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Fetal Growth and Neonatal Outcomes in Pregestational Diabetes Mellitus in a Population with a High Prevalence of Diabetes. J Pers Med 2022; 12:jpm12081320. [PMID: 36013269 PMCID: PMC9410378 DOI: 10.3390/jpm12081320] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/08/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
The aim of this retrospective study, conducted in an Italian tertiary care hospital, was to evaluate maternal-fetal and neonatal clinical outcomes in a group of patients with pregestational diabetes mellitus (PGDM), such as diabetes mellitus type 1 (DM1), diabetes mellitus type 2 (DM2), and maturity onset diabetes of the young (MODY). Overall, 174 pregnant women, nulliparous and multiparous, with a single pregnancy were enrolled. Data on pregnancy, childbirth, and newborns were collected from medical records. The selected patients were divided into two groups: the PGDM group (42 with DM1, 14 with DM2, and 2 with MODY), and the control group (116 patients with a negative pathological history of diabetes mellitus). We reported an incidence of preterm delivery of 55.2% in the PGDM group, including 59.5% of those with DM1 and 42.9% of those with DM2, vs. 6% in the controls. Fetal growth disorders, such as intrauterine growth retardation, small for gestational age, and fetal macrosomia were found in 19% and 3.6% in the case and control groups, respectively. A relationship between DM2 and gestational hypertension was found.
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Gortazar L, Goday A, Flores-Le Roux JA, Sarsanedas E, Payà A, Mañé L, Pedro-Botet J, Benaiges D. Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006-2015. BMJ Open Diabetes Res Care 2020; 8:8/1/e001254. [PMID: 33106331 PMCID: PMC7592254 DOI: 10.1136/bmjdrc-2020-001254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/17/2020] [Accepted: 07/13/2020] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION This study aims to assess trends in the prevalence of pre-existing diabetes and whether the risk of adverse perinatal outcomes decreased in women between 2006 and 2015 in Catalonia, Spain. RESEARCH DESIGN AND METHODS A population-based study of 743 762 singleton deliveries between 2006 and 2015 in Catalonia, Spain, was conducted using data from the Spanish Minimum Basic Data Set. Cases of type 1 diabetes (T1DM) and 'type 2 diabetes and other pre-existing diabetes' ('T2DM and other PGD') were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Crude and age-adjusted annual prevalences were calculated. Poisson regression model was used to assess trends in prevalence and perinatal outcomes during the study period. RESULTS Overall prevalences of pre-existing diabetes, T1DM and 'T2DM and other PGD' were 0.52% (95% CI 0.51 to 0.54), 0.17% (95% CI 0.17 to 0.18) and 0.35% (95% CI 0.33 to 0.36), respectively. From 2006 to 2015, rates increased for pre-existing diabetes (from 0.43 (95% CI 0.39 to 0.48) to 0.56% (0.50 to 0.62), p<0.001), T1DM (from 0.14 (0.11 to 0.17) to 0.20% (0.17 to 0.23), p<0.001) and 'T2DM and other PGD' (from 0.29 (0.25 to 0.33) to 0.36% (0.31 to 0.40), p<0.001). Pre-eclampsia rose in women with pre-existing diabetes (from 4.38% to 8.97%, adjusted p<0.001), T1DM (from 3.85% to 12.88%, p=0.005) and 'T2DM and other PGD' (from 4.63% to 6.78%, adjusted p=0.01). Prevalence of prematurity, cesarean section and small for gestational age remained stable in all diabetes groups. However, the prevalence of macrosomia fell in women with pre-existing diabetes (from 18.18% to 11.9%, adjusted p=0.011) and 'T2DM and other PGD' (from 14.71% to 11.06%, non-adjusted p=0.022, adjusted p=0.305) and large for gestational age decreased in all diabetes groups (from 39.73% to 30.25% in pre-existing diabetes, adjusted p=0.004). CONCLUSIONS The prevalence of pre-existing diabetes increased significantly in Catalonia between 2006 and 2015. Despite improvements in outcomes related to excessive birth weight, pre-eclampsia rates are rising and overall perinatal outcomes in women with pre-existing diabetes continue to be markedly worse than in the population without diabetes.
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Affiliation(s)
- Lucia Gortazar
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Goday
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Juana Antonia Flores-Le Roux
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Eugènia Sarsanedas
- Health Information Management Department, Hospital del Mar, Barcelona, Spain
| | - Antonio Payà
- Department of Gynaecology and Obstetrics, Hospital del Mar, Barcelona, Spain
| | - Laura Mañé
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Pedro-Botet
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - David Benaiges
- Department of Endocrinology and Nutrition, Hospital del Mar, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Consorci Sanitari de l'Alt Penedès Garraf, Vilafranca del Penedès, Spain
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Pintaudi B, Fresa R, Dalfrà M, Dodesini AR, Vitacolonna E, Tumminia A, Sciacca L, Lencioni C, Marcone T, Lucisano G, Nicolucci A, Bonomo M, Napoli A. The risk stratification of adverse neonatal outcomes in women with gestational diabetes (STRONG) study. Acta Diabetol 2018; 55:1261-1273. [PMID: 30221320 DOI: 10.1007/s00592-018-1208-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/06/2018] [Indexed: 01/10/2023]
Abstract
AIMS To assess the risk of adverse neonatal outcomes in women with gestational diabetes (GDM) by identifying subgroups of women at higher risk to recognize the characteristics most associated with an excess of risk. METHODS Observational, retrospective, multicenter study involving consecutive women with GDM. To identify distinct and homogeneous subgroups of women at a higher risk, the RECursive Partitioning and AMalgamation (RECPAM) method was used. Overall, 2736 pregnancies complicated by GDM were analyzed. The main outcome measure was the occurrence of adverse neonatal outcomes in pregnancies complicated by GDM. RESULTS Among study participants (median age 36.8 years, pre-gestational BMI 24.8 kg/m2), six miscarriages, one neonatal death, but no maternal death was recorded. The occurrence of the cumulative adverse outcome (OR 2.48, 95% CI 1.59-3.87), large for gestational age (OR 3.99, 95% CI 2.40-6.63), fetal malformation (OR 2.66, 95% CI 1.00-7.18), and respiratory distress (OR 4.33, 95% CI 1.33-14.12) was associated with previous macrosomia. Large for gestational age was also associated with obesity (OR 1.46, 95% CI 1.00-2.15). Small for gestational age was associated with first trimester glucose levels (OR 1.96, 95% CI 1.04-3.69). Neonatal hypoglycemia was associated with overweight (OR 1.52, 95% CI 1.02-2.27) and obesity (OR 1.62, 95% CI 1.04-2.51). The RECPAM analysis identified high-risk subgroups mainly characterized by high pre-pregnancy BMI (OR 1.68, 95% CI 1.21-2.33 for obese; OR 1.38 95% CI 1.03-1.87 for overweight). CONCLUSIONS A deep investigation on the factors associated with adverse neonatal outcomes requires a risk stratification. In particular, great attention must be paid to the prevention and treatment of obesity.
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Affiliation(s)
- Basilio Pintaudi
- SSD Diabetes Unit, Niguarda Cà Granda Hospital, 20162, Milan, Italy.
| | - Raffaella Fresa
- Endocrinology and Diabetes Unit, ASL Salerno, Salerno, Italy
| | | | | | - Ester Vitacolonna
- Department of Medicine and Aging, D'Annunzio University, Chieti-Pescara, Italy
| | - Andrea Tumminia
- Department of Clinical and Experimental Medicine, Endocrinology Section, University of Catania, Catania, Italy
| | - Laura Sciacca
- Department of Clinical and Experimental Medicine, Endocrinology Section, University of Catania, Catania, Italy
| | | | | | | | | | - Matteo Bonomo
- SSD Diabetes Unit, Niguarda Cà Granda Hospital, 20162, Milan, Italy
| | - Angela Napoli
- S. Andrea Hospital, Sapienza University, Rome, Italy
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Pitchika A, Jolink M, Winkler C, Hummel S, Hummel N, Krumsiek J, Kastenmüller G, Raab J, Kordonouri O, Ziegler AG, Beyerlein A. Associations of maternal type 1 diabetes with childhood adiposity and metabolic health in the offspring: a prospective cohort study. Diabetologia 2018; 61:2319-2332. [PMID: 30008062 DOI: 10.1007/s00125-018-4688-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/13/2018] [Indexed: 01/14/2023]
Abstract
AIMS/HYPOTHESIS Exposure to an intrauterine hyperglycaemic environment has been suggested to increase the offspring's later risk for being overweight or having metabolic abnormalities, but conclusive evidence for pregnancies affected by maternal type 1 diabetes is still lacking. This study aims to analyse the relationship between maternal type 1 diabetes and the offspring's metabolic health and investigate whether birthweight and/or changes in the offspring's metabolome are in the potential pathway. METHODS We analysed data from 610 and 2169 offspring having a first-degree relative with type 1 diabetes from the TEENDIAB and BABYDIAB/BABYDIET cohorts, respectively. Anthropometric and metabolic outcomes, assessed longitudinally at 0.3-18 years of age, were compared between offspring of mothers with type 1 diabetes and offspring of non-diabetic mothers but with fathers or siblings with type 1 diabetes using mixed regression models. Non-targeted metabolomic measurements were carried out in 500 individuals from TEENDIAB and analysed with maternal type 1 diabetes and offspring overweight status. RESULTS The offspring of mothers with type 1 diabetes had a higher BMI SD score (SDS) and an increased risk for being overweight than the offspring of non-diabetic mothers (e.g. OR for overweight status in TEENDIAB 2.40 [95% CI 1.41, 4.06]). Further, waist circumference SDS, fasting levels of glucose, insulin and C-peptide, and insulin resistance and abdominal obesity were significantly increased in the offspring of mothers with type 1 diabetes, even when adjusted for potential confounders and birthweight. Metabolite patterns related to androgenic steroids and branched-chain amino acids were found to be associated with offspring's overweight status, but no significant associations were observed between maternal type 1 diabetes and metabolite concentrations in the offspring. CONCLUSIONS/INTERPRETATION Maternal type 1 diabetes is associated with offspring's overweight status and metabolic health in later life, but this is unlikely to be caused by alterations in the offspring's metabolome.
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Affiliation(s)
- Anitha Pitchika
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
| | - Manja Jolink
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
| | - Christiane Winkler
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
- Forschergruppe Diabetes e.V., Helmholtz Zentrum München, Munich-Neuherberg, Germany
| | - Sandra Hummel
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
- Forschergruppe Diabetes e.V., Helmholtz Zentrum München, Munich-Neuherberg, Germany
| | - Nadine Hummel
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
| | - Jan Krumsiek
- Institute of Computational Biology, Helmholtz Zentrum München, Munich-Neuherberg, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Gabi Kastenmüller
- Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, Munich-Neuherberg, Germany
| | - Jennifer Raab
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
| | - Olga Kordonouri
- Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Germany
| | - Anette-Gabriele Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany.
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany.
- Forschergruppe Diabetes e.V., Helmholtz Zentrum München, Munich-Neuherberg, Germany.
| | - Andreas Beyerlein
- Institute of Diabetes Research, Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum rechts der Isar, Munich-Neuherberg, Germany
- Institute of Computational Biology, Helmholtz Zentrum München, Munich-Neuherberg, Germany
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McCarthy EA, Williamson R, Shub A. Pregnancy outcomes for women with pre‐pregnancy diabetes mellitus in Australian populations, rural and metropolitan: A review. Aust N Z J Obstet Gynaecol 2018; 59:183-194. [DOI: 10.1111/ajo.12913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 09/22/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Elizabeth A. McCarthy
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
- Department of Perinatal MedicineMercy Hospital for Women Melbourne Victoria Australia
| | - Rebecca Williamson
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
| | - Alexis Shub
- Department of Obstetrics and GynaecologyUniversity of Melbourne Melbourne Victoria Australia
- Mercy Hospital for Women Melbourne Victoria Australia
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Beyerlein A, Lack N, von Kries R. No further improvement in pregnancy-related outcomes in the offspring of mothers with pre-gestational diabetes in Bavaria, Germany, between 2001 and 2016. Diabet Med 2018; 35:1420-1424. [PMID: 29797595 DOI: 10.1111/dme.13691] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 11/27/2022]
Abstract
AIMS To investigate whether there has been further improvement in the risk of adverse outcomes in pregnancies in women with diabetes during 2008-2016 in Bavaria, Germany. METHODS Using cross-sectional data on all 1716 170 deliveries in Bavarian hospitals between 2001 and 2016, we assessed the risks of stillbirth, early neonatal death, preterm delivery, large for gestational age, malformations, low Apgar score and low umbilical cord pH by maternal group with diabetes (gestational, pre-gestational, or none) separately for 2001-2007 and 2008-2016. We also investigated the associations of specific risk factors such as maternal smoking with respect to early mortality and malformations in each group with diabetes during 2008-2016. RESULTS No further reduction in the risk for any adverse outcome in mothers with pre-gestational diabetes and their offspring during 2008-2016 was observed. Maternal smoking, multiple delivery and substandard antenatal care were the strongest additional predictors of both early perinatal mortality and malformations for mothers with pre-gestational diabetes. The respective risks were lower and also decreased over time for mothers with gestational diabetes. CONCLUSIONS No significant improvement has been achieved in the management of pregnancies affected by pre-gestational diabetes during the last decade. The apparent risk reductions in women with gestational diabetes may partly be due to a change in diagnostic criteria over time. Women with pre-gestational diabetes who smoke, carry more than one child, or are not regularly seen during pregnancy, may need particular attention.
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Affiliation(s)
- A Beyerlein
- Institute of Diabetes Research, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Computational Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - N Lack
- German Bavarian Quality Assurance Institute for Medical Care, Munich, Germany
| | - R von Kries
- Institute of Social Paediatrics and Adolescent Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
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Gabrys L, Heidemann C, Schmidt C, Baumert J, Teti A, Du Y, Paprott R, Ziese T, Banzer W, Böhme M, Borrmann B, Busse R, Freitag M, Hagen B, Holl R, Icks A, Kaltheuner M, Koch K, Kümmel S, Kuhn J, Kuß O, Laux G, Schubert I, Szecsenyi J, Uebel T, Zahn D, Scheidt-Nave C. Selecting and defining indicators for diabetes surveillance in Germany. JOURNAL OF HEALTH MONITORING 2018; 3:3-21. [PMID: 35586543 PMCID: PMC8852787 DOI: 10.17886/rki-gbe-2018-063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mainly because of the large number of people affected and associated significant health policy implications, the Robert Koch Institute (RKI) is developing a public health surveillance system using diabetes as an example. In a first step to ensure long-term and comparable data collection and establish efficient surveillance structures, the RKI has defined a set of relevant indicators for diabetes surveillance. An extensive review of the available literature followed by a structured process of consensus provided the basis for a harmonised set of 30 core and 10 supplementary indicators. They correspond to the following four fields of activity: (1) reducing diabetes risk, (2) improving diabetes early detection and treatment, (3) reducing diabetes complications, (4) reducing the disease burden and overall costs of the disease. In future, in addition to the primary data provided by RKI health monitoring diabetes surveillance needs to also consider the results from secondary data sources. Currently, barriers to accessing this data remain, which will have to be overcome, and gaps in the data closed. The RKI intentends to continuously update this set of indicators and at some point apply it also to further chronic diseases with high public health relevance.
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Affiliation(s)
| | | | | | | | | | - Yong Du
- Robert Koch Institute, Berlin
| | | | | | | | | | | | | | | | - Bernd Hagen
- Central Research Institute of Ambulatory Health Care in Germany, Cologne
| | | | - Andrea Icks
- Heinrich Heine University Düsseldorf.,German Diabetes Center Düsseldorf.,German Center for Diabetes Research, Neuherberg
| | | | - Klaus Koch
- Institute of Quality and Efficiency in Health Care, Cologne
| | - Stefanie Kümmel
- Institute for Applied Quality Improvement and Research in Health Care, Göttingen
| | - Joseph Kuhn
- Bavarian Health and Food Safety Authority, Oberschleißheim
| | - Oliver Kuß
- Institute for Biometrics and Epidemiology at the German Diabetes Center, Düsseldorf
| | | | | | | | - Til Uebel
- German College of General Practitioners and Family Physicians, Berlin
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Tamayo T, Tamayo M, Rathmann W, Potthoff P. Prevalence of gestational diabetes and risk of complications before and after initiation of a general systematic two-step screening strategy in Germany (2012-2014). Diabetes Res Clin Pract 2016; 115:1-8. [PMID: 27242116 DOI: 10.1016/j.diabres.2016.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/02/2016] [Accepted: 03/01/2016] [Indexed: 11/24/2022]
Abstract
AIMS Information on the prevalence of gestational diabetes mellitus is scarce on national and international level. On July 1st, 2013, a general two-step screening was implemented in Germany harmonizing gestational diabetes diagnoses. We aim to provide prevalence estimates for gestational diabetes and pregnancy-related complications for the large region of North Rhine for the 12 months before and after introduction of the general screening. METHODS Routine care data covering all outpatient diagnoses of more than 150,000 pregnancies per 12-month period in women aged 15-55 years was used to determine cases of gestational diabetes. Gestational diabetes diagnosis and pregnancy-related complications were assessed according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Relative Risks for pregnancy-related complications were calculated in pregnancies with and without gestational diabetes. RESULTS Before the screening, diagnosis of gestational diabetes was made in 6.02% of pregnancies and in 6.81% after this date (other types of diabetes mellitus: 1.67% and 1.76% respectively). The prevalence of GDM increased with age and was highest at age 36-40 years (8.45%). The relative increase in prevalence after introduction of the screening was highest in the age group≤25 years (24.9%). The frequency of pregnancy-related complications such as hypertension, pre-eclampsia, cesarean section was increased in pregnancies with gestational diabetes in comparison to those without independent of observation period. CONCLUSIONS We found a high prevalence of gestational diabetes, which has relatively increased by 13.12% after the introduction of the general screening.
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Affiliation(s)
- T Tamayo
- Institute of Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - M Tamayo
- Kassenärztliche Vereinigung Nordrhein, Düsseldorf, Germany
| | - W Rathmann
- Institute of Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - P Potthoff
- Kassenärztliche Vereinigung Nordrhein, Düsseldorf, Germany
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Grandi C, Tapia JL, Cardoso VC. Impact of maternal diabetes mellitus on mortality and morbidity of very low birth weight infants: a multicenter Latin America study. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2015. [DOI: 10.1016/j.jpedp.2015.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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10
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Grandi C, Tapia JL, Cardoso VC. Impact of maternal diabetes mellitus on mortality and morbidity of very low birth weight infants: a multicenter Latin America study. J Pediatr (Rio J) 2015; 91:234-41. [PMID: 25433204 DOI: 10.1016/j.jped.2014.08.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To compare mortality and morbidity in very low birth weight infants (VLBWI) born to women with and without diabetes mellitus (DM). METHODS This was a cohort study with retrospective data collection (2001-2010, n=11.991) from the NEOCOSUR network. Adjusted odds ratios and 95% confidence intervals were calculated for the outcome of neonatal mortality and morbidity as a function of maternal DM. Women with no DM served as the reference group. RESULTS The rate of maternal DM was 2.8% (95% CI: 2.5-3.1), but a significant (p=0.019) increase was observed between 2001-2005 (2.4%, 2.1-2.8) and 2006-2010 (3.2%, 2.8-3.6). Mothers with DM were more likely to have received a complete course of prenatal steroids than those without DM. Infants of diabetic mothers had a slightly higher gestational age and birth weight than infants of born to non-DM mothers. Distribution of mean birth weight Z-scores, small for gestational age status, and Apgar scores were similar. There were no significant differences between the two groups regarding respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, and patent ductus arteriosus. Delivery room mortality, total mortality, need for mechanical ventilation, and early-onset sepsis rates were significantly lower in the diabetic group, whereas necrotizing enterocolitis (NEC) was significantly higher in infants born to DM mothers. In the logistic regression analysis, NEC grades 2-3 was the only condition independently associated with DM (adjusted OR: 1.65 [95% CI: 1.2 -2.27]). CONCLUSIONS VLBWI born to DM mothers do not appear to be at an excess risk of mortality or early morbidity, except for NEC.
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Affiliation(s)
- Carlos Grandi
- Department of Pediatrics, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina.
| | - Jose L Tapia
- Department of Pediatrics, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Viviane C Cardoso
- Ribeirão Preto Medical School, Universidade de São Paulo, São Paulo, Brazil
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11
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Marufu TC, Ahankari A, Coleman T, Lewis S. Maternal smoking and the risk of still birth: systematic review and meta-analysis. BMC Public Health 2015; 15:239. [PMID: 25885887 PMCID: PMC4372174 DOI: 10.1186/s12889-015-1552-5] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/16/2015] [Indexed: 11/18/2022] Open
Abstract
Background Smoking in pregnancy is known to be associated with a range of adverse pregnancy outcomes, yet there is a high prevalence of smoking among pregnant women in many countries, and it remains a major public health concern. We have conducted a systematic review and meta-analysis to provide contemporary estimates of the association between maternal smoking in pregnancy and the risk of stillbirth. Methods We searched four databases namely MEDLINE, EMBASE, Psych Info and Web of Science for all relevant original studies published until 31st December 2012. We included observational studies that measured the association between maternal smoking during pregnancy and the risk of stillbirth. Results 1766 studies were screened for title analysis, of which 34 papers (21 cohorts, 8 case controls and 5 cross sectional studies) met the inclusion criteria. In meta-analysis smoking during pregnancy was significantly associated with a 47% increase in the odds of stillbirth (OR 1.47, 95% CI 1.37, 1.57, p < 0.0001). In subgroup analysis, smoking 1-9 cig/day and ≥10 cig/day was associated with an 9% and 52% increase in the odds of stillbirth respectively. Subsequently, studies defining stillbirth at ≥ 20 weeks demonstrated a 43% increase in odds for smoking mothers compared to mothers who do not smoke, (OR 1.43, 95% CI 1.32, 1.54, p < 0.0001), whereas studies with stillbirth defined at ≥ 24 weeks and ≥ 28 weeks showed 58% and 33% increase in the odds of stillbirth respectively. Conclusion Our review confirms a dose-response effect of maternal smoking in pregnancy on risk of stillbirth. To minimise the risk of stillbirth, reducing current smoking prevalence in pregnancy should continue to be a key public health high priority. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1552-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takawira C Marufu
- Division of Epidemiology and Public Health, Faculty of Medicine and Health Sciences, University of Nottingham, Clinical Sciences Building 2, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1 PB, UK.
| | - Anand Ahankari
- Division of Epidemiology and Public Health, Faculty of Medicine and Health Sciences, University of Nottingham, Clinical Sciences Building 2, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1 PB, UK. .,Halo Medical Foundation, Osmanabad, India.
| | - Tim Coleman
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK.
| | - Sarah Lewis
- Division of Epidemiology and Public Health, Faculty of Medicine and Health Sciences, University of Nottingham, Clinical Sciences Building 2, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1 PB, UK.
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Callec R, Perdriolle-Galet E, Sery GA, Lamy C, Floriot M, Fresson J, Morel O. [Type 2 diabetes and pregnancy: epidemiology and obstetrical consequences. A 97 women continuous series]. J Gynecol Obstet Hum Reprod 2015; 44:41-46. [PMID: 24315525 DOI: 10.1016/j.jgyn.2013.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To update the epidemiologic data of pregnant women with type 2 diabetes and to assess obstetrical outcomes. PATIENTS AND METHODS The pregnant women with type 2 diabetes who delivered between 2002 and 2010 were systematically involved in an observational study. Maternal and fetal outcomes were reviewed, as well as the potential impact of preconceptional management. The presented data were compared with those from the 2010 French perinatal study. RESULTS A rise in the incidence of type 2 diabetes was observed during the study period (from 0.19% to 0.35% between 2002 and 2010). Women with diabetes (n=97) were older and had a higher BMI than the general population (>35years: 49% vs 19%, P<0.00001, BMI>25: 86% vs 27.2, P<0.00001). The delivery mode was, for half of these women with diabetes, a C-section. Pregnancy was scheduled in only 4% of cases. Compared to the general population, prematurity rate was multiplied by 6 (28.7% vs 4.7%, P<0.0001) and the malformation rate by 3.2 (7.22% vs 2.2%, P<0.00001). CONCLUSION Obstetrical complications were more frequent than in the general population. Preconception care was almost inexistent, despite its potential benefits for the mother and child.
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Affiliation(s)
- R Callec
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France; Unité Inserm 947, IADI, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France.
| | - E Perdriolle-Galet
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France; Unité Inserm 947, IADI, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France
| | - G-A Sery
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France
| | - C Lamy
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France
| | - M Floriot
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France
| | - J Fresson
- Département d'informatique médicale, maternité régionale universitaire de Nancy, 54000 Nancy, France
| | - O Morel
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France; Unité Inserm 947, IADI, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France
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Callec R, Perdriolle-Galet E, Sery GA, Morel O. Type 2 diabetes in pregnancy: Rates of fetal malformations and level of preconception care. J OBSTET GYNAECOL 2014; 34:648-9. [DOI: 10.3109/01443615.2014.925856] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Feig DS, Hwee J, Shah BR, Booth GL, Bierman AS, Lipscombe LL. Trends in incidence of diabetes in pregnancy and serious perinatal outcomes: a large, population-based study in Ontario, Canada, 1996-2010. Diabetes Care 2014; 37:1590-6. [PMID: 24705609 DOI: 10.2337/dc13-2717] [Citation(s) in RCA: 228] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Women with diabetes in pregnancy have high rates of pregnancy complications. Our aims were to explore trends in the incidence of diabetes in pregnancy and examine whether the risk of serious perinatal outcomes has changed. RESEARCH DESIGN AND METHODS We performed a population-based cohort study of 1,109,605 women who delivered in Ontario, Canada, between 1 April 1996 and 31 March 2010. We categorized women as gestational diabetes (GDM) (n = 45,384), pregestational diabetes (pre-GDM) (n = 13,278), or no diabetes (n = 1,050,943). The annual age-adjusted rates of diabetes in pregnancy were calculated, and rates of serious perinatal outcomes were compared between groups and by year using Poisson regression. RESULTS The age-adjusted rate of both GDM (2.7-5.6%, P < 0.001) and pre-GDM (0.7-1.5%, P < 0.001) doubled from 1996 to 2010. The rate of congenital anomalies declined by 23%, whereas the rate of perinatal mortality did not change significantly. However, compared with women with no diabetes, women with pre-GDM and GDM faced an increased risk of congenital anomalies (relative risk 1.86 [95% CI 1.49-2.33] and 1.26 [1.09-1.45], respectively), and perinatal mortality remained elevated in women with pre-GDM (2.33 [1.59-3.43]). CONCLUSIONS The incidence of both GDM and pre-GDM in pregnancy has doubled over the last 14 years, and the overall burden of diabetes in pregnancy on society is growing. Although congenital anomaly rates have declined in women with diabetes, perinatal mortality rates remain unchanged, and the risk of both remains significantly elevated compared with nondiabetic women. Increased efforts are needed to reduce these adverse outcomes.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaInstitute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaDepartment of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, CanadaDivision of Endocrinology and Metabolism, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jeremiah Hwee
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Baiju R Shah
- Department of Medicine, University of Toronto, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaInstitute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaDivision of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Giliian L Booth
- Department of Medicine, University of Toronto, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaInstitute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaKeenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, CanadaDivision of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Arlene S Bierman
- Department of Medicine, University of Toronto, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaInstitute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaKeenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, CanadaDivision of Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lorraine L Lipscombe
- Department of Medicine, University of Toronto, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaInstitute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaWomen's College Research Institute and the Division of Endocrinology and Metabolism, Women's College Hospital, Toronto, Ontario, Canada
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Vinceti M, Malagoli C, Rothman KJ, Rodolfi R, Astolfi G, Calzolari E, Puccini A, Bertolotti M, Lunt M, Paterlini L, Martini M, Nicolini F. Risk of birth defects associated with maternal pregestational diabetes. Eur J Epidemiol 2014; 29:411-8. [PMID: 24861339 DOI: 10.1007/s10654-014-9913-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 05/13/2014] [Indexed: 01/01/2023]
Abstract
Maternal diabetes preceding pregnancy may increase the risk of birth defects in the offspring, but not all studies confirm this association, which has shown considerable variation over time, and the effect of having type 1 versus type 2 diabetes is unclear. We conducted a population-based cohort study in the Northern Italy Emilia-Romagna region linking administrative databases with a Birth Defects Registry. From hospital discharge records we identified all diabetic pregnancies during 1997-2010, and a population of non-diabetic parturients matched for age, residence, year and delivery hospital. We collected available information on education, smoking and drug prescriptions, from which we inferred the type of diabetes. We found 62 malformed infants out of 2,269 births among diabetic women, and 162 out of 10,648 births among non-diabetic women. The age-standardized prevalence ratio (PR) of malformation associated with maternal pregestational diabetes was 1.79 (95 % confidence interval 1.34-2.39), a value that varied little by age. Type of diabetes strongly influenced the PR, with higher values related to type 2 diabetic women. Most major subgroups of anomalies had PRs above 1, including cardiovascular, genitourinary, musculoskeletal, and chromosomal abnormalities. There was an unusually high PR for the rare defect 'extra-ribs', but it was based on only two cases. This study indicates that maternal pregestational type 2 diabetes is associated with a higher prevalence of specific birth defects in offspring, whereas for type 1 diabetic mothers, particularly in recent years, the association was unremarkable.
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Affiliation(s)
- Marco Vinceti
- CREAGEN - Environmental, Genetic and Nutritional Epidemiology Research Center, University of Modena and Reggio Emilia, Reggio Emilia, Italy,
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Cordero L, Thung S, Landon MB, Nankervis CA. Breast-feeding initiation in women with pregestational diabetes mellitus. Clin Pediatr (Phila) 2014; 53:18-25. [PMID: 23884968 DOI: 10.1177/0009922813496455] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine feeding practices and factors associated with breast-feeding initiation (BFI) in women with pregestational diabetes mellitus (PGDM) and their infants. METHODS In all, 392 PGDM (135 late preterm and 257 term) pregnancies were studied. Infant feeding preference was ascertained on admission. RESULTS After birth, 166 (42%) of the infants received well-baby care, whereas 226 (58%) were admitted to the newborn intensive care unit (NICU). Hypoglycemia (blood glucose <40 mg/dL), which occurred in 128 (33%) of all infants, did not influence BFI. Of 257 women who intended to BF, 55% initiated BF. Also, 5% of 105 women who intended to feed formula and 13% of the 30 undecided later initiated BF. CONCLUSIONS The BFI rate for women with PGDM is remarkably low even among those who intended to BF. Factors associated with BFI failure in this population were primiparity, African American race, lower education, smoking, lack of intention to BF, and NICU admission.
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Klemetti M, Nuutila M, Tikkanen M, Kari MA, Hiilesmaa V, Teramo K. Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989-2008. Diabetologia 2012; 55:2327-34. [PMID: 22752076 DOI: 10.1007/s00125-012-2627-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/24/2012] [Indexed: 12/12/2022]
Abstract
AIMS/HYPOTHESIS Our objective was to examine the trends in prepregnancy BMI and glycaemic control among Finnish type 1 diabetic patients and their relation to delivery mode and perinatal outcome. METHODS We analysed the obstetric records of 881 type 1 diabetic women with a singleton childbirth during 1989-2008. Maternal prepregnancy weight and height were obtained from the maternity cards, where they are recorded as reported by the mother. RESULTS Maternal BMI increased significantly during 1989-2008 (p < 0.001). The mean HbA(1c) in the first trimester remained unchanged, but the midpregnancy and the last HbA(1c) before delivery increased (p = 0.009 and 0.005, respectively). Elective Caesarean sections (CS) decreased (p for trend <0.001), while emergency CS increased (p for trend <0.001). The mean umbilical artery (UA) pH decreased in vaginal deliveries (p for trend <0.001). The frequency of UA pH <7.15 and <7.05 increased (p for trend <0.001 and 0.008, respectively). The macrosomia rate remained at 32-40%. Neonatal intensive care unit (NICU) admissions increased (p for trend 0.03) and neonatal hypoglycaemia frequency decreased (p for trend 0.001). In multiple logistic regression analysis, maternal BMI was associated with macrosomia and NICU admission. The last HbA(1c) value before delivery was associated with delivery before 37 weeks' gestation, UA pH <7.15, 1 min Apgar score <7, macrosomia, NICU admission and neonatal hypoglycaemia. CONCLUSIONS/INTERPRETATION Self-reported pregestational BMI has increased and glycaemic control during the second half of pregnancy has deteriorated. Poor glycaemic control seems to be associated with the observed increases in adverse obstetric and perinatal outcomes.
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Affiliation(s)
- M Klemetti
- Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, PO Box 140, Haartmaninku 2, 00029 Helsinki, Finland.
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Beyerlein A, Nehring I, Rosario AS, von Kries R. Gestational diabetes and cardiovascular risk factors in the offspring: results from a cross-sectional study. Diabet Med 2012; 29:378-84. [PMID: 21916975 DOI: 10.1111/j.1464-5491.2011.03454.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the association of gestational diabetes mellitus and abnormal glucose tolerance is beyond doubt, its associations with other cardiovascular disease risk factors in the offspring are less clearly established. Some of these associations, in particular overweight in the offspring, might be confounded by maternal overweight. METHODS Data on 12,542 children in the age of 3-17 years with full information about gestational diabetes mellitus and maternal BMI were available from the German nationwide KiGGS study. We calculated linear and logistic regression models for measurements of body composition, blood pressure, HbA(1c) and cholesterol values in the offspring with gestational diabetes mellitus as the explanatory variable, with and without adjustment for maternal BMI. RESULTS The prevalence of gestational diabetes mellitus in the dataset was 2.2%. Unadjusted regression analyses suggested weak positive effects of gestational diabetes mellitus on body composition measurements [e.g. a mean increase in BMI standard deviation scores (SDS) of 0.17 units (95% confidence interval: 0.03, 0.30)]. After adjustment for maternal BMI, the observed associations almost disappeared [e.g. BMI SDS: 0.07 (-0.06, 0.20)]. With respect to blood pressure and cholesterol, no potential effects of gestational diabetes mellitus were observed in both unadjusted and adjusted models. CONCLUSION Gestational diabetes mellitus does not appear to have a relevant effect on cardiovascular disease correlates such as blood pressure or cholesterol levels in children, and the potential effect of gestational diabetes mellitus on body composition seems to be widely explainable by maternal BMI.
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Affiliation(s)
- A Beyerlein
- Ludwig-Maximilians University of Munich, Institute of Social Paediatrics and Adolescent Medicine, Division of Epidemiology, Munich, Germany.
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Abstract
Metabolic characteristics of physiological and diabetic pregnancies are discussed. The basic factor of these changes is the increasing insulin resistance throughout pregnancy, which in case of diabetes may result in hyperglycemia with undesirable clinical consequences and complications for both the mother and the fetus. Prevention of these complications by maintaining physiological metabolic state of diabetic pregnant women is possible, which is similar to that of healthy women. The aim of treatment of pregnant diabetics is to achieve normoglycemic state during the whole gestation that is possible by early diagnosis in case of gestational diabetes and by adequate preconception care in case of pregestational diabetes. To obtain desirable glycemic conditions insulin treatment is necessary in most of the cases together with adequate, quantitative nutrition therapy, while oral antidiabetic drugs during pregnancy and lactation are to be avoided. For adequate care of the cases with diabetes and pregnancy interdisciplinary diabetes centers with well-trained experts are required.
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Affiliation(s)
- Eva Baranyi
- Honvédkórház-Állami Egészségügyi Központ Diabetológiai Szakrendelés Budapest Róbert Károly krt. 44. 1134.
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