Increased Hemoglobin A1c in Obese Pregnant Women after Exclusion of Gestational Diabetes

Sexual health and testosterone concentration in male lymphoma survivors: A systematic review

Advancements in lymphoma treatment have increased the number of long-term survivors who may experience late effects such as impaired sexual function and testosterone deficiency. The aim of this review was to determine the prevalence of testosterone deficiency and sexual dysfunction among male lymphoma survivors; and associations between the two. A systematic search identified 20 articles for inclusion. The prevalence of low total testosterone was 0%-50 %, with mean values within reference levels, and for luteinizing hormone above reference levels in 0%-80 %. Four studies included SHBG and free testosterone, with mixed results. Compromised sexual health was found in 23%-61 %. Overall, total testosterone and sexual health were associated. The risk of bias (ROBINS-E and RoB 2) was high/very high, leading to low/very low overall confidence in the bulk of evidence (GRADE). Longitudinal studies evaluating biologically active testosterone and sexual health are needed, to develop evidence based standard procedures for follow-up of sexual health.

Predicting the earliest deviation in weight gain in the course towards manifest overweight in offspring exposed to obesity in pregnancy: a longitudinal cohort study

BACKGROUND

Obesity in pregnancy and related early-life factors place the offspring at the highest risk of being overweight. Despite convincing evidence on these associations, there is an unmet public health need to identify "high-risk" offspring by predicting very early deviations in weight gain patterns as a subclinical stage towards overweight. However, data and methods for individual risk prediction are lacking. We aimed to identify those infants exposed to obesity in pregnancy at ages 3 months, 1 year, and 2 years who likely will follow a higher-than-normal body mass index (BMI) growth trajectory towards manifest overweight by developing an early-risk quantification system.

METHODS

This study uses data from the prospective mother-child cohort study Programming of Enhanced Adiposity Risk in CHildhood-Early Screening (PEACHES) comprising 1671 mothers with pre-conception obesity and without (controls) and their offspring. Exposures were pre- and postnatal risks documented in patient-held maternal and child health records. The main outcome was a "higher-than-normal BMI growth pattern" preceding overweight, defined as BMI z-score >1 SD (i.e., World Health Organization [WHO] cut-off "at risk of overweight") at least twice during consecutive offspring growth periods between age 6 months and 5 years. The independent cohort PErinatal Prevention of Obesity (PEPO) comprising 11,730 mother-child pairs recruited close to school entry (around age 6 years) was available for data validation. Cluster analysis and sequential prediction modelling were performed.

RESULTS

Data of 1557 PEACHES mother-child pairs and the validation cohort were analyzed comprising more than 50,000 offspring BMI measurements. More than 1-in-5 offspring exposed to obesity in pregnancy belonged to an upper BMI z-score cluster as a distinct pattern of BMI development (above the cut-off of 1 SD) from the first months of life onwards resulting in preschool overweight/obesity (age 5 years: odds ratio [OR] 16.13; 95% confidence interval [CI] 9.98-26.05). Contributing early-life factors including excessive weight gain (OR 2.08; 95% CI 1.25-3.45) and smoking (OR 1.94; 95% CI 1.27-2.95) in pregnancy were instrumental in predicting a "higher-than-normal BMI growth pattern" at age 3 months and re-evaluating the risk at ages 1 year and 2 years (area under the receiver operating characteristic [AUROC] 0.69-0.79, sensitivity 70.7-76.0%, specificity 64.7-78.1%). External validation of prediction models demonstrated adequate predictive performances.

CONCLUSIONS

We devised a novel sequential strategy of individual prediction and re-evaluation of a higher-than-normal weight gain in "high-risk" infants well before developing overweight to guide decision-making. The strategy holds promise to elaborate interventions in an early preventive manner for integration in systems of well-child care.

Late-Pregnancy Dysglycemia After Negative Testing for Gestational Diabetes and Risk of the Large-for-Gestational-Age Newborns: A Nest Case-Control Study Based on the Xi'an Longitudinal Mother-Child Cohort Study

BACKGROUND

The implications of gestational diabetes mellitus (GDM) on the short- and long-term health outcomes of both mother and child have been extensively studied. However, studies related to negative Oral Glucose Tolerance Test (OGTT) results in the second trimester but dysglycemia in late pregnancy on maternal and infant pregnancy outcomes are rare.

METHODS

We conducted a nest case-control study within the Xi'an Longitudinal Mother-Child Cohort study (XAMC) to investigate the risk of adverse pregnancy outcomes in mothers and children with maternal negative mid-pregnancy OGTT results but high glycated hemoglobin (HbA_1c) levels (≥5.7%) in late pregnancy. All target women who delivered from January 1st, 2017 to December 31st, 2018 in Northwest Women's and Children's Hospital in Xi'an were enrolled as the case group (HbA_1c ≥ 5.7%). Others with HbA_1c < 5.7% but without GDM were selected as the control group (HbA_1c < 5.7%) by matching with the same delivery period. The logistic regression models were used to find out the risk factors of adverse pregnancy outcomes in the target population.

RESULTS

A total of 2,116 and 1,907 women were finally enrolled in the case and control groups, respectively. Compared to the control group, more newborns with macrosomia (9.2% vs 4.1%, P < 0.001) and large for gestational age (LGA) (23.7% vs. 13.5%, P < 0.001), but less small for gestational age (SGA) (4.4% vs. 6.1%, P = 0.017) were found in the case group. The differences in other outcomes were not statistically significant. The multiple logistic regression analysis showed that gestational age, fetal length, prenatal HbA_1c, and total cholesterol (TG) were independent risk factors for newborns with large-for-gestational-age (LGA). The case group had a 2.516-fold (95% CI, 1.692-3.739) risk of delivering LGA newborns compared to the control group.

CONCLUSION

The glycemic management during the late pregnancy of non-GDM women should be given special consideration to reduce the risk of overweight offspring at birth.

Association between false positive glucose challenge test results and large-for-gestational-age infants: a retrospective cohort study

OBJECTIVES

There is no consensus regarding a possible relation between false positive glucose challenge test (GCT) results and large-for-gestational-age (LGA) infants. This study aimed to clarify the association between false positive GCT results and LGA, after adjusting for potential confounding factors, using a large clinical dataset.

DESIGN

Retrospective cohort study.

SETTING

National Hospital Organisation Kofu National Hospital, which is a community hospital, between January 2012 and August 2019.

PARTICIPANTS

Japanese women who underwent GCT between 24 and 28 weeks of gestation at the hospital were included. After excluding those with gestational diabetes mellitus, diabetes in pregnancy and multiple pregnancies, subjects were divided into a false positive GCT group (≥140 mg/dL) and a GCT negative group (<140 mg/dL).

METHODS

Obstetric records of patients were examined. The χ²-test and multivariable logistic regression analysis were used to investigate the association between false positive GCT results and LGA.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incidence of LGA and the association between false positive GCT results and LGA.

RESULTS

The mean subject age was 31.4±5.5 years, with 43.3% nulliparity (n=974) and 2160 (96.1%) term deliveries. The incidence of LGA was 9.4% (211/2248) and 11.4% (257/2248) of the women had false positive GCT results. False positive GCT results were significantly associated with an increased risk of LGA (OR, 1.51; 95% CI, 1.02 to 2.23), after controlling for maternal age, prepregnancy maternal weight, maternal weight gain during pregnancy and parity.

CONCLUSIONS

It appears that there is a significant association between false positive GCT results and LGA. Additional research is required to confirm these results and to investigate appropriate interventions for women with abnormal screens for gestational diabetes mellitus.

Late-pregnancy dysglycemia in obese pregnancies after negative testing for gestational diabetes and risk of future childhood overweight: An interim analysis from a longitudinal mother-child cohort study

BACKGROUND

Maternal pre-conception obesity is a strong risk factor for childhood overweight. However, prenatal mechanisms and their effects in susceptible gestational periods that contribute to this risk are not well understood. We aimed to assess the impact of late-pregnancy dysglycemia in obese pregnancies with negative testing for gestational diabetes mellitus (GDM) on long-term mother-child outcomes.

METHODS AND FINDINGS

The prospective cohort study Programming of Enhanced Adiposity Risk in Childhood-Early Screening (PEACHES) (n = 1,671) enrolled obese and normal weight mothers from August 2010 to December 2015 with trimester-specific data on glucose metabolism including GDM status at the end of the second trimester and maternal glycated hemoglobin (HbA1c) at delivery as a marker for late-pregnancy dysglycemia (HbA1c ≥ 5.7% [39 mmol/mol]). We assessed offspring short- and long-term outcomes up to 4 years, and maternal glucose metabolism 3.5 years postpartum. Multivariable linear and log-binomial regression with effects presented as mean increments (Δ) or relative risks (RRs) with 95% confidence intervals (CIs) were used to examine the association between late-pregnancy dysglycemia and outcomes. Linear mixed-effects models were used to study the longitudinal development of offspring body mass index (BMI) z-scores. The contribution of late-pregnancy dysglycemia to the association between maternal pre-conception obesity and offspring BMI was estimated using mediation analysis. In all, 898 mother-child pairs were included in this unplanned interim analysis. Among obese mothers with negative testing for GDM (n = 448), those with late-pregnancy dysglycemia (n = 135, 30.1%) had higher proportions of excessive total gestational weight gain (GWG), excessive third-trimester GWG, and offspring with large-for-gestational-age birth weight than those without. Besides higher birth weight (Δ 192 g, 95% CI 100-284) and cord-blood C-peptide concentration (Δ 0.10 ng/ml, 95% CI 0.02-0.17), offspring of these women had greater weight gain during early childhood (Δ BMI z-score per year 0.18, 95% CI 0.06-0.30, n = 262) and higher BMI z-score at 4 years (Δ 0.58, 95% CI 0.18-0.99, n = 43) than offspring of the obese, GDM-negative mothers with normal HbA1c values at delivery. Late-pregnancy dysglycemia in GDM-negative mothers accounted for about one-quarter of the association of maternal obesity with offspring BMI at age 4 years (n = 151). In contrast, childhood BMI z-scores were not affected by a diagnosis of GDM in obese pregnancies (GDM-positive: 0.58, 95% CI 0.36-0.79, versus GDM-negative: 0.62, 95% CI 0.44-0.79). One mechanism triggering late-pregnancy dysglycemia in obese, GDM-negative mothers was related to excessive third-trimester weight gain (RR 1.72, 95% CI 1.12-2.65). Furthermore, in the maternal population, we found a 4-fold (RR 4.01, 95% CI 1.97-8.17) increased risk of future prediabetes or diabetes if obese, GDM-negative women had a high versus normal HbA1c at delivery (absolute risk: 43.2% versus 10.5%). There is a potential for misclassification bias as the predominantly used GDM test procedure changed over the enrollment period. Further studies are required to validate the findings and elucidate the possible third-trimester factors contributing to future mother-child health status.

CONCLUSIONS

Findings from this interim analysis suggest that offspring of obese mothers treated because of a diagnosis of GDM appeared to have a better BMI outcome in childhood than those of obese mothers who-following negative GDM testing-remained untreated in the last trimester and developed dysglycemia. Late-pregnancy dysglycemia related to uncontrolled weight gain may contribute to the development of child overweight and maternal diabetes. Our data suggest that negative GDM testing in obese pregnancies is not an "all-clear signal" and should not lead to reduced attention and risk awareness of physicians and obese women. Effective strategies are needed to maintain third-trimester glycemic and weight gain control among otherwise healthy obese pregnant women.

Is There a Role for HbA1c in Pregnancy?

Outside pregnancy, HbA1c analysis is used for monitoring, screening for and diagnosing diabetes and prediabetes. During pregnancy, the role for HbA1c analysis is not yet established. Physiological changes lower HbA1c levels, and pregnancy-specific reference ranges may need to be recognised. Other factors that influence HbA1c are also important to consider, particularly since emerging data suggest that, in early pregnancy, HbA1c elevations close to the reference range may both identify women with underlying hyperglycaemia and be associated with adverse pregnancy outcomes. In later pregnancy, HbA1c analysis is less useful than an oral glucose tolerance test (OGTT) at detecting gestational diabetes. Postpartum, HbA1c analysis detects fewer women with abnormal glucose tolerance than an OGTT, but the ease of testing may improve follow-up rates and combining HbA1c analysis with fasting plasma glucose or waist circumference may improve detection rates. This article discusses the relevance of HbA1c testing at different stages of pregnancy.

Obese Nondiabetic Pregnancies and High Maternal Glycated Hemoglobin at Delivery as an Indicator of Offspring and Maternal Postpartum Risks: The Prospective PEACHES Mother-Child Cohort

BACKGROUND

We investigated whether obese pregnant women negative for gestational diabetes (GDM) still experience dysglycemia, as indicated by high glycated hemoglobin (Hb A1c) at delivery, and whether this impacts offspring and long-term maternal outcomes.

METHODS

Data of 462 mother-child pairs of our prospective Programming of Enhanced Adiposity Risk in Childhood - Early Screening (PEACHES) cohort study were analyzed. Of 885 obese and normal-weight pregnancies prospectively enrolled after GDM testing according to the International Association of Diabetes and Pregnancy Study Groups criteria, 462 GDM-negative mothers and their offspring were investigated. We assessed associations of maternal Hb A1c at delivery with large-for-gestational-age (LGA) birth weights, cord-blood C-peptide, and biomarkers of glucose metabolism and inflammation in obese mothers followed for 2.9 years (median) postpartum (n = 42).

RESULTS

Cumulative distribution analysis in GDM-negative normal-weight women (n = 155) revealed that 12% had Hb A1c ≥5.7% at delivery (high Hb A1c). Among obese GDM-negative women (n = 307), 31.9% (95% CI, 26.7%-37.4%) equaled or exceeded this cutoff. In obese GDM-negative women with Hb A1c ≥5.7% (n = 98) vs <5.7% (n = 209) at delivery, newborns were more likely to be born LGA [adjusted odds ratio 3.56 (95% CI, 1.64-8.02)], and mean cordblood serum C-peptide was increased by 0.09 ng/mL (95% CI, 0.01-0.17 ng/mL). In the mothers at follow-up, mean postpartum Hb A1c, fasting glucose, high-sensitivity C-reactive protein, and fibrinogen concentrations were higher by 0.3% (95% CI, 0.1%-0.5%), 6.0 mg/dL (95% CI, 2.4-9.5 mg/dL), 6.8 mg/L (95% CI, 1.4-12.3 mg/L), and 74.9 mg/dL (95% CI, 13.6-136.2 mg/dL), respectively.

CONCLUSIONS

Increased Hb A1c in obese GDM-negative women at delivery indicates gestational dysglycemia, potentially conferring offspring and long-term maternal health risks. These findings should raise awareness as to careful monitoring of obese pregnancies. Measurement of Hb A1c at delivery could help select women who may need closer postpartum health checks.

Prediction of excessive gestational weight gain from week-specific cutoff values: a cohort study

OBJECTIVE

To assess the prognostic validity of the Institute of Medicine/National Research Council (IOM/NRC) week-specific cutoff values for inadequate or excessive total gestational weight gain (GWG) by 4-week intervals.

STUDY DESIGN

We merged data from two German cohorts (LMU cohort (all maternal-weight categories) and PEACHES cohort (obese women)) to provide information on GWG for 749 women (365 normal weight, 199 overweight and 185 obese). We calculated the prognostic values for suboptimal and excessive GWG according to the IOM/NRC cutoff values.

RESULT

The positive predictive values for excessive total GWG for those who experienced excessive GWG early in pregnancy was 70.1% (95% confidence interval (CI) 60.5; 78.6) as of week 12/1 to 16/0 in normal-weight women, 89.5% (95% CI 75.2; 97.1) and 95.2 (76.2; 99.9) 95.2% (95% CI 76.2; 99.9) as of week 8/1 to 12/0 for overweight and obese women, respectively. In absence of excessive GWG as of week 12/1 to 16/0, normal-weight women had 77.5% (95% CI 77.1; 83.1) probability of not experiencing excessive total GWG (negative predictive value). In overweight and obese women, the negative predictive value was considerably lower up to week 24/1 to 28/0 (60.0% (95% CI 48.8; 70.5) in week 20/1 to 24/0 and 50.6% (95% CI 39.3; 61.9) in week 24/1 to 28/0). Most women with inadequate GWG in the first and second trimester had adequate total final GWG (positive predictive value for total inadequate GWG <50% up to week 16/1 to 20/0 in all groups).

CONCLUSION

As women with excessive weight gain can be identified with high confidence if the GWG exceeds the IOM/NRC week-specific cutoff values, interventions may be initiated early in pregnancy.

Gestational diabetes predicts the risk of childhood overweight and abdominal circumference independent of maternal obesity

AIM

Gestational diabetes mellitus is believed to be a risk factor for childhood overweight/obesity. We aimed to assess whether this association is either a reflection or independent of confounding by maternal BMI.

METHODS

Data from 7355 mother-child dyads of the German Perinatal Prevention of Obesity cohort with full anthropometric information on mothers and children, gestational diabetes and confounding factors were obtained at school entry health examination. We calculated crude and adjusted logistic regression models for the association of gestational diabetes and childhood overweight/obesity and abdominal adiposity defined by age- and sex-specific percentiles for BMI and waist circumference.

RESULTS

Among all children (mean age 5.8 years), 8.1% were overweight, 2.6% were obese and 15.5% had abdominal adiposity. The prevalence of overweight (obesity) was 21% (8.2%) in children of mothers with gestational diabetes and 10.4% (2.4%) in children of healthy mothers. Analyses with adjustment for maternal BMI and other potential confounders yielded an odds ratio of 1.81 (95% CI 1.23-2.65) and 2.80 (95% CI 1.58-4.99) for the impact of gestational diabetes on childhood overweight and obesity, respectively. Similar results were obtained for the risk of childhood abdominal adiposity (odds ratio 1.64, 95% CI 1.16-2.33) by maternal gestational diabetes.

CONCLUSIONS

The postulated increased risk of overweight and abdominal adiposity in offspring of mothers with gestational diabetes cannot be explained by maternal BMI alone and may be stronger for childhood obesity than for overweight.