The impact of risk factors and more stringent diagnostic criteria of gestational diabetes on outcomes in central European women

Clinical Factors for Predicting Pharmacotherapy in Twin Pregnancies Complicated by Gestational Diabetes Mellitus

Controlling blood glucose levels is the main target in pregnant women with gestational diabetes mellitus (GDM). Twin pregnancies are offered the same screening selection and have the same diagnostic criteria as well as treatment of gestational diabetes as singleton pregnancies, even though the risks for pregnancy complications are increased. The aim of this study was to assess the association between predicting factors, OGTT glucose levels and pharmacotherapy requirements in twin pregnancies with GDM. This retrospective cohort study included 446 GDM patients with twin pregnancies (246 managed with lifestyle modifications and 200 requiring pharmacotherapy) over a time period of 18 years. An evaluation of maternal characteristics and a standardized 75 g oral glucose test (OGGT) for glucose concentrations at fasting, 1 h and 2 h were conduced. OGTT glucose levels at fasting (=0 min, p < 0.01) and 1 h (p < 0.01) were significantly associated with the later requirement of pharmacotherapy. Also, clinical risk factors (pre-pregnancy BMI p < 0.01, multiparity p < 0.05, GDM in previous pregnancy p < 0.01, assisted reproduction p < 0.05) showed a predictive accuracy for insulin therapy in twin pregnancies complicated by GDM, whereas age and chorionicity had no effect. OGTT glucose measures in addition to clinical risk factors are promising variables for risk stratification in mothers with GDM and twin pregnancy.

[Gestational diabetes mellitus (Update 2023)]

Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and the offspring. Women detected to have diabetes early in pregnancy receive the diagnosis of overt, non-gestational, diabetes (glucose: fasting ≥ 126 mg/dl, spontaneous ≥ 200 mg/dl or HbA_1c ≥ 6.5% before 20 weeks of gestation). GDM is diagnosed by an oral glucose tolerance test (oGTT) or increased fasting glucose (≥ 92 mg/dl). Screening for undiagnosed type 2 diabetes at the first prenatal visit is recommended in women at increased risk (history of GDM/pre-diabetes; malformation, stillbirth, successive abortions or birth weight > 4500 g previously; obesity, metabolic syndrome, age > 35 years, vascular disease; clinical symptoms of diabetes (e.g. glucosuria) or ethnic origin with increased risk for GDM/T2DM (Arab, South- and Southeast Asian, Latin American)) using standard diagnostic criteria. Performance of the oGTT (120 min; 75 g glucose) may already be indicated in the first trimester in high-risk women but is mandatory between gestational week 24-28 in all pregnant women with previous non-pathological glucose metabolism. Following WHO recommendations, which are based on the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, GDM is defined, if fasting venous plasma glucose is ≥ 92 mg/dl or 1 h ≥ 180 mg/dl or 2 h ≥ 153 mg/dl after glucose loading (international consensus criteria). In case of one pathological value a strict metabolic control is mandatory. After bariatric surgery we do not recommend to perform an oGTT due to risk of postprandial hypoglycemia. All women with GDM should receive nutritional counseling, be instructed in blood glucose self-monitoring and motivated to increase physical activity to moderate intensity levels-if not contraindicated (Evidence level A). If blood glucose levels cannot be maintained in the therapeutic range (fasting < 95 mg/dl and 1 h after meals < 140 mg/dl, Evidence level B) insulin therapy should be initiated as first choice (Evidence level A). Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. Regular obstetric examinations including ultrasound examinations are recommended (Evidence level A). Neonatal care of GDM offspring at high risk for hypoglycaemia includes blood glucose measurements after birth and if necessary appropriate intervention. Monitoring the development of the children and recommendation of healthy lifestyle are important issues to be tackled for the whole family. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g oGTT (WHO criteria) 4-12 weeks postpartum. Assessment of glucose parameters (fasting glucose, random glucose, HbA_1c or optimally oGTT) are recommended every 2-3 years in case of normal glucose tolerance. All women have to be instructed about their increased risk of type 2 diabetes and cardiovascular disease at follow-up. Possible preventive meassures, in particular lifestyle changes as weight management and maintenance/increase of physical activity should be discussed (evidence level A).

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

OBJECTIVE

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

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

REVIEW REGISTRATION

PROSPERO CRD42021265837.

[Gestational diabetes mellitus (Update 2019)]

Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mother and child. Women who fulfil the criteria of a manifest diabetes in early pregnancy (fasting plasma glucose >126 mg/dl, spontaneous glucose level >200 mg/dl or HbA1c > 6.5% before 20 weeks of gestation) should be classified as having manifest diabetes in pregnancy and treated as such. Screening for undiagnosed type 2 diabetes at the first prenatal visit (evidence level B) is particularly recommended in women at increased risk (history of GDM or prediabetes, malformation, stillbirth, successive abortions or birth weight >4500 g in previous pregnancies, obesity, metabolic syndrome, age >35 years, vascular disease, clinical symptoms of diabetes, e. g. glucosuria, or ethnic groups with increased risk for GDM/T2DM, e.g. Arabian countries, south and southeast Asia and Latin America). A GDM is diagnosed by an oral glucose tolerance test (OGTT) or a fasting glucose concentration ≥92 mg/dl. Performance of the OGTT (120 min, 75 g glucose) may already be indicated in the first trimester in high risk women but is mandatory between 24-28 gestational weeks in all pregnant women with previous non-pathological glucose metabolism (evidence level B). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study and following the recent WHO recommendations, GDM is present if the fasting plasma glucose level exceeds 92 mg/dl, the 1 h level exceeds 180 mg/dl or the 2 h level exceeds 153 mg/dl after glucose loading (OGTT international consensus criteria). A single increased value is sufficient for the diagnosis and a strict metabolic control is mandatory. After bariatric surgery an OGTT is not recommended due to the risk of postprandial hypoglycemia. All women with GDM should receive nutritional counselling, be instructed in self-monitoring of blood glucose and to increase physical activity to moderate intensity levels, if not contraindicated. If blood glucose levels cannot be maintained in the therapeutic range (fasting <95 mg/dl and 1 h postprandial <140 mg/dl) insulin therapy should be initiated as first choice. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be re-evaluated by a 75 g OGTT (WHO criteria) 4-12 weeks postpartum to reclassify the glucose tolerance and every 2 years in cases of normal glucose tolerance (evidence level B). All women have to be informed about their (sevenfold increased relative) risk of developing type 2 diabetes (T2DM) at follow-up and possible preventive measures, in particular weight management, healthy diet and maintenance/increase of physical activity. Monitoring of the development of children and recommendations for a healthy lifestyle are necessary for the whole family. Regular obstetric examinations including ultrasound examinations are recommended. Within the framework of neonatal care, neonates of GDM mothers should undergo blood glucose measurements and if necessary appropriate measures should be initiated.

Serum levels of adipokines in gestational diabetes: a systematic review

OBJECTIVE

To determine the difference of serum levels of 10 adipokines (apelin, chemerin, fatty acid-binding protein-4, fibroblast growth factor-21, monocyte chemoattractant protein-1, nesfatin-1, omentin-1, resistin, vaspin, and visfatin) among women with gestational diabetes and healthy pregnant controls.

MATERIALS AND METHODS

Literature search was conducted using the Medline (1966-2018), Scopus (2004-2018), Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2018), Clinicaltrials.gov (2008-2018) and Google Scholar (2004-2018) databases, along with the reference list of the included studies.

RESULTS

Ninety-one studies were included in the present review, with a total number of 11,074 pregnant women. A meta-analysis was not conducted due to the high inter-study heterogeneity. Current evidence suggests that fatty acid-binding protein-4 levels are significantly increased in pregnancies complicated with gestational diabetes, while no association of serum apelin and monocyte chemoattractant protein-1 with the disease can be supported. Data regarding the rest adipokines are conflicting, since the available studies did not unanimously indicate a significant change of their levels in gestational diabetes.

CONCLUSIONS

The findings of the present systematic review suggest the promising role of fatty acid-binding protein-4 in the prediction of gestational diabetes, while inconsistent evidence exists regarding the rest novel adipokines. Future cohorts are needed to assess their predictive efficacy and fully elucidate their contribution in the disease.

Gestational diabetes risk factors and long-term consequences for both mother and offspring: a literature review

INTRODUCTION

Established risk factors for gestational diabetes mellitus (GDM) include ethnicity, obesity, and family history of diabetes. Untreated GDM patients have higher rates of maternal and perinatal morbidity. GDM is an independent risk factor for future longer-term risk of type 2 diabetes mellitus (T2DM), metabolic syndrome, cardiovascular morbidity, malignancies, ophthalmic, psychiatric, and renal disease in the mother. Offspring risk long-term adverse health outcomes, including T2DM, subsequent obesity, impacted neurodevelopmental outcome, increased neuropsychiatric morbidity, and ophthalmic disease.

AREAS COVERED

We critically review data from retrospective, prospective, and meta-analysis studies pertaining to established GDM risk factors, complications during pregnancy and birth (both mother and offspring), and long-term consequences (both mother and offspring).

EXPERT COMMENTARY

Many of the adverse consequences of GDM might be avoided with proper management and treatment. Patients belonging to high-risk ethnic groups, and/or with body mass index ≥ 25 kg/m², and/or known history of diabetes in first-degree relatives may benefit from universal screening and diagnostic criteria proposed by the International Association of Diabetes and Pregnancy Study Group (IADPSG). The IADPSG one-step method has several advantages, including simplicity of execution, greater patient-friendliness, and higher diagnostic accuracy. Additionally, evidence suggests that the recent increased popularity of bariatric surgery will help to decrease GDM rates over next 5 years. Similarly, metformin may be useful for treating and preventing obstetrical complications in confirmed GDM patients.

The participation rate of migrant women in gestational diabetes screening in Austria: a retrospective analysis of 3293 births

Purpose

This study evaluated the extent to which migrant women participate in the mandatory oral glucose tolerance test (OGTT) for gestational diabetes mellitus (GDM) screening in Austria.

Methods

A retrospective data analysis was carried out of births at an obstetrics unit in a university hospital between January 2013 and December 2015. The inclusion criteria were singleton pregnancies, live births, birth weight ≥ 3500, and no preexisting diabetes mellitus. The patient’s extramurally obtained OGTT values and history of GDM were checked. If the mother’s country of birth was not Austria, the woman was classified as a migrant. Three groups were defined: group 1—women with normal OGTT; group 2—women with pathological OGTT; and group 3—women without OGTT or with an incomplete OGTT.

Main outcome measures: Numbers of complete and incomplete OGTTs and rate of women with pathological OGTTs not treated in accordance with the guidelines among mothers born in Austria or migrants. The groups were compared using the t-test, chi-squared test, or Fisher’s exact test.

Results

A total of 3293 births met the inclusion criteria, and 43.52% of all mothers were migrants; 16.8% of all women had pathological OGTT findings. Only 60.1% of the latter received treatment in accordance with the guidelines. The proportion of mothers born in Austria who did not have OGTTs, or only incomplete ones, was 5.4%. In the group of migrant women, the corresponding figure was 10.5% (P < 0.01).

Conclusions

Migrant women have significantly lower rates of participation in GDM screening.

Incidence, risk factors, and pregnancy outcomes of gestational diabetes mellitus using one-step versus two-step diagnostic approaches: A population-based cohort study in Isfahan, Iran

AIMS

To study the incidence, risk factors, and pregnancy outcomes associated with gestational diabetes mellitus (GDM) diagnosed with one-step and two-step screening approaches.

METHODS

1000 pregnant women who were eligible and consented to participate underwent fasting plasma glucose testing at the first prenatal visit (6-14 weeks). The women free from GDM or overt diabetes were screened at 24-28 weeks using the 50-g glucose challenge test (GCT) followed by 100-g, 3-h oral glucose tolerance test (OGTT) (two-step method). Regardless of the GCT result, all women underwent a 75-g, 2-h OGTT within one-week interval (one-step method).

RESULTS

GDM incidence using the one-step and two-step methods was 9.3% (95% CI: 7.4-11.2) and 4.2% (95% CI: 2.9-5.5). GDM significantly increased the risk of macrosomia, gestational hypertension, preeclampsia, and cesarean section and older age and family history of diabetes significantly increased the risk of developing GDM in both approaches. In two-step method, higher pre-pregnancy body mass index and lower physical activity during pregnancy along with higher earlier cesarean section also increased significantly the risk of developing GDM.

CONCLUSIONS

Despite a higher incidence of GDM using the one-step approach, more risk factors for and a stronger effect of GDM on adverse pregnancy outcomes were found when using the two-step approach. Longer follow-up of women with and without GDM may change the results using both approaches.

Effect of maternal glycemia and weight status on offspring birth measures and BMI-z among Chinese population in the first year

To investigate the effects of maternal fasting plasma glucose (FPG) and pre-pregnancy weight status (PPWS) on offspring birth measures and body mass index z-score (BMI-z) in the first year, we conducted a prospective study of 1,096 mother-infant dyads in Guangdong, China, 2014–2015. Multivariate logistic regression was used to test independent/interaction associations of maternal FPG and PPWS with macrosomia/large for gestational age (LGA). Association of PPWS and FPG with offspring BMI-z in the first year was assessed by the linear mixed effects models. For each 1-mmol/L increase in FPG, the risk of macrosomia and LGA was elevated by 2.74 and 2.01 (95% CI: 1.85, 7.60 and 1.54, 5.88), respectively. No main effect of PPWS or interaction association of FPG and PPWS on macrosomia/LGA was observed (P > 0.05). A relation between maternal FPG and PPWS was detected (P < 0.05). Infants of Q5 FPG mothers, those who were born to OWO mothers, had a 0.35 increase in the BMI-z (95% CI: 0.16, 0.55) compared with infants of NW mothers. In conclusion, maternal FPG is positively associated with macrosomia/LGA. Maternal PPWS and FPG considerably interacted for the association with the risk of offspring high BMI-z in the first year.

Family history of diabetes and the risk of gestational diabetes mellitus in Iran: A systematic review and meta-analysis

OBJECTIVE

Gestational diabetes is the most prevalent metabolic disorder being firstly diagnosed during pregnancy. The relationship between the family history of diabetes and the gestational diabetes mellitus (GDM) has been investigated in several primary studies with a number of contradictions in the results. Hence, the purpose of the present study is to determine the relationship between the GDM and the family history of diabetes using the meta-analysis method.

METHOD

All published papers in main national and international databases were systematically searched with some specific keywords to find the related studies between 2000 and 2016. We calculated the odds ratio (OR) with 95% confidence interval (CI) in analysis for each study using a random-effect and Mantel-Haenzel method. We also determined heterogeneity among these 33 articles and their publication bias.

RESULTS

We entered 33 relevant studies of 2516 articles into the meta-analysis process including 2697 women with family history of diabetes mellitus as well as 29134 women without. Of them, 954 and 4372 subjects developed GDM respectively. Combining the results of the primary studies using the meta-analysis method, the overall odds ratio of family history for developing GDM was estimated as of 3.46 (95% CI: 2.80-4.27).

CONCLUSION

This meta-analysis study revealed that the family history of diabetes is an important risk factor for the gestational diabetes mellitus.

[Gestational diabetes mellitus]

Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and offspring. Women detected to have diabetes early in pregnancy receive the diagnosis of overt, non-gestational, diabetes (glucose: fasting > 126 mg/dl, spontaneous > 200 mg/dl or HbA1c > 6.5 % before 20 weeks of gestation). GDM is diagnosed by an oral glucose tolerance test (OGTT) or fasting glucose concentrations (> 92 mg/dl). Screening for undiagnosed type 2 diabetes at the first prenatal visit (Evidence level B) is recommended in women at increased risk using standard diagnostic criteria (high risk: history of GDM or pre-diabetes (impaired fasting glucose or impaired glucose tolerance); malformation, stillbirth, successive abortions or birth weight > 4,500 g in previous pregnancies; obesity, metabolic syndrome, age > 45 years, vascular disease; clinical symptoms of diabetes (e. g. glucosuria)). Performance of the OGTT (120 min; 75 g glucose) may already be indicated in the first trimester in some women but is mandatory between 24 and 28 gestational weeks in all pregnant women with previous non-pathological glucose metabolism (Evidence level B). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study GDM is defined, if fasting venous plasma glucose exceeds 92 mg/dl or 1 h 180 mg/dl or 2 h 153 mg/dl after glucose loading (OGTT; international consensus criteria). In case of one pathological value a strict metabolic control is mandatory. This diagnostic approach was recently also recommended by the WHO. All women should receive nutritional counseling and be instructed in blood glucose self-monitoring and to increase physical activity to moderate intensity levels- if not contraindicated. If blood glucose levels cannot be maintained in the normal range (fasting < 95 mg/dl and 1 h after meals < 140 mg/dl) insulin therapy should be initiated as first choice. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g OGTT (WHO criteria) 6-12 weeks postpartum and every 2 years in case of normal glucose tolerance (Evidence level B). All women have to be instructed about their (sevenfold increased relative) risk of type 2 diabetes at follow-up and possibilities for diabetes prevention, in particular weight management and maintenance/increase of physical activity. Monitoring of the development of the offspring and recommendation of healthy lifestyle of the children and family is recommended.

Maternal 75-g OGTT glucose levels as predictive factors for large-for-gestational age newborns in women with gestational diabetes mellitus

OBJECTIVE

Our goal was to investigate which glucose measurement from the 75-g oral glucose tolerance test (OGTT) has more capability of predicting large for-gestational-age (LGA) newborns of mothers with gestational diabetes mellitus (GDM).

SUBJECTS AND METHODS

The study group consisted of 118 consecutively pregnant women with singleton pregnancy, patients of Outpatients Department of the Endocrinology, Diabetes, and Metabolic Disorders Clinic. All were prospectively screened for GDM between 24th and 28th week of pregnancy and followed to delivery. Outcome measures included: patients' ages, pre-pregnancy BMI, BMI before delivery, FPG, 1 and 2 hour OGTT glucose values, haemoglobin A1c at third trimester, gestational week of delivery, mode of delivery and baby birth weight.

RESULTS

From 118 pregnancies, 78 (66.1%) women were with GDM, and 40 (33.9%) without GDM. There were statistically significant differences (30.7 versus 5.0%, p < 0.01) between LGA newborns from GDM and control group, respectively. Gestation week of delivery and fasting glucose levels were independent predictors for LGA (Beta = 0.58 and Beta = 0.37 respectively, p < 0.01). Areas under the receiver operator characteristic curve (AUC) were compared for the prediction of LGA (0.782 (0.685-0.861) for fasting, 0.719 (0.607-0.815) for 1-hour and 0.51 (0.392-0.626) for 2-hour OGTT plasma glucose levels).

CONCLUSION

Fasting and 1-hour plasma glucose levels from OGTT may predict LGA babies in GDM pregnancies.

Prevalence of gestational diabetes mellitus and associated risk factors in Turkish women: the Trabzon GDM Study

INTRODUCTION

The aim of this study was to investigate the prevalence of gestational diabetes mellitus (GDM) in Turkish pregnant women in the Trabzon Region and further to identify population-specific risk factors for GDM.

MATERIAL AND METHODS

In this prospective cross-sectional survey, universal screening for GDM was performed in 815 pregnant women. Screening was done with a 50-g oral glucose challenge test (GCT) with a 140 mg/dl cut-off point, then a diagnostic 100 g oral glucose tolerance test (OGTT) was performed according to Carpenter and Coustan (CC) criteria.

RESULTS

The GCT was positive in 182 (22.3%) cases. The OGTT was performed on the 182 screen-positive pregnant women. Thirty-five were diagnosed with GDM on the basis of their results for a prevalence of 4.3% (35/815). Of the pregnancies with negative GCT but having high risk factors for GDM (n = 31), 4 were diagnosed with GDM (0.5%). Prevalence of GDM was found to be 4.8% (n = 39) for all pregnant women. Gestational diabetes mellitus was positively associated with advanced maternal age (p < 0.001), prepregnancy body mass index (p < 0.001), cessation of cigarette smoking (p < 0.001), excessive weight gain during pregnancy (p = 0.003), previous history of GDM (p < 0.001), history of selected medical conditions (p = 0.018), family history of diabetes (FHD) (p < 0.001), and existence of at least one high risk factor for GDM (p < 0.001). In multiple logistic regression analysis, independent predictors for GDM were maternal age, cessation of cigarette smoking, increasing prepregnancy body mass index, weight gain of more than 8 kg during pregnancy, GDM history in previous pregnancies and a history of diabetes in first-degree relatives of pregnant women.

CONCLUSIONS

The prevalence of GDM in Trabzon province was found as moderate. Commonly recognized risk factors including older age, prepregnancy obesity, FHD and past history of GDM, are valid for our urban Turkish population. Also, excessive weight gain in pregnancy and cigarette cessation were observed to be nontradional risk factors of GDM. It was concluded that all pregnant women should be screened for GDM if prevalence was not low.

Elevated plasma SPARC levels are associated with insulin resistance, dyslipidemia, and inflammation in gestational diabetes mellitus

Objective

Recent studies suggested that secreted protein acidic and rich in cysteine (SPARC), a novel adipokine, is a key player in the pathology of obesity and type 2 diabetes. We aimed to determine whether concentrations of SPARC were altered in patients with gestational diabetes mellitus (GDM) compared to normal glucose tolerance (NGT) controls and to investigate the relationships between SPARC and metabolic parameters in pregnant women.

Design/Methods

Cross-sectional study of 120 pregnant women with GDM and 60 controls with NGT, in a university hospital setting. Plasma levels of SPARC, adiponectin, fibroblast growth factor 21 (FGF21), insulin and proinsulin were determined by ELISA.

Results

GDM women had higher SPARC and lower adiponectin than NGT subjects; no difference was found in FGF21. SPARC levels were the lowest in subjects in the third tertile of insulin sensitivity index (ISI_OGTT) and correlated positively with pre-pregnant BMI, insulin and 3 h glucose during 100-g OGTT, HOMA-IR, fasting proinsulin, hsCRP and white blood cells count, and negatively with ISI_OGTT, when adjusting for gestational age. Triglyceride (TG), Apolipoprotein A1, apolipoprotein B and lipoprotein (a) correlated with SPARC in partial Pearson correlation. Correlations between SPARC with adiponectin, systolic blood pressure and TG were marginally significant in partial Spearman correlation analysis. In multivariate regression analysis, SPARC was an independent negative indicator of ISI_OGTT.

Conclusions

SPARC levels are correlated significantly with inflammation and may also be correlated with dyslipidemia and represent an independent determinant of insulin resistance in late pregnancy, indicating a potential role of SPARC in the pathophysiology of GDM.

Italian risk factor-based screening for gestational diabetes

There is a debate about whether universal or risk factors-based screening is most appropriate for gestational diabetes diagnosis. The aim of our retrospective study was to compare in our population the universal screening test recommended by the International Association of Diabetes in Pregnancy Study Group (IADPSG) panel and the American Diabetes Association (ADA) versus the selective screening proposed by the United Kingdom National Institute for Health and Clinical Excellence guidelines (NICE) but modified by the Italian National Institute of Health. From May 2010 to October 2011 all consecutive pregnant women were screened for gestational diabetes according to the IADPSG's panel criteria, while all the risk factors for each patient were registered. Of the 1015 pregnant women included in the study, 113 (11%) were diagnosed with gestational diabetes and 26 (23%) of them would not have been identified by the selective screening proposed by the Italian National Institute of Health. However, all the risk factors considered by the selective screening revealed a good predictive role except for maternal age ≥ 35 years (OR: 0.98). In the group without the risk factors considered, it was reported the predictive role for gestational diabetes of prepregnancy BMI and nulliparity. The selective risk factors-based screening proposed by the Italian National Institute of Health has detected 77% of gestational diabetes cases in our population, sparing the oral glucose tolerance test for more than 40% of pregnant women at the same time. More information on the clinical impact of this choice could be obtained by a strict analysis of treatment, perinatal outcome and follow-up of an adequate sample size of "missed" gestational diabetes.

Original research: postpartum testing rates among women with a history of gestational diabetes--systematic review

AIMS

Gestational diabetes mellitus (GDM) is increasing and 30% have persistent postpartum dysglycemia. Reported compliance with recommended postpartum testing ranges 9-95% without a clear explanation for this wide variation. Small and conflicting differences in testing rates are associated with some demographics (race, use of insulin), but system factors likely play a larger role. A systematic literature review was performed to identify system based factors that could explain the broad variation in postpartum GDM testing rates.

METHODS

Original articles reporting postpartum testing rates among women with GDM were identified within PubMed, OVID, EMBASE, and the Cochrane Database of systematic reviews. Articles that did not report rates for the entire GDM cohort were excluded.

RESULTS

54/307 citations met inclusion criteria. The use of proactive patient contact programs increased postpartum testing rates from an average of 33% (range 9-71%) up to 60% (range 14-95%).

CONCLUSIONS

Proactively contacting patients via phone calls, education programs, or postal reminders was associated with higher postpartum testing rates. Rather than working to identifying individual demographic factors, systems based approaches were associated with a larger potential impact, and appear easily generalizable. Clinicians should think beyond individual habits and consider systematic approaches to improving testing rates.

Quantification of excess risk for diabetes for those born in times of hunger, in an entire population of a nation, across a century

Based on a unique dataset comprising all 325,000 Austrian patients that were under pharmaceutical treatment for diabetes during 2006 and 2007, we measured the excess risk of developing diabetes triggered by undernourishment in early life. We studied the percentage of all diabetes patients in the total population specifically for each year of birth, from 1917 to 2007. We found a massive excess risk of diabetes in people born during the times of the three major famines and immediately after, which occurred in Austria in the 20th century: 1918-1919, 1938, and 1946-1947. Depending on the region, there was an up to 40% higher chance of having diabetes when born in 1919-1921, compared with 1918 or 1922, where age-specific typical diabetes ratios are observed. The excess risk for diabetes was practically absent in those provinces of Austria that were less affected by the famines. We show that diabetes rates exhibit nontrivial, age-specific sex differences, and correlate with the economic wealth of the region. Our results might be of relevance for establishing higher awareness in the health system for those born in high-risk years, and underline the importance of ensuring sufficient nutrition in prenatal and early stages of life.

A two-step screening algorithm including fasting plasma glucose measurement and a risk estimation model is an accurate strategy for detecting gestational diabetes mellitus

AIMS/HYPOTHESIS

It is currently not clear how to construct a time- and cost-effective screening strategy for gestational diabetes mellitus (GDM). Thus, we elaborated a simple screening algorithm combining (1) fasting plasma glucose (FPG) measurement; and (2) a multivariable risk estimation model focused on individuals with normal FPG levels to decide if a further OGTT is indicated.

METHODS

A total of 1,336 women were prospectively screened for several risk factors for GDM within a multicentre study conducted in Austria. Of 714 women (53.4%) who developed GDM using recent diagnostic guidelines, 461 were sufficiently screened with FPG. A risk prediction score was finally developed using data from the remaining 253 women with GDM and 622 healthy women. The screening algorithm was validated with a further 258 pregnant women.

RESULTS

A risk estimation model including history of GDM, glycosuria, family history of diabetes, age, preconception dyslipidaemia and ethnic origin, in addition to FPG, was accurate for detecting GDM in participants with normal FPG. Including an FPG pretest, the receiver operating characteristic AUC of the screening algorithm was 0.90 (95% CI 0.88, 0.91). A cut-off value of 0.20 was able to differentiate between low and intermediate risk for GDM with a high sensitivity. Comparable results were seen with the validation cohort. Moreover, we demonstrated an independent association between values derived from the risk estimation and macrosomia in offspring (OR 3.03, 95% CI 1.79, 5.19, p < 0.001).

CONCLUSIONS/INTERPRETATION

This study demonstrates a new concept for accurate but cheap GDM screening. This approach should be further evaluated in different populations to ensure an optimised diagnostic algorithm.

Human breath gas analysis in the screening of gestational diabetes mellitus

BACKGROUND

We present a pilot study on the feasibility of the application and advantages of online, noninvasive breath gas analysis (BGA) by proton transfer reaction quadrupole mass spectrometry for the screening of gestational diabetes mellitus (GDM) in 52 pregnant women by means of an oral glucose tolerance test (OGTT).

SUBJECTS AND METHODS

We collected and identified samples of end-tidal breath gas from patients during OGTT. Time evolution parameters of challenge-responsive volatile organic compounds (VOCs) in human breath gas were estimated. Multivariate analysis of variance and permutation analysis were used to assess feasibility of BGA as a diagnostic tool for GDM.

RESULTS

Standard OGTT diagnosis identified pregnant women as having GDM (n = 8), impaired glucose tolerance (n = 12), and normal glucose tolerance (n = 32); a part of this latter group was further subdivided into a "marginal" group (n = 9) because of a marginal high 1-h or 2-h OGTT value. We observed that OGTT diagnosis (four metabolic groups) could be mapped into breath gas data. The time evolution of oxidation products of glucose and lipids, acetone metabolites, and thiols in breath gas after a glucose challenge was correlated with GDM diagnosis (P = 0.035). Furthermore, basal (fasting) values of dimethyl sulfide and values of methanol in breath gas were inversely correlated with phenotype characteristics such as homeostasis model assessment of insulin resistance index (R = -0.538; P = 0.0002, P(corrected) = 0.0034) and pregestational body mass index (R = -0.433; P = 0.0013, P(corrected) = 0.022).

CONCLUSIONS

Noninvasive BGA in challenge response studies was successfully applied to GDM diagnosis and offered an insight into metabolic pathways involved. We propose a new approach to the identification of diagnosis thresholds for GDM screening.

Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review

BACKGROUND

Gestational diabetes mellitus is a potentially serious condition that affects many pregnancies and its prevalence is increasing. Evidence suggests early detection and treatment improves outcomes, but this is hampered by continued disagreement and inconsistency regarding many aspects of its diagnosis.

METHODS

The Vitamin D and Lifestyle Intervention for Gestational Diabetes Mellitus Prevention (DALI) research programme aims to promote pan-European standards in the detection and diagnosis of gestational diabetes and to develop effective preventive interventions. To provide an overview of the context within which the programme will be conducted and its findings interpreted, systematic searching and narrative synthesis have been used to identify and review the best available European evidence relating to the prevalence of gestational diabetes, current screening practices and barriers to screening.

RESULTS

Prevalence is most often reported as 2-6% of pregnancies. Prevalence may be lower towards the Northern Atlantic seaboard of Europe and higher in the Southern Mediterranean seaboard. Screening practice and policy is inconsistent across Europe, hampered by lack of consensus on testing methods, diagnostic glycaemic thresholds and the value of routine screening. Poor clinician awareness of gestational diabetes, its diagnosis and local clinical guidelines further undermine detection of gestational diabetes.

CONCLUSIONS

Europe-wide agreement on screening approaches and diagnostic standards for gestational diabetes could lead to better detection and treatment, improved outcomes for women and children and a strengthened evidence base. There is an urgent need for well-designed research that can inform decisions on best practice in gestational diabetes mellitus screening and diagnosis.

Glucose absorption in gestational diabetes mellitus during an oral glucose tolerance test

OBJECTIVE

Women with gestational diabetes mellitus (GDM) show reduced insulin sensitivity and markedly elevated glucose excursions. After delivery, GDM mostly reverts to normal glucose tolerance (NGT), although leaving an increased risk of type 2 diabetes. Because gastrointestinal function changes during pregnancy causing vomiting, constipation, or reduced motility, we thought that gut glucose absorption in GDM or pregnancy might be altered to affect circulating glucose excursions.

RESEARCH DESIGN AND METHODS

By undergoing 180-min oral glucose tolerance tests (OGTTs), pregnant women with GDM (GDMpreg; n=15, BMI=32±2 kg/m2, aged 33±1 years) were compared with NGT women (NGTpreg; n=7, BMI=28±1 kg/m2, aged 34±2 years), matching for major anthropometric characteristics (each P>0.2). After delivery (6-7 months later), both groups were studied the same way. We computed and mathematically modeled gut glucose absorption from insulin-mediated glucose disappearance and endogenous glucose production (EGP). Whole-body insulin sensitivity was calculated using the Clamp-like Index.

RESULTS

GDMpreg showed 16-25% higher plasma glucose concentrations (P<0.04) during the final 2 h of OGTT, similar EGP, but lower (P<0.01) insulin sensitivity (2.7±0.2 mg·kg(-1)·min(-1) vs. NGTpreg: 4.5±0.8 mg·kg(-1)·min(-1)). In GDMpreg, gut glucose absorption rates were ≤52% lower from 30 to 120 min (P<0.03 vs. conditions after delivery or NGTpreg). In contrast, glucose absorption rates in NGTpreg were comparable during and after pregnancy. None of the studied women developed diabetes after delivery.

CONCLUSIONS

In GDMpreg, OGTT gut glucose absorption is markedly lower during hyperglycemia, whereas both glycemia and glucose absorption in NGTpreg are comparable between pregnant and postpartum states. Thus, hyperglycemia in GDM does not seem to result from too rapid or increased glucose absorption.

Preliminary report: circulating levels of the adipokine vaspin in gestational diabetes mellitus and preeclampsia

The objective of the study was to investigate serum levels of the insulin-sensitizing adipokine vaspin in patients with gestational diabetes mellitus (GDM) and preeclampsia (PE) as compared with healthy controls of similar gestational age. Vaspin serum levels were quantified by enzyme-linked immunosorbent assay in control (n = 102), GDM (n = 40), and PE (n = 22) subjects. Median maternal vaspin concentrations were not significantly different in GDM, PE, and control subjects. Furthermore, vaspin did not significantly correlate to clinical and biochemical measures of renal function, glucose, and lipid metabolism, as well as inflammation. Circulating vaspin levels are not significantly different between GDM, PE, and control subjects and do not correlate with insulin sensitivity in pregnant subjects.

Gestational diabetes screening after HAPO: has anything changed?

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. It is defined as diabetes that is first recognized during pregnancy. The diagnosis of GDM is important because it impacts maternal health care during and after pregnancy. The American Diabetes Association, American Congress of Obstetrics and Gynecology, the World Health Organization, and the National Diabetes Data Group all have recommendations for screening; however, there is no consensus. The Hyperglycemia and Adverse Pregnancy Outcome Research Cooperative Study Group published their findings that show hyperglycemia has a significant effect on pregnancy outcome. In addition, recent studies showed that treatment of mild hyperglycemia may affect adverse outcomes. However, at this time no new guidelines for screening and diagnosis of gestational diabetes have been published. This article summarizes the current state of screening for gestational diabetes.

Serum fibroblast growth factor 21 levels in gestational diabetes mellitus in relation to insulin resistance and dyslipidemia

Fibroblast growth factor 21 (FGF21) has beneficial effects on glucose homeostasis and insulin sensitivity. In the current study, we investigated serum concentrations of FGF21 in patients with gestational diabetes mellitus (GDM) as compared with healthy pregnant controls matched for gestational age and fasting insulin. Fibroblast growth factor 21 was determined by enzyme-linked immunosorbent assay in control (n = 80) and GDM (n = 40) patients and correlated to clinical and biochemical measures of renal function, glucose and lipid metabolism, as well as inflammation in both groups. Median maternal serum FGF21 concentrations were not significantly different in subjects with GDM (97.5 ng/L) as compared with healthy pregnant controls (102.9 ng/L). Fibroblast growth factor 21 significantly and positively correlated with markers of insulin resistance (increased homeostasis model assessment of insulin resistance, decreased adiponectin) and dyslipidemia (increased triglycerides, decreased high-density lipoprotein cholesterol) in univariate and multivariate analyses. Furthermore, FGF21 serum levels were highest in patients in the third tertile of homeostasis model assessment of insulin resistance. Fibroblast growth factor 21 is independently associated with markers of insulin resistance and an adverse lipid profile but is not dysregulated in GDM if patients are matched with controls for fasting insulin.

Metabolic diseases and associated complications: sex and gender matter!

BACKGROUND

Clinicians and health professionals are increasingly challenged to understand and consider the different health needs of women and men. The increase of gender awareness and the expanding science of gender medicine will affect more and more clinical practice. This review addresses gender-specific aspects in metabolic disorders and related complications, which represent an increasing burden of this century and a great challenge to public health.

DESIGN

There is increasing evidence of gender-related differences in risk factors, clinical manifestation and sequelae of obesity and diabetes and increasing knowledge that prevention, detection and therapy of illness affect men and women differently.

RESULTS

Some gender-specific aspects, especially regarding cardiovascular disease, have been studied in more detail, but for many complications sex-related analyses of the results of both clinical trials and basic science are still missing or disregarded. Impaired glucose and lipid metabolism as well as dysregulation of energy balance and body fat distribution have a great impact on overall health via neuroendocrine changes and inflammatory pathways and deteriorate the course of many diseases with particular harm for women. Metabolic diseases dramatically affect life of men and women from infancy up to old age and are a major challenge for women during pregnancy. Great impact is attached to the intrauterine period and the lifelong implications of fetal programming.

CONCLUSIONS

Initiation of prospective studies on the impact of gender as primary outcome and investigation of gender-related pathophysiological mechanisms of chronic diseases will help to improve patient care and to implement evidence-based gender-specific prevention programs and clinical recommendations in future.

Comparison of National Diabetes Data Group and American Diabetes Association diagnostic criteria for gestational diabetes in their identification of postpartum risk of glucose intolerance

AIMS

Gestational diabetes mellitus (GDM) is associated with adverse obstetrical outcomes and postpartum pre-diabetes/diabetes. As the American Diabetes Association (ADA) criteria for GDM may capture obstetrical risk better than the National Diabetes Data Group (NDDG) criteria, we compared these criteria in their detection of postpartum risk of glucose intolerance.

METHODS

487 Women underwent oral glucose tolerance test in pregnancy and at 3-month postpartum. Participants were stratified into the following 5 groups: normal glucose tolerance (NGT) by both ADA and NDDG; gestational impaired glucose tolerance (GIGT) by ADA only; GIGT by both ADA and NDDG; GDM by ADA only; and GDM by both ADA and NDDG.

RESULTS

The prevalence of postpartum glucose intolerance (pre-diabetes/diabetes) varied across the groups (NGT by both ADA and NDDG: 5.9%; GIGT by ADA only: 14.3%; GIGT by both ADA and NDDG: 10.6%; GDM by ADA only: 21.6%; GDM by both ADA and NDDG: 32.8%; overall p<0.0001). Importantly, however, for predicting postpartum pre-diabetes/diabetes, abnormal antepartum glucose tolerance by NDDG and ADA, respectively, exhibited comparable positive predictive value (26% vs. 24%) and area-under-the-receiver-operating-characteristic-curve (0.67 vs. 0.66, p=0.63).

CONCLUSIONS

Unlike with obstetrical outcomes, NDDG and ADA criteria for GDM are similar in their ability to identify postpartum metabolic risk.

The antepartum glucose values that predict neonatal macrosomia differ from those that predict postpartum prediabetes or diabetes: implications for the diagnostic criteria for gestational diabetes

BACKGROUND/OBJECTIVE

The diagnosis of gestational diabetes mellitus on oral glucose tolerance test (OGTT) is used to identify risk of both neonatal large-for-gestational-age (LGA) and maternal postpartum prediabetes/diabetes. An assumption inherent in this practice, however, is that the glucose values that define gestational diabetes mellitus on the OGTT relate to both of these outcomes in the same way. Thus, to test this assumption, we sought to evaluate the predictive capacity of each glucose value on antepartum OGTT in relation to LGA and postpartum prediabetes/diabetes.

DESIGN/SETTING/PARTICIPANTS

A total of 412 women representing the full spectrum of antepartum glucose tolerance underwent 3-h OGTT in pregnancy, assessment of obstetrical outcome at delivery, and 2-h OGTT at 3 months postpartum.

RESULTS

Of the four glucose values (fasting, 1h, 2 h, 3 h) on antepartum OGTT, only the fasting measure was a significant predictor of LGA [odds ratio (OR) 2.00 per mmol/liter, 95% confidence interval (CI) 1.20-3.34] (P = 0.0076). In contrast, all three postload glucose values were significant predictors of postpartum prediabetes/diabetes (1 h glucose: OR 1.37, 95% CI 1.17-1.61, P < 0.0001; 2 h glucose: OR 1.55, 95% CI 1.32-1.83, P < 0.0001; 3 h glucose: OR 1.30, 95% CI 1.10-1.53, P = 0.002), whereas fasting glucose was not. Furthermore, whereas fasting glucose had the highest area under the receiver operating characteristic curve for predicting LGA (0.62), the 1- and 2-h glucose measures had the highest area under the receiver operating characteristic curve values for postpartum prediabetes/diabetes (0.68 and 0.72, respectively).

CONCLUSIONS

On antepartum OGTT, the fasting glucose value best predicts LGA risk, whereas postload glucose values predict postpartum prediabetes/diabetes. These relationships may have implications for the glycemic thresholds that define obstetrical and metabolic risk.

Serum levels of adipocyte fatty acid binding protein are increased in gestational diabetes mellitus

OBJECTIVE

Adipocyte fatty acid binding protein (AFABP) was recently introduced as a novel adipokine, serum levels of which independently correlate with the development of the metabolic syndrome and cardiovascular disease in humans. In the current study, we investigated serum concentrations of AFABP in patients with gestational diabetes mellitus (GDM) as compared with healthy pregnant controls matched for gestational age and fasting insulin.

DESIGN AND METHODS

AFABP was determined by ELISA in controls (n=80) and GDM patients (n=40) and correlated to clinical and biochemical measures of renal function, glucose and lipid metabolism, as well as inflammation, in both groups.

RESULTS

Median serum AFABP concentrations were significantly elevated in subjects with GDM (22.9 microg/l) as compared with healthy pregnant controls (18.3 microg/l; P<0.05). Furthermore, GDM was independently associated with AFABP concentrations in multiple regression analysis (P<0.05). In addition, markers of adiposity (body mass index, serum leptin), triglycerides and serum creatinine were independently associated with circulating AFABP (P<0.05).

CONCLUSIONS

Maternal AFABP concentrations are significantly increased in GDM. The adipokine might contribute to the increased metabolic and cardiovascular risk of the disease.

Risk assessment does not explain high prevalence of gestational diabetes mellitus in a large group of Sardinian women

BACKGROUND

A very high prevalence (22.3%) of gestational diabetes mellitus (GDM) was recently reported following our study on a large group of Sardinian women. In order to explain such a high prevalence we sought to characterise our obstetric population through the analysis of risk factors and their association with the development of GDM.

METHODS

The prevalence of risk factors and their association with the development of GDM were evaluated in 1103 pregnancies (247 GDM and 856 control women). The association of risk factors with GDM was calculated according to logistic regression. Sensitivity and specificity of risk assessment strategy were also calculated.

RESULTS

None of the risk factors evaluated showed an elevated frequency in our population. The high risk patients were 231 (20.9%). Factors with a stronger association with GDM development were obesity (OR 3.7, 95% CI 2.08-6.8), prior GDM (OR 3.1, 95% CI 1.69-5.69), and family history of Type 2 diabetes (OR 2.6, 95% CI 1.81-3.86). Only patients over 35 years of age were more represented in the GDM group (38.2% vs 22.6% in the non-GDM cases, P < 0.001). Type 2 diabetes in second-degree relatives was equally represented in GDM and non-GDM subjects, while prior poor obstetrical outcomes mostly characterized non-GDM women (17.5% vs 10.6%, P < 0.001). The "average risk" assessment better characterized non-GDM patients (76.8% vs 57.8%, P < 0.001). The logistic regression analysis confirmed that Type 2 diabetes in second-degree relatives, prior poor obstetrical outcomes and the "average risk" definition did not predict the development of GDM.

CONCLUSION

Such a high prevalence of GDM in our population does not seem to be related to the abnormal presence of some known risk factors, and appears in contrast with the prevalence of Type 2 diabetes in Sardinia. Further studies are needed to explain the cause such a high prevalence of GDM in Sardinia. The "average risk" definition is not adequate to predict GDM in our population.