Gestational diabetes mellitus diagnosed at 24 to 28 weeks of gestation in older and obese Women: Is it too late?

The effects of gestational diabetes mellitus on fetal growth: is it different for low-risk and medium-high-risk pregnant women?

BACKGROUND

It has been suggested that gestational diabetes mellitus (GDM) alters the growth trajectory of a fetus and increases the risk of abnormal birth weight. In spite of this, there is still a significant debate regarding the mode and optimal timing of diagnosing this condition. Our aim was to determine fetal growth velocity and birth biometry in pregnant women with GDM at varying risk levels.

METHODS

We conducted a cohort study involving 1023 pregnant women at a maternity hospital in Ma'anshan, China. All women completed an oral glucose tolerance test at 24-28 weeks' gestation. We measured fetal head circumference (HC), femoral length (FL), abdominal circumference (AC), biparietal diameter (BPD), and estimate fetal weight (EFW) by ultrasound at 17, 24, 31, and 35 weeks' gestation, respectively.

RESULTS

Overall, 5115 ultrasound scans were performed. Among both low-risk and medium-high-risk pregnant women at 17-24 weeks' gestation, GDM exposure was associated with an increase in fetal growth velocity. Neonates born to women with GDM at medium-high risk had significantly larger birth weights than those born to women without GDM, while this was not observed in women at low risk.

CONCLUSION

In medium-high-risk pregnant women, exposure to GDM has a greater effect on the fetus, leading to abnormal fetal growth velocity that lasts beyond week 24. It is evident from our results that the effects of GDM on fetal growth differ between medium-high-risk pregnant women and low-risk pregnant women, and therefore a different screening program based on the risk factor for GDM is warranted.

Fetal size monitoring in women with gestational diabetes and normal glucose tolerance

AIMS

To monitor fetal size and identify predictors for birthweight in women with gestational diabetes (GDM) and normal glucose tolerance (NGT).

METHODS

Cohort study of 1843 women universally screened for GDM, with routine ultrasounds each trimester. Women with GDM and NGT were categorized in subgroups by birthweight centile.

RESULTS

Of the total cohort, 231 (12.5%) women were diagnosed with GDM. Fetal size, incidence of large-for-gestational age (LGA: 12.3% of GDM vs. 12.9% of NGT, p = 0.822) and small-for-gestational age (SGA) neonates (4.8% of GDM vs. 5.1% of NGT, p = 0.886) were similar between GDM and NGT. GDM women with LGA neonates were more insulin resistant at baseline and had more often estimated fetal weight (EFW) ≥ P90 on the 28-33 weeks ultrasound (p = 0.033) than those with AGA (appropriate-for-gestational age) neonates. Compared to NGT women with AGA neonates, those with LGA neonates were more often obese and multiparous, had higher fasting glycemia, a worse lipid profile, and higher insulin resistance between 24 -28 weeks, with more often excessive gestational weight gain. On the 28-33 weeks ultrasound, abdominal circumference ≥ P95 had a high positive predictive value for LGA neonates in GDM (100%), whereas, in both GDM and NGT, EFW ≥ P90 and ≤ P10 had a high negative predictive value for LGA and SGA neonates (> 88%), respectively.

CONCLUSIONS

There were no differences in fetal size throughout pregnancy nor in LGA incidence between GDM and NGT women. EFW centile at 28-33 weeks correlated well with birthweight. This indicates that GDM treatment is effective and targeted ultrasound follow-up is useful. TRIAL REGISTRATION CLINICALTRIALS.GOV: NCT02036619. Registration date: January 15, 2014. https://clinicaltrials.gov/ct2/show/NCT02036619 .

Fetal abdominal obesity in women with one value abnormality on diagnostic test for gestational diabetes mellitus

Previous studies have shown that fetal abdominal obesity (FAO) was already observed at the time of gestational diabetes mellitus (GDM) diagnosis and persisted until delivery despite management in older and/or obese women. In this study, we investigated whether fetuses of women with milder hyperglycemia than GDM have accelerated abdominal growth, leading to adverse pregnancy outcomes. We retrospectively reviewed the medical records of 7,569 singleton pregnant women who were universally screened using a 50-g glucose challenge test (GCT) and underwent a 3-h 100-g oral glucose tolerance test (OGTT) if GCT result was ≥140mg/dL. GDM, one value abnormality (OVA), and normal glucose tolerance (NGT, NGT1: GCT negative, NGT2: GCT positive & OGTT negative) were diagnosed using Carpenter-Coustan criteria. With fetal biometry data measured simultaneously with 50-g GCT, relative fetal abdominal overgrowth was investigated by assessing the fetal abdominal overgrowth ratios (FAORs) of the ultrasonographically estimated gestational age (GA) of abdominal circumference(AC) per actual GA by the last menstruation period(LMP), biparietal diameter(BPD) or femur length(FL), respectively. FAO was defined as FAOR ≥90th percentile The FAORs of GA-AC/GA-LMP and GA-AC/GA-BPD were significantly higher in OVA subjects compared to NGT subjects but not in NGT2 subjects. Although the frequency of FAO in OVA (12.1%) was between that of NGT (9.6%) and GDM (18.3%) without statistically significant difference, the prevalence of large for gestational age at birth and primary cesarean delivery rates were significantly higher in OVA (9.8% and 29.7%) than in NGT (5.1% and 21.5%, p<0.05). Particularly, among OVA subjects with FAO, the prevalence (33.3% and 66.7%) was significantly higher than in those without FAO (9.7% and 24.2%, p<0.05). The degree of fetal abdominal growth acceleration in OVA subjects was intermediate between that of NGT and GDM subjects. OVA subjects with FAO at the time of GDM diagnosis were strongly associated with adverse pregnancy outcomes.

Serum Vaspin Levels in Gestational Diabetes Mellitus: A Meta-Analysis

The objective of this study was to evaluate the potential relationship between serum vaspin levels and gestational diabetes mellitus (GDM). The PubMed, EBSCO, Web of Science, the Cochrane Library, and the China National Knowledge Infrastructure (CNKI) database were searched for articles published before December 2022. The publication language was restricted to English and Chinese. A meta-analysis was conducted by combining all studies that met the inclusion and exclusion criteria. Twenty-two studies (1990 women with GDM and 1597 pregnant women without GDM) were ultimately included in this meta-analysis. The meta-analysis showed that the serum vaspin levels are significantly higher in GDM compared with the controls (standardized mean difference: 0.720, 95% confidence interval: 0.440-1.000, Z = 5.041, P < 0.001). Subgroup analyses by stage of pregnancy and body mass index showed results similar to the overall outcome. No publication bias was identified, and the sensitivity analysis confirmed the robustness of the final result. Our results show that the serum vaspin levels are significantly higher in GDM. These findings suggest that high vaspin concentration is closely related to GDM and the serum vaspin levels might be a potential biomarker to indicate risk of GDM, more randomized control trials comparing the expression levels of vaspin between early and standard diagnosis of GDM are needed to strengthen our findings.

Fetal abdominal obesity and the ensuing adverse perinatal outcomes in older obese pregnant women with or without obesity and with normal glucose tolerance

To investigate whether the increased risk of fetal abdominal obesity (FAO) is present in the older (≥ 35 years) and/or obese (≥ body mass index 25 kg/m2) women with normal glucose tolerance, we reviewed medical record of 6721 singleton pregnancy. At 24-28 gestational weeks (GW), fetal abdominal overgrowth was assessed by the fetal abdominal overgrowth ratios (FAORs) of the ultrasonographically estimated gestational age (GA) of abdominal circumference per actual GA by the last menstruation period, estimated GA of biparietal diameter or femur length, respectively. FAO was defined as FAOR ≥ 90th percentile. Compared to young and non-obese women, older women showed significantly higher FAORs irrespective of obesity and the prevalence of FAO in older and non-obese women was significantly higher (11.8% vs. 8.6%, p < 0.05). The odds ratio for large for gestational age at birth were 3.06(1.96-4.77, p < 0.005), 1.47(1.16-1.86, p < 0.005) and 2.82(1.64-4.84, p < 0.005) in young and obese, older and non-obese, and older and obese women, respectively. The odds ratio for primary cesarean delivery in older and non-obese women was 1.33 (1.18-1.51, p < 0.005). An increased risk of FAO at 24-28 GW and subsequent adverse perinatal outcomes have been observed in the older women with or without obesity, compared to younger and non-obese women, despite normal glucose tolerance.

Circulating lncRNAs NONHSAT054669.2 and ENST00000525337 can be used as early biomarkers of gestational diabetes mellitus

Early diagnosis can help prevent and reduce the adverse effects of gestational diabetes mellitus (GDM). This study intended to investigate key circulating long non-coding RNAs (lncRNAs) as novel biomarkers for diagnosis of GDM at the early stages. First, lncRNA microarray analysis was conducted for plasma samples of GDM women before delivery and 48 h after delivery. The expression of differentially expressed lncRNAs in clinical samples at different trimesters was randomly validated by quantitative polymerase chain reaction (PCR). Moreover, the correlation between lncRNA expression and oral glucose tolerance test (OGTT) level in GDM women during the second trimester was analyzed, followed by evaluating the diagnostic value of key lncRNAs during different trimesters using receiver operating characteristic (ROC) curve. Higher NONHSAT054669.2 expression and lower ENST00000525337 expression were revealed in GDM women before delivery relative to 48 h after delivery (P < 0.05). The expression of NONHSAT054669.2 and ENST00000525337 in GDM women during the first and second trimesters was dramatically higher than pregnant women (P < 0.05) with normal glucose tolerance (NGT). During the second trimester, NONHSAT054669.2 expression was positively related to OGTT level at 1 h (r = 0.41455, P < 0.001). Furthermore, ROC curve analysis revealed that ENST00000525337 alone, NONHSAT054669.2 alone, and their combination had high diagnostic value for GDM during the first (area under the ROC curve (AUC) = 0.979, 0.956, and 0.984, respectively) and second (AUC = 0.829, 0.809, and 0.838, respectively) trimesters (all P < 0.001). The plasma level of NONHSAT054669.2 and ENST00000525337 may be applied as novel diagnostic biomarkers for early diagnosis of GDM.

The role of 25(OH)D3 and circRNAs in early diagnosis of gestational diabetes mellitus

OBJECTIVE

To explore the relationship between 25(OH)D3 and circular RNAs (circRNAs) in the early diagnosis of gestational diabetes mellitus (GDM) and to screen for biological markers for early prediction of GDM.

METHODS

A cohort study was conducted using samples and data collected from pregnant women registered at the Li Huili hospital in China between April 2018 and January 2020. Four circRNAs (hsa_circ_0003218, hsa_circ_0002968, hsa_circ_0007430, and hsa_circ_0006260) were selected as potential biomarkers, and quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) was used to measure their concentration in the serum and to analyze their correlation with 25(OH)D3. The Pearson correlation test was used to assess the correlation between the 25(OH)D3, circRNAs, and various clinical variables. The area under the receiver operating characteristic (ROC) curve was used to assess the diagnostic value of circRNAs and 25(OH)D3 in the early stage of pregnancy.

RESULTS

Weight, body mass index (BMI), triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and 25(OH)D3 were found to be risk factors for GDM. The level of 25(OH)D3 correlated significantly with HDL-C with a correlation coefficient of 0.298 (p < 0.05). The expression of hsa_circ_0003218 was significantly downregulated in the GDM group (p < 0.05). Hsa_circ_0002968, hsa_circ_0007430, and hsa_circ_0006260 did not show any differential expression between the two groups (p > 0.05). Furthermore, hsa_circ_0003218 level correlated significantly with 25(OH)D3 and the correlation coefficient was 0.357 (p < 0.05). The AUC of hsa_circ_0003218 combined with 25(OH)D3 was 0.789 ([0.700-0.877], p < 0.001), with sensitivity and specificity of 63.04% and 80.65%, respectively.

CONCLUSIONS

Hsa_circ_0003218 and 25(OH)D3 may jointly participate in the metabolic process of GDM. Thus, the combination of 25(OH)D3 and hsa_circ_0003218 represents a potential biomarker for the prediction of GDM in the early stages of pregnancy.

Metabonomics fingerprint of volatile organic compounds in serum and urine of pregnant women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is a metabolic disease with an increasing annual incidence rate. Our previous observational study found that pregnant women with GDM had mild cognitive decline.

AIM

To analyze the changes in metabonomics in pregnant women with GDM and explore the mechanism of cognitive function decline.

METHODS

Thirty GDM patients and 30 healthy pregnant women were analyzed. Solid-phase microextraction gas chromatography/mass spectrometry was used to detect organic matter in plasma and urine samples. Statistical analyses were conducted using principal component analysis and partial least squares discriminant analysis.

RESULTS

Differential volatile metabolites in the serum of pregnant women with GDM included hexanal, 2-octen-1-ol, and 2-propanol. Differential volatile metabolites in the urine of these women included benzene, cyclohexanone, 1-hexanol, and phenol. Among the differential metabolites, the conversion of 2-propanol to acetone may further produce methylglyoxal. Therefore, 2-propanol may be a potential marker for serum methylglyoxal.

CONCLUSION

2-propanol may be a potential volatile marker to evaluate cognitive impairment in pregnant women with GDM.

The association between second trimester ultrasound fetal biometrics and gestational diabetes

OBJECTIVE

Gestational diabetes mellitus (GDM) is the most common metabolic complication of pregnancy. The incidence of GDM is increasing worldwide and 5-25% of pregnancies are diagnosed with GDM depending on screening strategies and diagnostic criteria. GDM may lead to obstetric complications and increases the risk of adult metabolic disease in the offspring. Timely identification of GDM allows for regulation of maternal glucose levels which may reduce the obstetric complications considerably. The aim of this study is to investigate the association between second trimester ultrasound biometrics and GDM.

STUDY DESIGN

This is a retrospective cohort study including 2697 singleton pregnancies attending second trimester ultrasound scan at 20 + 0 to 20 + 6 weeks' gestation and giving birth at Aalborg University Hospital in the year 2020. Ultrasound measurements included head circumference (HC), abdominal circumference (AC), femur length (FL) and estimated fetal weight (EFW) by Hadlock's formula. Women with pregestational diabetes were excluded. GDM screening was performed on indication using oral-glucose-tolerance-test (OGTT) including 75 g glucose and a 2-hour serum glucose value ≥ 9 mmol/L was considered diagnostic. The association between fetal biometrics and GDM was investigated by logistic regression.

RESULTS

A total of 174 (6.5 %) were diagnosed with GDM. The incidence of GDM in pregnancies with biometrics above the 90th centile was; FL: 10.5 %, HC: 8.8 %, AC: 7.6 %, EFW: 9.3 %. Fetal biometrics above the 90th centile was significantly associated with GDM; OR_FL = 2.07, p = 0.001; OR_HC = 1.89, p = 0.001; OR_AC = 1.63, p = 0.033; OR_EFW = 1.64, p = 0.036. This association remained significant for HC and FL when adjusted for maternal obesity (Body Mass Index ≥ 27): OR_HC(adj)=1.56, p = 0.019; OR_FL(adj) = 1.57, p = 0.049.

CONCLUSION

At the second trimester scan, fetal biometrics above the 90th centile increase the risk of GDM. In pregnancies that are later diagnosed with GDM fetal growth is increased already at the second trimester scan. Such knowledge underlines the importance of early identification of GDM.

Sex-dependent influence of maternal predictors on fetal anthropometry in pregnancies with gestational diabetes mellitus

Background

Third trimester fetal anthropometric parameters are known to predict neonatal complications. A better understanding of predictors of adverse fetal parameters might help to personalize the use and frequency of fetal ultrasound. The objectives of this study were:

(a) to evaluate the utility of maternal sociodemographic, anthropometric and metabolic predictors to predict 3^rd trimester fetal anthropometric parameters in women with gestational diabetes mellitus (GDM),

(b) to assess whether the impact of these maternal predictors is fetal sex-dependent, and

(c) to provide a risk stratification for markers of fetal overgrowth (fetal weight centile (FWC) and fetal abdominal circumference centile (FACC) depending on prepregnancy BMI and gestational weight gain (GWG) until the 1^st GDM visit.

Methods

This prospective study included 189 women with GDM. Maternal predictors were age, ethnicity, prepregnancy BMI, GWG and excessive weight gain until the 1^st GDM visit, fasting, 1-hour and 2-hour blood glucose oral glucose tolerance test values, HbA1c at the 1^st visit and medical treatment requirement. Fetal outcomes included FWC, FWC >90% and <10%, FACC, FACC >90% and <10%, at 29 0/7 to 35 6/7 weeks of gestational age. We performed univariate and multivariate regression analyses and probability analyses.

Results

In multivariate analyses, prepregnancy BMI was associated with FWC, FWC > 90% and FACC. GWG until the 1^st GDM visit was associated with FWC, FACC and FACC > 90% (all p ≤ 0.045). Other maternal parameters were not significantly associated with fetal anthropometry in multivariate analyses (all p ≥ 0.054). In female fetuses, only GWG was associated with FACC (p= 0.044). However, in male fetuses, prepregnancy BMI was associated with FWC, FWC > 90% and FACC and GWG with FWC in multivariate analyses (all p ≤ 0.030). In women with a prepregnancy BMI of ≥ 25 kg/m² and a GWG until the 1^st GDM visit ≥ 10.3 kg (mean GWG), the risk for FWC > 90% and FACC > 90% was 5.3 and 4 times higher than in their counterparts.

Conclusions

A personalized fetal ultrasound surveillance guided by fetal sex, prepregnancy BMI and GWG may be beneficial in reducing adverse fetal and neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04767-z.

Circulating exosomal hsa_circRNA_0039480 is highly expressed in gestational diabetes mellitus and may be served as a biomarker for early diagnosis of GDM

Background

Gestational diabetes mellitus (GDM) seriously affects the health of mothers and babies, and there are still no effective early diagnostic markers. Therefore, it is necessary to find diagnostic biomarkers for screening GDM in early pregnancy. Circular RNA (circRNA) is more stable than linear RNA, and can be encapsulated in exosomes and participate in the pathological process of various diseases, which makes it a better candidate biomarker for various diseases. In this study, we attempted to identify the exosomal circRNA biomarkers for detecting early GDM.

Methods

We performed microarray analysis to compare the plasma exosomal circRNA expression profiles of three GDM patients 48 h before and 48 h after delivery. The repeatability of the expression of circRNAs were randomly validated by RT-PCR analysis. Pearson correlation analysis was applied to evaluate the correlation between circRNAs and OGTT level. ROC curve was established to assess the diagnostic value of circRNAs for GDM at different stages.

Results

Plasma exosomal hsa_circRNA_0039480 and hsa_circRNA_0026497 were highly expressed in GDM patients before delivery (P < 0.05). The hsa_circRNA_0039480 expression was higher for GDM group than NGT group at different stages, and was also positively correlated with OGTT during the second trimester (P < 0.05). The expression of hsa_circRNA_0026497 was higher for GDM group during the third, and second trimesters. And there was a strong correlation between two circRNAs in GDM patients during the first-trimester (r = 0.496, P = 0.014). Hsa_circRNA_0039480 showed significant diagnostic value in the first, second, and third trimesters of pregnancy (AUC = 0.704, P = 0.005; AUC = 0.898, P < 0.001 and AUC = 0.698, P = 0.001, respectively). Notably, the combination of hsa_circRNA_0039480 and hsa_circRNA_0026497 exhibited promising discriminative effect on GDM in the first trimesters (AUC = 0.754, P < 0.001).

Conclusion

Plasma exosomal hsa_cirRNA_0039480 is highly expressed in GDM patients at different stages and may be served as a candidate biomarker for early detection of GDM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-03195-5.

Fetal abdominal overgrowth is already present at 20-24 gestational weeks prior to diagnosis of gestational diabetes mellitus

Fetal abdominal obesity (FAO) was detected at the time of gestational diabetes mellitus (GDM) diagnosis at 24–28 gestational weeks (GW) in older (≥ 35 years) and/or obese (≥ body mass index 25 kg/m²) women and persisted until delivery. We investigated whether FAO is already present at 20–24 GW. Medical records of 7820 singleton pregnancy including 384 GDM were reviewed. Fetal abdominal overgrowth was assessed by the fetal abdominal overgrowth ratios (FAORs) of the ultrasonographically estimated gestational age (GA) of abdominal circumference per actual GA by the last menstruation period, biparietal diameter or femur length, respectively. FAO was defined as FAOR ≥ 90th percentile. FAORs measured at 20–24 GW in older and/or obese but not in young and non-obese GDM subjects were significantly higher than those in NGT subjects. Relative to NGT subjects without FAO at 20–24 GW, odds ratios for exhibiting FAO at GDM diagnosis and large for gestational age in GDM with FAO at 20–24 GW were 10.15 and 5.57, and their primary cesarean delivery rate was significantly higher than those in GDM without FAO (44% vs. 29%). Earlier diagnosis and active interventions of GDM well before 20–24 GW might be necessary to prevent FAO in the older and/or obese women.

Glycated albumin as a biomarker for diagnosis of diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Glycated albumin (GA), the non-enzymatic glycation product of albumin in plasma, became a glycemic marker in the beginning of the 21st century. The assay is not affected by hemoglobin levels and reflects the glycemic status over a shorter period as compared to HbA1c measurements. Thus, GA may contributes as an intermediate glucose index in the current diabetes mellitus (DM) diagnostic system.

AIM

To search and summarize the available data on glycated albumin measurements required for the diagnosis of diabetes mellitus.

METHODS

Databases, including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL), among others, were systematically searched. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was applied for the assessment of quality, and the bivariate model was used to pool the sensitivity and specificity. The hierarchical summary receiver operator characteristic curves (HSROC) model was utilized to estimate the summary receiver operating characteristics curve (SROC). Sensitivity analysis was performed to investigate the association of the study design and patient characteristics with the test accuracy and meta-regression to find the source of heterogeneity.

RESULTS

Three studies regarding gestational diabetes mellitus (GDM) and a meta-analysis of 16 non-GDM studies, comprising a total sample size of 12876, were included in the work. Results reveal that the average cut-off values of GA reported for the diagnosis of GDM diagnosis was much lower than those for non-GDM. For non-GDM cases, diagnosing DM with a circulating GA cut-off of 14.0% had a sensitivity of 0.766 (95%CI: 0.539, 0.901), specificity of 0.687 (95%CI: 0.364, 0.894), and area under the curve of 0.80 (95%CI: 0.76, 0.83) for the SROC. The estimated SROC at different GA cut-off values for non-GDM exhibited that the average location parameter lambda of 16 non-GDM studies was 2.354 (95%CI: 2.002, 2.707), and the scale parameter beta was -0.163 (95%CI: -0.614, 0.288). These non-GDM studies with various thresholds had substantial heterogeneity, which may be attributed to the type of DM, age, and body mass index as possible sources.

CONCLUSION

Glycated albumin in non-DM exhibits a moderate diagnostic accuracy. Further research on the diagnostic accuracy of GA for GDM and combinational measurements of GA and other assays is suggested.

Triglyceride glycemic index as a biomarker for gestational diabetes mellitus: a systemic review and meta-analysis

BACKGROUND

Triglyceride glycemic (TyG) index is a novel tool for assessing insulin resistance (IR). Recently, TyG index as a potential biomarker for gestational diabetes mellitus (GDM) has been studied, but its performance is yet inconclusive. Thus, we performed this systemic review and meta-analysis to evaluate the performance of TyG index in predicting GDM.

METHODS

Studies published before March 1, 2021, with comparison of TyG index between GDM patients and healthy controls were retrieved from multiple databases (PubMed, Web of Science, The Cochrane Library, and Embase). The mean difference (MD) of TyG index in GDM patients and healthy controls was pooled using random-effect models.

RESULTS

Differentiation of TyG index between patients with GDM and controls showed significant results. Overall, there is a four-fold increase in TyG index in GDM patients compared with controls (MD: 0.22, 95% CI: 0.07-0.36, P = 0.003; I2 = 71%, P = 0.009). In subgroup analyses according to gestational time, TyG index in the second trimester predicted GDM with low heterogeneity (MD: 0.26, 95% CI: 0.15-0.37, P < 0.001; I2 = 0%, P = 0.54), while no such correlation was found in the first trimester.

CONCLUSION

TyG index, especially in the second trimester, could be a promising biomarker for predicting GDM.

The Association Between High Hemoglobin Levels and Pregnancy Complications, Gestational Diabetes and Hypertension, Among Palestinian Women

INTRODUCTION

Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are the principal causes of maternal morbidity and mortality. The maternal morbidity and mortality burden for Palestinian women is relatively high, suggesting a substandard quality of care. Therefore, an early diagnosis of GDM and gestational hypertension (GH) can improve prenatal care for pregnant women and improve pregnancy outcomes. Previous studies demonstrated that elevated Hb levels in the first trimester indicate possible pregnancy complications and should not only be considered as good iron status. However, ethnic differences could play a role in determining the magnitude of the association. We hypothesized that high Hb levels (≥12.5 g/dl) in the first trimester (6-13 gestational weeks, GW) are associated with increased risk of fasting blood sugar (FBS) ≥126 mg/dl, systolic blood pressure (SBP) ≥140 mmHg, and diastolic blood pressure (DBP) ≥90 mmHg among pregnant Palestinian women visiting prenatal clinics in Palestine.

METHODS

Medical records (N=5263) were reviewed for singleton pregnancies who had their first maternity care clinic visit (6-13 GW) at primary healthcare centers of the Palestinian Ministry of Health in the north of the West Bank in 2018 and 2019. Women were excluded if they had FBS ≥92 mg/dl, SBP ≥140 mmHg, DBP ≥90 mmHg, ultrasound-based gestational age >13 weeks, or who were previously diagnosed with diabetes mellites, GDM, hypertension, GH, taking drugs for these conditions, or were smoking during pregnancy. Hb levels in g/dl were divided to low (<11.0), normal (11-12.49), and high (≥12.5). The associations between high hemoglobin levels and pregnancy complications in pregnant women were assessed by calculating the odds ratios (OR) and their 95% confidence intervals (CIs) using logistic regression. P-values of <0.05 were considered significant.

RESULTS

The final number of eligible records was 2565. Pregnant women with high Hb levels in the first trimester were at higher risk of high FBS (≥126 mg/dl; OR=2.99, 95%CI, [1.675-5.368]) and high systolic blood pressure (≥140 mmHg; OR=3.048, 95%CI, [1.252-7.421]) at 24 GW. Gravidity was significantly associated with decreased risk of high FBS (OR=0.838, 95%CI [0.704-0.991]).

CONCLUSION

Our findings suggest that Hb level at registration could be utilized in predicting the risk of GDM and HP among Palestinian women who never had a previous history of these conditions. The results of this study could have important clinical implications for early screening, which could improve preventive and curative health services to promote the health of pregnant women and children.

Comparison of pregnancy outcomes between women of advanced maternal age (≥35 years) versus younger women in a tertiary care center in Saudi Arabia

BACKGROUND

Pregnancy in women aged 35 years or above is generally considered an advanced maternal age (AMA). AMA is associated with an increased rate of maternal and neonatal complications.

OBJECTIVES

Assess the effect of AMA on maternal and neonatal outcomes.

DESIGN

Analytical cross-sectional study of medical records.

SETTINGS

In-patient hospital tertiary care setting in Jeddah.

PATIENTS AND METHODS

All women who attended antenatal care and delivered at King Abdulaziz Medical City in Jeddah in the first half of 2018 were included in the study. Outcomes for women 35 years of age or older were compared with younger women. Significant factors in a univariate analysis were entered in a multiple logistic regression model to assess the association between AMA and outcomes.

MAIN OUTCOME MEASURES

Rates of maternal neonatal complications, analysis of factors associated with advanced maternal, gestational diabetes mellitus (GDM), cesarean delivery.

SAMPLE SIZE

1586 women.

RESULTS

Of the 1586 women, 406 were 35 years of age or older (25.6%), and 1180 were younger than 35 years. The AMA group had a significantly higher proportion of GDM (32.0% versus 13.2%, P<.001). The adjusted odds ratio (OR) for GDM was 2.6 (95% CI 2-3.5, P<.001.) compared with younger women in the multivariate logistic regression analysis. Older women had a higher rate of cesarean delivery (43.6% versus 30.8%, P<.001). The adjusted OR for cesarean vs. vaginal delivery was 1.5 (CI 1.2-1.9, P=.002).

CONCLUSION

Pregnancy in women 35 years or older was associated with an increased risk of GDM and cesarean delivery.

LIMITATIONS

Cross-sectional design, small sample size, single hospital.

CONFLICT OF INTEREST

None.

A Glimpse at the Size of the Fetal Liver-Is It Connected with the Evolution of Gestational Diabetes?

Gestational diabetes mellitus (GDM) is defined as an impairment of glucose tolerance, manifested by hyperglycemia, which occurs at any stage of pregnancy. GDM is more common in the third trimester of pregnancy and usually disappears after birth. It was hypothesized that the glycemic status of the mother can modulate liver development and growth early during the pregnancy. The simplest modality to monitor the evolution of GDM employs noninvasive techniques. In this category, routinely obstetrical ultrasound (OUS) examinations (simple or 2D/3D) can be employed for specific fetal measurements, such as fetal liver length (FLL) or volume (FLV). FLL and FLV may emerge as possible predictors of GDM as they positively relate to the maternal glycated hemoglobin (HbA1c) levels and to the results of the oral glucose tolerance test. The aim of this review is to offer insight into the relationship between GDM and fetal nutritional status. Risk factors for GDM and the short- and long-term outcomes of GDM pregnancies are also discussed, as well as the significance of different dietary patterns. Moreover, the review aims to fill one gap in the literature, investigating whether fetal liver growth can be used as a predictor of GDM evolution. To conclude, although studies pointed out a connection between fetal indices and GDM as useful tools in the early detection of GDM (before 23 weeks of gestation), additional research is needed to properly manage GDM and offspring health.

Fetal Abdominal Obesity Detected At 24 to 28 Weeks of Gestation Persists Until Delivery Despite Management of Gestational Diabetes Mellitus

BACKGROUND

Fetal abdominal obesity (FAO) has been reported to be affected at gestational diabetes mellitus (GDM) diagnosis at 24 to 28 weeks of gestation in older and/or obese women. This study investigated whether the management of GDM improves FAO in GDM subjects near term.

METHODS

Medical records of 7,099 singleton pregnant women delivering at CHA Gangnam Medical Center were reviewed retrospectively. GDM was diagnosed by 100-g oral glucose tolerance test after 50-g glucose challenge test based on Carpenter-Coustan criteria. GDM subjects were divided into four study groups according to maternal age and obesity. FAO was defined as ≥90th percentile of fetal abdominal overgrowth ratios (FAORs) of the ultrasonographically estimated gestational age (GA) of abdominal circumference per actual GA by the last menstruation period, biparietal diameter, or femur length, respectively.

RESULTS

As compared with normal glucose tolerance (NGT) subjects near term, FAORs and odds ratio for FAO were significantly higher in old and/or obese women with GDM but not in young and nonobese women with GDM. For fetuses of GDM subjects with FAO at the time of GDM diagnosis, the odds ratio for exhibiting FAO near term and being large for GA at birth were 7.87 (95% confidence interval [CI], 4.38 to 14.15) and 10.96 (95% CI, 5.58 to 20.53) compared with fetuses of NGT subjects without FAO at GDM diagnosis.

CONCLUSION

Despite treatment, FAO detected at the time of GDM diagnosis persisted until delivery. Early diagnosis and treatment might be necessary to prevent near term FAO in high-risk older and/or obese women.

Gestational Diabetes Mellitus (GDM) Risk for Declared Family History of Diabetes, in Combination with BMI Categories

Whether categories of family history of diabetes can act as independent risk factors for gestational diabetes mellitus (GDM-1, -2) has not yet been established, and neither has it been established how categories of body mass index (BMI) affect these relationships. A group of 912 women without chronic diseases, recruited in the first trimester, was investigated: 125 (13.7%) women developed GDM-1 (treated with diet); 21 (2.3%) women developed GDM-2 (treated with insulin); and a control group consisted of 766 non-diabetic women. A multiple logistic regression was used to evaluate adjusted odds ratios (AOR (95% confidence intervals)) of GDM-1 and GDM-2 for declared diabetes in the parents or grandparents (separately). These relationships were investigated in the whole cohort and subgroups of pre-pregnancy BMI. (1) Some categories of the family history were independent risk factors of GDM-1 or GDM-2. Compared to ‘absence of diabetes in the family’, women with diabetes in the father had a 3.68-fold increase in GDM-1 risk (AOR-b = 3.68 (2.23–6.07)), and women with diabetes in the mother had a 2.13-fold increase in GDM-1 risk (AOR-b = 2.13 (1.1–4.14)) and a 4.73-fold increase in GDM-2 risk (AOR-b = 4.73 (1.26–17.77)). Women with diabetes in the grandmother had a 2.34-fold increase in GDM-1 risk (AOR-b = 2.34 (1.29–4.24)). (2) The cumulative assessment of diabetes in the parents and/or grandparents was not related to the intensification of the risk of GDM, except for the increased risk of GDM-1 for diabetes in both mother and grandmothers simultaneously (AOR-b = 8.80 (1.16–66.57)), however, this group was very small. (3) The analyses in the subgroups of BMI categories showed that diabetes in the father was also an independent risk factor of GDM in the subgroup of pregnant women with normal BMI. In the subgroups of overweight and/or obesity, the risk of GDM for paternal and maternal diabetes was approximately twice as high as compared to the results of pregnant women with normal BMIs. Additionally, apart from the maternal influence of diabetes, the results suggest a significant influence of diabetes in the father on the risk of GDM, even (interestingly) in lean pregnant women.

The diagnosis of Gestational Diabetes Mellitus and its impact on In Vitro Fertilization pregnancies. A pilot study

BACKGROUND

In Vitro Fertilization (IVF) is increasingly becoming a necessary mode of reproduction. This high risk group is prone to Gestational Diabetes Mellitus (GDM) which further exposes these pregnancies to an increased risk of adverse outcomes. In light of the limited data in the current literature, further investigation is needed regarding the time of GDM diagnosis in IVF pregnancies as well as the outcome of IVF pregnancies complicated by GDM.

METHODS

In this three center pilot cross sectional study, the data of 101 singleton IVF pregnancies complicated by GDM were analyzed. Prompt GDM diagnosis in IVF pregnancies was accomplished by self-blood glucose monitoring (SMBG) from the first antenatal visit and confirmed by an OGTT. To evaluate pregnancy outcome, maternal and fetal complications in the 101 GDM IVF group was compared to 101 IVF as well as 101 spontaneous conceptions (SC). The three groups were matched by age. The effect of demographic and glycemic parameters on the outcome of GDM IVF pregnancies was investigated.

RESULTS

GDM diagnosis was made before the 24th week in 37.6% of the GDM IVF group. The week of delivery was earlier for the GDM IVF group (37 ± 1.7) relative to the IVF (37.9 ± 0.9, p < 0.001) and the SC group (38.1 ± 0.8, p < 0.001). GDM IVF pregnancies exhibited greater preeclampsia rates and 84.8% underwent caesarian section. No significant difference regarding LGA and SGA birth weights was found. Complications of GDM IVF pregnancies were associated with the 1-h postprandial BG (r = 0.267, p = 0.007).

CONCLUSION

GDM screening in IVF pregnancies may be considered earlier than the 24th week. IVF pregnancies affected by GDM are prone to increased maternal and fetal complications which are associated with 1-h postprandial BG.

Increased individual glucose tolerance test values in women with gestational diabetes

BACKGROUND

Individual oral glucose tolerance test (OGTT) values may be of interest to clinicians. We evaluate factors associated with these values.

METHODS

This retrospective study included 225 pregnant women diagnosed with gestational diabetes by abnormal 100-gram oral GTT. Predictor variables were maternal age, race/ethnicity, gravida, parity, pre-pregnancy body mass index (BMI), weight gain in current pregnancy, family history of diabetes, personal history of gestational diabetes, and neonate gender. Outcome variables were continuous OGTT and categorical elevated OGTT for fasting, 1-hour postprandial, 2-hour postprandial, and 3-hour postprandial.

RESULTS

Obese BMI was associated with increased odds for higher fasting level in the continuous OGTT and elevated categorical OGTT; for 1-hour postprandial this significant obese association only occurred for the continuous OGTT. Higher weight gain in pregnancy was associated with a higher fasting level continuous OGTT and elevated categorical OGTT. Higher maternal age at time of delivery was associated with higher 2-hour continuous OGTT and an elevated 1-hour categorical OGTT. Female neonate gender was associated with decreased odds for elevated 2-hour categorical OGTT. Hispanic and Black race/ethnicities were each associated with higher 3-hour continuous OGTT.

CONCLUSIONS

These findings can help clinicians identify the women potentially at risk for having abnormal GTT values diagnostic of GDM to provide preemptive early intervention. Clinicians have the goals to identify these women early so that women can be properly educated and counseled in terms of their nutrition status and as to what negative clinical outcomes may occur should their glucose levels remain poorly controlled in the pregnancy.

Effect of publicly funded assisted reproductive technology on maternal and infant outcomes: a pre- and post-comparison study

STUDY QUESTION

Does publicly funded assisted reproductive technology result in improved maternal and infant outcomes?

SUMMARY ANSWER

Publicly funded ART in Quebec was associated with reduced risks of preeclampsia, cesarean delivery, preterm birth, low birth weight and other adverse outcomes.

WHAT IS KNOWN ALREADY

Publicly funded ART programs that provide free access to single embryo transfer are known to decrease the rate of multiple pregnancy, but the impact on other pregnancy outcomes is unknown.

STUDY DESIGN, SIZE, DURATION

We conducted a pre- and post-comparison study of 597 416 pregnancies conceived between July 2008 and September 2015 in Quebec, Canada, a region where public funding of ART began in August 2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included all pregnant women who conceived by ART (n = 14 309) or spontaneously (n = 583 107) and delivered a live or stillborn infant in hospitals of Quebec. The main exposure measure was conception before versus during the publicly funded ART program. Outcomes included measures of maternal and infant morbidity and mortality. We estimated risk ratios (RR) and 95% confidence intervals for the association of publicly funded ART with maternal and infant outcomes using log-binomial regression models adjusted for maternal characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

In this study, 2638 pregnancies were conceived by ART before, and 11 671 were conceived by ART, during public funding. Compared with no public funding, ART funding was associated with reduced risks of severe maternal morbidity (RR 0.64, 95% CI 0.50-0.83), preeclampsia (RR 0.55, 95% CI 0.44-0.68), cesarean delivery (RR 0.83, 95% CI 0.77-0.89), preterm birth (RR 0.67, 95% CI 0.60-0.75), low birth weight (RR 0.63, 95% CI 0.55-0.72), severe neonatal morbidity (RR 0.75, 95% CI 0.57-0.99) and neonatal intensive care unit admission (RR 0.65, 95% CI 0.53-0.78). When multiple pregnancies were excluded, ART funding continued to be associated with a lower risk of preeclampsia (RR 0.61, 95% CI 0.48-0.79) and preterm birth (RR 0.85, 95% CI 0.73-0.99). However, ART funding was associated with increased risk of gestational diabetes.

LIMITATIONS, REASONS FOR CAUTION

We had no information on the type of ART, number of in-vitro fertilization cycles or number of embryos transferred. We lacked data on body mass index, ethnicity and smoking and cannot rule out residual confounding.

WIDER IMPLICATION OF THE FINDINGS

Our findings suggest that publicly funded ART programs that encourage single embryo transfer may have substantial benefits for a range of maternal and infant outcomes, beyond prevention of multiple births.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grant 6D02363004 from the Public Health Agency of Canada. N.A. acknowledges a career award from the Fonds de recherche du Québec-Santé (34695). The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Appropriate Timing of Gestational Diabetes Mellitus Diagnosis in Medium- and Low-Risk Women: Effectiveness of the Italian NHS Recommendations in Preventing Fetal Macrosomia

BACKGROUND

Screening strategies for gestational diabetes mellitus (GDM) earlier than 24-28 weeks of gestation should be considered to prevent adverse pregnancy outcomes. Nonetheless, there is uncertainty about which women would benefit most from early screening and which screening strategies should be offered to women with GDM. The Italian National Healthcare Service (NHS) recommendations on selective screening for GDM at 16-18 weeks of gestation are effective in preventing fetal macrosomia in high-risk (HR) women, but the appropriateness of timing and effectiveness of these recommendations in medium- (MR) and low-risk (LR) women are still controversial. Patients and Methods. We retrospectively enrolled 769 consecutive singleton pregnant women who underwent both anomaly scan at 19-21 weeks of gestation and screening for GDM at 16-18 and/or 24-28 weeks of gestation, in agreement with the NHS recommendations and risk stratification criteria. Comparison of maternal characteristics, fetal biometric parameters at anomaly scan (head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC), femur length (FL), estimated fetal weight (EFW)), and neonatal birth weight (BW) percentile among risk groups was examined.

RESULTS

219 (28.5%) women were diagnosed with GDM, while 550 (71.5%) were normal glucose-tolerant women. Out of 164 HR women, only 62 (37.8%) underwent the recommended early screening for GDM at 16-18 weeks of gestation. AC and EFW percentiles, as well as neonates' BW percentiles, were significantly higher in HR women diagnosed with GDM at 24-28 weeks of gestation with respect to normal glucose-tolerant women, as well as MR and LR women who tested positive for GDM. Comparative analysis between MR and LR women with GDM and women with normal glucose tolerance revealed significant differences in both AC and EFW percentiles (P < 0.05), while there was no significant difference in neonatal BW percentiles.

CONCLUSION

In MR and LR women with GDM, a mild acceleration of fetal growth can be detected at the time of anomaly scan. However, in these at-risk categories, the NHS recommendations for screening and treatment of GDM at 24-28 weeks of gestation are still effective in normalizing BW and preventing fetal macrosomia, thus supporting a risk factor-based selective screening program for GDM.