Diabetes in pregnancy in associations with perinatal and postneonatal mortality in First Nations and non-Indigenous populations in Quebec, Canada: population-based linked birth cohort study

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.

Refining the diagnosis of gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Perinatal outcomes vary for women with gestational diabetes mellitus (GDM). The precise factors beyond glycemic status that may refine GDM diagnosis remain unclear. We conducted a systematic review and meta-analysis of potential precision markers for GDM.

METHODS

Systematic literature searches were performed in PubMed and EMBASE from inception to March 2022 for studies comparing perinatal outcomes among women with GDM. We searched for precision markers in the following categories: maternal anthropometrics, clinical/sociocultural factors, non-glycemic biochemical markers, genetics/genomics or other -omics, and fetal biometry. We conducted post-hoc meta-analyses of a subset of studies with data on the association of maternal body mass index (BMI, kg/m2) with offspring macrosomia or large-for-gestational age (LGA).

RESULTS

A total of 5905 titles/abstracts were screened, 775 full-texts reviewed, and 137 studies synthesized. Maternal anthropometrics were the most frequent risk marker. Meta-analysis demonstrated that women with GDM and overweight/obesity vs. GDM with normal range BMI are at higher risk of offspring macrosomia (13 studies [n = 28,763]; odds ratio [OR] 2.65; 95% Confidence Interval [CI] 1.91, 3.68), and LGA (10 studies [n = 20,070]; OR 2.23; 95% CI 2.00, 2.49). Lipids and insulin resistance/secretion indices were the most studied non-glycemic biochemical markers, with increased triglycerides and insulin resistance generally associated with greater risk of offspring macrosomia or LGA. Studies evaluating other markers had inconsistent findings as to whether they could be used as precision markers.

CONCLUSIONS

Maternal overweight/obesity is associated with greater risk of offspring macrosomia or LGA in women with GDM. Pregnancy insulin resistance or hypertriglyceridemia may be useful in GDM risk stratification. Future studies examining non-glycemic biochemical, genetic, other -omic, or sociocultural precision markers among women with GDM are warranted.

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec

OBJECTIVES

Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec.

DESIGN

Population-based birth cohort study through administrative health data linkage.

SETTING AND PARTICIPANTS

Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec.

RESULTS

Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities.

CONCLUSIONS

The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

The impact of diabetes during pregnancy on neonatal outcomes among the Aboriginal population in Western Australia: a whole-population study

BACKGROUND

Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have a high prevalence of diabetes in pregnancy (DIP), which includes pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). We aimed to characterize the impact of DIP in babies born to Aboriginal mothers.

METHODS

A retrospective cohort study, using routinely collected linked health data that included all singleton births (N = 510 761) in Western Australia between 1998 and 2015. Stratified by Aboriginal status, generalized linear mixed models quantified the impact of DIP on neonatal outcomes, estimating relative risks (RRs) with 95% CIs. Ratio of RRs (RRRs) examined whether RRs differed between Aboriginal and non-Aboriginal populations.

RESULTS

Exposure to DIP increased the risk of adverse outcomes to a greater extent in Aboriginal babies. PGDM heightened the risk of large for gestational age (LGA) (RR: 4.10, 95% CI: 3.56-4.72; RRR: 1.25, 95% CI: 1.09-1.43), macrosomia (RR: 2.03, 95% CI: 1.67-2.48; RRR: 1.39, 95% CI: 1.14-1.69), shoulder dystocia (RR: 4.51, 95% CI: 3.14-6.49; RRR: 2.19, 95% CI: 1.44-3.33) and major congenital anomalies (RR: 2.14, 95% CI: 1.68-2.74; RRR: 1.62, 95% CI: 1.24-2.10). GDM increased the risk of LGA (RR: 2.63, 95% CI: 2.36-2.94; RRR: 2.00, 95% CI: 1.80-2.22), macrosomia (RR: 1.95, 95% CI: 1.72-2.21; RRR: 2.27, 95% CI: 2.01-2.56) and shoulder dystocia (RR: 2.78, 95% CI: 2.12-3.63; RRR: 2.11, 95% CI: 1.61-2.77). Birthweight mediated about half of the DIP effect on shoulder dystocia only in the Aboriginal babies.

CONCLUSIONS

DIP differentially increased the risks of fetal overgrowth, shoulder dystocia and congenital anomalies in Aboriginal babies. Improving care for Aboriginal women with diabetes and further research on preventing shoulder dystocia among these women can reduce the disparities.

Effects of dietary polyphenols on maternal and fetal outcomes in maternal diabetes

The incidences of short-term or long-term adverse maternal and fetal outcomes caused by maternal diabetes are increasing. Due to toxicity or side effects, economic pressures, and other problems associated with injections or oral hypoglycemic drugs, many researchers have investigated natural treatment methods. Polyphenols can protect against chronic pathologies by regulating numerous physiological processes and provide many health benefits. Moreover, polyphenols have anti-diabetic properties and can be used to treat diabetic complications. Diets rich in polyphenols are beneficial to pregnant women with diabetes. Here, we review the epidemiological and experimental evidence on the impact of dietary polyphenols on maternal and fetal outcomes in pregnant women with diabetes, and the effects of polyphenols on biological changes and possible mechanisms. Previous data (mainly from in vitro and animal experiments) showed that polyphenols can alleviate gestational diabetes mellitus and diabetic embryopathy by reducing maternal hyperglycemia and insulin resistance, alleviating inflammation and oxidative stress, and regulating related signaling pathways. Although polyphenols have shown many health benefits, further research is needed to better understand the complex interactions between polyphenols and maternal diabetes.

Indigenous maternal health and health services within Canada: a scoping review

BACKGROUND

Globally, there are disparities in access to maternal health care services and equity in maternal health outcomes between Indigenous and non-Indigenous populations. While the literature is growing, it has not been systematically synthesized. This review addresses this gap by synthesizing the existing literature on the organizational structure of maternity care, accessibility and delivery of services, and clinical disparities impacting Indigenous maternal health within Canada. It also identifies current knowledge gaps in research on these topics.

METHODS

A scoping review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines and the extension for scoping reviews. The search for relevant papers was performed in PubMed, CINAHL, and SCOPUS electronic databases and included any empirical literature written in English and published during 2006 - 2021. The research team inductively coded 5 articles to develop a coding scheme, which was then applied to the remaining articles.

RESULTS

A total of 89 articles were included in the review, of which 32 were qualitative papers, 40 quantitative, 8 were mixed-methods publications, and 9 were review papers. The analysis of the articles resulted in identifying a range of overarching themes pertaining to the maternal health of Indigenous women within Canada including provision of services, clinical issues, education, health disparities, organization, spatial context, and impact of informal support. The results suggest that physical, psychological, organizational, and systemic barriers inhibit the quality-of-care pregnant Indigenous women receive, and that maternal health services are not consistently provided in a culturally safe manner. Results also suggest that, compared to non-Indigenous pregnant women, Indigenous women are more likely to develop clinical complications during pregnancy, reflecting the structural impacts of colonization that continue to negatively influence Indigenous maternal health and well-being.

CONCLUSIONS

There are many complex barriers that prevent Indigenous women from receiving high quality and culturally appropriate maternal care. Possible areas that could address the service gaps illuminated through this review include the implementation of cultural considerations across health care jurisdictions within Canada.

Vitamin D Status of Infants of Mothers with Gestational Diabetes: Status at Birth and a Randomized Controlled Trial of Vitamin D Supplementation across Infancy

BACKGROUND

Vitamin D status and requirements of infants of women with gestational diabetes mellitus (GDM) are unclear.

OBJECTIVES

The objectives were to assess vitamin D status in infants of mothers with GDM and compare vitamin D status in response to 400 vs. 1000 IU/d vitamin D supplementation in infants born with serum 25-hydroxyvitamin D [25(OH)D] <50 nmol/L.

METHODS

Women with GDM delivering full-term infants (n = 98; March 2017-2019, Montreal, Canada) were surveyed for demographic and lifestyle factors. Pregnancy history was obtained from medical records. Newborn serum 25(OH)D was measured (immunoassay) and categorized as <30 (deficient) or ≥40 nmol/L (adequate). Breastfed neonates (n = 16) with serum 25(OH)D <50 nmol/L at birth were randomly assigned to 400 or 1000 IU/d of supplemental cholecalciferol (vitamin D3), and serum 25(OH)D was measured at baseline (≤1 mo) and 3, 6, and 12 mo of age. Groups were compared using a linear mixed-effects model and Tukey-Kramer post hoc tests.

RESULTS

Mean newborn serum 25(OH)D was 46.4 (95% CI: 43.9, 49.9) nmol/L, with 15.3% (95% CI: 8.2%, 22.4%) <30 nmol/L and 61.2% (95% CI: 51.6%, 70.9%) ≥40 nmol/L. During the trial, most infants were breastfed to 3 mo (400 IU/d: 87.5%; 1000 IU/d: 75.0%). Mean (± SEM) infant serum 25(OH)D was higher in the 1000-IU/d group at 3 mo (79.9 ± 5.9 vs. 111.5 ± 15.2 nmol/L; P = 0.0263), and although not different at 6-12 mo, was maintained at >50 nmol/L.

CONCLUSIONS

Most infants of women with GDM had adequate vitamin D status in this study. In those born with serum 25(OH)D <50 nmol/L, vitamin D status was corrected by 3 mo of age in response to 400 or 1000 IU/d of supplemental vitamin D. Dietary guidance should continue to recommend that all women who could become pregnant take a multivitamin supplement and that breastfed infants receive 400 IU/d of supplemental vitamin D. This study and ancillary trial were registered at clinicaltrials.gov (https://www.

CLINICALTRIALS

gov/ct2/show/NCT02563015) as NCT02563015.

Canada First Nations Strengths in Community-Based Primary Healthcare

INTRODUCTION

First Nation (FN) peoples and communities in Canada are still grappling with the effects of colonization. Health and social inequities result in higher disease burden and significant disparities in healthcare access and responsiveness. For resilience, survival, and self-determination, FN are looking inwards for strengths. This paper reports on the cultural, community, and family strengths that have supported FN communities in developing community-based primary healthcare (CBPHC) strategies to support health and wellbeing.

METHODS

The study was a partnership between university-based researchers; The First Nations Health and Social Secretariat of Manitoba; and eight First Nation communities in Manitoba. Community-based participatory research methods were used to engage the participating communities. One hundred and eighty-three in-depth, semi-structured key informant interviews were completed between 2014 and 2016 with key members of the First Nation communities, i.e., community-based health providers and users of primary healthcare services, representing all age and genders. Data-collection and analysis were conducted following iterative grounded theory analysis.

RESULTS

Community-based healthcare models based on local strengths support easier access and shorter wait times for care and compassionate care delivery. Resources such as homecare and medical transportation are helpful. Community cooperation, youth power, responsive leadership, and economic development as well as a strong cultural and spiritual base are key strengths supporting health and social wellbeing.

CONCLUSIONS

Locally led, self-determined care adds strength in FN communities, and is poised to create long-lasting primary healthcare transformation.

Maternal and neonatal outcomes in pregnancies with type 2 diabetes in First Nation and other Manitoban people: a population-based study

BACKGROUND

First Nation people living in Canada experience a high prevalence of type 2 diabetes in pregnancy. In this study, we aimed to describe maternal and neonatal outcomes in First Nation and all other females with type 2 diabetes living in Manitoba, Canada.

METHODS

This was a population-level retrospective cohort study using linked administrative data from Manitoba (2012-2017). We compared First Nation females with type 2 diabetes with all other Manitoban females with type 2 diabetes, using relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

A total of 2181 females with type 2 diabetes were included, and 1218 (55.8%) were First Nation. First Nation females with type 2 diabetes were significantly more likely to experience stillbirth (RR 2.14, 95% CI 1.11-4.13) and perinatal death (RR 2.39, 95% CI 1.37-4.17) than all other Manitoban females with type 2 diabetes. Offspring of First Nation females with type 2 diabetes had a higher risk of most neonatal complications than offspring of all other Manitoban females with type 2 diabetes, including a higher risk of congenital malformations (RR 1.97, 95% CI 1.30-2.99), but First Nation people did not have a higher risk of most maternal complications.

INTERPRETATION

First Nation pregnant individuals living with type 2 diabetes experienced a higher risk for adverse pregnancy outcomes than all other Manitoban females with type 2 diabetes. Additional studies are needed to identify both high-risk and protective factors for pregnancy complications in First Nation people living with type 2 diabetes in pregnancy.

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.

Trends and burden of diabetes in pregnancy among Aboriginal and non-Aboriginal mothers in Western Australia, 1998-2015

Background

Diabetes in pregnancy (DIP), which includes pre-gestational and gestational diabetes, is more prevalent among Aboriginal women. DIP and its adverse neonatal outcomes are associated with diabetes and cardiovascular disease in the offspring. This study investigated the impact of DIP on trends of large for gestational age (LGA) in Aboriginal and non-Aboriginal populations, and added to the limited evidence on temporal trends of DIP burden in these populations.

Methods

We conducted a retrospective cohort study that included all births in Western Australia between 1998 and 2015 using linked population health datasets. Time trends of age-standardised and crude rates of pre-gestational and gestational diabetes were estimated in Aboriginal and non-Aboriginal mothers. Mixed-effects multivariable logistic regression was used to estimate the association between DIP and population LGA trends over time.

Results

Over the study period, there were 526,319 births in Western Australia, of which 6.4% were to Aboriginal mothers. The age-standardised annual rates of pre-gestational diabetes among Aboriginal mothers rose from 4.3% in 1998 to 5.4% in 2015 and remained below 1% in non-Aboriginal women. The comparable rates for gestational diabetes increased from 6.7 to 11.5% over the study period in Aboriginal women, and from 3.5 to 10.2% among non-Aboriginal mothers. LGA rates in Aboriginal babies remained high with inconsistent and no improvement in pregnancies complicated by gestational diabetes and pre-gestational diabetes, respectively. Regression analyses showed that DIP explained a large part of the increasing LGA rates over time in Aboriginal babies.

Conclusions

There has been a substantial increase in the burden of pre-gestational diabetes (Aboriginal women) and gestational diabetes (Aboriginal and non-Aboriginal) in recent decades. DIP appears to substantially contribute to increasing trends in LGA among Aboriginal babies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12663-6.

Risks of specific congenital anomalies in offspring of women with diabetes: A systematic review and meta-analysis of population-based studies including over 80 million births

BACKGROUND

Pre-gestational diabetes mellitus (PGDM) has been known to be a risk factor for congenital heart defects (CHDs) for decades. However, the associations between maternal PGDM and gestational diabetes mellitus (GDM) and the risk of specific types of CHDs and congenital anomalies (CAs) in other systems remain under debate. We aimed to investigate type-specific CAs in offspring of women with diabetes and to examine the extent to which types of maternal diabetes are associated with increased risk of CAs in offspring.

METHODS AND FINDINGS

We searched PubMed and Embase from database inception to 15 October 2021 for population-based studies reporting on type-specific CAs in offspring born to women with PGDM (combined type 1 and 2) or GDM, with no limitation on language. Reviewers extracted data for relevant outcomes and performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. Risk of bias appraisal was performed using the Cochrane Risk of Bias Tool. This study was registered in PROSPERO (CRD42021229217). Primary outcomes were overall CAs and CHDs. Secondary outcomes were type-specific CAs. Overall, 59 population-based studies published from 1990 to 2021 with 80,437,056 participants met the inclusion criteria. Of the participants, 2,407,862 (3.0%) women had PGDM and 2,353,205 (2.9%) women had GDM. The meta-analyses showed increased risks of overall CAs/CHDs in offspring born to women with PGDM (for overall CAs, relative risk [RR] = 1.99, 95% CI 1.82 to 2.17, P < 0.001; for CHDs, RR = 3.46, 95% CI 2.77 to 4.32, P < 0.001) or GDM (for overall CAs, RR = 1.18, 95% CI 1.13 to 1.23, P < 0.001; for CHDs, RR = 1.50, 95% CI 1.38 to 1.64, P < 0.001). The results of the meta-regression analyses showed significant differences in RRs of CAs/CHDs in PGDM versus GDM (all P < 0.001). Of the 23 CA categories, excluding CHD-related categories, in offspring, maternal PGDM was associated with a significantly increased risk of CAs in 21 categories; the corresponding RRs ranged from 1.57 (for hypospadias, 95% CI 1.22 to 2.02) to 18.18 (for holoprosencephaly, 95% CI 4.03 to 82.06). Maternal GDM was associated with a small but significant increase in the risk of CAs in 9 categories; the corresponding RRs ranged from 1.14 (for limb reduction, 95% CI 1.06 to 1.23) to 5.70 (for heterotaxia, 95% CI 1.09 to 29.92). The main limitation of our analysis is that some high significant heterogeneity still persisted in both subgroup and sensitivity analyses.

CONCLUSIONS

In this study, we observed an increased rate of CAs in offspring of women with diabetes and noted the differences for PGDM versus GDM. The RRs of overall CAs and CHDs in offspring of women with PGDM were higher than those in offspring of women with GDM. Screening for diabetes in pregnant women may enable better glycemic control, and may enable identification of offspring at risk for CAs.

Exploring modifiable risk-factors for premature birth in the context of COVID-19 mitigation measures: A discussion paper

During the COVID-19 pandemic, parents with sick or premature babies have faced challenges following admission to a neonatal unit due to the imposed lock-down restrictions on social contact, hospital visitation and the wearing of personal protective equipment. The negative short-term impact on neonatal care in relation to the prevention of close proximity, contact and bonding between parents and babies is potentially significant. However, an interesting finding has been reported of a reduction in premature birth admissions to the neonatal intensive care unit during the pandemic, raising important questions. Why was this? Was it related to the effect of the modifiable risk-factors for premature birth? This discussion paper focuses on an exploration of these factors in the light of the potential impact of COVID-19 restrictions on neonatal care. After contextualising both the effect of premature birth and the pandemic on neonatal and parental short-term outcomes, the discussion turns to the modifiable risk-factors for premature birth and makes recommendations relevant to the education, advice and care given to expectant mothers.

Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review

In spite of the huge progress in the treatment of diabetes mellitus, we are still in the situation that both pregestational (PGDM) and gestational diabetes (GDM) impose an additional risk to the embryo, fetus, and course of pregnancy. PGDM may increase the rate of congenital malformations, especially cardiac, nervous system, musculoskeletal system, and limbs. PGDM may interfere with fetal growth, often causing macrosomia, but in the presence of severe maternal complications, especially nephropathy, it may inhibit fetal growth. PGDM may also induce a variety of perinatal complications such as stillbirth and perinatal death, cardiomyopathy, respiratory morbidity, and perinatal asphyxia. GDM that generally develops in the second half of pregnancy induces similar but generally less severe complications. Their severity is higher with earlier onset of GDM and inversely correlated with the degree of glycemic control. Early initiation of GDM might even cause some increase in the rate of congenital malformations. Both PGDM and GDM may cause various motor and behavioral neurodevelopmental problems, including an increased incidence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Most complications are reduced in incidence and severity with the improvement in diabetic control. Mechanisms of diabetic-induced damage in pregnancy are related to maternal and fetal hyperglycemia, enhanced oxidative stress, epigenetic changes, and other, less defined, pathogenic mechanisms.

Epidemiology of Diabetes in Pregnancy Among First Nations and Non-First Nations Women in Saskatchewan, 1980‒2013. Part 2: Predictors and Early Complications; Results From the DIP: ORRIIGENSS Project

OBJECTIVES

Because of disparities in incidence of diabetes in pregnancy (DIP) among First Nations (FN) and non-First Nations (non-FN) women in Saskatchewan, we compared predictors and early maternal/child complication rates of gestational diabetes (GDM) and pre-GDM between the 2 populations from 1980 to 2013.

METHODS

Using Ministry of Health administrative databases, we examined overall GDM and pre-GDM predictors among a cohort of FN and non-FN women using logistic regression models. We compared early birth complications by ethnicity and DIP status using chi-square analysis.

RESULTS

Deidentified data were obtained for 69,176 FN and 344,410 non-FN pregnancies. Important GDM and pre-GDM predictors for FN and non-FN pregnancies were increasing maternal age, a previous high birthweight (HBW) or stillborn infant, and, most importantly, previous maternal GDM. Both GDM and pre-GDM were over 2.3-fold as likely to occur among FN in multivariable analysis. FN and non-FN pregnancies with GDM and pre-GDM had higher rates of prematurity, shoulder dystocia, caesarean section, HBW and stillborn and infant death than those with no DIP. The largest rate disparities between FN and non-FN with DIP occurred with stillborn, HBW and shoulder dystocia.

CONCLUSIONS

Along with previously recognized predictors of GDM and pre-GDM, FN ethnicity was an independent determinant of DIP in Saskatchewan from 1980 to 2013. Early mother/child birth complications were increased in both FN and non-FN with DIP, but more so in FN. Effective DIP prevention strategies, and improvements in preconception, prenatal and perinatal care, are required to remove ethnicity-based disparities in DIP rates and outcomes.

Epidemiology of Diabetes in Pregnancy Among First Nations and Non-First Nations Women in Saskatchewan, 1980‒2013. Part 1: Populations, Methodology and Frequencies (1980‒2009); Results From the DIP: ORRIIGENSS Project

OBJECTIVES

Because of the immediate and long-term consequences of diabetes in pregnancy (DIP) for mother and child, we compared frequencies of gestational diabetes (GDM) and pre-GDM between First Nations (FN) and non-FN people in Saskatchewan from 1980 to 2009.

METHODS

Using Ministry of Health administrative databases, we conducted a retrospective cohort study of GDM and pre-GDM rates within all FN and non-FN pregnancies in Saskatchewan. Annual crude and 10-year age-adjusted incidence of GDM and pre-GDM were determined as were maternal age-specific rates of DIP.

RESULTS

De-identified data were obtained for 69,176 FN and 344,410 non-FN pregnancies. The crude annual incidence of GDM rose from 1.0% to 6.6% among FN and from 0.4% to 3.6% among non-FN between 1980 and 2009. The crude annual incidence of pre-GDM rose from 0.7% to 2.0% among FN and from 0.4% to 0.9% among non-FN over the same period. The 10-year age-standardized incidence of GDM increased from 3.53% in 1980-1989 to 8.37% in 2000-2009 for FN, and from 1.55% to 3.13% for non-FN. For pre-GDM, the corresponding increases were from 1.65% to 3.26% for FN and from 0.5% to 0.91% for non-FN. Both GDM and pre-GDM rates increased with increasing maternal age, reaching 10.9% and 8.0% of FN pregnancies, and 7.7% and 1.1% of non-FN pregnancies, respectively, for mothers >40 years old.

CONCLUSIONS

The proportion of pregnancies complicated by DIP increased steadily among FN and non-FN women in Saskatchewan in 1980‒2009, but the incidence of GDM and pre-GDM is 2- to 3-fold higher among FN.

Screening for gestational diabetes in pregnancy in Northwestern Ontario

Introduction

We estimate the screening and prevalence of gestational diabetes mellitus (GDM) in a primarily first nations obstetrical population in Northwestern Ontario.

Methods

The study is an 8-year retrospective analysis of all gestational glucose challenge and tolerance tests performed at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) laboratory from 1 January, 2010 to 31 December, 2017. Test, gestational timing and completion rate of screening were recorded, and GDM prevalence was calculated on the tested population. Screening completion rates were recorded for the subset of women who delivered at SLMHC from 2014 to 2017.

Results

The average annual GDM prevalence was 12%, double the Ontario rate. Over the 8-year period, 513 patients were diagnosed with GDM among the 4298 patients screened. Patients were screened with the 2-step (90%) or the 1-step (10%) protocol. Screening occurred <20 weeks in 3%; 54% occurred in <28 weeks and 40% >28 weeks. Seventy percent of the tests were from remote nursing stations. The screening completion rate for women delivering at SLMHC in 2017 was 80.8%.

Conclusion

The prevalence of GDM in Northwestern Ontario is twice the provincial rate. Most screening used the 2-step protocol; early screening was underused. Improvements in screening programming are underway and future research may match surveillance rates and results to GDM outcomes.

Intimate partner violence during pregnancy and risk of fetal and neonatal death: a meta-analysis with socioeconomic context indicators

OBJECTIVE

The objective of the study was to summarize the results from observational studies examining the risk of fetal and neonatal death (perinatal death) as a function of the experience of intimate partner violence during pregnancy and examine the influence of socioeconomic context indicators on this association.

DATA SOURCES

Bibliographic searches were conducted in PubMed, EMBASE, CINAHL, and LILACS until March 2019.

STUDY ELIGIBILITY CRITERIA

We considered observational studies that provided data on the association between intimate partner violence during pregnancy and perinatal death.

STUDY APPRAISAL AND SYNTHESIS METHODS

Information collected included study characteristics, type, and prevalence of intimate partner violence and the reported association between intimate partner violence and perinatal death. Quality of the included studies was assessed using the Newcastle-Ottawa scale. Two reviewers independently conducted all review procedures; disagreements were resolved by a third reviewer. Meta-analyses were conducted based on the specific type of intimate partner violence (physical, psychological, sexual, unspecified) and also based on any type of intimate partner violence, considering 1 effect size per study, regardless of the type of intimate partner violence analyzed. Meta-regression analyses were performed to assess the possible effects of socioeconomic context. The proportion of deaths attributable to the exposure of intimate partner violence based on the crude data from the 3 cohort studies available also was calculated.

RESULTS

Seventeen studies were included. The random-effects model showed a statistically significant increase in the odds of perinatal death among women exposed to unspecified intimate partner violence (odds ratio, 3.18; 95% confidence interval, 1.88-5.38), physical intimate partner violence (odds ratio, 2.46; 95% confidence interval, 1.76-3.44), and any type of intimate partner violence during pregnancy (odds ratio, 2.89; 95% confidence interval, 2.03-4.10). Meta-regression analysis showed stronger associations in countries with higher gross domestic product (odds ratio, 1.03; 95% confidence interval, 1.02-1.04) and a higher percentage of health expenditure (odds ratio, 1.27; 95% confidence interval, 1.09-1.46). The proportion of deaths attributable to exposure to intimate partner violence in cohort studies was attributable proportion, 60%; 95% confidence interval, 15-81%.

CONCLUSION

Pregnant women who experience intimate partner violence during pregnancy may be about 3 times more likely to suffer perinatal death compared with women who do not experience intimate partner violence. It should be a priority to include intimate partner violence screenings or other detection strategies in pregnancy monitoring or family-planning programs because these could help avoid preventable perinatal deaths.

Diabetes during pregnancy and perinatal outcomes among First Nations women in Ontario, 2002/03-2014/15: a population-based cohort study

BACKGROUND

In Canada, increasing numbers of women, especially First Nations women, are affected by diabetes during pregnancy, which is a major risk factor for adverse maternal and neonatal outcomes. The aim of this study was to examine temporal trends in pregnancy outcomes and use of health care services in a population-based cohort of First Nations women compared to other women in Ontario according to diabetes status during pregnancy.

METHODS

Using health administrative databases, we created annual cohorts of pregnant women from 2002/03 to 2014/15 and identified those with preexisting diabetes and gestational diabetes. We used the Indian Register to identify First Nations women. We estimated rates of adverse maternal and infant outcomes, and measures of use of health care services in each population.

RESULTS

There were 1 671 337 deliveries among 1 065 950 women during the study period; of these deliveries, 31 417 (1.9%) were in First Nations women, and 1 639 920 (98.1%) were in other women. First Nations women had a higher prevalence of preexisting diabetes and gestational diabetes than other women in Ontario. First Nations women with preexisting diabetes had higher rates of preeclampsia (3.2%-5.6%), labour induction (33.4%-42.9%) and cesarean delivery (47.8%-53.7%) than other women in Ontario, as did First Nations women with gestational diabetes (3.2%-4.7%, 38.5%-46.9% and 41.4%-43.4%, respectively). The rate of preterm birth was similar between First Nations women and other women in Ontario. Although First Nations women had a higher rate of babies who were large for gestational age than other women, regardless of diabetes status, obstructed labour rates were similar for the 2 cohorts. Almost all First Nations women, regardless of diabetes status, were seen by a primary care provider during their pregnancy, but rates of use of specialty care were lower for First Nations women than for other women. Fifteen percent of all pregnant women with preexisting diabetes visited an ophthalmologist during their pregnancy.

INTERPRETATION

Our results confirm disparities in maternal and neonatal outcomes between First Nations women and other women in Ontario. Access to primary care for pregnant women seemed adequate, but access to specialized care, especially for women with preexisting diabetes, needs to improve.

Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up

OBJECTIVE

To evaluate the associations between maternal diabetes diagnosed before or during pregnancy and early onset cardiovascular disease (CVD) in offspring during their first four decades of life.

DESIGN

Population based cohort study.

SETTING

Danish national health registries.

PARTICIPANTS

All 2 432 000 liveborn children without congenital heart disease in Denmark during 1977-2016. Follow-up began at birth and continued until first time diagnosis of CVD, death, emigration, or 31 December 2016, whichever came first.

EXPOSURES FOR OBSERVATIONAL STUDIES

Pregestational diabetes, including type 1 diabetes (n=22 055) and type 2 diabetes (n=6537), and gestational diabetes (n=26 272).

MAIN OUTCOME MEASURES

The primary outcome was early onset CVD (excluding congenital heart diseases) defined by hospital diagnosis. Associations between maternal diabetes and risks of early onset CVD in offspring were studied. Cox regression was used to assess whether a maternal history of CVD or maternal diabetic complications affected these associations. Adjustments were made for calendar year, sex, singleton status, maternal factors (parity, age, smoking, education, cohabitation, residence at childbirth, history of CVD before childbirth), and paternal history of CVD before childbirth. The cumulative incidence was averaged across all individuals, and factors were adjusted while treating deaths from causes other than CVD as competing events.

RESULTS

During up to 40 years of follow-up, 1153 offspring of mothers with diabetes and 91 311 offspring of mothers who did not have diabetes were diagnosed with CVD. Offspring of mothers with diabetes had a 29% increased overall rate of early onset CVD (hazard ratio 1.29 (95% confidence interval 1.21 to 1.37); cumulative incidence among offspring unexposed to maternal diabetes at 40 years of age 13.07% (12.92% to 13.21%), difference in cumulative incidence between exposed and unexposed offspring 4.72% (2.37% to 7.06%)). The sibship design yielded results similar to those of the unpaired design based on the whole cohort. Both pregestational diabetes (1.34 (1.25 to 1.43)) and gestational diabetes (1.19 (1.07 to 1.32)) were associated with increased rates of CVD in offspring. We also observed varied increased rates of specific early onset CVDs, particularly heart failure (1.45 (0.89 to 2.35)), hypertensive disease (1.78 (1.50 to 2.11)), deep vein thrombosis (1.82 (1.38 to 2.41)), and pulmonary embolism (1.91 (1.31 to 2.80)). Increased rates of CVD were seen in different age groups from childhood to early adulthood until age 40 years. The increased rates were more pronounced among offspring of mothers with diabetic complications (1.60 (1.25 to 2.05)). A higher incidence of early onset CVD in offspring of mothers with diabetes and comorbid CVD (1.73 (1.36 to 2.20)) was associated with the added influence of comorbid CVD but not due to the interaction between diabetes and CVD on the multiplicative scale (P value for interaction 0.94).

CONCLUSIONS

Children of mothers with diabetes, especially those mothers with a history of CVD or diabetic complications, have increased rates of early onset CVD from childhood to early adulthood. If maternal diabetes does have a causal association with increased CVD rate in offspring, the prevention, screening, and treatment of diabetes in women of childbearing age could help to reduce the risk of CVD in the next generation.