Diabetes and perinatal mortality in twin pregnancies

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.

Temporal trends in the birth rates and perinatal mortality of twins: A population-based study in China

OBJECTIVE

Until now, little was known about the epidemiological characteristics of twins in China due to a lack of reliable national data. In this study, we aimed to analyze temporal trends and perinatal mortality of twins from China.

METHODS

Data on twins between 2007 and 2014 were obtained from the China National Population-Based Birth Defects Surveillance System. Twin and singleton deliveries after at least 28 weeks of gestation were recruited and followed until postnatal day 42. Twinning rates were defined as the number of twin individuals per 1000 births(stillbirths and live births). The Weinberg's differential method was utilized to estimate the number of monozygotic and dizygotic twins.

RESULTS

During 2007-2014, the twinning rate increased by 32.3% from 16.4 to 21.7 per 1000 total births with an average of 18.8‰. Among twins, both the perinatal mortality rate (26.1 per 1000 total births) and neonatal death rate (15.7 per 1000 live births) presented a downward tendency but remained at a high level. Large urban-rural and geographic disparities were identified in twinning rates, in perinatal and neonatal mortality, and in their temporal trends.

CONCLUSIONS

The upward trend of twinning rates in China paired with the relatively high rates of perinatal and neonatal mortality among twins highlights the need for improved perinatal care in the light of socio-demographic differences.

Polysaccharide IV from Lycium barbarum L. Improves Lipid Profiles of Gestational Diabetes Mellitus of Pregnancy by Upregulating ABCA1 and Downregulating Sterol Regulatory Element-Binding Transcription 1 via miR-33

Lycium barbarum L. (LBL) has beneficial effects on gestational diabetes mellitus (GDM) but the related mechanism remains unclear. Polysaccharides of LBL (LBLP) are the main bioactive components of LBL. miR-33, ATP-binding cassette transporter A1 (ABCA1) and sterol regulatory element-binding transcription 1 (SREBF1) affect lipid profiles, which are associated with GDM risk. LBLP may exert protective against GDM by affecting these molecules. Four LBLP fractions: LBLP-I, LBLP-II, LBLP-III, and LBLP-IV were isolated from LBL and further purified by using DEAE-Sephadex column. The effects of purified each fraction on pancreatic beta cells were comparatively evaluated. A total of 158 GDM patients were recruited and randomly divided into LBL group (LG) and placebo group (CG). miR-33 levels, lipid profiles, insulin resistance and secretory functions were measured. The association between serum miR-33 levels and lipid profiles were evaluated by using Spearman's rank-order correlation test. After 4-week therapy, LBL reduced miR-33 level, insulin resistance and increased insulin secretion of GDM patients. LBL increased the levels of ABCA1, high-density lipoprotein cholesterol (HDL-C) and reduced miR-33, SREBF1, low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), and malondialdehyde. Homeostatic model assessment of β-cell function and insulin resistance was lower in LG than in CG, whereas homeostatic model assessment of β-cell function and insulin secretory function was higher in LG than in CG. There was a strong positive association between miR-33 level and TG, or TC and or LDL-C, and a strong negative association between miR-33 level and HDL-C. The levels of miR-33 had negative relation with ABCA1 and positive relation with SREBF1. ABCA1 has negative relation with TG, TC, and LDL-C and positive relation with HDL-C. Inversely, SREBF1 had positive relation with TG, TC, and LDL-C and negative relation with HDL-C. The main bioactive compound LBLP-IV of LBL increased insulin secretion of beta cells and the levels of ABCA1, and reduced miR-33 levels and SREBF1 in beta cells. However, LBLP-IV could not change the levels of these molecules anymore when miR-33 was overexpressed or silenced. LBLP-IV had the similar effects with LBL on beta cells while other components had no such effects. Thus, LBLP-IV from LBL improves lipid profiles by upregulating ABCA1 and downregulating SREBF1 via miR-33.

Outcomes of twin pregnancies complicated by gestational diabetes: a meta-analysis of observational studies

OBJECTIVE

Gestational diabetes mellitus (GDM) in singleton pregnancy is associated with large for gestational age neonates and adverse perinatal outcomes; however, the impact of GDM in twin pregnancy is unclear. Thus, the aim of this study is to assess the perinatal outcomes of twin pregnancies complicated by GDM by performing a meta-analysis of observational studies.

STUDY DESIGN

Studies investigating GDM in twin pregnancy were identified through an online search of three databases: Medline, Embase and Web of Science. Selection criteria comprised full paper observational studies (retrospective or prospective) published in English that examined GDM in twin pregnancy compared with non-GDM twin pregnancy and reported on birth weight and/or adverse perinatal outcomes. Random-effects models with inverse-variance weighting were used to calculate standardized mean differences and unadjusted odds ratios. Sensitivity analyses were carried out to determine the impact of possible maternal confounders (body mass index and age) and GDM diagnostic criteria on perinatal outcomes.

RESULTS

Thirteen observational studies were included. GDM twins were born at the same gestation as non-GDM twins, with marginally lower birth weight. There was no difference in the incidence of large or small for gestational age neonates. Although there was no correlation between GDM in twin pregnancy and respiratory distress, neonatal hypoglycemic or low Apgar score, GDM twins had a higher rate of neonatal intensive care unit admission (OR 1.49; 95% confidence interval: 1.10, 2.02; P<0.01).

CONCLUSION

Identification and subsequent treatment of GDM in twin pregnancy demonstrates a similar risk of adverse perinatal outcomes compared with non-GDM twin pregnancies.

Pregestational diabetes is associated with adverse outcomes in twin pregnancies: a regional register-based study

INTRODUCTION

The incidence of pregnancies complicated by twinning and diabetes is increasing in the UK. This is a worrying trend as both diabetes and twin gestations are associated with a high risk of adverse pregnancy outcomes. The few studies that have specifically addressed how twinning and pregestational diabetes in the same pregnancy may affect outcome have reported conflicting results.

MATERIAL AND METHODS

We analyzed data on 27 women with a twin pregnancy and pregestational diabetes (54 babies) and 6407 women with a twin pregnancy without diabetes (12 814 babies) from the Northern Survey of Twin and Multiple Pregnancy during 1998-2010. A composite adverse pregnancy outcome (comprising fetal loss before 24 weeks, termination of pregnancy, stillbirth, infant death or any major congenital anomaly), extended perinatal mortality (stillbirths and neonatal deaths) and major congenital anomaly were the main outcome measures. Adjusted rate ratios were estimated using generalized estimating equations for Poisson regression controlling for potential confounders.

RESULTS

Mothers with twin pregnancies with diabetes were older (p = 0.001) and had higher body mass indices (p < 0.0001) than those without diabetes. Their twins were more likely to be delivered earlier (p = 0.026), be delivered by cesarean section (80.4% vs. 49.7%; p < 0.0001), be large-for-gestational-age (p < 0.0001) and require admission to a special care baby unit (p < 0.0001). Pregestational diabetes was associated with significantly increased rates of the composite adverse outcome and major congenital anomalies in twins (adjusted rate ratios 2.66, 95% confidence interval 1.14-6.20 and adjusted rate ratios 3.51, 95% confidence interval 1.31-9.40, respectively).

CONCLUSION

Maternal pregestational diabetes in twin pregnancies is associated with a significantly increased risk of an adverse pregnancy outcome.

Maternal and neonatal outcomes in multiple pregnancy: A multicentre study in the Beijing population

Objective

To compare the adverse maternal and neonatal outcomes of multiple pregnancy and singleton pregnancy from multiple medical centers in Beijing.

Methods

Data concerning maternal and neonatal adverse outcomes in multiple and singleton pregnancies were collected from 15 hospitals in Beijing by a systemic cluster sampling survey conducted from 20 June to 30 November 2013. The SPSS software (version 20.0) was used for data analysis. The χ² test was used for statistical analyses.

Results

The rate of caesarean deliveries was much higher in women with multiple pregnancies (85.8%) than that in women with singleton pregnancies (42.6%, χ² = 190.8, P < 0.001). The incidences of anemia (χ² = 40.023, P < 0.001), preterm labor (χ² = 1021.172, P < 0.001), gestational diabetes mellitus (χ² = 9.311, P < 0.01), hypertensive disorders (χ² = 122.708, P < 0.001) and post-partum hemorrhage (χ² = 48.550, P < 0.001) was significantly increased with multiple pregnancy. In addition, multiple pregnancy was associated with a significantly higher rate of small-for-gestational-age infants (χ² = 92.602, P < 0.001), low birth weight (χ² = 1141.713, P < 0.001), and neonatal intensive care unit (NICU) admission (χ² = 340.129, P < 0.001).

Conclusions

Multiple pregnancy is a significant risk factor for adverse maternal and neonatal outcomes in Beijing. Improving obstetric care for multiple pregnancy, particularly in reducing preterm labor, is required to reduce the risk to mothers and infants.

Comparison of maternal morbidity and medical costs during pregnancy and delivery between patients with gestational diabetes and patients with pre-existing diabetes

AIMS

To evaluate the effects of gestational diabetes and pre-existing diabetes on maternal morbidity and medical costs, using data from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service.

METHODS

Delivery cases in 2010, 2011 and 2012 (459 842, 442 225 and 380 431 deliveries) were extracted from the Health Insurance Review and Assessment Service database. The complications and medical costs were compared among the following three pregnancy groups: normal, gestational diabetes and pre-existing diabetes.

RESULTS

Although, the rates of pre-existing diabetes did not fluctuate (2.5, 2.4 and 2.7%) throughout the study, the rate of gestational diabetes steadily increased (4.6, 6.2 and 8.0%). Furthermore, the rates of pre-existing diabetes and gestational diabetes increased in conjunction with maternal age, pre-existing hypertension and cases of multiple pregnancy. The risk of pregnancy-induced hypertension, urinary tract infections, premature delivery, liver disease and chronic renal disease were greater in the gestational diabetes and pre-existing diabetes groups than in the normal group. The risk of venous thromboembolism, antepartum haemorrhage, shoulder dystocia and placenta disorder were greater in the pre-existing diabetes group, but not the gestational diabetes group, compared with the normal group. The medical costs associated with delivery, the costs during pregnancy and the number of in-hospital days for the subjects in the pre-existing diabetes group were the highest among the three groups.

CONCLUSIONS

The study showed that the rates of pre-existing diabetes and gestational diabetes increased with maternal age at pregnancy and were associated with increases in medical costs and pregnancy-related complications.

Is gestational hypertension protective against perinatal mortality in twin pregnancies?

BACKGROUND

Pregnancy-induced or gestational hypertension is a common pregnancy complication. Paradoxically, gestational hypertension has been associated with a protective effect against perinatal mortality in twin pregnancies in analytic models (logistic regression) without accounting for survival time. Whether this effect is real remains uncertain. This study aimed to validate the impact of gestational hypertension on perinatal mortality in twin pregnancies using a survival analysis approach.

METHODS

This was a retrospective cohort study of 278,821 twin pregnancies, using the U.S. 1995-2000 matched multiple birth dataset (the largest dataset available for multiple births). Cox proportional hazard models were applied to estimate the adjusted hazard ratios (aHR) of perinatal death (stillbirth and neonatal death) comparing gestational hypertensive vs. non-hypertensive pregnancies controlling for maternal characteristics and twin cluster-level dependence.

RESULTS

Comparing births in gestational hypertensive vs. non-hypertensive twin pregnancies, perinatal mortality rates were significantly lower (1.20% vs. 3.38%), so were neonatal mortality (0.72% vs. 2.30%) and stillbirth (0.48% vs. 1.10%) rates. The aHRs (95% confidence intervals) were 0.34 (0.31-0.38) for perinatal death, 0.31 (0.27-0.34) for neonatal death, and 0.45 (0.38-0.53) for stillbirth, respectively. The protective effect of gestational hypertension against perinatal death became weaker over advancing gestational age; the aHRs in very preterm (<32 weeks), mild preterm (32-36 weeks) and term (37+ weeks) births were 0.29, 0.48 and 0.76, respectively. The largest risk reductions in neonatal mortality were observed for infections and immaturity-related conditions.

CONCLUSIONS

Gestational hypertension appears to be beneficial for fetal survival in twin pregnancies, especially in those ending more prematurely or for deaths due to infections and immaturity-related conditions. Prospective studies are required to rule out the possibility of unmeasured confounders.