Good glycemic control of gestational diabetes mellitus is associated with the attenuation of future maternal cardiovascular risk: a retrospective cohort study

Mitigation of gestational diabetes-induced endothelial dysfunction through FGF21-NRF2 pathway activation involving L-Cystine

Gestational diabetes mellitus (GDM) disrupts glucolipid metabolism, endangering maternal and fetal health. Despite limited research on its pathogenesis and treatments, we conducted a study using serum samples from GDM-diagnosed pregnant women. We performed metabolic sequencing to identify key small molecule metabolites and explored their molecular interactions with FGF21. We also investigated FGF21's impact on GDM using blood samples from affected women. Our analysis revealed a novel finding: elevated levels of L-Cystine in GDM patients. Furthermore, we observed a positive correlation between L-Cystine and FGF21 levels, and found that L-Cystine induces NRF2 expression via FGF21 for a period of 96 h. Under high glucose (HG) conditions, FGF21 upregulates NRF2 and downstream genes NQO1 and EPHX1 via AKT phosphorylation induced by activation of IRS1, enhancing endothelial function. Additionally, we confirmed that levels of FGF21, L-Cystine, and endothelial function at the third trimester were effectively enhanced through appropriate exercise and diet during pregnancy in GDM patients (GDM + ED). These findings suggest FGF21 as a potential therapeutic agent for GDM, particularly in protecting endothelial cells. Moreover, elevated L-Cystine via appropriate exercise and diet might be a potential strategy to enhance FGF21's efficacy.

Risk prediction models for postpartum glucose intolerance in women with a history of gestational diabetes mellitus: a scoping review

Objective

The objective of this scoping review was to investigate the effectiveness and limitations of risk prediction models for postpartum glucose intolerance in women with gestational diabetes mellitus (GDM). The aim was to provide valuable insights for healthcare professionals in the development of robust risk prediction models.

Methods

A comprehensive literature search was conducted across multiple databases, including PubMed, EBSCO, Web of Science Core Collection, Ovid Full-Text Medical Journal Database, ProQuest, Elsevier ClinicalKey, China National Knowledge Infrastructure, China Biology Medicine, and WanFang Database, spanning from January 1990 to July 2023. To assess the quality of the included models, the Predictive Model Risk of Bias Assessment Tool (PROBAST) was employed.

Results

Fourteen relevant studies were identified and included in the final review, all focusing on model development. The discrimination ability of the included models ranged from 0.725 to 0.940, indicating satisfactory prediction accuracy. However, a notable limitation was that nine of these models (64.3%) did not provide clear guidelines on the selection of potential predictors. Furthermore, only six models (42.86%) underwent internal validation, with none undergoing external validation. A high risk of bias was observed across the included models. Logistic regression, Cox regression, and machine learning were the primary methods employed in the construction of these models.

Conclusion

The risk prediction models included in this review demonstrated favorable prediction accuracy. However, due to variations in construction methodologies, direct comparison of their performance is challenging. These models exhibited certain shortcomings, such as inadequate handling of missing data and a lack of internal and external validation, resulting in a high risk of bias. Therefore, it is recommended that these models be updated and externally validated. The development of prospective, multi-center studies is encouraged to construct predictive models with low risk of bias and high clinical applicability, ultimately guiding evidence-based clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01330-1.

Risk for fetal malformations and unfavorable neonatal outcomes in early-onset gestational diabetes mellitus

BACKGROUND

Early-onset gestational diabetes mellitus (GDM) is diagnosed before the 24th gestational week. Since early GDM is associated with first trimester hyperglycemia, many clinicians treat these women as having pre-GDM. However, whether early GDM increases the risk for unfavorable pregnancy outcomes and particularly for fetal malformations to a greater extent than late-onset GDM were not studied sufficiently. We aimed to examine the effect of early-onset GDM on unfavorable pregnancy outcomes.

METHODS

A retrospective cohort study of women with GDM delivering singletons during 2005-2018 was conducted. Women were divided into GDM diagnosed at the first (Trimester1; up to 13.6 weeks; N = 117), the second (Trimester2; up to 23.6 weeks; N = 126), and the third trimester (Trimester3; N = 2334). The primary outcomes were neonatal malformations and a composite of large-for-age newborns, hypoglycemia and hyperbilirubinemia treated with phototherapy. Comparisons were made between early- (Trimester1 + Trimester2-groups) and late-onset GDM (Trimester3-group), and between the three trimesters.

RESULTS

Fetal malformations were low and comparable between the trimester1, trimester2, trimester3 groups (2 (1.7%), 3 (2.4%), and 110 (4.7%), respectively). The composite neonatal complications was similar between the groups (68 (58%), 58 (46%), and 1087 (47%), respectively). In early-onset, the rates of neonatal hypoglycemia and shoulder dystocia were higher than in the late-onset GDM group (OR 95% CI 3.5 [2.0-6.1] and 10.3 [2.4-44.6], respectively). Macrosomia was higher in trimester1 compared with trimester2 and trimester3 cohorts (OR 95% CI 5.3 [1.7-16.9] and 2.8 [1.5-5.2], respectively).

CONCLUSIONS

The risk for fetal malformations was low and comparable between the first, second and third trimester GDM. Since the risks for macrosomia, shoulder dystocia, and neonatal hypoglycemia are higher in early-onset GDM, these women should undergo strict glycemic control, intensive monitoring, and careful neonatal evaluation.

The effect of oral probiotics on glycemic control of women with gestational diabetes mellitus-a multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Gestational diabetes mellitus should be treated adequately to avoid maternal hyperglycemia-related complications. Previously, probiotic supplements were suggested to improve fasting blood glucose in women with gestational diabetes mellitus. However, a major limitation of previous studies was that preprandial and especially postprandial glucose values, which are important predictors of pregnancy outcomes, were not studied.

OBJECTIVE

This study aimed to examine the effect of a mixture of probiotic strains on maternal glycemic parameters, particularly preprandial and postprandial glucose values and pregnancy outcomes among women with gestational diabetes mellitus.

STUDY DESIGN

A multicenter prospective randomized, double-blind, placebo-controlled trial was conducted. Women newly diagnosed with gestational diabetes mellitus were randomly allocated into a research group, receiving 2 capsules of oral probiotic formula containing Bifidobacterium bifidum, B lactis, Lactobacillus acidophilus, L paracasei, L rhamnosus, and Streptococcus thermophilus (>6 × 109/capsule), and a control group, receiving a placebo (2 capsules/day) until delivery. Glycemic control was evaluated by daily glucose charts. After 2 weeks, pharmacotherapy was started in case of poor glycemic control. The primary outcomes were the rate of women requiring medications for glycemic control and mean daily glucose charts after 2 weeks of treatment with the study products.

RESULTS

Forty-one and 44 women were analyzed in the treatment and placebo cohorts, respectively. Mean daily glucose during the first 2 weeks in the probiotics and placebo groups was 99.7±7.9 and 98.0±9.3 mg/dL, respectively (P=.35). The rate of women needing pharmacotherapy because of poor glycemic control after 2 weeks of treatment in the probiotics and placebo groups was 24 (59%) and 18 (41%), respectively (P=.10). Mean preprandial and postprandial glucose levels throughout the study period were similar between the groups (P>.05). There were no differences in maternal and neonatal outcomes, including birthweight and adverse effect profile between the groups.

CONCLUSION

The oral probiotic product tested in this study did not affect glycemic control of women with gestational diabetes mellitus.

Risk of type 2 diabetes after diagnosed gestational diabetes is enhanced by exposure to PM2.5

BACKGROUND

Air pollution and gestational diabetes mellitus (GDM) are both associated with increased diabetes mellitus (DM) occurrence. However, whether air pollutants modify the effects of GDM on the occurrence of DM has been unknown. This study aims to determine whether the effect of GDM on DM development can be modified by exposure to ambient air pollutants.

METHODS

Women with one singleton birth delivery during 2004-14 according to the Taiwan Birth Certificate Database (TBCD) were included as the study cohort. Those newly diagnosed as having DM 1 year or later after childbirth were identified as DM cases. Controls were selected among women without DM diagnosis during follow-up. Personal residence was geocoded and linked with interpolated concentrations of air pollutants into township levels. Conditional logistic regression was used to determine the odds ratio (OR) of pollutant exposure and GDM, adjusting for age, smoking and meteorological variables.

RESULTS

There were 9846 women who were newly diagnosed as having DM over a mean follow-up period of 10.2 years. We involved them and the 10-fold matching controls involved in our final analysis. The OR (odds ratio) (95% confidence interval, 95% CI) of DM occurrence per interquartile range increased in particulate matter (PM) smaller than or equal to 2.5 µm (PM2.5) and ozone (O3) was 1.31 (1.22-1.41) and 1.20 (1.16-1.25), respectively. The effects of PM exposure on DM development were significantly higher in the GDM group (OR: 2.46, 95% CI: 1.84-3.30) than in the non-GDM group (OR: 1.30, 95% CI: 1.21-1.40).

CONCLUSIONS

Exposure to high levels of PM2.5 and O3 elevates the risk of DM. GDM acted synergistically in DM development with exposure to PM2.5 but not with that to O3.

Influence of Gestational Diabetes Mellitus on Diabetes Risk and Glycemic Control in a Retrospective Population-Based Cohort

OBJECTIVE

Racial/ethnic-specific estimates of the influence of gestational diabetes mellitus (GDM) on type 2 diabetes remain underexplored in large population-based cohorts. We estimated racial/ethnic differences in the influence of GDM on diabetes risk and glycemic control in a multiethnic, population-based cohort of postpartum women.

RESEARCH DESIGN AND METHODS

Hospital discharge and vital registry data for New York City (NYC) births between 2009 and 2011 were linked with NYC A1C Registry data between 2009 and 2017. Women with baseline diabetes (n = 2,810) were excluded for a final birth cohort of 336,276. GDM on time to diabetes onset (two A1C tests of ≥6.5% from 12 weeks postpartum onward) or glucose control (first test of A1C <7.0% following diagnosis) was assessed using Cox regression with a time-varying exposure. Models were adjusted for sociodemographic and clinical factors and stratified by race/ethnicity.

RESULTS

The cumulative incidence for diabetes was 11.8% and 0.6% among women with and without GDM, respectively. The adjusted hazard ratio (aHR) of GDM status on diabetes risk was 11.5 (95% CI 10.8, 12.3) overall, with slight differences by race/ethnicity. GDM was associated with a lower likelihood of glycemic control (aHR 0.85; 95% CI 0.79, 0.92), with the largest negative influence among Black (aHR 0.77; 95% CI 0.68, 0.88) and Hispanic (aHR 0.84; 95% CI 0.74, 0.95) women. Adjustment for screening bias and loss to follow-up modestly attenuated racial/ethnic differences in diabetes risk but had little influence on glycemic control.

CONCLUSIONS

Understanding racial/ethnic differences in the influence of GDM on diabetes progression is critical to disrupt life course cardiometabolic disparities.

The Incidence and Management of Type 2 Diabetes Mellitus After Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) refers to a transient state of impaired glucose tolerance that develops during pregnancy, affecting a significant proportion of expectant mothers globally. This review aimed to comprehensively examine the subsequent incidence and management of type 2 diabetes mellitus (T2DM) in women who have previously experienced GDM. The transition from GDM to T2DM is a well-recognized continuum, with affected women facing an increased risk of developing T2DM postpartum. Several studies have demonstrated that women with a history of GDM face a substantially higher risk of developing T2DM compared to normoglycemic pregnant women. The long-term consequences of developing T2DM following GDM are significant, as it not only affects the health of the mother but also poses risks to the offspring. The most common risk factors associated with the progression of GDM to T2DM include pregnancy at an advanced age, insulin treatment during pregnancy, and delivering an overweight baby. As GDM women are at higher risk of developing T2DM, effective management strategies such as lifestyle changes, postpartum care, breastfeeding, screening tests, and gaining awareness of risk are crucial to mitigate the risk of T2DM in this population. The current review was conducted to guide healthcare providers and women with a history of GDM about the potential risks of T2DM and management strategies to prevent the condition. This review provides a summary of evidence on the incidence rate of T2DM in GDM patients, its associated risk factors, and approaches to mitigate this challenge.

The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review

In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.

Predictors and risk factors of short-term and long-term outcomes among women with gestational diabetes mellitus (GDM) and their offspring: Moving toward precision prognosis?

As part of the American Diabetes Association Precision Medicine in Diabetes Initiative (PMDI) - a partnership with the European Association for the Study of Diabetes (EASD) - this systematic review is part of a comprehensive evidence evaluation in support of the 2 ^nd International Consensus Report on Precision Diabetes Medicine. Here, we sought to synthesize evidence from empirical research papers published through September 1 ^st , 2021 to evaluate and identify prognostic conditions, risk factors, and biomarkers among women and children affected by gestational diabetes mellitus (GDM), focusing on clinical endpoints of cardiovascular disease (CVD) and type 2 diabetes (T2D) among women with a history of GDM; and adiposity and cardiometabolic profile among offspring exposed to GDM in utero. We identified a total of 107 observational studies and 12 randomized controlled trials testing the effect of pharmaceutical and/or lifestyle interventions. Broadly, current literature indicates that greater GDM severity, higher maternal body mass index, belonging to racial/ethnic minority group; and unhealthy lifestyle behaviors would predict a woman's risk of incident T2D and CVD, and an unfavorable cardiometabolic profile among offspring. However, the level of evidence is low (Level 4 according to the Diabetes Canada 2018 Clinical Practice Guidelines for diabetes prognosis) largely because most studies leveraged retrospective data from large registries that are vulnerable to residual confounding and reverse causation bias; and prospective cohort studies that may suffer selection and attrition bias. Moreover, for the offspring outcomes, we identified a relatively small body of literature on prognostic factors indicative of future adiposity and cardiometabolic risk. Future high-quality prospective cohort studies in diverse populations with granular data collection on prognostic factors, clinical and subclinical outcomes, high fidelity of follow-up, and appropriate analytical approaches to deal with structural biases are warranted.

Effects of Probiotics on Glycemic Control and Metabolic Parameters in Gestational Diabetes Mellitus: Systematic Review and Meta-Analysis

Objectives: To assess the effects of probiotic supplements on glycemic control and metabolic parameters in women with gestational diabetes mellitus (GDM) by performing a systematic review and meta-analysis of randomized controlled trials. The primary outcome was glycemic control, i.e., serum glucose and insulin levels. Secondary outcomes were maternal weight gain, neonatal birth weight, and lipid parameters. Weighted mean difference (WMD) was used. Cochrane’s Q test of heterogeneity and I2 were used to assess heterogeneity. Results: Of the 843 papers retrieved, 14 (n = 854 women) met the inclusion criteria and were analyzed. When compared with placebo, women receiving probiotic supplements had significantly lower mean fasting serum glucose, fasting serum insulin, homeostatic model assessment for insulin resistance (HOMA-IR), triglycerides, total cholesterol, and VLDL levels. Decreased neonatal birth weight was witnessed in supplements containing Lactobacillus acidophilus. Conclusion: Probiotic supplements may improve glycemic control and lipid profile and reduce neonatal birth weight in women with GDM.

Maternal and infant outcomes in women with and without gestational diabetes mellitus in the COVID-19 era in China: Lessons learned

Aims

The global COVID-19 pandemic has required a drastic transformation of prenatal care services. Whether the reformulation of the antenatal care systems affects maternal and infant outcomes remains unknown. Particularly, women with gestational diabetes mellitus (GDM) are among those who bear the greatest brunt. Thus, this study aimed to evaluate the impact of COVID-19 lockdown during late pregnancy on maternal and infant outcomes in women stratified by the GDM status in China.

Study design

The participants were women who experienced the COVID-19 lockdown during late pregnancy (3185 in the 2020 cohort) or not (2540 in the 2019 cohort) that were derived from the Beijing Birth Cohort Study. Maternal metabolic indicators, neonatal outcomes, and infant anthropometrics at 12 months of age were compared between the two cohorts, stratified by the GDM status.

Results

Participants who experienced COVID-19 lockdown in late pregnancy showed lower gestational weight gain than those in the control cohort. Nevertheless, they displayed a worse metabolic profile. COVID-19 lockdown during pregnancy was associated with higher glycosylated hemoglobin (HbA1c) (β= 0.11, 95% CI = 0.05-0.16, q-value = 0.002) and lower high density lipoprotein cholesterol level (HDL-C) level (β=-0.09, 95% CI = -0.14 to -0.04, q-value = 0.004) in women with GDM, adjusted for potential confounders. In normoglycemic women, COVID-19 lockdown in late pregnancy was associated with higher fasting glucose level (β= 0.10, 95% CI = 0.08-0.12, q-value <0.0001), lower HDL-C level (β=-0.07, 95% CI = -0.08 to -0.04, q-value <0.0001), and increased risk of pregnancy-induced hypertension (adjusted OR=1.80, 95%CI=1.30-2.50, q-value=0.001). The fasting glucose level decreased less from early to late pregnancy in women who experienced COVID-19 lockdown than in the controls, regardless of the GDM status. The HDL-C has risen less with COVID-19 lockdown in the normoglycemic subgroup. In contrast, no significant differences regarding neonatal outcomes or infant weight were found between the two cohorts.

Conclusion

Experiencing the COVID-19 lockdown in pregnancy was associated with worse maternal metabolic status but similar neonatal outcomes and infant weight.

What is an appropriate gestational weight gain for women with gestational diabetes mellitus: based on the adverse pregnancy outcomes of over 12 thousand participants?

BACKGROUND

Evidence showed possible benefits of a less gestational weight gain (GWG) than the US Institute of Medicine (IOM) recommendation in gestational diabetes mellitus (GDM) pregnancy. Here, we aimed to explore an appropriate GWG range in GDM women according to adverse pregnancy outcomes.

METHODS

We enrolled all the singleton GDM pregnant women (n = 14,213) from January 2015 to December 2018 in Xi'an, Northwest China. According to the pre-pregnancy body mass index (BMI), they were classified into the Underweight (< 18.5 kg/m²), Normal weight (18.5-24.9 kg/m²⁾, Overweight (25.0-29.9 kg/m²) and Obesity (≥ 30.0 kg/m²) group, respectively. Logistic regression analysis was used to calculate the odds ratio (OR) and 95% confidence intervals (95% CI). The appropriate ranges of GWG were determined based on a significant protective association (OR < 1).

RESULTS

Totally, 12,712 participants were finally recruited. There were 1180 (9.3%), 9134 (71.9%), 2097 (16.5%), and 301 (2.4%) patients in the Underweight, Normal weight, Overweight, and Obesity groups, respectively. Adverse outcomes increased with the elevation of pre-pregnancy BMI. Among them, the risk of cesarean section was the highest, followed by large for gestational age (LGA), small for gestational age (SGA), preeclampsia, and gestational hypertension. Through the analysis of the risk of adverse outcomes in continuous GWG categories in each group, an ideal GWG range obtained in this study was as follows: 10-15.9 kg, 8-11.9 kg, 6-7.9 kg, and -5-3.9 kg for the Underweight, Normal weight, Overweight and Obesity group, respectively. Furthermore, the ranges in this study were more protective for adverse outcomes than those from IOM.

CONCLUSIONS

Based on the adverse pregnancy outcomes of over 12 thousand participants, our findings showed a more stringent GWG range for GDM women than the IOM criteria recommendation.

Comparison of Parameters of Fetal Doppler Echocardiography Between Mothers with and Without Diabetes

BACKGROUND

The current study aimed to compare fetal myocardial function and ventricular thickness in diabetic and normal pregnancies.

METHODS

Women with singleton pregnancies in the second or third trimester who were referred for routine prenatal or anomaly ultrasounds within March 2020 to February 2021 were enrolled in the study. Women with a positive history of overt or gestational diabetes mellitus (GDM) were considered the case group (n = 50), and women without GDM were considered the control group (n = 50). The study did not include women with multifetal pregnancy, hypertension, intrauterine growth retardation, and polyhydramnios. A complete fetal Doppler echocardiography was performed to measure isovolumic relaxation time (IVRT), left myocardial performance index (MPI), E/A ratio, right and left ventricular wall thickness, and end-diastolic interventricular septal thickness (IVST). The data were analyzed using three types of decision tree (DT) algorithms, and the performance of each DT was measured on the testing dataset.

RESULTS

The frequency of IVRT > 41 milliseconds was significantly higher in the case group than in the control group. The mean MPI values were 0.53 ± 0.15 and 0.43 ± 0.09 (P < 0.05), respectively, and the mean IVST values were 3.3 ± 1.11 and 2.49 ± 0.55 mm (P < 0.05) in the case and control groups, respectively, but not different between the subjects with overt or GDM (P > 0.05). Additionally, in the case group, the mean left MPI values were 0.57 ± 0.18 and 0.49 ± 0.12 in participants with poor and good glycemic control, respectively (P = 0.12).

CONCLUSIONS

Complete prenatal echocardiography performed in the second or third trimester is an appropriate tool for the diagnosis of fetal cardiac dysfunction in diabetic mothers and is suggested to perform for diabetic mothers, even those with good glycemic control.

The relationship between poor glycaemic control at different time points of gestational diabetes mellitus and pregnancy outcomes

We aimed to identify the complications of gestational diabetes mellitus (GDM) associated with poor control of fasting plasma glucose (FPG) and postload plasma glucose (PPG) on the 75-g oral glucose tolerance test (OGTT). This retrospective study included 997 singleton pregnancy GDM patients who were assigned to poor or good glycaemic control groups. Multivariate analysis indicated that poor FPG control and poor PPG control were both independent predictors of hypertensive disorder complicating pregnancy (HDCP) (odd ratio (OR) of 2.551 (95% CI [1.146-5.682], p = .022) and OR of 2.084 (95% [1.115-3.894], p = .021) compared with good glycaemic control groups, respectively). Poor PPG control promoted the rate of caesarean delivery (1.534 (95% CI [1.063-2.214]), p = .022), whereas good PPG control increased the risk of premature rupture of membranes (PROM) (0.373 (95% CI [0.228-0.611]), p < .001). Conclusively, poor control FPG and PPG dissimilarly affect pregnancy complications in GDM; these findings may help clinicians in the effective implementation of measures to prevent pregnancy complications in GDM.IMPACT STATEMENTWhat is already known on this subject? Previous studies displayed that GDM patients with 2-h PPG elevated at 24-28 week of gestation had a 2.254-fold increased risk of postpartum dysglycaemia. Abnormal plasma glucose in GDM mother increased the probability of childhood obesity in the offspring. With the implementation of China's second-child policy, the incidence of GDM is rising.What do the results of this study add? Our results indicated that the older patients with GDM, the greater the risk of abnormal plasma glucose control. In addition, maternal age and prenatal BMI were notably correlated with poor plasma glucose control of FPG and PPG, respectively. We also found that both poor FPG and PPG control notably increased the incidence of HDCP in pregnant women. The incidence of PROM was higher in the good PPG control group compared with the poor PPG control group.What are the implications of these findings for clinical practice and/or further research? This study displayed that the effects of poor FPG and PPG control on pregnancy complications and newborn outcomes were heterogeneous, which might be related to the specificity of plasma glucose metabolism at different time points. Good glycaemic control, especially PPG control, was of great significance for improving pregnancy complications and perinatal conditions.

Development of type 2 diabetes in women with comorbid gestational diabetes and common mental disorders in the Born in Bradford cohort

OBJECTIVES

To compare, in a population of women with gestational diabetes mellitus (GDM), the time to diagnosis of Type 2 diabetes in those with and without common mental disorder (CMD) (depression and/or anxiety) during pregnancy.

DESIGN AND SETTING

prospective study of the Born in Bradford cohort in Bradford, UK.

PARTICIPANTS

909 women diagnosed with GDM between 2007 and 2010, with linkage to their primary care records until 2017. The exposed population were women with an indicator of CMD during pregnancy in primary care records. The unexposed were those without an indicator.

OUTCOME MEASURES

Time to diagnosis of type 2 diabetes as indicated by a diagnosis in primary care records.

ANALYSIS

time to event analysis using Cox regression was employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education, preconception CMD and tobacco smoking during pregnancy.

RESULTS

165 women (18%) were diagnosed with type 2 diabetes over a follow-up period of around 10 years. There was no evidence of an effect of antenatal CMD on the development of type 2 diabetes following GDM (adjusted HR 0.95; 95% CI 0.57 to 1.57).

CONCLUSIONS

Women with CMD were not at an increased risk of type 2 diabetes following GDM. This is reassuring for women with these co-morbidities but requires replication in other study populations.

Glucose levels during gestational diabetes pregnancy and the risk of developing postpartum diabetes or prediabetes

BACKGROUND

Blood glucose levels during pregnancy may reflect the severity of insulin secretory defects and/or insulin resistance during gestational diabetes mellitus (GDM) pregnancy. We hypothesized that suboptimal glycemic control in women with GDM could increase the risk of postpartum type 2 diabetes mellitus (T2DM) or prediabetes. Our objective was to evaluate the impact of plasma glucose levels throughout GDM pregnancy on the risk of postpartum T2DM or prediabetes.

METHODS

The medical records of 706 women with GDM who underwent a postpartum 75-g, 2-hour oral glucose tolerance test at our institution between January 2011 and December 2018 were reviewed. These women were classified into 2 groups according to glycemic control during pregnancy: ≤ 1 occasion of either fasting glucose ≥ 95 mg/dL or 2-hour postprandial glucose ≥ 120 mg/dL was defined as optimal glycemic control or else was classified as suboptimal glycemic control. Rates of postpartum T2DM and prediabetes were compared between women with optimal (n = 505) and suboptimal (n = 201) glycemic control.

RESULTS

The rates of postpartum T2DM and prediabetes were significantly higher in the suboptimal glycemic control group than in the optimal glycemic control group: 22.4% vs. 3.0%, P < 0.001 for T2DM and 45.3% vs. 23.5%, P < 0.001 for prediabetes. In a multivariate analysis, suboptimal glucose control during pregnancy was an independent risk factor for developing either postpartum T2DM or prediabetes. The adjusted odds ratios were 8.4 (95% confidence interval, 3.5-20.3) for T2DM and 3.9 (95% confidence interval, 2.5-6.1) for prediabetes.

CONCLUSION

Our findings suggest that blood glucose levels during GDM pregnancy have an impact on the risk of postpartum T2DM and prediabetes.

Adverse metabolic outcomes in the early and late postpartum after gestational diabetes are broader than glucose control

INTRODUCTION

Gestational diabetes mellitus is associated with an increased cardiovascular risk. To better target preventive measures, we performed an in-depth characterization of cardiometabolic risk factors in a cohort of women with gestational diabetes in the early (6-8 weeks) and late (1 year) postpartum.

RESEARCH DESIGN AND METHODS

Prospective cohort of 622 women followed in a university gestational diabetes clinic between 2011 and 2017. 162 patients who attended the late postpartum visit were analyzed in a nested long-term cohort starting in 2015. Metabolic syndrome (MetS) was based on the International Diabetes Federation definition, and then having at least two additional criteria of the MetS (blood pressure, triglycerides, high-density lipoprotein (HDL) cholesterol, plasma glucose above or below the International Diabetes Federation cut-offs).

RESULTS

Compared with prepregnancy, weight retention was 4.8±6.0 kg in the early postpartum, and the prevalence of obesity, pre-diabetes, MetS-body mass index (BMI) and MetS-waist circumference (WC) were 28.8%, 28.9%, 10.3% and 23.8%, respectively. Compared with the early postpartum, weight did not change and waist circumference decreased by 2.6±0.6 cm in the late postpartum. However, the prevalence of obesity, pre-diabetes, MetS-WC and MetS-BMI increased (relative increase: 11% for obesity, 82% for pre-diabetes, 50% for MetS-WC, 100% for MetS-BMI; all p≤0.001).Predictors for obesity were the use of glucose-lowering treatment during pregnancy and the prepregnancy BMI. Predictors for pre-diabetes were the early postpartum fasting glucose value and family history of diabetes. Finally, systolic blood pressure in pregnancy and in the early postpartum, the 2-hour post oral glucose tolerance test glycemia and the HDL-cholesterol predicted the development of MetS (all p<0.05).

CONCLUSIONS

The prevalence of metabolic complications increased in the late postpartum, mainly due to an increase in fasting glucose and obesity, although weight did not change. We identified predictors of late postpartum obesity, pre-diabetes and MetS that could lead to high-risk identification and targeted preventions.

Effect of mobile health based peripartum management of gestational diabetes mellitus on postpartum diabetes: A randomized controlled trial

AIMS

To investigate the effects of mobile health based peripartum management of gestational diabetes mellitus (GDM) on postpartum diabetes and factors associated with postpartum diabetes.

METHODS

Women with GDM (n = 309) were randomly assigned to receive standard management (SM) or mobile management (MM). 75-g OGTT was performed at 6 weeks postpartum.

RESULTS

The incidence of postpartum T2DM in the MM group was much higher than that in SM group (12.36% vs. 3.88%, P =  0.0291). The fasting, 1-h and 2 h OGTT at 24-28 weeks of gestation of T2DM women were higher than those women without T2DM (fasting, 6.08 vs. 4.90, P = 0.0052; 1-h, 13.20 vs. 10.00, P < 0.0001; 11.96 vs. 8.83, P = 0.0026) in MM group. The 1-h and 2 h OGTT at 24-28 weeks of gestation of T2DM women were higher than those women without T2DM (11.54 vs. 9.78, P = 0.0484; 10.68 vs. 8.68, P = 0.0108) in SM group. Higher OGTT values at 24-28 weeks of gestation were risk factors of postpartum T2DM.

CONCLUSIONS

Higher OGTT values at 24-28 weeks of gestation were risk factors to develop postpartum T2DM. Mobile health based peripartum management of GDM increased the risk of postpartum diabetes among women with GDM for lacking of postpartum management. Further studies of mobile health based postpartum management of GDM are needed. ClinicalTrials.gov registration number NCT03748576.

The Role of Lifestyle Intervention in the Prevention and Treatment of Gestational Diabetes

Obesity during pregnancy is associated with the development of adverse outcomes, including gestational diabetes mellitus (GDM). GDM is highly associated with obesity and independently increases the risk of both complications during pregnancy and future impaired glycemic control and risk factors for cardiovascular disease for both the mother and child. Despite extensive research evaluating the effectiveness of lifestyle interventions incorporating diet and/or exercise, there remains a lack of definitive consensus on their overall efficacy alone or in combination for both the prevention and treatment of GDM. Combination of diet and physical activity/exercise interventions for GDM prevention demonstrates limited success, whereas exercise-only interventions report of risk reductions ranging from 3 to 49%. Similarly, combination therapy of diet and exercise is the first-line treatment of GDM, with positive effects on maternal weight gain and the prevalence of infants born large-for-gestational age. Yet, there is inconclusive evidence on the effects of diet or exercise as standalone therapies for GDM treatment. In clinical care, women with GDM should be treated with a multidisciplinary approach, starting with lifestyle modification and escalating to pharmacotherapy if needed. Several key knowledge gaps remain, including how lifestyle interventions can be optimized during pregnancy, and whether intervention during preconception is effective for preventing the rising prevalence of GDM.

One elevated oral glucose tolerance test value in pregnancy increases the risk for future diabetes mellitus type 2

PURPOSE

Women with only one elevated 100 g OGTT value are not considered as having gestational diabetes mellitus (GDM) and therefore there are no recommendations to address this population as a risk group for type 2 diabetes mellitus (T2DM). We aimed to elucidate whether one elevated OGTT value increases the risk for T2DM.

METHODS

A retrospective population-based cohort study of women with a first diagnosis of GDM who delivered between 1991 and 2011 was conducted. Women were divided according to GDM diagnosis criteria into three groups: (1) at least two elevated values of Carpenter and Coustan criteria (C&C; N = 209), (2) At least two elevated values of the National Diabetes Data Group (NDDG) criteria (NDDG2; N = 290) and (3) only one elevated value of the NDDG criteria (NDDG1; N = 226). A fourth group comprising women without GDM was included (control; N = 352). The primary outcome was the development of T2DM.

RESULTS

The mean follow-up was 12.4 ± 5.3 years and the mean age at follow-up was 43.0 ± 5.7 years. The rate of T2DM in the control, C&C, NDDG1 and NDDG2 groups were 5%, 18%, 19% and 31%, respectively. All GDM diagnoses were independent risk factors for T2DM in multivariable Cox regression when compared to controls, adjusted hazard ratio and 95% CI: C&C 7.8 [95% CI 3.7-16.4], NDDG1 5.5 [2.6-11.6], and NDDG2 10.5 [5.2-21.4]. Additional independent risk factors were parity, fasting and 1-h post-glucose load of the OGTT and insulin use.

CONCLUSIONS

Women with one elevated OGTT value using the NDDG criteria are at increased risk for T2DM. Further studies are needed to decide whether those women should be considered a focus group for long-term surveillance and T2DM prevention interventions.

Metformin Ameliorates Gestational Diabetes Mellitus-Induced Endothelial Dysfunction via Downregulation of p65 and Upregulation of Nrf2

Gestational diabetes mellitus (GDM) causes oxidative stress in mothers and infants and causes vascular endothelial dysfunction, which is a key factor for maternal and fetal cardiovascular diseases in the later stage of GDM, seriously threatening the life and health of mothers and infants. Nowadays, metformin (MET) has been discovered to improve endothelial function, but studies regarding the mechanism of MET improving endothelial cell function and alleviating endothelial function under hyperglycemia are still extremely limited. We aimed to investigate whether MET exerts its protective role against hyperglycemia-induced endothelial dysfunction through p65 and Nrf2. In our studies, applying cell migration assay and tube formation assay, we observed an obvious improvement of endothelial function under MET-treated, as characterized by that MET accelerated GDM-attenuated migration and angiogenesis of HUVECs. And ELISA assay results uncovered that Nrf2 expression level was decreased in GDM placenta, HVUECs and maternal serum comparing with normal group, however activation Nrf2 largely ameliorated tube formation under hyperglycemic condition. Furthermore, MET elevated the Nrf2 expression level and the level of nuclear Nrf2 accumulation in hyperglycemic HUVECs. Besides, preliminary evidence predicted that Nrf2 expression was modulated by transcription factor p65, which was increased in GDM peripheral blood, placenta and HUVECs, and suppression of p65 could recover GDM-induced suppression of angiogenesis. In addition, we also confirmed MET restores the GDM-induced angiogenesis impairment may via downregulation of p65 and upregulation of Nrf2. Taken together, the endothelial protective effect of MET under GDM (HG) conditions could be partly attributed to its role in downregulating p65 and upregulating Nrf2.

Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis

OBJECTIVE

To estimate and compare progression rates to type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) and healthy controls.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline and Embase between January 2000 and December 2019, studies published in English and conducted on humans.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Observational studies investigating progression to T2DM. Inclusion criteria were postpartum follow-up for at least 12 months, incident physician based diagnosis of diabetes, T2DM reported as a separate outcome rather than combined with impaired fasting glucose or impaired glucose tolerance, and studies with both a group of patients with GDM and a control group.

RESULTS

This meta-analysis of 20 studies assessed a total of 1 332 373 individuals (67 956 women with GDM and 1 264 417 controls). Data were pooled by random effects meta-analysis models, and heterogeneity was assessed by use of the I² statistic. The pooled relative risk for the incidence of T2DM between participants with GDM and controls was estimated. Reasons for heterogeneity between studies were investigated by prespecified subgroup and meta-regression analyses. Publication bias was assessed by funnel plots and, overall, studies were deemed to have a low risk of bias (P=0.58 and P=0.90). The overall relative risk for T2DM was almost 10 times higher in women with previous GDM than in healthy controls (9.51, 95% confidence interval 7.14 to 12.67, P<0.001). In populations of women with previous GDM, the cumulative incidence of T2DM was 16.46% (95% confidence interval 16.16% to 16.77%) in women of mixed ethnicity, 15.58% (13.30% to 17.86%) in a predominantly non-white population, and 9.91% (9.39% to 10.42%) in a white population. These differences were not statistically significant between subgroups (white v mixed populations, P=0.26; white v non-white populations, P=0.54). Meta-regression analyses showed that the study effect size was not significantly associated with mean study age, body mass index, publication year, and length of follow-up.

CONCLUSIONS

Women with a history of GDM appear to have a nearly 10-fold higher risk of developing T2DM than those with a normoglycaemic pregnancy. The magnitude of this risk highlights the importance of intervening to prevent the onset of T2DM, particularly in the early years after pregnancy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019123079.