Risk of large for gestational age births at early, full and late term in relation to pre-pregnancy body mass index: Mediation by gestational diabetes status

Developing and validating a predictive model of delivering large-for-gestational-age infants among women with gestational diabetes mellitus

BACKGROUND

The birth of large-for-gestational-age (LGA) infants is associated with many short-term adverse pregnancy outcomes. It has been observed that the proportion of LGA infants born to pregnant women with gestational diabetes mellitus (GDM) is significantly higher than that born to healthy pregnant women. However, traditional methods for the diagnosis of LGA have limitations. Therefore, this study aims to establish a predictive model that can effectively identify women with GDM who are at risk of delivering LGA infants.

AIM

To develop and validate a nomogram prediction model of delivering LGA infants among pregnant women with GDM, and provide strategies for the effective prevention and timely intervention of LGA.

METHODS

The multivariable prediction model was developed by carrying out the following steps. First, the variables that were associated with LGA risk in pregnant women with GDM were screened by univariate analyses, for which the P value was < 0.10. Subsequently, Least Absolute Shrinkage and Selection Operator regression was fit using ten cross-validations, and the optimal combination factors were selected by choosing lambda 1se as the criterion. The final predictors were determined by multiple backward stepwise logistic regression analysis, in which only the independent variables were associated with LGA risk, with a P value < 0.05. Finally, a risk prediction model was established and subsequently evaluated by using area under the receiver operating characteristic curve, calibration curve and decision curve analyses.

RESULTS

After using a multistep screening method, we establish a predictive model. Several risk factors for delivering an LGA infant were identified (P < 0.01), including weight gain during pregnancy, parity, triglyceride-glucose index, free tetraiodothyronine level, abdominal circumference, alanine transaminase-aspartate aminotransferase ratio and weight at 24 gestational weeks. The nomogram's prediction ability was supported by the area under the curve (0.703, 0.709, and 0.699 for the training cohort, validation cohort, and test cohort, respectively). The calibration curves of the three cohorts displayed good agreement. The decision curve showed that the use of the 10%-60% threshold for identifying pregnant women with GDM who are at risk of delivering an LGA infant would result in a positive net benefit.

CONCLUSION

Our nomogram incorporated easily accessible risk factors, facilitating individualized prediction of pregnant women with GDM who are likely to deliver an LGA infant.

Genetic Causal Relationship Between Alanine Aminotransferase Levels and Risk of Gestational Diabetes Mellitus: Mendelian Randomization Analysis Based on Two Samples

Gestational diabetes mellitus (GDM) is a frequent complication of pregnancy. The specific mechanisms underlying GDM have not yet been fully elucidated. Contemporary research indicates a potential association between liver enzyme irregularities and an increased risk of metabolic disorders, including diabetes. The alanine aminotransferase (ALT) level is recognized as a sensitive marker of liver injury. An increase in ALT levels is hypothesized to be linked to the pathogenesis of insulin resistance and diabetes. Nonetheless, the definitive causal link between ALT levels and GDM still needs to be determined. This investigation utilized two-sample Mendelian randomization (MR) to examine the genetic causation between alanine aminotransferase (ALT) and GDM. We acquired alanine aminotransferase (ALT)-related GWAS summary data from the UK Biobank, Million Veteran Program, Rotterdam Study, and Lifeline Study. Gestational diabetes data were obtained from the FinnGen Consortium. We employed various MR analysis techniques, including inverse-variance weighted (IVW), MR Egger, weighted median, simple, and weighted weighting. In addition to MR-Egger intercepts, Cochrane's Q test was also used to assess heterogeneity in the MR data, and the MR-PRESSO test was used to assess horizontal pleiotropy. To assess the association's sensitivity, a leave-one-out approach was employed. The IVW results confirmed the independent risk factor for GDM development, as indicated by the ALT level (p = .011). As shown by leave-one-out analysis, horizontal pleiotrophy did not significantly skew the causative link (p > .05). Our dual-sample MR analysis provides substantiated evidence of a genetic causal relationship between alanine aminotransferase (ALT) levels and gestational diabetes.

Role of Nutritional Habits during Pregnancy in the Developing of Gestational Diabetes: A Single-Center Observational Clinical Study

(1) Background and Objective: Excessive gestational weight gain is associated with serious complications such as pre-eclampsia, fetal macrosomia and a more frequent need for cesarean section. The aim of this study is to develop a simple screening model that includes maternal age, BMI and nutritive habits in the second trimester in order to predict the risk of GDM in the population of pregnant women in the territory of the Republic of Serbia. (2) Materials and Methods: This single-center, prospective and case-control study was performed in the University Clinical Center "Dr. Dragisa Misovic Dedinje", Belgrade, Serbia and included 54 women with singleton pregnancies during the second trimester from July 2023 to November 2023. We used basic demographic and socio-epidemiological data, as well as data of the present comorbidities and previous pregnancies/births. The Serbian version of the Nutritive Status Questionnaire (NSQ) was used to estimate the nutritive habits in GDM (n = 22) and non-GDM groups (n = 32). (3) Results: We observed less frequent vegetable and fruit consumption in the GDM group in comparison with the non-GDM group; meat and chicken intake was 2-3 times per week in both groups; meat products were consumed 2-3 times per week in the GDM group and 2-3 times per month in the non-GDM group; milk products were consumed once a day in 31.8% of GDM patients and twice per day in 24.1% of non-GDM patients. Sweets (cakes, ice creams, biscuits) were consumed very often (2-3 times per week) in the GDM group (36.4%), while in the non-GDM group this habit was less frequent (26.7%). Cronbach alpha and internal consistency for this instrument were very good (Cronbach alpha = 0.87). (4) Conclusions: We have found that a non-adequate intake of fruits/vegetables, dairy and whole grain, as well as an excessive intake of sugar/artificially sweetened beverages and dairy, was associated with a higher risk of gestational diabetes mellitus (OR = 0.04; 95% CI).

Antepartum Fetal Surveillance and Optimal Timing of Delivery in Diabetic Women: A Narrative Review

Antepartum fetal surveillance (AFS) is essential for pregnant women with diabetes to mitigate the risk of stillbirth. However, there is still no universal consensus on the optimal testing method, testing frequency, and delivery timing. This review aims to comprehensively analyze the evidence concerning AFS and the most advantageous timing for delivery in both gestational and pregestational diabetes mellitus cases. This review's methodology involved an extensive literature search encompassing international diabetes guidelines and scientific databases, including PubMed, MEDLINE, Google Scholar, and Scopus. The review process meticulously identified and utilized pertinent articles for analysis. Within the scope of this review, a thorough examination revealed five prominent international guidelines predominantly addressing gestational diabetes. These guidelines discuss the utility and timing of fetal well-being assessments and recommendations for optimal pregnancy resolution timing. However, the scarcity of clinical trials directly focused on this subject led to a reliance on observational studies as the basis for most recommendations. Glucose control, maternal comorbidities, and the medical management received are crucial in making decisions regarding AFS and determining the appropriate delivery timing.

Incidence of stillbirth among women with different risk profiles in Stockholm 2001-2020: a repeated cross-sectional study

INTRODUCTION

The incidence of stillbirth in Sweden has started to decline. However, some comparable high-income countries in Europe have an even lower incidence, indicating a potential for further reduction. The aim of our study was to investigate how the incidence of stillbirth for singleton pregnancies has changed over the past two decades in the Stockholm Region in different groups of women to detect the groups at highest risk.

MATERIAL AND METHODS

This was a repeated cross-sectional study with data from the Stockholm Stillbirth Database and the Pregnancy Register including all cases of stillbirth in Stockholm in singleton pregnancies between 2001 and 2020, in total 1804 stillbirths. The time period was divided into four equal groups and the incidence of stillbirth was compared between the groups.

RESULTS

The overall incidence of stillbirth in the Stockholm Region has decreased from 3.8/1000 births in 2001-2005 to 2.9/1000 births in 2016-2020 (P-value <0.001). In most of the groups studied, the incidence decreased, but among women originating from sub-Saharan Africa the incidence significantly rose from 7.9/1000 births in 2001-2005 to 10.1/1000 births in 2016-2020 (P-value 0.025). In this group, stillbirth occurred prematurely to a higher extent and the women were more likely to be multiparous.

CONCLUSIONS

The incidence of stillbirth in the Stockholm Region has declined. However, among women originating from sub-Saharan Africa the incidence was significantly higher compared with women originating from other regions and it is still rising. More research is needed to understand why this group is at higher risk and how to monitor their pregnancies to decrease this risk.

In-Hospital Formula Feeding Hindered Exclusive Breastfeeding: Breastfeeding Self-Efficacy as a Mediating Factor

Breastfeeding self-efficacy (BSE), defined as a mother's confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.

Remnant cholesterol, but not other cholesterol parameters, is associated with gestational diabetes mellitus in pregnant women: a prospective cohort study

OBJECTIVE

No evidence has been found of a relationship between remnant cholesterol (RC) and the likelihood of gestational diabetes mellitus (GDM) in pregnant women. The aim of our study was to investigate the link between serum RC at 12-14 weeks of gestation and the risk of GDM.

METHODS

This was a secondary analysis with data from a prospective cohort study in Korea. A total of 590 single pregnant women attending two hospitals in Korea, up to 14 weeks gestation, from November 2014 to July 2016 were included in the study. The formula used to calculate RC in detail was RC (mg/dL) = TC (mg/dL)-HDL-c (mg/dL)-LDL-c (mg/dL). Logistic regression models were employed to examine the relationship between RC and GDM and explore the association between other lipoprotein cholesterol parameters and the risk of GDM. Furthermore, receiver operating characteristic (ROC) analysis was performed to assess the ability of RC to identify GDM. Additionally, sensitivity and subgroup analyses were conducted.

RESULTS

The mean age of participants was 32.06 ± 3.80 years. The median of RC was 34.66 mg/dL. 37 pregnant women (6.27%) were eventually diagnosed with GDM. Multivariate adjusted logistic regression analysis showed that RC was positively associated with the risk of GDM (OR = 1.458, 95% CI 1.221, 1.741). There was no significant association between other lipoprotein cholesterols (including TC, LDL-c, HDL-c) and the risk of GDM. The area under the ROC curve for RC as a predictor of GDM was 0.8038 (95% CI 0.7338-0.8738), and the optimal RC cut-off was 24.30 mg/dL. Our findings were demonstrated to be robust by performing a series of sensitivity analyses.

CONCLUSION

Serum RC levels at 12-14 weeks of gestation are positively associated with GDM risk in pregnant women. RC in early pregnancy is an early warning indicator of GDM in pregnant women, especially those with normal HDL-c, LDL-c, and TC that are easily overlooked. There is a high risk of developing GDM in pregnant women whose RC is more than 24.30 mg/dL. This study may help optimize GDM prevention in pregnant women and facilitate communication between physicians, pregnant patients, and their families.

Low-Grade Inflammation in Gestational Diabetes Mellitus and Its Correlation with Maternal Insulin Resistance and Fetal Growth Indices

Introduction

Chronic low-grade inflammation (LGI) plays a role in the pathogenesis of gestational diabetes mellitus (GDM). LGI, on the one hand, promotes insulin resistance and at the same time, affects fetal development. The study aimed to use clinically feasible means to evaluate the association between maternal LGI and maternal insulin resistance and fetal growth indices by ultrasound in the third trimester.

Methods

A crossectional and descriptive study on 248 first-time diagnosed GDM in Vietnam.

Results

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte (PLR) indices were significantly higher in GDM than in normal glucose-tolerant pregnancies (p = 0.048 and 0.016, respectively). GDM with LGI witnessed significantly higher systolic blood pressure, BMI, HbA1c, and significantly lower quantitative Insulin Sensitivity Check Index (QUICKI) than those without LGI. After adjusting for maternal BMI, fasting plasma glucose (FPG), age, and parity, C-reactive protein (CRP) was positively correlated with HOMA2-IR (B=0.13, p<0.01) and Mathews index (B=0.29, p<0.01). Regarding fetal characteristics, LGI was associated with fetal growth indices in the third trimester of GDM. NLR was negatively correlated with estimated fetal weight (EFW) (B=-64.4, p<0.05) after adjusting for maternal BMI and FPG. After adjusting for maternal BMI, FPG, age, and parity, PLR was negatively correlated with biparietal diameter (B=-0.02, p<0.01) and abdominal circumference (AC) (B=-0.16, p<0.05), and EFW (B=-1.1, p<0.01), and head circumference (HC) (B=-0.06, p<0.01); CRP was negatively correlated with AC (B=-0.16, p<0.001), EFW (B=-85.3, p<0.001), and HC (B=-5.0, p<0.001).

Conclusion

In the third trimester, LGI was associated with maternal glucose and insulin resistance in GDM. Moreover, LGI was associated with fetal characteristics in ultrasonic images. There were negative correlations between LGI and fetal developmental characteristics.

Metformin in pregnancy and risk of abnormal growth outcomes at birth: a register-based cohort study

We previously reported an increased risk of being small for gestational age (SGA) and a decreased risk of being large for gestational age (LGA) after in utero exposure to metformin compared with insulin exposure. This follow-up study investigated if these observations remain when metformin exposure (henceforth, metformin cohort) is compared with non-pharmacological antidiabetic treatment of gestational diabetes mellitus (GDM; naïve cohort), instead of insulin. RESEARCH DESIGN AND METHODS : This was a Finnish population register-based cohort study from singleton children born during 2004-2016. Birth outcomes from metformin cohort (n=3964) and the naïve cohort (n=82 675) were used in the main analyses. Additional analyses were conducted in a subcohort, restricting the metformin cohort to children of mothers with GDM only (n=2361). Results were reported as inverse probability of treatment weighted OR (wOR), with the naïve cohort as reference. RESULTS  : No difference was found for the outcome of SGA between the cohorts in the main analyses (wOR 0.97, 95% CI 0.73 to 1.27) or in the additional analyses (wOR 1.01, 95% CI 0.75 to 1.37). No difference between the cohorts was found for the risk of LGA (wOR 0.91, 95% CI 0.75 to 1.11) in the main analyses but a decreased risk was observed in the additional analyses (wOR 0.72, 95% CI 0.56 to 0.92). CONCLUSIONS : This follow-up study found no increase in the risk of SGA or LGA after in utero exposure to metformin, compared with drug-naïve GDM. The decreased risk of LGA in mothers with GDM may suggest residual confounding. The lack of increased SGA risk aligns with findings from studies using metformin in non-diabetic pregnancies. In contrast, lower birth weight and increased SGA birth risk were observed in GDM pregnancies for metformin versus insulin. Metformin should be avoided with emerging growth restriction in utero. The interplay of intrauterine hyperglycemia and pharmacological treatments needs further assessment.

Gestational Diabetes Mellitus—Recent Literature Review

Gestational diabetes mellitus (GDM), which is defined as a state of hyperglycemia that is first recognized during pregnancy, is currently the most common medical complication in pregnancy. GDM affects approximately 15% of pregnancies worldwide, accounting for approximately 18 million births annually. Mothers with GDM are at risk of developing gestational hypertension, pre-eclampsia and termination of pregnancy via Caesarean section. In addition, GDM increases the risk of complications, including cardiovascular disease, obesity and impaired carbohydrate metabolism, leading to the development of type 2 diabetes (T2DM) in both the mother and infant. The increase in the incidence of GDM also leads to a significant economic burden and deserves greater attention and awareness. A deeper understanding of the risk factors and pathogenesis becomes a necessity, with particular emphasis on the influence of SARS-CoV-2 and diagnostics, as well as an effective treatment, which may reduce perinatal and metabolic complications. The primary treatments for GDM are diet and increased exercise. Insulin, glibenclamide and metformin can be used to intensify the treatment. This paper provides an overview of the latest reports on the epidemiology, pathogenesis, diagnosis and treatment of GDM based on the literature.

Gestational Diabetes Mellitus and High Triglyceride Levels Mediate the Association between Pre-Pregnancy Overweight/Obesity and Macrosomia: A Prospective Cohort Study in Central China

The purpose of this study is to investigate whether the link between pre-pregnancy overweight/obesity and risk of macrosomia is mediated by both gestational diabetes mellitus (GDM) and high maternal triglyceride (mTG) levels. This prospective study finally included 29,415 singleton term pregnancies. The outcome of interest was macrosomia (≥4000 g). High mTG levels were denoted as values ≥90th percentile. GDM was diagnosed using a standard 75 g 2 h oral glucose tolerance test. The mediation analysis was conducted using log-binomial regression while controlling for maternal age, education, parity, gestational weight gain, gestational hypertension, smoking, drinking and infant sex. Overall, 15.9% of pregnant women were diagnosed with GDM, and 4.3% were macrosomia. Mediation analysis suggested that overweight had a total effect of 0.009 (95% CI, 0.006–0.013) on macrosomia, with a direct effect of 0.008 (95% CI, 0.004–0.012) and an indirect effect of 0.001 (95% CI, 0.001–0.002), with an estimated proportion of 11.1% mediated by GDM and high mTG levels together. Furthermore, we also discovered a total effect of obesity on macrosomia of 0.038 (95% CI, 0.030–0.047), consisting of a direct effect of 0.037 (95% CI, 0.028–0.045) and an indirect effect of 0.002 (95% CI, 0.001–0.002), with an estimated proportion of 5.3% mediated by GDM and high mTG levels combined. Both GDM and high mTG levels enhanced the risk of macrosomia independently and served as significant mediators in the relationship between pre-pregnancy overweight/obesity and macrosomia.

Pre-Pregnancy Body Mass Index and Risk of Macrosomia and Large for Gestational Age Births with Gestational Diabetes Mellitus as a Mediator: A Prospective Cohort Study in Central China

This study aimed to examine the risk of macrosomia and large for gestational age (LGA) births in relation to maternal pre-pregnancy body mass index (BMI) status mediated through gestational diabetes mellitus (GDM). This prospective study included 34,104 singleton pregnancies at 8–14 weeks of gestation. The interesting outcomes were macrosomia (≥4000 g) and LGA (≥90th percentile). Mediation analyses were conducted using log-binomial regression adjusted for age, education, parity, fetal sex, and gestational weight gain. The proportion mediated was estimated based on the risk difference scale, and the E-value was utilized to assess potential confounders. Overall, 15.9% of women had GDM, and there were 4.0% macrosomia and 9.9% LGA births. The proportion mediated by GDM on macrosomia was up to 40% among obese women, and the estimate of the total effect was 6.18 (95% CI: 5.26–7.26), of the natural direct effect was 4.10 (95% CI: 3.35–4.99), and of the natural indirect effect was 1.51 (95% CI: 1.31–1.76). Likewise, among overweight women, the proportion mediated by GDM on macrosomia was up to 40%. Furthermore, consistent findings were evident for the outcome of LGA births. Pre-pregnancy overweight/obesity increased the risk of macrosomia and LGA births independently and partly mediated by GDM.

Blastocyst quality and perinatal outcomes of frozen-thawed single blastocyst transfer cycles

OBJECTIVE

To investigate the effects of blastocyst quality and morphological grade on the perinatal outcomes in patients undergoing frozen-thawed single blastocyst transfer cycles.

METHODS

This single-center retrospective cohort study included 2648 singleton neonates resulting from frozen-thawed single blastocyst transfers performed between January 2017 and September 2021. Multivariate logistic regression was performed to evaluate perinatal outcomes for their association with blastocyst quality and morphological parameters.

RESULT

Transfer of a good-quality blastocyst in a frozen-thawed cycle was associated with a lower rate of preterm delivery (PTD, adjusted OR =0.7, 95% CI 0.5-0.9; P=0.020) and a higher likelihood of a male neonate (adjusted OR =1.2, 95%CI 1.0-1.5; P=0.048). Compared with grade C inner cell mass (ICM) blastocyst transfer, grade B ICM (adjusted OR =0.5, 95%CI 0.2-0.9; P=0.027) and grade A ICM (adjusted OR =0.6, 95%CI 0.3-1.5; P=0.290) blastocyst transfers were associated with a lower rate of PTD, which was more evident for grade B ICM. After adjusting for confounders, the likelihood of a male neonate (grade B TE, OR =1.2, 95%CI 1.0-1.5, P=0.037; grade A TE OR =1.9, 95%CI 1.3-28, P=0.002) increased with increasing trophectoderm (TE) quality. Compared with expansion stage 4, the likelihood of a male neonate was 1.5 times greater with transfer of a stage 6 blastocyst (OR =1.5, 95%CI 1.0-2.3; P=0.06), and the risk of small for gestational age (SGA) was greater with transfer of a stage 5 blastocyst (adjusted OR =3.5, 95%CI 1.5-8.0; P=0.004). The overall grading of the blastocyst, expansion stage, ICM grade, and TE grade were not associated with length at birth, birthweight, large for gestational age (LGA), or birth defects (all P>0.05).

CONCLUSIONS

In frozen-thawed single blastocyst transfer cycles, transfer of a good-quality blastocyst was associated with a lower rate of PTD and a greater likelihood of a male neonate. Transfer of grade B ICM blastocysts decreased the rate of PTD, and TE quality was positively correlated with the likelihood of a male neonate.