maternal early-pregnancy non-fasting glucose levels are associated with decreased fetal growth rates in mid-pregnancy and increased fetal growth rates from late pregnancy onwards, and an increased risk of delivering a large-for-gestational-age infant. Future preventive strategies need to focus on screening for an impaired maternal glucose metabolism from preconception and early pregnancy onwards to improve birth outcomes.

Perinatal Outcomes in Mexican Women with Untreated Mild Gestational Diabetes Mellitus Diagnosed by the International Association of Diabetes and Pregnancy Study Groups Criteria

PURPOSE

To compare the risk of adverse perinatal outcomes (APO) between pregnant women with mild gestational diabetes mellitus (GDM) diagnosed by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, on no specific treatment, versus pregnant women without GDM.

PATIENTS AND METHODS

A retrospective cohort study of pregnant women referred to the Instituto Nacional de Perinatología, in Mexico City, for prenatal care and delivery. Eligibility criteria were singleton pregnancy, age >18 years, gestational age 20-28 weeks, and no history of pre-gestational diabetes. The study population was divided into two groups: Group 1, comprising women with mild GDM defined by one abnormal glucose value at the oral glucose tolerance test (OGTT) according to IADPSG criteria [fasting: 5.1-5.2 mmol/L (92-94 mg/dL) or 2h 8.5-8.56 mmol/L (153-154 mg/dL)], who did not receive specific treatment for GDM, and Group 2, comprising women without GDM, matched for maternal age and pre-gestational body mass index (BMI). Women with two or more abnormal OGTT values, pre-gestational diabetes, any chronic disease, or multiple pregnancies were excluded.

RESULTS

As many as 282 women were included in each group. There were no significant differences in basal characteristics between groups. APO analysis showed that newborn weight was significantly higher in Group 1 (3042.4±499g) vs Group 2 (2910±565g) p=0.003; conversely, the incidence of large for gestational age (LGA) and macrosomic neonates was similar in both groups (6 vs 5.7% and 2.1 vs 2.2%, respectively). There were no differences in rates of preeclampsia and gestational hypertension, cesarean and preterm delivery, or premature rupture of membranes. A sub-analysis by maternal pre-gestational BMI showed that LGA incidence was significantly higher among babies born to women with pre-gestational BMI ≥30 kg/m² in both groups.

CONCLUSION

The risk of APO was similar among Mexican women with mild untreated GDM diagnosed by IADPSG criteria, compared to pregnant women without GDM. Pre-gestational BMI was an independent risk factor for LGA.

Attenuation of maternal weight gain impacts infant birthweight: systematic review and meta-analysis

Despite many interventions aiming to reduce excessive gestational weight gain (GWG), it is currently unclear the impact on infant anthropometric outcomes. The aim of this review was to evaluate offspring anthropometric outcomes in studies designed to reduce GWG. A systematic search of seven international databases, one clinical trial registry and three Chinese databases was conducted without date limits. Studies were categorised by intervention type: diet, physical activity (PA), lifestyle (diet + PA), other, gestational diabetes mellitus (GDM) (diet, PA, lifestyle, metformin and other). Meta-analyses were reported as weighted mean difference (WMD) for birthweight and birth length, and risk ratio (RR) for small for gestational age (SGA), large for gestational age (LGA), macrosomia and low birth weight (LBW). Collectively, interventions reduced birthweight, risk of macrosomia and LGA by 71 g (WMD: -70.67, 95% CI -101.90 to -39.43, P&lt;0.001), 16% (RR: 0.84, 95% CI 0.73-0.98, P=0.026) and 19% (RR: 0.81, 95% CI 0.69-0.96, P=0.015), respectively. Diet interventions decreased birthweight and LGA by 99 g (WMD -98.80, 95% CI -178.85 to -18.76, P=0.016) and 65% (RR: 0.35, 95% CI 0.17-0.72, P=0.004). PA interventions reduced the risk of macrosomia by 51% (RR: 0.49, 95% CI 0.26-0.92, P=0.036). In women with GDM, diet and lifestyle interventions reduced birthweight by 211 and 296 g, respectively (WMD: -210.93, 95% CI -374.77 to -46.71, P=0.012 and WMD:-295.93, 95% CI -501.76 to -90.10, P=0.005, respectively). Interventions designed to reduce excessive GWG lead to a small reduction in infant birthweight and risk of macrosomia and LGA, without influencing the risk of adverse outcomes including LBW and SGA.

Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews

BACKGROUND

Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies.

OBJECTIVES

To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies.

METHODS

We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded.Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data.

MAIN RESULTS

We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high- to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM.EffectiveLifestyle versus usual careLifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality).PromisingNo evidence for any outcome for any comparison could be classified to this category.Ineffective or possibly harmful Lifestyle versus usual careLifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality).Exercise versus controlExercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality).Insulin versus oral therapyInsulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality).Probably ineffective or harmful interventionsInsulin versus oral therapyFor insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality).InconclusiveLifestyle versus usual careThe evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality).Exercise versus controlThe evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality).Insulin versus oral therapyThe evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes.Insulin versus dietThe evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality).Insulin versus insulinThe evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality).No conclusions possibleNo conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low-quality.

AUTHORS' CONCLUSIONS

Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed.

Attenuating Pregnancy Weight Gain-What Works and Why: A Systematic Review and Meta-Analysis

Excessive maternal gestational weight gain (GWG) contributes to generational obesity. Our aim was to explore efficacy and intervention characteristics (trimester, duration, frequency, intensity, and delivery method) of interventions to prevent excessive GWG. CINAHL, Cochrane, EMBASE, LILACS, MEDLINE, PsycINFO, and Scopus were searched up to May 2018 (no date or language restrictions). Keywords and MeSH terms for diet, GWG, intervention, lifestyle, maternal, physical activity, and pregnancy were used to locate randomized-controlled trials (RCTs). The Cochrane Collaboration tool for assessing risk of bias was applied. Eighty-nine RCTs were included. Meta-analysis (60 trials) estimated that women in diet only (WMD: -3.27; 95% CI: -4.96, -1.58, p < 0.01), physical activity (PA) (WMD: -1.02; 95% CI: -1.56, -0.49, p < 0.01), and lifestyle interventions (combining diet and PA) (WMD: -0.84; 95% CI: -1.29, -0.39, p < 0.01) gained significantly less weight than controls. The three eHealth interventions favored neither intervention nor control (WMD: -1.06; 95% CI: -4.13, 2.00, p = 0.50). Meta-regression demonstrated no optimal duration, frequency, intensity, setting, or diet type. Traditional face to face delivery of weight management interventions during pregnancy can be successful. Delivery via eHealth has potential to extend its reach to younger women but needs further evaluation of its success.

The identification and treatment of women with hyperglycaemia in pregnancy: an analysis of individual participant data, systematic reviews, meta-analyses and an economic evaluation

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with a higher risk of important adverse outcomes. Practice varies and the best strategy for identifying and treating GDM is unclear.

AIM

To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with GDM.

METHODS

We analysed individual participant data (IPD) from birth cohorts and conducted systematic reviews to estimate the association of maternal glucose levels with adverse perinatal outcomes; GDM prevalence; maternal characteristics/risk factors for GDM; and the effectiveness and costs of treatments. The cost-effectiveness of various strategies was estimated using a decision tree model, along with a value of information analysis to assess where future research might be worthwhile. Detailed systematic searches of MEDLINE^® and MEDLINE In-Process & Other Non-Indexed Citations^®, EMBASE, Cumulative Index to Nursing and Allied Health Literature Plus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database, Maternity and Infant Care database and the Cochrane Methodology Register were undertaken from inception up to October 2014.

RESULTS

We identified 58 studies examining maternal glucose levels and outcome associations. Analyses using IPD alone and the systematic review demonstrated continuous linear associations of fasting and post-load glucose levels with adverse perinatal outcomes, with no clear threshold below which there is no increased risk. Using IPD, we estimated glucose thresholds to identify infants at high risk of being born large for gestational age or with high adiposity; for South Asian (SA) women these thresholds were fasting and post-load glucose levels of 5.2 mmol/l and 7.2 mmol/l, respectively and for white British (WB) women they were 5.4 and 7.5 mmol/l, respectively. Prevalence using IPD and published data varied from 1.2% to 24.2% (depending on criteria and population) and was consistently two to three times higher in SA women than in WB women. Lowering thresholds to identify GDM, particularly in women of SA origin, identifies more women at risk, but increases costs. Maternal characteristics did not accurately identify women with GDM; there was limited evidence that in some populations risk factors may be useful for identifying low-risk women. Dietary modification additional to routine care reduced the risk of most adverse perinatal outcomes. Metformin (Glucophage,^® Teva UK Ltd, Eastbourne, UK) and insulin were more effective than glibenclamide (Aurobindo Pharma - Milpharm Ltd, South Ruislip, Middlesex, UK). For all strategies to identify and treat GDM, the costs exceeded the health benefits. A policy of no screening/testing or treatment offered the maximum expected net monetary benefit (NMB) of £1184 at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year (QALY). The NMB for the three best-performing strategies in each category (screen only, then treat; screen, test, then treat; and test all, then treat) ranged between -£1197 and -£1210. Further research to reduce uncertainty around potential longer-term benefits for the mothers and offspring, find ways of improving the accuracy of identifying women with GDM, and reduce costs of identification and treatment would be worthwhile.

LIMITATIONS

We did not have access to IPD from populations in the UK outside of England. Few observational studies reported longer-term associations, and treatment trials have generally reported only perinatal outcomes.

CONCLUSIONS

Using the national standard cost-effectiveness threshold of £20,000 per QALY it is not cost-effective to routinely identify pregnant women for treatment of hyperglycaemia. Further research to provide evidence on longer-term outcomes, and more cost-effective ways to detect and treat GDM, would be valuable.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004608.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Neonatal delivery weight and risk of future maternal diabetes

OBJECTIVE

To investigate associations between neonatal delivery weight and future risk of maternal type 1 or type 2 diabetes.

METHODS

Data included in the Swedish Medical Birth Registry and Swedish National Diabetes Registry were merged to include all women born during 1930-1989; patients with pre-existing diabetes or gestational diabetes were excluded. Cox regression analyses were performed to identify associations between the neonatal delivery weight from the most recent pregnancy and later occurrence of diabetes.

RESULTS

There were 1 873 440 patients included in the analyses. An increased risk of type 1 (hazard ratio 3.60, 95% confidence interval [CI] 3.23-4.01) or type 2 diabetes (hazard ratio 2.77, 95% CI 2.68-2.87) was observed among patients who had a large for gestational age neonate compared with patients who had neonates within one standard definition of the mean weight for gestational age; the odds of developing type 1 (odds ratio 10.27, 95% CI 7.37-14.31) or type 2 diabetes (odds ratio 8.50, 95% CI 6.01-12.02) within 1 year of delivery was also increased compared with patients who had a neonate within one standard deviation of the mean weight for gestational age.

CONCLUSIONS

Delivering a large for gestational age neonate was a potent risk factor for the later development of maternal type 1 or type 2 diabetes.

The effects of various diets on glycemic outcomes during pregnancy: A systematic review and network meta-analysis

Aims

Evidence to support dietary modifications to improve glycemia during pregnancy is limited, and the benefits of diet beyond limiting gestational weight gain is unclear. Therefore, a systematic review and network meta-analysis of randomized trials was conducted to compare the effects of various common diets, stratified by the addition of gestational weight gain advice, on fasting glucose and insulin, hemoglobin A1c (Hb_A1c), and homeostatic model assessment for insulin resistance (HOMA-IR) in pregnant women.

Methods

MEDLINE, EMBASE, Cochrane database, and reference lists of published studies were searched through April 2017. Randomized trials directly comparing two or more diets for ≥2-weeks were eligible. Bayesian network meta-analysis was performed for fasting glucose. Owing to a lack of similar dietary comparisons, a standard pairwise meta-analysis for the other glycemic outcomes was performed. The certainty of the pooled effect estimates was assessed using the GRADE tool.

Results

Twenty-one trials (1,865 participants) were included. In general, when given alongside gestational weight gain advice, fasting glucose improved in most diets compared to diets that gave gestational weight gain advice only. However, fasting glucose increased in high unsaturated or monounsaturated fatty acids diets. In the absence of gestational weight gain advice, fasting glucose improved in DASH-style diets compared to standard of care. Although most were non-significant, similar trends were observed for these same diets for the other glycemic outcomes. Dietary comparisons ranged from moderate to very low in quality of evidence.

Conclusion/Interpretation

Alongside with gestational weight gain advice, most diets, with the exception of a high unsaturated or a high monounsaturated fatty acid diet, demonstrated a fasting glucose improvement compared with gestational weight gain advice only. When gestational weight gain advice was not given, the DASH-style diet appeared optimal on fasting glucose. However, a small number of trials were identified and most dietary comparisons were underpowered to detect differences in glycemic outcomes. Further studies that are high in quality and adequately powered are needed to confirm these findings.

Registration

PROSPERO CRD42015026008

Treatments for gestational diabetes: a systematic review and meta-analysis

OBJECTIVE

To investigate the effectiveness of different treatments for gestational diabetes mellitus (GDM).

DESIGN

Systematic review, meta-analysis and network meta-analysis.

METHODS

Data sources were searched up to July 2016 and included MEDLINE and Embase. Randomised trials comparing treatments for GDM (packages of care (dietary and lifestyle interventions with pharmacological treatments as required), insulin, metformin, glibenclamide (glyburide)) were selected by two authors and double checked for accuracy. Outcomes included large for gestational age, shoulder dystocia, neonatal hypoglycaemia, caesarean section and pre-eclampsia. We pooled data using random-effects meta-analyses and used Bayesian network meta-analysis to compare pharmacological treatments (ie, including treatments not directly compared within a trial).

RESULTS

Forty-two trials were included, the reporting of which was generally poor with unclear or high risk of bias. Packages of care varied in their composition and reduced the risk of most adverse perinatal outcomes compared with routine care (eg, large for gestational age: relative risk0.58 (95% CI 0.49 to 0.68; I2=0%; trials 8; participants 3462). Network meta-analyses suggest that metformin had the highest probability of being the most effective treatment in reducing the risk of most outcomes compared with insulin or glibenclamide.

CONCLUSIONS

Evidence shows that packages of care are effective in reducing the risk of most adverse perinatal outcomes. However, trials often include few women, are poorly reported with unclear or high risk of bias and report few outcomes. The contribution of each treatment within the packages of care remains unclear. Large well-designed and well-conducted trials are urgently needed.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42013004608.

Lifestyle interventions for the treatment of women with gestational diabetes

BACKGROUND

Gestational diabetes (GDM) is glucose intolerance, first recognised in pregnancy and usually resolving after birth. GDM is associated with both short- and long-term adverse effects for the mother and her infant. Lifestyle interventions are the primary therapeutic strategy for many women with GDM.

OBJECTIVES

To evaluate the effects of combined lifestyle interventions with or without pharmacotherapy in treating women with gestational diabetes.

SEARCH METHODS

We searched the Pregnancy and Childbirth Group's Trials Register (14 May 2016), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (14th May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included only randomised controlled trials comparing a lifestyle intervention with usual care or another intervention for the treatment of pregnant women with GDM. Quasi-randomised trials were excluded. Cross-over trials were not eligible for inclusion. Women with pre-existing type 1 or type 2 diabetes were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. All selection of studies, data extraction was conducted independently by two review authors.

MAIN RESULTS

Fifteen trials (in 45 reports) are included in this review (4501 women, 3768 infants). None of the trials were funded by a conditional grant from a pharmaceutical company. The lifestyle interventions included a wide variety of components such as education, diet, exercise and self-monitoring of blood glucose. The control group included usual antenatal care or diet alone. Using GRADE methodology, the quality of the evidence ranged from high to very low quality. The main reasons for downgrading evidence were inconsistency and risk of bias. We summarised the following data from the important outcomes of this review. Lifestyle intervention versus control groupFor the mother:There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of hypertensive disorders of pregnancy (pre-eclampsia) (average risk ratio (RR) 0.70; 95% confidence interval (CI) 0.40 to 1.22; four trials, 2796 women; I2 = 79%, Tau2 = 0.23; low-quality evidence); caesarean section (average RR 0.90; 95% CI 0.78 to 1.05; 10 trials, 3545 women; I2 = 48%, Tau2 = 0.02; low-quality evidence); development of type 2 diabetes (up to a maximum of 10 years follow-up) (RR 0.98, 95% CI 0.54 to 1.76; two trials, 486 women; I2 = 16%; low-quality evidence); perineal trauma/tearing (RR 1.04, 95% CI 0.93 to 1.18; one trial, n = 1000 women; moderate-quality evidence) or induction of labour (average RR 1.20, 95% CI 0.99 to 1.46; four trials, n = 2699 women; I2 = 37%; high-quality evidence).More women in the lifestyle intervention group had met postpartum weight goals one year after birth than in the control group (RR 1.75, 95% CI 1.05 to 2.90; 156 women; one trial, low-quality evidence). Lifestyle interventions were associated with a decrease in the risk of postnatal depression compared with the control group (RR 0.49, 95% CI 0.31 to 0.78; one trial, n = 573 women; low-quality evidence).For the infant/child/adult:Lifestyle interventions were associated with a reduction in the risk of being born large-for-gestational age (LGA) (RR 0.60, 95% CI 0.50 to 0.71; six trials, 2994 infants; I2 = 4%; moderate-quality evidence). Birthweight and the incidence of macrosomia were lower in the lifestyle intervention group.Exposure to the lifestyle intervention was associated with decreased neonatal fat mass compared with the control group (mean difference (MD) -37.30 g, 95% CI -63.97 to -10.63; one trial, 958 infants; low-quality evidence). In childhood, there was no clear evidence of a difference between groups for body mass index (BMI) ≥ 85th percentile (RR 0.91, 95% CI 0.75 to 1.11; three trials, 767 children; I2 = 4%; moderate-quality evidence).There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of perinatal death (RR 0.09, 95% CI 0.01 to 1.70; two trials, 1988 infants; low-quality evidence). Of 1988 infants, only five events were reported in total in the control group and there were no events in the lifestyle group. There was no clear evidence of a difference between lifestyle intervention and control groups for a composite of serious infant outcome/s (average RR 0.57, 95% CI 0.21 to 1.55; two trials, 1930 infants; I2 = 82%, Tau2 = 0.44; very low-quality evidence) or neonatal hypoglycaemia (average RR 0.99, 95% CI 0.65 to 1.52; six trials, 3000 infants; I2 = 48%, Tau2 = 0.12; moderate-quality evidence). Diabetes and adiposity in adulthood and neurosensory disability in later childhoodwere not prespecified or reported as outcomes for any of the trials included in this review.

AUTHORS' CONCLUSIONS

Lifestyle interventions are the primary therapeutic strategy for women with GDM. Women receiving lifestyle interventions were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born LGA and decreased neonatal adiposity. Long-term maternal and childhood/adulthood outcomes were poorly reported.The value of lifestyle interventions in low-and middle-income countries or for different ethnicities remains unclear. The longer-term benefits or harms of lifestyle interventions remains unclear due to limited reporting.The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy. Lifestyle interventions are useful as the primary therapeutic strategy and most commonly include healthy eating, physical activity and self-monitoring of blood glucose concentrations.Future research could focus on which specific interventions are most useful (as the sole intervention without pharmacological treatment), which health professionals should give them and the optimal format for providing the information. Evaluation of long-term outcomes for the mother and her child should be a priority when planning future trials. There has been no in-depth exploration of the costs 'saved' from reduction in risk of LGA/macrosomia and potential longer-term risks for the infants.

Prevalence of hyperglycaemia first detected during pregnancy and subsequent obstetric outcomes at St. Francis Hospital Nsambya

BACKGROUND

Women with hyperglycaemia detected during pregnancy are at greater risk for adverse pregnancy outcomes. Data on hyperglycaemia in pregnancy in sub-Saharan Africa is scanty and varied depending on the populations studied and the methodologies used to define hyperglycaemia in pregnancy. With the recent 2013 World Health Organisation (WHO) diagnostic criteria and classification, there is yet no sufficient data on the prevalence of hyperglycaemia in sub-Saharan Africa. The objective was to determine the prevalence of Hyperglycaemia first detected during pregnancy and subsequent obstetric outcomes among patients attending antenatal care (ANC) at St. Francis Hospital Nsambya.

METHODS

A prospective cohort study. All women with no history of diabetes mellitus attending at or after 24 weeks gestation were eligible to participate in the study. Participants underwent a standard 75 g oral glucose tolerance test (OGTT) after an informed written consent. The primary outcome was diagnosis of hyperglycaemia. Enrolled participants were followed up to delivery to assess obstetric outcomes (secondary outcomes were birth weight, neonatal admission, maternal genital trauma, delivery mode, neonatal and maternal status at discharge).

RESULTS

251 women were screened between December 2013 and February 2014. The prevalence of hyperglycaemia first detected in pregnancy was 31.9%. We found 23.8 % of women with hyperglycaemia had no known risk factor. Macrosomia was the only obstetric outcome that was significantly associated with hyperglycaemia.

CONCLUSION

The prevalence of hyperglycaemia first detected in pregnancy was high in the studied population. Clinicians, therefore, should become more vigilant to screen for the condition. Selective screening may miss 23.8% of pregnant women with hyperglycaemia. However the cost/benefit implications of screening strategy and the recent 2013 WHO diagnostic criteria need to be studied in our setting.

Effects of management in gestational diabetes mellitus with normal prepregnancy body mass index on pregnancy outcomes and placental ultrastructures: a prospective cohort study

A great quantity of gestational diabetes mellitus with normal prepregnancy body mass index have emerged with the new criteria of gestational diabetes mellitus in China based on the International Diabetes in Pregnancy Consensus group criteria, and understanding placental changes and how they affect outcomes are necessary in order to develop effective management approach. The aim of this study was to prospectively explore the effect of active management starting from the late second trimester in gestational diabetes mellitus women with normal prepregnancy body mass index on pregnancy outcomes and placental ultrastructures, and to provide scientific evidences for optimizing the management of gestational diabetes mellitus in China. Gestational diabetes mellitus women with normal prepregnancy body mass index in the same period of this prospective cohort study were divided into intervention group (n = 51) and control group (n = 55). The intervention group was managed rigorously, while the control group received conventional prenatal cares. The glucose profile, gestational weight gain and pregnancy outcomes were followed up and placental ultrastructures were observed and recorded by transmission electron microscopy. The blood glucose level and gestational weight gain in intervention group were significantly better controlled than those in control group (P < 0.01). The incidences of fetal distress, cesarean section and large for gestational age were significantly lower in intervention group than in control group (P < 0.05). There was a significant reduction in the incidence of abnormal placental ultrastructure in the intervention group (P < 0.01). After adjustment for confounding factors, the undesirable glycemic control and conventional management were related to abnormal placental ultrastructure (P < 0.05). Meanwhile, the undesirable glycemic control, abnormal placental ultrastructure and conventional management made sense in the incidence of fetal distress (P < 0.05), and the target glycemic control, recommend weight gain and active management were associated with reductions in the prevalence of cesarean delivery and large for gestational age (P < 0.05). The active management of gestational diabetes mellitus women with normal prepregnancy body mass index can improve pregnancy outcomes and placental ultrastructures, and the abnormal placental ultrastructure might be closely associated with the undesirable glycemic control and adverse pregnancy outcomes.

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.

Single abnormal value on 3-hour oral glucose tolerance test during pregnancy is associated with adverse maternal and neonatal outcomes: a systematic review and metaanalysis

OBJECTIVE DATA

The purpose of this study was to determine whether women with 1 abnormal value on 3-hour 100-g oral glucose tolerance test are at an increased risk for adverse pregnancy outcomes.

STUDY

Gestational diabetes mellitus is diagnosed by a 2-step method, with a 3-hour, 100-g oral glucose tolerance test that is reserved for women with an abnormal 1-hour, 50-g glucose challenge test. Although the increased maternal-fetal morbidity with gestational diabetes mellitus is well established, controversy remains about the risk that is associated with an isolated abnormal value during a 3-hour, 100-g oral glucose tolerance test.

STUDY APPRAISAL AND SYNTHESIS METHODS

Prospective and retrospective studies that evaluated the maternal and perinatal impact of 1 abnormal glucose value during a 3-hour, 100-g oral glucose tolerance test were identified with the use of computerized databases. Data were extracted and quantitative analyses were performed.

RESULTS

Twenty-five studies (7 prospective and 18 retrospective) that met criteria for metaanalysis included 4466 women with 1 abnormal glucose value on oral glucose tolerance test. Patients with 1 abnormal glucose value had significantly worse pregnancy outcomes compared with women with zero abnormal values with the following pooled odds ratios: macrosomia, 1.59 (95% confidence interval, 1.16-2.19); large for gestational age, 1.38 (95% confidence interval, 1.09-1.76); increased mean birthweight, 44.5 g (95% confidence interval, 8.10-80.80 g); neonatal hypoglycemia, 1.88 (95% confidence interval, 1.05-3.38); total cesarean delivery, 1.69 (95% confidence interval, 1.40-2.05); pregnancy-induced hypertension, 1.55 (95% confidence interval, 1.31-1.83), and Apgar score of <7 at 5 minutes, 6.10 (95% confidence interval, 2.65-14.02). There was also an increase in neonatal intensive care unit admission and respiratory distress syndrome. Similar results were seen that compared 1 abnormal glucose value to a population with a normal 1-hour 50-g glucose challenge test (normal glucose screen). With the exception of birthweight, outcomes of patients with 1 abnormal glucose value were similar to outcomes of patients with gestational diabetes mellitus.

CONCLUSION

Women with 1 abnormal value on 3-hour, 100-g oral glucose tolerance test have a significantly increased risk for poor outcomes comparable with women who have gestational diabetes mellitus.

Gestational Diabetes Screening: The International Association of the Diabetes and Pregnancy Study Groups Compared With Carpenter-Coustan Screening

OBJECTIVE

To evaluate whether one-step gestational diabetes screening recommended by The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) is associated with better maternal, perinatal, or neonatal outcomes than the two-step Carpenter-Coustan screening.

METHODS

In this before-after retrospective cohort study conducted between July 1, 2010, and December 31, 2013, we compared Carpenter-Coustan and IADPSG screening in patients with singleton pregnancies. All patients diagnosed with gestational diabetes received intensive teaching, home glucose monitoring, and medications as indicated. The primary outcome was the rate of large-for-gestational-age neonates. Secondary outcome measures were macrosomia (greater than 4,000 g), primary cesarean delivery, neonatal intensive care unit admission, preterm delivery, preeclampsia, and hyperbilirubinemia. We determined that a sample size of 2,782 per group was sufficient to detect a 2% difference in the primary outcome between groups with 80% power assuming a 10% incidence in the before group. The groups were compared using Fisher exact test for proportions and a χ test for odds ratios.

RESULTS

In the before (Carpenter-Coustan) group, 513 (17%) of the 2,972 patients were diagnosed with gestational diabetes, and in the after (IADPSG) group, 847 (27%) of the 3,094 patients were so diagnosed (P<.001). There was no significant difference in rates of large for gestational age, 10% and 9%, respectively (P=.25). The IADPSG group had a significantly higher primary cesarean delivery rate-16% compared with 20% (P<.001), but there were no significant differences in any other pregnancy outcomes.

CONCLUSION

Although one-step screening was associated with more patients being treated for gestational diabetes, it was not associated with a decrease in large-for-gestational-age or macrosomic neonates but was associated with an increased rate of primary cesarean delivery. Our results did not support the IADPSG-recommended screening protocol.

[Gestational diabetes mellitus]

While the prevalence of gestational diabetes mellitus (GDM) was estimated between 5 and 10% in 2010, the application of new thresholds recommended by IADPSG and adopted in 2010 by CNGOF seems to significantly increase the number of patients affected by this pathology. A prospective single-center French study estimated in 2014 the prevalence of gestational diabetes at 14% with these criteria, making it one of the most frequent complications during pregnancy. However, to date, there is no published study using these criteria to show a benefit to the health of women and children. If a diagnosis of GDM or type 2 diabetes during pregnancy is definitively an important risk factor for maternal as well as newborn and child complications, it is probably not the case for moderate hyperglycemia discovered during pregnancy.

Assessing use of a printed lifestyle intervention tool by women with borderline gestational diabetes and their achievement of diet and exercise goals: a descriptive study

BACKGROUND

The purpose of this study is to assess use of a booklet by pregnant women to record and assist dietary and lifestyle changes; to describe diet and exercise goals set during the initial lifestyle discussions; and to assess achievement of goals.

METHODS

Participants were women with borderline gestational diabetes who received a printed pregnancy record booklet, as part of a randomised trial, to record and set monthly goals for diet and exercise. Outcomes included women's use of the booklets and their achievement of dietary and exercise goals after 1 month.

RESULTS

Fifty-six women returned their used pregnancy record booklets and were included in this study. These women set a total of 197 dietary goals and 65 exercise goals. In the first month, over 80% of dietary goals that targeted grains, dairy and overall diet were achieved, but only 20-30% of goals about vegetables, and foods high in fat, sugar and/or salt were achieved. After 1 month, women had achieved 86.4% of their exercise goals to maintain their current level of activity, but only 25.0 % exercise goals to increase walking during pregnancy.

CONCLUSIONS

Women who used pregnancy record booklets reported good achievement rates for goals related to grains, fruits, dairy and overall diet, but they were less likely to be successful in achieving goals to increase intake of vegetables, and limit foods that high in fat, sugar and/or salt. Maintaining an active lifestyle during pregnancy was feasible for women although increases in physical activity were less often achieved. Using a pregnancy record booklet may be helpful in assisting and encouraging behavioural changes, although further investigations of long-term effects and in different populations are warranted.

Gene expression profile of whole blood cells differs in pregnant women with positive screening and negative diagnosis for gestational diabetes

OBJECTIVE

To evaluate the gene expression profile of whole blood cells in pregnant women without diabetes (with positive screening and negative diagnosis for gestational diabetes mellitus (GDM)) compared with pregnant women with negative screening for GDM.

RESEARCH DESIGN AND METHODS

Pregnant women were recruited in the Diabetes Perinatal Research Centre-Botucatu Medical School-UNESP and Botucatuense Mercy Hospital (UNIMED). Distributed into 2 groups: control (n=8), women with negative screening and non-diabetic (ND, n=13), with positive screening and negative diagnosis of GDM. A peripheral blood sample was collected for glucose, glycated hemoglobin, and microarray gene expression analyses.

RESULTS

The evaluation of gene expression profiles showed significant differences between the control group and the ND group, with 22 differentially expressed gene sequences. Gene networks and interaction tables were generated to evaluate the biological processes associated with differentially expressed genes of interest.

CONCLUSIONS

In the group with positive screening, there is an apparent regulatory balance between the functions of the differentially expressed genes related to the pathogenesis of diabetes and a compensatory attempt to mitigate the possible etiology. These results support the 'two-step Carpenter-Coustan' strategy because pregnant women with negative screening do not need to continue on diagnostic investigation of gestational diabetes, thus reducing the cost of healthcare and the medicalization of pregnancy. Although not diabetic, they do have risk factors, and thus attention to these genes is important when considering disease evolution because this pregnant women are a step toward developing diabetes compared with women without these risk factors.

The influence of maternal BMI and gestational diabetes on pregnancy outcome

AIMS

To evaluate the effect of maternal body mass index (BMI) on gestational diabetes (GDM) and the risk of adverse pregnancy outcomes in women who are overweight or obese.

METHODS

A prospective cohort study nested within the LIMIT randomised controlled trial. A total of 1030 women were recruited between 10 and 20 weeks' gestation, with a BMI≥25 kg/m(2), and were grouped into BMI subclasses utilising World Health Organisation criteria. Women underwent a fasting oral glucose tolerance test at 26-28 weeks' gestation, and a diagnosis of GDM was made if fasting blood glucose was ≥5.5 mmol/L or ≥7.8 mmol/L after 2h. Maternal and neonatal health outcomes were evaluated.

RESULTS

The prevalence of GDM increased with increasing maternal BMI (6.74% overweight vs 13.42% obese subclass 1 vs 12.79% obese subclass 2 vs 20.00% obese subclass 3). Women who were diagnosed with GDM were significantly less likely to give birth to an infant with birth weight above 4 kg (RR 0.60; 95% CI 0.36 to 1.00; p=0.05). The need for caesarean delivery (RR 1.27; 95% CI 1.07 to 1.50; p=0.006) and incidence of birth weight >90% (RR 1.38; 95% CI 1.07 to 1.77; p=0.01) was significantly increased in women who were obese, independent of GDM.

CONCLUSION

Increasing maternal BMI is a significant risk factor for the development of GDM, and our findings demonstrate a considerably higher prevalence than has been previously described. Raised maternal BMI is a risk factor for high infant birth weight, which may be modified by lifestyle intervention.

Glycemic targets in pregnancies affected by diabetes: historical perspective and future directions

The definition of optimal glycemic control in pregnancies affected by diabetes remains enigmatic. Diabetes phenotypes are heterogeneous. Moreover, fetal macrosomia insidiously occurs even with excellent glycemic control. Current blood glucose (BG) targets (FBG ≤95, 1-h post-prandial <140, 2 h <120 mg/dL) have improved perinatal outcomes, but arguably they have not normalized. The conventional management approach has been to replicate a pattern of glycemia in normal pregnancy. Although these patterns are lower than previously appreciated, a randomized controlled trial (RCT) has never compared current vs. lower glucose targets powered on maternal/fetal outcomes. This paper provides historical context to the current targets by reviewing evidence supporting their evolution. Using lower targets (FBG <90, 1 h <122, 2 h <110, mean BG ≤95 mg/dL) may help normalize outcomes, but phenotypic differences (type 1 vs. type 2 vs. gestational diabetes) might require different glycemic goals. There remains a critical need for well-designed RCTs to confirm optimal glycemic control that minimizes both small for and large for gestational age across pregnancies affected by diabetes.

Effects of dietary interventions on neonatal and infant outcomes: a systematic review and meta-analysis

BACKGROUND

Nutrition plays a fundamental role in fetal growth and birth outcomes.

OBJECTIVE

We synthesized effects of dietary interventions before or during pregnancy on neonatal and infant outcomes.

DESIGN

Randomized controlled trials that assessed the whole diet or dietary components and neonatal or infant outcomes were included. Two authors independently identified articles to be included and assessed the methodologic quality. A meta-analysis was conducted separately for each outcome by using a random-effects model. Results were reported by dietary intervention as follows: 1) counseling, 2) food and fortified food products, or 3) a combination (counseling plus food) intervention, and 4) collectively for all dietary interventions. Results were subanalyzed by the nutrient of interest, country income, and BMI.

RESULTS

Of 2326 abstracts screened, a total of 29 randomized controlled trials (31 publications) were included in this review. Food and fortified food products were effective in increasing birth weight [standardized mean difference (SMD): 0.27; 95% CI: 0.14, 0.40; P < 0.01] and reducing the incidence of low birth weight (SMD: -0.22; 95% CI: -0.37, -0.06; P < 0.01). All dietary interventions and those focused on macronutrient intake also increased birth weight (P < 0.01) and length (P < 0.05) and reduced the incidence of low birth weight (P < 0.01). Dietary interventions in low-income countries and underweight or nutritionally at-risk populations increased birth weight (P < 0.05) and reduced the incidence of low birth weight (P = 0.01). No effects were seen for the following other outcomes: placental weight, head circumference, macrosomia, Apgar score, small for gestational age, large for gestational age, and perinatal mortality.

CONCLUSION

Additional high-quality randomized controlled trials that test different dietary interventions are required to identify maternal diet intakes that optimize neonatal and infant outcomes.

Effects of dietary interventions on pregnancy outcomes: a systematic review and meta-analysis

Dietary intake during pregnancy influences maternal health. Poor dietary practices during pregnancy have been linked to maternal complications. The objective was to determine the effect of dietary intervention before or during pregnancy on pregnancy outcomes. A systematic review was conducted without date restrictions. Randomised controlled trials (RCTs) evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified papers for inclusion and assessed methodological quality. Meta-analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (1) counselling; (2) food and fortified food products; or (3) combination (counseling + food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index. Of 2326 screened abstracts, a total of 28 RCTs were included in this review. Dietary counselling during pregnancy was effective in reducing systolic [standardised mean difference (SMD) -0.26, 95% confidence interval (CI) -0.45 to -0.07; P < 0.001] and diastolic blood pressure (SMD -0.57, 95% CI -0.75 to -0.38; P < 0.001). Macronutrient dietary interventions were effective in reducing the incidence of preterm delivery (SMD -0.19, 95% CI -0.34 to -0.04; P = 0.01). No effects were seen for other outcomes. Dietary interventions showed some small, but significant differences in pregnancy outcomes including a reduction in the incidence of preterm birth. Further high-quality RCTs, investigating micronutrient provision from food, and combination dietary intervention, are required to identify maternal diet intakes that optimise pregnancy outcomes.

Maternal glucose level and body mass index measured at gestational diabetes mellitus screening and the risk of macrosomia: results from a perinatal cohort study

OBJECTIVE

To examine the impact of maternal blood glucose (BG) level and body mass index (BMI) measured at gestational diabetes mellitus (GDM) screening on the risk of macrosomia.

DESIGN

A perinatal cohort of women were followed up from receiving perinatal healthcare to giving birth.

SETTING

Beichen District, Tianjin, China between June 2011 and October 2012.

PARTICIPANTS

1951 women aged 19-42 years with valid values of BMI and BG level at GDM screening (24-28 weeks gestation), singleton birth and birth weight (BW)>2500 g.

MAIN OUTCOMES AND MEASURES

Primary outcome was macrosomia (BW>4000 g). BG level and BMI were measured at GDM screening.

RESULTS

191 (9.7%) newborns were macrosomia. The ORs (95% CIs) of macrosomia from multiple logistic regression were 1.14 (1.10 to 1.19, p<0.0001) for BMI and 1.11 (1.01 to 1.23, p=0.03) for BG. When BMI and BG levels (continuous) were modelled simultaneously, the OR for BMI was similar, but significantly attenuated for BG. Areas of receiver operating characteristics (ROC) were 0.6530 (0.6258 to 0.6803) for BMI and 0.5548 (0.5248 to 0.5848) for BG (χ(2)=26.17, p<0.0001). BG (mmol/L, <6.7, 6.7-7.8 or ≥7.8) and BMI in quintiles (Q1-Q5) were evaluated with BG <6.7 and Q2 BMI as the reference group. The ORs of macrosomia were not statistically different for mothers in Q1 or Q2 of BMI regardless of the BG levels; the ORs for ≥Q3 of BMI were elevated significantly with the highest OR observed in Q5 of BMI and BG levels ≥7.8 (6.93 (2.61 to 18.43), p<0.0001).

CONCLUSIONS

High BMI measured at GDM screening was the most important determinant for risk of macrosomia. These findings suggest that GDM screening may be a critical gestational time point to initiate maternal weight control oriented intervention strategy to lower the risk.

Effect of treatment of gestational diabetes mellitus: a systematic review and meta-analysis

Objective

To assess the efficacy and safety of treating pregnant women with gestational diabetes mellitus in comparison to usual antenatal care.

Methods

A systematic review and meta-analysis was conducted by including randomized controlled trials comparing any form of therapeutic intervention in comparison to usual antenatal care. A literature search was conducted using electronic databases together with a hand search of relevant journals and conference proceedings.

Results

Ten studies involving 3,881 patients contributed to meta-analysis. Our results indicated that gestational diabetes mellitus treatment significantly reduced the risk for macrosomia (RR, 0.47; 95% CI, 0.38–0.57), large for gestational age births (RR, 0.55; 95% CI, 0.45–0.67), shoulder dystocia (RR, 0.42; 95% CI, 0.23–0.77) and gestational hypertension (RR, 0.68; 95% CI, 0.53–0.87) without causing any significant increase in the risk for small for gestational age babies. However, no significant difference was observed between the two groups regarding perinatal/neonatal mortality, neonatal hypoglycemia, birth trauma, preterm births, pre-eclampsia, caesarean section and labor induction.

Conclusion

Treating GDM reduces risk for many important adverse pregnancy outcomes and its association with any harm seems unlikely.

2-Hour postload serum glucose levels and maternal blood pressure as independent predictors of birth weight in "appropriate for gestational age" neonates in healthy nondiabetic pregnancies

INTRODUCTION

Increased neonatal birth weight (NBW), often associated with diabetic pregnancies, is a recognized indicator of childhood obesity and future metabolic risk. Predictors of NBW in healthy non-diabetic pregnancies are not yet established. Here, we investigated the association of maternal parameters of healthy non-diabetic mothers with NBW of their "appropriate-for-gestational age" neonates.

METHODS

The study involved 36 healthy mother/infant pairs. Examined parameters included NBW, maternal age, first and last trimester (BMI), weight gain, fasting serum lipids and glucose, 2-hour postload glucose levels and blood pressure.

RESULTS

Postload-glucose levels were significantly higher in mothers of heavier neonates. ANOVA results indicated that 15% increase in postload-glucose levels corresponded to more than 0.5 Kg increase in NBW in the third tertile. NBW correlated positively with postload glucose levels, and negatively with systolic blood pressure. Regression analysis showed that the main predictors of NBW were postload-glucose levels (B = 0.455, P = 0.003), followed by systolic blood pressure (B = -0.447, P = 0.004), together predicting 31.7% NBW variation.

CONCLUSION

This study highlights that increased maternal postload sugar levels and blood pressure, within the normal range, highly predicts NBW of healthy mothers. These findings may provide focus for early dietary intervention measures to avoid future risks to the mother and baby.

Diet and carbohydrate food knowledge of multi-ethnic women: a comparative analysis of pregnant women with and without Gestational Diabetes Mellitus

Background

Diet therapy is the cornerstone for the management of gestational diabetes mellitus (GDM). Carbohydrate is the primary nutrient affecting postprandial blood glucose levels. Hence, knowledge of food containing carbohydrates can assist women with GDM optimize glycemic control. Despite that, there is a paucity of research on carbohydrate-related knowledge of women with GDM. The United Arab Emirates (UAE) has one of the highest prevalence of diabetes (19.2%) in the world. This study compared diet and knowledge of carbohydrate-containing foods among pregnant women with and without GDM in the UAE.

Methods

The sample consisted of multi-ethnic women with GDM (n = 94) and a control group of healthy pregnant women (n = 90) attending prenatal clinics in three hospitals in Al Ain, UAE. Data were collected using a questionnaire and a 24-hour recall. Knowledge of food sources of carbohydrate, dietary patterns, and nutrient intakes of the two groups were compared.

Results

There were no significant differences in the mean knowledge score of food sources of carbohydrate between women with GDM and that of pregnant women without GDM. Similarly, there were no significant differences in energy and nutrient intakes between the two groups with the exception of percent energy from protein. Women with GDM reported significantly lower intake of fruits and fruit juices (P = 0.012) and higher consumption of milk and yogurt (P = 0.004) compared to that of women without GDM. Twenty-two percent of women with GDM indicated they never visited a dietitian for counseling while 65% reported they visited a dietitian only once or twice during the pregnancy. Predictors of carbohydrate knowledge score were perceived knowledge of diet and GDM and parity among women with GDM and parity and educational level among those without GDM.

Conclusion

The results of the study highlight the urgent need to provide nutrition education for women with GDM in the UAE.

Gestational diabetes mellitus among Norwegian women with polycystic ovary syndrome: prevalence and risk factors according to the WHO and the modified IADPSG criteria

OBJECTIVE

The consequences of the recently proposed International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) in women with polycystic ovary syndrome (PCOS) are not known. We compared the prevalence rates and risk factors for GDM in PCOS women according to both the WHO and the modified IADPSG criteria.

DESIGN

Post hoc analyses from a randomized, multicenter study were used.

METHODS

Fasting and 2-h plasma glucose levels were measured using a 75 g oral glucose tolerance test. GDM was diagnosed according to both the WHO and the modified IADPSG criteria.

RESULTS

The prevalence rates of GDM according to the WHO and the modified IADPSG criteria were 9.2 and 15.0% at week 12, 18.7 and 18.7% at week 19, and 25.6 and 24.2% at week 32. Shorter stature and increased insulin levels were correlated with WHO-GDM, but not with modified IADPSG-GDM at weeks 12 and 19. Less weight gain in pregnancy predicted GDM according to both sets of criteria. GDM diagnosis was correlated with less maternal weight loss the first year post-partum.

CONCLUSIONS

No difference was found in the prevalence of GDM between the two sets of criteria used. Less weight gain in pregnancy was associated with GDM, independent of the diagnostic criteria used. Reduced weight loss the first year post-partum in women with GDM raises the question of whether GDM diagnosis per se or the fact that these women lose less weight after pregnancy predicts later diabetes mellitus.

Fetal macrosomia and shoulder dystocia in women with gestational diabetes: risks amenable to treatment?

Fetal macrosomia and maternal diabetes are independent risk factors for shoulder dystocia, an obstetrical emergency that may cause permanent neonatal injury. Randomized trials of glycemic control in pregnancies complicated by gestational diabetes reveal decreased rates of macrosomia and shoulder dystocia among those treated. However, definitions of gestational diabetes vary and a specific glycemic threshold for clinically significant risk reduction remains to be delineated. This review discusses risks associated with gestational diabetes including macrosomia (birth weight above 4000-4500 g) and delivery-related morbidity, specifically, shoulder dystocia. Subsequently, we will review recent randomized trials assessing the impact of glycemic control on these delivery-related morbidities. Finally, we will examine a large observational study that found associations with delivery-related morbidity and hyperglycemia below current diabetic thresholds, observations which may suggest reexamination of current diagnosis guidelines for gestational diabetes.

Effectiveness of gestational diabetes treatment: a systematic review with quality of evidence assessment

AIMS

To evaluate the effectiveness of gestational diabetes (GDM) treatment compared to usual antenatal care, in the prevention of adverse pregnancy outcomes. Additionally, to assess the quality of the evidence to support GDM treatment according to GRADE guidelines.

METHODS

Fourteen electronic databases and reference lists of relevant literature were searched for articles published from inception to February, 2012. Controlled clinical trials comparing GDM treatment to usual antenatal care were included. Independent extraction of articles was done by two authors using predefined data fields.

RESULTS

Seven trials involving 3157 women were included. We found high quality evidence that treatment of GDM reduces macrosomia (RR=0.47; 95% CI, 0.34-0.65; NNT=11.4) and large for gestational age birth (RR=0.57; 95% CI, 0.47-0.71; NNT=12.2); moderate quality evidence that treatment reduces preeclampsia (RR=0.61; 95% CI, 0.46-0.81; NNT=21.0) and hypertensive disorders in pregnancy (RR=0.64; 95% CI, 0.51-0.81; NNT=18.1); and low quality evidence that treatment reduces shoulder dystocia (RR=0.41; 95% CI, 0.22-0.76; NNT=48.8). No statistically significant reduction was seen for caesarean section. No increase in small for gestational age or preterm birth was found.

CONCLUSIONS

Treatment of GDM is effective in reducing macrosomia (high quality evidence), preeclampsia and shoulder dystocia.

The IDEAL study: investigation of dietary advice and lifestyle for women with borderline gestational diabetes: a randomised controlled trial - study protocol

BACKGROUND

The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) showed that treatment of pregnant women with mild gestational diabetes mellitus is beneficial for both women and their infants. It is still uncertain whether there are benefits of similar treatment for women with borderline gestational diabetes.This trial aims to assess whether dietary and lifestyle advice and treatment given to pregnant women who screen for borderline gestational diabetes reduces neonatal complications and maternal morbidities.

METHODS/DESIGN

DESIGN

Multicentre, randomised controlled trial.

INCLUSION CRITERIA

Women between 240 and 346 weeks gestation with a singleton pregnancy, a positive oral glucose challenge test (venous plasma glucose ≥7.8 mmol/L) and a normal oral 75 gram glucose tolerance test (fasting venous plasma glucose <5.5 mmol/L and a 2 hour glucose <7.8 mmol/L) with written, informed consent.Trial entry and randomisation: Women with an abnormal oral glucose tolerance test (fasting venous plasma glucose ≥5.5 mmol/L or 2 hour glucose ≥7.8 mmol/L) will not be eligible and will be offered treatment for gestational diabetes, consistent with recommendations based on results of the ACHOIS trial. Eligible women will be randomised into either the 'Routine Care Group' or the 'Intervention Group'.Study groups: Women in the 'Routine Care Group' will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the 'Intervention Group' will receive obstetric care, which will include dietary and lifestyle advice, monitoring of blood glucose and further medical treatment for hyperglycaemia as appropriate.Primary study outcome: Incidence of large for gestational age infants.

SAMPLE SIZE

A sample size of 682 women will be sufficient to show a 50% reduction in the risk of large for gestational age infants (alpha 0.05 two-tailed, 80% power, 4% loss to follow up) from 14% to 7% with dietary and lifestyle advice and treatment.

DISCUSSION

A conclusive trial outcome will provide reliable evidence of relevance for the care of women with borderline glucose intolerance in pregnancy and their infants.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry - ACTRN12607000174482.

Gestational diabetes mellitus: maternal and perinatal outcomes in 220 saudi women

OBJECTIVES

To assess the maternal and fetal complications of pregnancy in mothers with gestational diabetes mellitus (GDM) compared with non-diabetic patients who delivered in the hospital during the study period.

METHODS

The outcome of pregnancy in 220 Saudi patients with GDM identified from the delivery register/hospital database and matched for age, parity and body mass index with 220 non-diabetic controls were studied retrospectively from their case files. Patients with multiple pregnancies and abnormal presentation of the fetus were excluded from the study.

RESULTS

The GDM patients were treated with either diet alone or with additional insulin in some patients who required better control of their blood sugar levels. Patients with GDM had a significantly higher incidence of pre-eclampsia (p<0.0001); preterm delivery (p=0.0226); induction of labor (p<0.0001); cesarean section (p=0.0019); higher mean birth weight (p<0.0001) of babies; large for gestational age infants (p=0.0011); macrosomia (p=0.0186); and admission to the neonatal intensive care unit (p=0.0003), compared with the control group. However, the rates of Apgar score <7 at 5 minutes, respiratory distress syndrome, neonatal hypoglycemia, hyperbilirubinemia and the need for phototherapy were similar in both groups of patients. Congenital anomalies and perinatal mortality rates were not significantly different in the two groups.

CONCLUSION

GDM is recognized to be associated with increased rates of adverse maternal and neonatal outcomes, which are supported by the findings of this study. Even the mild form of GDM seems to have significant consequences for women and their offspring and is recommended to be aggressively treated. Evidence suggests that early diagnosis and strict control of blood sugar levels throughout the pregnancy can significantly reduce maternal and fetal complications. A multicenter, randomized controlled trial, based on universally accepted criteria for GDM screening test, standardized diagnostic OGTT and management of all patients with GDM versus the standard obstetric management of the control is warranted.

Interventions for pregnant women with hyperglycaemia not meeting gestational diabetes and type 2 diabetes diagnostic criteria

BACKGROUND

Pregnancy hyperglycaemia without meeting gestational diabetes mellitus (GDM) diagnostic criteria affects a significant proportion of pregnant women each year. It is associated with a range of adverse pregnancy outcomes. Although intensive management for women with GDM has been proven beneficial for women and their babies, there is little known about the effects of treating women with hyperglycaemia who do not meet diagnostic criteria for GDM and type 2 diabetes (T2DM).

OBJECTIVES

To assess the effects of different types of management strategies for pregnant women with hyperglycaemia not meeting diagnostic criteria for GDM and T2DM (referred as borderline GDM in this review).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011).

SELECTION CRITERIA

Randomised and cluster-randomised trials comparing alternative management strategies for women with borderline GDM.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed risk of bias of included studies. Data were checked for accuracy.

MAIN RESULTS

We included four trials involving 543 women and their babies (but only data from 521 women and their babies is included in our analyses). Three of the four included studies had moderate to high risk of bias and one study was at low to moderate risk of bias. Babies born to women receiving management for borderline GDM (generally dietary counselling and metabolic monitoring) were less likely to be macrosomic (birthweight greater than 4000 g) (three trials, 438 infants, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.19 to 0.74) or large-for-gestational (LGA) age (three trials, 438 infants, RR 0.37, 95% CI 0.20 to 0.66) when compared with those born to women in the routine care group. There were no significant differences in rates of caesarean section (three trials, 509 women, RR 0.93, 95% CI 0.68 to 1.27) and operative vaginal birth (one trial, 83 women, RR 1.37, 95% CI 0.20 to 9.27) between the two groups.

AUTHORS' CONCLUSIONS

This review found interventions including providing dietary advice and blood glucose level monitoring for women with pregnancy hyperglycaemia not meeting GDM and T2DM diagnostic criteria helped reduce the number of macrosomic and LGA babies without increasing caesarean section and operative vaginal birth rates. It is important to notice that the results of this review were based on four small randomised trials with moderate to high risk of bias without follow-up outcomes for both women and their babies.

Asymmetric dimethylarginine level in hyperglycemic gestation

We aimed to evaluate plasma asymmetric dimethylarginine (ADMA) concentrations and its relation with insulin sensitivity/resistance indices in pregnant women with different degrees of carbohydrate intolerance. This study included a two step approach; 50 g glucose challenge test (GCT) followed by 100 g oral glucose tolerance test (OGTT) was used for diagnosis of carbohydrate intolerance within 24-28th weeks of gestation. Pregnant women with positive GCT but negative OGTT (AGCT group, n=30) and gestational diabetics (GDM group, n=58) were compared to healthy pregnant controls (n=50). Plasma ADMA concentration and its relationship with glucose and insulin levels and insulin sensitivity/resistance indices (HOMA-IR, QUICKI, ISIOGTT) were evaluated. Both AGCT and GDM groups were found to have similarly higher plasma ADMA levels than control subjects (3.60±1.21; 4.00±1.70; 2.65±0.82 μmol/l, respectively, P=0.001). ADMA was significantly but slightly correlated with insulin sensitivity/resistance indices and moderately correlated with 2-h insulin level. The 2-h insulin value of the OGTT was the independent influencing constant for ADMA (R=0.57, P=0.0001). In conclusion, plasma asymmetric dimethylarginine level was higher in cases with abnormal glucose challenge test but normal OGTT as well as in gestational diabetics, compared to pregnant women with normal glucose tolerance. The elevated ADMA level in pregnant women with carbohydrate intolerance may possibly be due to elevated insulin level.

Gestational diabetes mellitus in primigravidae: a mild disease

This prospective observational study was done to analyse the prevalence of gestational diabetes mellitus (GDM) among primigravidae and its outcome. All healthy primigravidae with singleton pregnancies were offered universal glucose tolerance testing between 16 and 28 weeks gestation. GDM and non GDM groups were managed according to hospital protocol. The antenatal features and pregnancy outcomes were analysed. Out of 616 primigravidae, 113 (18.34%) were GDM with slightly older (27.9 +/- 4.2 versus 26.32 +/- 3.3, p < 0.001) age. The mean fasting and two hours postprandial blood glucose in both groups were 4.99 +/- 1.08 mmol/l, 8.86 +/- 1.41 mmol/l(GDM) and 4.36 +/- 0.43 mmol/l, 5.71 +/- 1.11 mmol/l (Non GDM), respectively. Maternal family history of diabetes mellitus, weight exceeding 80 Kg, polyhydramnios (2.65% versus 0.2%, p = 0.028) and neonatal hyperbilirubinaemia (9.73% versus 2.98%, p = 0.01) occurred significantly more frequent in the GDM group compared to normal. There was no significant difference in other pregnancy outcomes and complications between the two groups. In conclusion GDM in primigravidae was detected at a relatively young age with more frequent maternal family history of DM, weight exceeding 80 Kg, polyhydromnions and neonatal hyperbilirubinaemia. The degree of disease was mild and treatment led to no significant complication.

Contribution of first trimester fasting plasma insulin levels to the incidence of glucose intolerance in later pregnancy: Tanaka women's clinic study

AIMS

To clarify risk factors predictive of glucose intolerance in later pregnancy.

METHODS

We prospectively studied 509 pregnant women who visited the obstetrics clinic in Tokyo prior to week 13 of gestation, between September 2008 and January 2010. Biochemical parameters were measured in fasting plasma samples collected at week 8.0 ± 2.0 of gestation. A 50 g glucose challenge test (GCT) was performed between weeks 26 and 29: plasma glucose levels ≥ 7.8 mmol/l 1h after ingestion indicated a positive GCT. Logistic regression was performed, adjusting for relevant covariates.

RESULTS

We identified 114 patients with positive GCTs, including 8 with gestational diabetes mellitus (GDM). After correcting for baseline body mass index, only the homeostasis model assessment of insulin resistance value remained a significant predictor of GCT positivity (OR 2.07; 1.21-3.55). We identified threshold values of fasting plasma glucose (FPG) ≥ 3.66 mmol/l and fasting plasma insulin (FPI) ≥ 36.69 pmol/l as indicative of a higher risk of positive GCT (OR 2.38; 1.49-3.80).

CONCLUSIONS

First trimester FPI levels improve the predictive ability of FPG level on subsequent GCT positivity.

Obstetric and neonatal risks among extremely macrosomic babies and their mothers

OBJECTIVE

We estimated the risk of complications at birth of extremely large babies (≥5000 g).

STUDY DESIGN

This was a cohort study including all births of extremely large babies in 1996 through 2005 and comparison cohort with normal birthweight (1:2) identified in the national birth registration.

RESULTS

There were 343 extremely large babies or 0.9% of all singletons. Compared to the normal birthweight cohort (n = 679), there were increased odds of shoulder dystocia (odds ratio [OR], 26.9; 95% confidence interval [CI], 11.1-65.1), emergency cesarean section (OR, 5.2; 95% CI, 3.4-8.0), and failed labor induction (OR, 4.3; 95% CI, 1.7-11.0). The risk of elective section was not increased (OR, 1.1; 95% CI, 0.6-2.0). Minor congenital malformations were more frequent (OR, 2.1; 95% CI, 1.2-3.7), as were birth injuries (OR, 3.7; 95% CI, 2.1-6.8) and minor metabolic disturbance (OR, 2.5; 95% CI, 1.1-6.2), but not asphyxial births.

CONCLUSION

The risk of shoulder dystocia for very large babies is markedly raised, as are minor complications, while for mothers the main risk is emergency section.