Perinatal mortality in Japanese women diagnosed with gestational diabetes mellitus and diabetes mellitus

Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2=82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2=82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2=0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2=0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2=87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2=0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

Association between maternal cholesterol level during pregnancy and placental weight and birthweight ratio: data from the Japan Environment and Children's Study

BACKGROUND

Placental weight to birthweight ratio (PW/BW ratio), or its inverse, is used as an indicator of placental efficiency. Past studies have shown an association between an abnormal PW/BW ratio and adverse intrauterine environment, however, no previous studies have examined the effect of abnormal lipid levels during pregnancy on PW/BW ratio. We aimed to evaluate the association between maternal cholesterol levels during pregnancy and placental weight to birthweight ratio (PW/BW ratio).

METHODS

This study was a secondary analysis using the data from the Japan Environment and Children's Study (JECS). 81 781 singletons and their mothers were included in the analysis. Maternal serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels during pregnancy were obtained from participants. Associations between maternal lipid levels and placental weight and PW/BW ratio were assessed by regression analysis using restricted cubic splines.

RESULTS

Dose-response relationships were observed between maternal lipid level during pregnancy and placental weight and PW/BW ratio. High TC and LDL-C levels were associated with heavy placental weight and high PW/BW ratio, i.e., inappropriately heavy placenta for birthweight. Low HDL-C level was also associated with inappropriately heavy placenta. Low TC and LDL-C levels were associated with low placental weight and low PW/BW ratio, i.e., inappropriately light placenta for birthweight. High HDL-C was not associated with PW/BW ratio. These findings were independent of pre-pregnancy body mass index and gestational weight gain.

CONCLUSIONS

Abnormal lipid levels such as elevated TC and LDL-C, and low HDL-C level, during pregnancy were associated with inappropriately heavy placental weight.

Secular trends and age-period-cohort effect on adverse perinatal outcomes in Hubei, China (2011-2019)

The increasing trend in the incidence of adverse perinatal outcomes is a public health concern globally as well as in China. However, the causes of the increasing trend are not well understood. The present tertiary-hospital-based retrospective study (2011-2019) aims to determine the secular trends and age-period-cohort effect on adverse perinatal outcomes in Hubei, China. The age-standardized incidence rates of adverse perinatal outcomes significantly decreased such as preterm births by 22% [AAPC - 3.4% (95% CI - 7.8, - 1.2)], low birth weight (LBW) by 28.5% [AAPC - 4.7% (95% CI - 6.0, - 3.3)], and fetal distress by 64.2% [AAPC - 14.0% (95% CI - 17.8, - 10.0)] during 2011-2019. Both extremes of maternal age groups (18-20 years and 42-44 years) had a higher risk ratio for adverse perinatal outcomes including preterm birth, perinatal mortality, LBW, low ponderal index (LPI), low Apgar score, and congenital defect compared to the reference age group (30-32 years). A higher risk ratio for perinatal mortality, intrauterine growth restriction (IUGR), and fetal distress and a lower risk ratio for preterm births and LBW were observed in the period 2017-2019. Both the young cohort (1997-1999) and the old cohort (1976-1969) had a higher risk ratio for preterm birth, perinatal mortality, macrosomia, and congenital defect compared to the reference cohort (1982-1984). In conclusion, some of the adverse perinatal outcomes incidence significantly decreased in the last 9 years in Hubei. However, extremes of maternal age groups and both young and old cohorts were associated with a higher risk of preterm birth, perinatal mortality, and congenital defect.

Neurodevelopmental delay up to the age of 4 years in infants born to women with gestational diabetes mellitus: The Japan Environment and Children's Study

AIMS/INTRODUCTION

This study aimed to investigate the neurodevelopment of infants born to women with gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

Data from the National Birth Cohort in the Japan Environment and Children's Study from 2011 to 2014 (n = 81,705) were used. Japan uses the GDM guidelines of the International Association of Diabetes and Pregnancy Study Groups. The Japanese translation of the Ages and Stages Questionnaires, third Edition, was used to assess neurodevelopment in the following domains: communication skills, gross motor skills, fine motor skills, problem-solving ability, and personal and social skills. The survey was carried out every 6 months from the age of 6 months to 4 years (total of eight times). Generalized estimating equations were used to evaluate the association between maternal GDM and neurodevelopmental delay based on odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Neurodevelopmental delays, particularly in problem-solving ability, fine motor skills, and personal and social skills, were significantly higher in infants born to women with GDM than in those born to women without GDM (adjusted OR 1.24, 95% CI 1.12-1.36; adjusted OR 1.15, 95% CI 1.03-1.27; and adjusted OR 1.18, 95% CI 1.04-1.33). Furthermore, stratification showed no significant increase in the adjusted ORs (95% CIs) of girls.

CONCLUSIONS

Neurodevelopment was significantly delayed up to 4 years-of-age among boys born to women with GDM.

Effect of Different Types of Diagnostic Criteria for Gestational Diabetes Mellitus on Adverse Neonatal Outcomes: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

Evidence supporting various diagnostic criteria for diagnose gestational diabetes mellitus (GDM) are consensus-based, needs for additional evidence related to outcomes. Therefore, the aim of this systematic-review and meta-analysis was to assess the impact of different GDM diagnostic-criteria on the risk of adverse-neonatal-outcomes.

METHODS

Electronic databases including Scopus, PubMed, and Web of Sciences were searched to retrieve English original, population-based studies with the universal GDM screening approach, up to January-2020. GDM diagnostic criteria were classified in seven groups and International Association of the Diabetes and Pregnancy Study Groups (IADPSG) was considered as reference one. We used the Mantel-Haenszel method to calculate the pooled odds of events. The possibility of publication bias was examined by Begg's test.

RESULTS

A total of 55 population-based studies consisting of 1,604,391 pregnant women with GDM and 7,770,855 non-GDM counterparts were included. Results showed that in all diagnostic-criteria subgroups, the risk of adverse neonatal outcomes including macrosomia, hyperbilirubinemia, respiratory distress syndrome, neonatal hypoglycemia, neonatal intensive care unit admission, preterm birth, and birth-trauma were significantly higher than the non-GDM counterparts were significantly higher than non-GDM counterparts. Meta-regression analysis revealed that the magnitude of neonatal risks in all diagnostic-criteria subgroups are similar.

CONCLUSION

Our results showed that the risk of adverse-neonatal-outcome increased among women with GDM, but the magnitude of risk was not different among those women who were diagnosed through more or less intensive strategies. These findings may help health-care-providers and policy-makers to select the most cost-effective approach for the screening of GDM among pregnant women.

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

OBJECTIVE

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

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

REVIEW REGISTRATION

PROSPERO CRD42021265837.

Association between pre-pregnancy body mass index and gestational weight gain and perinatal outcomes in pregnant women diagnosed with gestational diabetes mellitus: The Japan Environment and Children's Study

AIMS/INTRODUCTION

We investigated the association between gestational diabetes mellitus (GDM) and perinatal outcomes stratified by pre-pregnancy body mass index (BMI) and/or gestational weight gain (GWG).

MATERIALS AND METHODS

Data from the national birth cohort in the Japan Environment and Children's Study from 2011 to 2014 (n = 85,228) were used. Japan uses the GDM guidelines of the International Association of Diabetes and Pregnancy Study Groups. The odds ratios (ORs) of perinatal outcomes were compared between women with and those without GDM.

RESULTS

The OR (95% confidence interval) of having a small for gestational age infant in the GDM group with a pre-pregnancy BMI of ≥25.0 kg/m2 and insufficient GWG (<2.75 kg) was 1.78 (1.02-3.12). The OR of having a large for gestational age infant of the same BMI group with excessive GWG (>7.25 kg) was 2.04 (1.56-2.67). The OR of hypertensive disorders of pregnancy was higher in women with a BMI ≥18.5 kg/m2 in the GDM group than in the non-GDM group.

CONCLUSIONS

Large for gestational age and hypertensive disorders of pregnancy were associated with pre-pregnancy BMI and GWG in either normal weight or overweight/obese women, and the relationship was strengthened when GDM was present. Women with GDM and a BMI of ≥25.0 kg/m2 are at risk of having small for gestational age and large for gestational age infants depending on GWG.

The association between gestational diabetes and stillbirth: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Controversy exists over whether gestational diabetes increases the risk of stillbirth. The aim of this review was to examine the association between gestational diabetes and stillbirth.

METHODS

We performed searches of the published literature to May 2021. Study selection and data extraction were performed in duplicate by independent reviewers. Meta-analyses of summary measures were conducted using random-effect models for cohort and case-control studies separately. The study protocol was registered in PROSPERO (registration ID CRD42020166939).

RESULTS

From 9981 citations, 419 were identified for full-text review and 73 met inclusion criteria (n = 70,292,090). There was no significant association between gestational diabetes and stillbirth in cohort studies (pooled OR 1.04 [95% CI 0.90, 1.21]; I² 86.1%) or in case-control studies (pooled OR 1.57 [95% CI 0.83, 2.98]; I² 94.8%). Gestational diabetes was associated with lower odds of stillbirth among cohort studies presenting with an adjusted OR (pooled OR 0.78 [95% CI 0.68, 0.88]; I² 42.7%). Stratified analyses by stillbirth ≥28 weeks' gestation, studies published prior to 2013 and studies identified as low quality demonstrated a significantly higher odds of stillbirth in meta-regression (p = 0.016, 0.023 and 0.005, respectively). Egger's test for all included cohort studies (p = 0.018) suggests publication bias for the main meta-analysis.

CONCLUSIONS/INTERPRETATION

Given the substantial heterogeneity across studies, there are insufficient data to define the relationship between stillbirth and gestational diabetes adequately. In the main analyes, gestational diabetes was not associated with an increased risk of stillbirth. However, heterogeneity across studies means this finding should be interpreted cautiously.

Association between fetal vascular malperfusion and gestational diabetes

AIM

Diabetes mellitus (DM) is a major complication in pregnancy. Placental lesions with DM remain unclear and controversial. Recently, the terms of placental pathological findings, such as maternal and fetal vascular malperfusions (MVM and FVM, respectively) were introduced by the Amsterdam Placental Workshop Group Consensus Statement (APWGCS). FVM cases were classified as the partial obstruction type (global FVM) and the complete obstruction type (segmental FVM). The aim of this study was to clarify the pathological characteristics of the placenta with pregestational DM/gestational DM; GDM according to APWGCS.

METHODS

We studied the placentas of 182 DM women (27 pregestational DM and 155 GDM) and control placentas of 460 women without DM during 2011-2018. We excluded cases of intrauterine fetal death or multiple pregnancies. We reviewed microscopical findings including, MVM, FVM, chorioamnionitis with the slides according to the APWGCS.

RESULTS

Microscopically, the incidence of FVM was significantly higher in GDM patients than control (17% vs. 10%, p = 0.0138), but not significant in pregestational DM (11%, p = 0.7410). Segmental FVM (complete obstruction) was significantly more observed in GDM than control group (5% vs. 0.4%, p = 0.0013). Segmental FVM in GDM showed high incidence of light-for-dates infant (three of seven cases, 43%, p = 0.0288). In addition, several segmental FVM findings (villous stromal-vascular karyorrhexis and stem vessel occlusion) were frequently noted in 2 or 3 points positive of 75 g oral glucose tolerance test than 1 point positive GDM.

CONCLUSION

Our placental findings suggest disorder of carbohydrate metabolism might affect the fetal vascular damage, especially complete fetal vascular obstruction.

Phoenixin-20 ameliorates gestational diabetes mellitus (GDM) symptoms and placental insults in an experimental mouse model

BACKGROUND AND PURPOSE

Gestational diabetes mellitus (GDM) is a complication commonly observed in pregnancy, closely associated with increased oxidative stress, inflammatory response, and endoplasmic reticulum (ER) stress. Phoenixin-20 (PNX-20) is a newly reproductive hormone from the hypothalamus that has displayed pleiotropic effects. The promising inhibitory effects of PNX-20 on inflammation have recently been widely reported. The present study aims to investigate the protective effect of PNX-20 on GDM induced placental insults.

METHODS

A GDM model was established on C57BLKsJ ^db/+ mice. The expression level of GPR173 was evaluated using RT-PCR and western blotting analysis. The serum level of glucose, insulin, lipid profiles, and oxidative stress indicators were detected with commercial kits. Fetal analysis was performed to evaluate the reproductive ability. ELISA was used to detect the production of inflammatory factors. The expressions of p-eIF-2α, ATF4, and GRP78 were evaluated with western blotting assay.

RESULTS

Firstly, we found that GPR173 is expressed in the placenta tissue. Secondly, the elevated blood glucose level and lipid level, declined serum insulin level, fetus alive ratio, fetal and placenta weight, and shorten crown-rump length, were observed in the placenta tissue of GDM mice, which were reversed by treatment with PNX-20. Thirdly, the excessively released inflammatory factors and activated oxidative stress in GDM mice were alleviated by the administration of PNX-20. Lastly, the activated eIF-2α/ATF4 ER stress signaling pathway in GDM mice was dramatically suppressed by PNX-20.

CONCLUSION

Our data revealed a protective property of PNX-20 against placental insults resulted from GDM.

Identifying risk factors for perinatal mortality from a preceding pregnancy without perinatal mortality

OBJECTIVE

To identify risk factors in first pregnancy for perinatal mortality in the subsequent pregnancy.

METHODS

A retrospective population-based nested case-control study was conducted, including all women with two first singleton consecutive deliveries. Women with perinatal mortality in their first pregnancy were excluded, and cases with perinatal mortality in the second pregnancy were compared with controls who delivered a live birth. Characteristics and complications of the first pregnancy were compared between the groups using multivariable logistic models.

RESULTS

A total of 43 043 women were included in the study, 385 (0.9%) were cases. Cases, as compared with controls (live births), were younger (22.62 ± 4.0 vs 23.22 ± 4.0 years), with shorter inter-pregnancy interval (1.38 ± 1.55 vs 1.56 ± 1.53 years), and were more likely to have the following complications in their first pregnancy: severe pre-eclampsia (3.4% vs 1.7%), small for gestational age (12.5% vs 8.0%), preterm delivery (17.7% vs 7.8%), and congenital or chromosomal malformations (9.6% vs 5.9%). In multivariable analysis the risk for perinatal mortality was greater with each additional complication (adjused odds ratio [aOR] 1.64, 95% confidence interval [CI] 1.30-2.07, P < 0.001; aOR 2.55, 95% CI 1.61-4.04, P < 0.001; aOR 7.88, 95% CI 3.81-16.29, P < 0.001 for one, two, and three or more complications, compared with no complications, respectively).

CONCLUSION

Complications in first pregnancy ending with live birth are associated with increased risk for perinatal mortality in a subsequent pregnancy.

The Impact of Diagnostic Criteria for Gestational Diabetes Mellitus on Adverse Maternal Outcomes: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to examine the impact of different gestational-diabetes (GDM) diagnostic-criteria on the risk of adverse-maternal-outcomes. The search process encompassed PubMed (Medline), Scopus, and Web of Science databases to retrieve original, population-based studies with the universal GDM screening approach, published in English language and with a focus on adverse-maternal-outcomes up to January 2020. According to GDM diagnostic criteria, the studies were classified into seven groups. A total of 49 population-based studies consisting of 1409018 pregnant women with GDM and 7,667,546 non-GDM counterparts were selected for data analysis and knowledge synthesis. Accordingly, the risk of adverse-maternal-outcomes including primary-cesarean, induction of labor, maternal-hemorrhage, and pregnancy-related-hypertension, overall, regardless of GDM diagnostic-criteria and in all diagnostic-criteria subgroups were significantly higher than non-GDM counterparts. However, in meta-regression, the increased risk was not influenced by the GDM diagnostic-classification and the magnitude of the risks among patients, using the IADPSG criteria-classification as the most strict-criteria, was similar to other criteria. In conclusion, a reduction in the diagnostic-threshold increased the prevalence of GDM, but the risk of adverse-maternal-outcome was not different among those women who were diagnosed through more or less intensive strategies. Our review findings can empower health-care-providers to select the most cost-effective approach for the screening of GDM among pregnant women.