Polycystic ovary syndrome and risk factors for gestational diabetes

Prospective risk of Type 2 diabetes in 99 892 Nordic women with polycystic ovary syndrome and 446 055 controls: national cohort study from Denmark, Finland, and Sweden

STUDY QUESTION

What is the prospective risk of Type 2 diabetes (T2D) in Nordic women with polycystic ovary syndrome (PCOS) compared to controls?

SUMMARY ANSWER

A diagnosis of PCOS and BMI ≥30 kg/m2 is a high-risk phenotype for a prospective risk of T2D diagnosis across Nordic countries.

WHAT IS KNOWN ALREADY

The risk of T2D in women with PCOS is increased. The risk of T2D is related to BMI and the magnitude of risk in normal weight women with PCOS has been discussed. However, prospective data regarding risk of T2D in population-based cohorts of women with PCOS are limited.

STUDY DESIGN, SIZE, DURATION

This national register-based study included women with PCOS and age-matched controls. The main study outcome was T2D diagnosis occurring after PCOS diagnosis. T2D was defined according to ICD-10 diagnosis codes and/or filled medicine prescriptions of anti-diabetic medication excluding metformin.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study cohort included women originating from Denmark (PCOS Denmark, N = 27 016; controls, N = 133 994), Finland (PCOS Finland, N = 20 467; controls, N = 58 051), and Sweden (PCOS Sweden, N = 52 409; controls, N = 254 010). The median age at cohort entry was 28 years in PCOS Denmark, Finland, and Sweden with a median follow-up time (interquartile range) in women with PCOS of 8.5 (4.0-14.8), 9.8 (5.1-15.1), and 6.0 (2.0-10.0) years, respectively. Cox regression analyses were adjusted for BMI and length of education.

MAIN RESULTS AND THE ROLE OF CHANCE

The crude hazard ratio (HR, 95% CI) for T2D diagnosis in women with PCOS was 4.28 (3.98-4.60) in Denmark, 3.40 (3.11-3.74) in Finland, and 5.68 (5.20-6.21) in Sweden. In adjusted regression analyses, BMI ≥30 vs <25 kg/m2 was associated with a 7.6- to 11.3-fold risk of T2D. In a combined meta-analysis (PCOS, N = 99 892; controls, N = 446 055), the crude HR for T2D in PCOS was 4.64 (3.40-5.87) and, after adjustment for BMI and education level, the HR was 2.92 (2.32-3.51).

LIMITATIONS, REASONS FOR CAUTION

Inclusion of more severe cases of PCOS in the present study design could have lead to an overestimation of risk estimates in our exposed population. However, some women in the control group would have undiagnosed PCOS, which would lead to an underestimation of T2D risk in women with PCOS. BMI data were not available for all participants. The present study should be repeated in study cohorts with higher background risks of T2D, particularly in populations of other ethnicities.

WIDER IMPLICATIONS OF THE FINDINGS

The prospective risk for diagnosis of T2D is increased in women with PCOS, and the risk is aggravated in women with BMI ≥30 kg/m2.

STUDY FUNDING/COMPETING INTEREST(S)

Funding in Denmark was from the Region of Southern Denmark, Overlægerådet, Odense University Hospital. Funding in Finland was from Novo Nordisk Foundation, Finnish Research Council and Sigrid Juselius Foundation, the National Regional Fund, Sakari Alhopuro Foundation and Finnish Diabetes Research Foundation. E.E. has received a research grant from Ferring Pharmaceuticals (payment to institution) and serves as medical advisor for Tilly AB, not related to this manuscript. The remaining authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Investigating the causal impact of polycystic ovary syndrome on gestational diabetes mellitus: a two-sample Mendelian randomization study

Introduction

Determining the causal relationship between polycystic ovary syndrome (PCOS) and gestational diabetes mellitus (GDM) holds significant implications for GDM prevention and treatment. Despite numerous observational studies suggesting an association between PCOS and GDM, it remains unclear whether a definitive causal relationship exists between these two conditions and which specific features of PCOS contribute to increased incidence of GDM.

Methods

The causal relationship between polycystic ovary syndrome (PCOS), its characteristic indices, and gestational diabetes mellitus (GDM) was investigated using a two-sample Mendelian randomization study based on publicly available statistics from genome-wide association studies (GWAS). The inverse-variance weighted method was employed as the primary analytical approach to examine the association between PCOS, its characteristic indices, and GDM. MR Egger intercept was used to assess pleiotropy, while Q values and their corresponding P values were utilized to evaluate heterogeneity. It is important to note that this study adopts a two-sample MR design where PCOS and its characteristic indices are considered as exposures, while GDM is treated as an outcome.

Results

The study results indicate that there is no causal relationship between PCOS and GDM (all methods P > 0.05, 95% CI of OR values passed 1). The IVW OR value was 1.007 with a 95% CI of 0.906 to 1.119 and a P value of 0.904. Moreover, the MR Egger Q value was 8.141 with a P value of 0.701, while the IVW Q value was also 8.141 with a P value of 0.774, indicating no significant heterogeneity. Additionally, the MR Egger intercept was 0.0004, which was close to zero with a P value of 0.988, suggesting no pleiotropy. However, the study did find a causal relationship between several other factors such as testosterone, high-density lipoprotein, sex hormone-binding globulin, body mass index, waist-hip ratio, apolipoprotein A-I, number of children, diabetes illnesses of mother, father and siblings, hemoglobin A1c, fasting insulin, fasting blood glucose, years of schooling, and GDM based on the IVW method.

Conclusion

We observed no association between genetically predicted PCOS and the risk of GDM, implying that PCOS itself does not confer an increased susceptibility to GDM. The presence of other PCOS-related factors such as testosterone, high-density lipoprotein, and sex hormone-binding globulin may elucidate the link between PCOS and GDM. Based on these findings, efforts aimed at preventing GDM in individuals with PCOS should prioritize those exhibiting high-risk features rather than encompassing all women with PCOS.

Polycystic Ovary Syndrome, Gestational Diabetes Mellitus, and the Mediating Role of Obesity: A Population-Based Cohort Study

This population-based cohort study in Ontario, Canada evaluated the association between polycystic ovary syndrome (PCOS) and gestational diabetes mellitus, and the mediating effect of obesity. The study included 1 268 901 pregnancies between 2006 and 2018; 387 748 with maternal PCOS and 881 153 without PCOS. Modified Poisson regression generated relative risks adjusted for maternal covariates. Causal mediation analyses accounted for the indirect effect of obesity. Relative to individuals without PCOS, those with PCOS had a slightly higher rate (6.0% vs. 4.9%) and adjusted relative risk (1.05; 95% CI 1.03-1.06) of gestational diabetes mellitus. Obesity mediated a significant proportion (90%) of this association. Preconception counselling and future research should include strategies to support weight optimization in patients with PCOS.

Evaluation of pregnancy and neonatal outcomes according to the phenotypic types of polycystic ovary syndrome: A prospective study

OBJECTIVE

We aimed to compare pregnancy and neonatal outcomes in the phenotypic subtypes of patients with polycystic ovary syndrome (PCOS).

METHODS

This prospective cohort included the patients with PCOS (n = 121) diagnosed according to the presence of androgen excess, ovulatory dysfunction, and/or polycystic ovary morphology and healthy controls (n = 125). We stratified PCOS as phenotype A (n = 45), phenotype B (n = 8), phenotype C (n = 32) and phenotype D (n = 35) and followed throughout pregnancy, comparing their outcomes.

RESULTS

The study population had a mean age of 28.7 ± 4.9 years and a mean BMI of 31.6 kg/m2 with no difference between the groups. Primary cesarean deliveries were significantly more common in PCOS patients (23.3%) than in the control group (17.6%, P = 0.021). The phenotype A group had significantly higher rates of gestational diabetes mellitus (GDM) (42.2%, P < 0.001) and fetal macrosomia (14.6%, P = 0.002) compared with the control group (4.8% and 0.8%m respectively). We detected a significantly lower rate of normal risk score on the double screening test in the PCOS group (59.0%) than in the control group (75.4%) and in the other groups (P = 0.001).

CONCLUSION

The rates of GDM, fetal macrosomia, and cesarean section were higher in the PCOS group, depending on the phenotype. We observed changes in risk calculation according to phenotypic types at aneuploidy screening.

Gestational Diabetes Mellitus in the Setting of Polycystic Ovarian Syndrome: A Systematic Review

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy that arises in the 2nd and 3rd trimesters, leading to significant complications for the mother and her neonates, such as an increased rate of pregnancy-induced hypertension and miscarriages, while neonates may have a large birth weight, hypoglycemia, or macrosomnia. Numerous risk factors can lead to GDM; however, a significant one is polycystic ovarian syndrome (PCOS). PCOS is the most common endocrine pathology beginning before puberty, and due to significant hormonal changes, it is not diagnosed until after puberty. PCOS requires at least three of the following symptoms: hyperandrogenism, menstrual irregularities, or polycystic ovary morphology. While it is agreed that women with PCOS are at a significantly increased risk of GDM, no publication to our knowledge has evaluated the full relationship of GDM in the setting of PCOS. This paper aimed to assess this relationship and determine how it may differ for pregnant women with only GDM by determining the prevalence of GDM, the variations within phenotypes, the influence of fertilization methods, specific risk factors, maternal outcomes, and neonatal outcomes. The prevalence of GDM was significantly increased in women with PCOS compared to healthy controls, and some studies have found that phenotype A may be more likely to lead to GDM. Risk factors were similar to pregnant women with only GDM, but with GDM and PCOS specifically, preconception low sex hormone-binding globulin, increased BMI > 25 kg/m2, and preconception impaired glucose tolerance were specific. While maternal outcomes were similar to pregnant women with only GDM, women with GDM and PCOS were even more likely to develop pregnancy-induced hypertension and early miscarriage. Neonates from mothers with GDM and PCOS were more likely to have low birth weights compared to mothers with just GDM who had high birth weights. The evaluation of the relationship between GDM and PCOS allows for illumination of the need to evaluate influences that currently lack research, such as phenotype variation and influences of fertilization method. This also promotes the need to develop predictive algorithms based on risk factors to prevent these adverse outcomes for mothers and neonates.

Signature precursor and mature microRNAs in cervical ripening during gestational diabetes mellitus lead to pre-term labor and other impediments in future

Gestational diabetes mellitus (GDM) is a pathological condition in which the placenta releases a hormone called human placental lactogen that prevents maternal insulin uptake. GDM is characterised by varying degrees of carbohydrate intolerance and is first identified during pregnancy. Around 5-17% of pregnancies are GDM pregnancies. Older or obese women have a higher risk of developing GDM during gestation. Hyperglycemia is a classic manifestation of GDM and leads to alterations in eNOS and iNOS expression and subsequently causes ROS and RNS overproduction. ROS and RNS play an important role in maintaining normal physiology, when present in low concentrations. Increased concentrations of ROS is harmful and can cause cellular and tissue damage. Oxidative stress is defined as an imbalance between pro-oxidant and antioxidant molecules that manifests due to hyperglycemia. miRNAs are short, non-coding RNAs that play a critical role in regulating gene expression. Studies have shown that the placenta expresses more than 500 miRNAs, which play a crucial role in trophoblast division, movement, and apoptosis. Latest research has revealed that hyperglycemic conditions and increased oxidative stress, characteristic of GDM, can lead to the dysregulation of miRNAs. The placenta also releases miRNAs into the maternal circulation. The secreted miRNAs are encapsulated in exosomes or vesicles. These exosomes interact with tissues and organs at distant sites, releasing their cargo intracellularly. This crosstalk between hyperglycemia, ROS and miRNA expression in GDM has detrimental effects on both foetal and maternal health. One of the complications of GDM is preterm labour. GDM induced iNOS expression has been implicated in cervical ripening, which in turn causes preterm birth. This article focuses on the speculations of oxidative and nitrative stress markers that lead to detrimental effects in GDM. We have also envisaged the role of non-coding miRNA interactions in regulating gene expression for oxidative damage.

Graphical Abstract

Holistic view of miRNA in GDM. I)(A) Placenta as a metabolic organ that provides the foetus with nutrients, oxygen and hormones to maintain pregnancy. Human placental lactogen (hPL) is one such hormone that is released into maternal circulation. hPL is known to induce insulin resistance. (B) ß-cell dysfunction leads to reduced glucose sensing and insulin production. Insulin resistance, a characteristic of GDM, exacerbates insulin ß cell dysfunction leading to maternal hyperglycemia. Hyperglycemia leads to increased ROS and RNS production through several mechanisms. Consequently, GDM is characterised by increased oxidative and nitrative stress.II)Exposure to maternal hyperglycemia causes increased ROS and RNS production in trophoblast cells. Oxidative stress caused by hyperglycemia may lead to eNOS uncoupling, causing eNOS to behave as a superoxide producing enzyme. iNOS expression in trophoblast cells leads to increased NO production. iNOS-derived NO reacts with ROS to produce RNS, thereby increasing nitrosative stress. Expression of antioxidant defences are reduced. Hyperglycemia and oxidative stress may alter the expression of some miRNAs. Some miRNAs are upregulated while others are downregulated. Some miRNAs are secreted into maternal circulation in the form of exosomes. Oxidative stress markers, nitrative stress markers and circulating miRNAs are found to be increased in maternal circulation.

Serum ceramides in early pregnancy as predictors of gestational diabetes

Ceramides contribute to the development of type 2 diabetes but it is uncertain whether they predict gestational diabetes (GDM). In this multicentre case-control study including 1040 women with GDM and 958 non-diabetic controls, early pregnancy (mean 10.7 gestational weeks) concentrations of four ceramides-Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/24:0) and Cer(d18:1/24:1)-were determined by a validated mass-spectrometric method from biobanked serum samples. Traditional lipids including total cholesterol, LDL, HDL and triglycerides were measured. Logistic and linear regression and the LASSO logistic regression were used to analyse lipids and clinical risk factors in the prediction of GDM. The concentrations of four targeted ceramides and total cholesterol, LDL and triglycerides were higher and HDL was lower among women with subsequent GDM than among controls. After adjustments, Cer(d18:1/24:0), triglycerides and LDL were independent predictors of GDM, women in their highest quartile had 1.44-fold (95% CI 1.07-1.95), 2.17-fold (95% CI 1.57-3.00) and 1.63-fold (95% CI 1.19-2.24) odds for GDM when compared to their lowest quartiles, respectively. In the LASSO regression modelling ceramides did not appear to markedly improve the predictive performance for GDM alongside with clinical risk factors and triglycerides. However, their adverse alterations highlight the extent of metabolic disturbances involved in GDM.

Diabetes detection in women with gestational diabetes and polycystic ovarian syndrome

Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) represent two of the highest risk factors for development of type 2 diabetes mellitus in young women. As these increasingly common conditions generally affect younger women, early detection of dysglycemia is key if preventative measures are to be effective. While international guidance recommends screening for type 2 diabetes, current screening strategies suffer from significant challenges.First, guidance lacks consensus in defining which tests to use and frequency of monitoring, thereby sending mixed messages to healthcare professionals.Second, conformity to guidance is poor, with only a minority of women having tests at the recommended frequency (where specified). Approaches to improve conformity have focused on healthcare related factors (largely technology driven reminder systems), but patient factors such as convenience and clear messaging around risk have been neglected.Third, and most critically, current screening strategies are too generic and rely on tests that become abnormal far too late in the trajectory towards dysglycemia to offer opportunities for effective preventative measures. Risk factors show wide interindividual variation, and insulin sensitivity and β cell function are often abnormal during pre-diabetes stage, well before frank diabetes.New, consistent, targeted screening strategies are required that incorporate early, prevention focused testing and personalised risk stratification.

Risk prediction of gestational diabetes mellitus in women with polycystic ovary syndrome based on a nomogram model

Women with polycystic ovary syndrome are prone to develop gestational diabetes mellitus, a disease which may have significant impact on the postpartum health of both mother and infant. We performed a retrospective cohort study to develop and test a model that could predict gestational diabetes mellitus in the first trimester in women with polycystic ovary syndrome. Our study included 434 pregnant women who were referred to the obstetrics department between December 2017 and March 2020 with a diagnosis of polycystic ovary syndrome. Of these women, 104 were diagnosed with gestational diabetes mellitus in the second trimester. Univariate analysis revealed that in the first trimester, Hemoglobin A1c (HbA1C), age, total cholesterol(TC), low-density lipoprotein cholesterol (LDL-C), SBP (systolic blood pressure), family history, body mass index (BMI), and testosterone were predictive factors of gestational diabetes mellitus (P < 0.05). Logistic regression revealed that TC, age, HbA1C, BMI and family history were independent risk factors for gestational diabetes mellitus. The area under the ROC curve of the gestational diabetes mellitus risk prediction model was 0.937 in this retrospective analysis, demonstrating a great discriminatory ability. The sensitivity and specificity of the prediction model were 0.833 and 0.923, respectively. The Hosmer-Lemeshow test also showed that the model was well calibrated.

Idiopathic Hirsutism and Metabolic Status: A Population-based Prospective Cohort Study

BACKGROUND

A limited number of studies have investigated the impact of idiopathic hirsutism (IH) on cardiometabolic parameters with contradictory and inconclusive results. This study aimed to explore the effect of IH on metabolic outcomes.

METHOD

In this population-based prospective study, 334 women with IH and 1226 women as healthy controls were selected from Tehran Lipid and Glucose Study. The generalized estimation equations method was applied to investigate the secular longitudinal trends of metabolic indices, including fasting blood sugar (FBS), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL), non-HDL, triglyceride (TG), systolic blood pressure (SBP), diastolic blood pressure (DBP), and waist circumference (WC) in both groups. Unadjusted and adjusted Cox regression models were applied to assess the hazard ratios (HR) and 95% CIs for the association between IH and metabolic disorders. Potential confounding factors such as age, body mass index, smoking, physical activity, history of hypertension (HTN), and family history of diabetes were included in the adjusted model.

RESULTS

This study showed that compared with healthy controls, women with IH had lower SHBG and higher total testosterone (median [interquartile ratio; IQR]: 0.37 [0.16-0.70] vs 0.33 [0.14-0.58]; P = 0.01), free androgen index (median [IQR]: 0.85 [0.38-1.54] vs 0.54 [0.26-0.97]; P = 0.001), androstenedione (median [IQR]: 1.60 [1.00-2.25] vs 1.10 [0.90-1.70]; P = 0.001), and dehydroepiandrosterone sulfate (median [IQR]: 168.5 [91.1-227.8] vs 125.2 [66.3-181]; P = 0.001). Over time, mean changes of FBS, HDL-C, LDL-C, non-HDL-C, TG, SBP, DBP, and WC were not significantly different in women with IH, compared with healthy controls. According to the unadjusted Cox regression model, except for type 2 diabetes mellitus (T2DM) (HR [95% CI]: 1.45 [1.00-2.11]) P = 0.05; there was no statistically significant difference in hazard of metabolic disorders (ie, HTN, pre-HTN, pre-T2DM, and metabolic syndrome) in IH, compared with healthy controls. Besides, the adjusted Cox regression model showed no significant differences in the hazard of these outcomes.

CONCLUSION

This study showed no significant difference in overtime mean changes of metabolic risk factors and cardiometabolic outcomes in women with IH, compared with the healthy control group, except marginally significant difference on T2DM, which disappeared after further adjustment for potential confounders. Accordingly, routine screening of women for these metabolic outcomes should not recommend.

Dietary Impacts on Gestational Diabetes: Connection between Gut Microbiome and Epigenetic Mechanisms

Gestational diabetes mellitus (GDM) is one of the most common obstetric complications due to an increased level of glucose intolerance during pregnancy. The prevalence of GDM increases due to the obesity epidemic. GDM is also associated with an increased risk of gestational hypertension and preeclampsia resulting in elevated maternal and perinatal morbidity and mortality. Diet is one of the most important environmental factors associated with etiology of GDM. Studies have shown that the consumption of certain bioactive diets and nutrients before and during pregnancy might have preventive effects against GDM leading to a healthy pregnancy outcome as well as beneficial metabolic outcomes later in the offspring's life. Gut microbiome as a biological ecosystem bridges the gap between human health and diseases through diets. Maternal diets affect maternal and fetal gut microbiome and metabolomics profiles, which consequently regulate the host epigenome, thus contributing to later-life metabolic health in both mother and offspring. This review discusses the current knowledge regarding how epigenetic mechanisms mediate the interaction between maternal bioactive diets, the gut microbiome and the metabolome leading to improved metabolic health in both mother and offspring.

Gestational diabetes and other adverse pregnancy outcomes in polycystic ovary syndrome

PURPOSE OF REVIEW

This review provides an update on gestational diabetes (GDM) and other adverse pregnancy outcomes in individuals with polycystic ovary syndrome (PCOS), one of the most common metabolic disorders and causes of infertility.

RECENT FINDINGS

Recent studies using Rotterdam diagnostic criteria for PCOS have supported prior literature suggesting that pregnant individuals with PCOS are at an increased risk of GDM. Risk factors for GDM in this population include overweight/obesity, insulin resistance, hyperandrogenism, amenorrhea, and history of miscarriage. It is possible that subtypes of PCOS (metabolic vs. lean/reproductive) pose differential risk. There are no current screening or treatment guidelines specifically for individuals with PCOS for GDM prevention. Although metformin has been studied for GDM prevention in PCOS, there has been no proven benefit. For infertility treatment, assisted reproductive technology and in-vitro fertilization do not appear to increase the risk of GDM in individuals with PCOS desiring pregnancy.

SUMMARY

Recent studies of pregnant individuals with PCOS suggest an increased risk of adverse pregnancy outcomes, including GDM. Larger, prospective studies using standardized diagnostic criteria are warranted to determine if the risk is from PCOS generally, or if there are subtypes of PCOS (metabolic vs. lean/reproductive) at a higher risk of GDM than others.

Adverse Pregnancy Outcomes and Postpartum Care as a Pathway to Future Health

Adverse pregnancy outcomes (APOs) collectively represent the leading causes of maternal and neonatal morbidity and mortality. Beyond the potentially devastating impact of APOs during pregnancy and the puerperium, women diagnosed with APOs have a 2-fold to 4-fold increased risk of future cardiovascular disease. Fortunately, APOs occur at an opportune time, in early-adulthood to mid-adulthood, when primary and secondary prevention strategies can alter the disease trajectory and improve long-term health outcomes. This chapter takes a life-course approach to (1) the epidemiology of APOs, (2) evidence-based strategies for clinicians to manage APOs, and (3) future directions for APO research and clinical practice.

Prospective Risk of Type 2 Diabetes in Normal Weight Women with Polycystic Ovary Syndrome

Background: Polycystic ovary syndrome (PCOS) is associated with obesity and increased risk for type 2 diabetes (T2D). However, the prospective risk of T2D in normal weight women with PCOS is debated, together with the relevant prospective screening programs for T2D in normal weight women with PCOS. Aim: To review and discuss prospective risk of T2D in normal weight women with PCOS, and to give recommendations regarding prospective screening for T2D in normal weight women with PCOS. Methods: Systematic review. Results: A systematic literature search resulted in 15 published prospective studies (10 controlled studies and 5 uncontrolled studies) regarding risk of T2D in study cohorts of PCOS, where data from normal weight women with PCOS were presented separately. In controlled studies, higher risk of T2D in normal weight women with PCOS compared to controls was reported in 4/10 studies, which included one study where T2D diagnosis was based on glucose measurement, two register-based studies, and one study where diagnosis of T2D was self-reported. Six of the 10 controlled studies reported no increased risk of T2D in normal weight women with PCOS. Four of these studies based the diagnosis of T2D on biochemical measurements, which supported the risk of surveillance bias in PCOS. In uncontrolled studies, 2/5 reported a higher risk of T2D in lean women with PCOS compared to the general population. We discuss the evidence for insulin resistance and β-cell dysfunction in normal weight women with PCOS, and aggravation in the hyperandrogenic phenotype, ageing women, and women with Asian ethnicity. Impaired glucose tolerance could be an important metabolic and vascular risk marker in PCOS. Conclusions: The risk of T2D may be increased in some normal weight women with PCOS. Individual risk markers such as hyperandrogenism, age >40 years, Asian ethnicity, and weight gain should determine prospective screening programs in normal weight women with PCOS.

LongITools: Dynamic longitudinal exposome trajectories in cardiovascular and metabolic noncommunicable diseases

The current epidemics of cardiovascular and metabolic noncommunicable diseases have emerged alongside dramatic modifications in lifestyle and living environments. These correspond to changes in our "modern" postwar societies globally characterized by rural-to-urban migration, modernization of agricultural practices, and transportation, climate change, and aging. Evidence suggests that these changes are related to each other, although the social and biological mechanisms as well as their interactions have yet to be uncovered. LongITools, as one of the 9 projects included in the European Human Exposome Network, will tackle this environmental health equation linking multidimensional environmental exposures to the occurrence of cardiovascular and metabolic noncommunicable diseases.

Higher hemoglobin levels are an independent risk factor for gestational diabetes

Incidence of gestational diabetes (GDM) has increased rapidly. It poses significant risks for both mother and fetus affecting also negatively their longer-term metabolic heath. We asked whether early pregnancy maternal hemoglobin (Hb) levels, indicative for tissue oxygenation, would affect mother's metabolic health and fetal outcome. We assessed in FinnGeDi, a Finnish multicenter case-control study for GDM (n = 1828), association of maternal 1st trimester Hb levels with metabolic parameters and perinatal outcome. Our data show that mothers with GDM had higher Hb levels compared to controls (mean difference 1.746 g/L). Hb levels associated positively with pre-pregnancy body mass index (BMI), fasting glucose levels and glucose levels in a glucose tolerance test and systolic and diastolic blood pressure (bp) levels. When assessed in quartiles the highest Hb quartile had more chronic and gestational hypertension and the most adverse outcome of the metabolic parameters, dose-dependency seen in bp, BMI and glucose levels. In a multivariable regression analysis Hb levels remained an independently associated parameter for GDM after adjusting for key covariates (OR 1.019, 95% CI [1.007; 1.031]). In conclusion, higher maternal Hb levels within the normal variation are an independent risk factor for GDM in this population but have little effect on perinatal outcome.

Maternal haemoglobin levels in pregnancy and child DNA methylation: a study in the pregnancy and childhood epigenetics consortium

Altered maternal haemoglobin levels during pregnancy are associated with pre-clinical and clinical conditions affecting the fetus. Evidence from animal models suggests that these associations may be partially explained by differential DNA methylation in the newborn with possible long-term consequences. To test this in humans, we meta-analyzed the epigenome-wide associations of maternal haemoglobin levels during pregnancy with offspring DNA methylation in 3,967 newborn cord blood and 1,534 children and 1,962 adolescent whole-blood samples derived from 10 cohorts. DNA methylation was measured using Illumina Infinium Methylation 450K or MethylationEPIC arrays covering 450,000 and 850,000 methylation sites, respectively. There was no statistical support for the association of maternal haemoglobin levels with offspring DNA methylation either at individual methylation sites or clustered in regions. For most participants, maternal haemoglobin levels were within the normal range in the current study, whereas adverse perinatal outcomes often arise at the extremes. Thus, this study does not rule out the possibility that associations with offspring DNA methylation might be seen in studies with more extreme maternal haemoglobin levels.

A retrospective cohort study of obstetric complications and birth outcomes in women with polycystic ovarian syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women and a high risk factor for adverse pregnancy complications. Therefore, we aimed to analyse the relationship between PCOS and pregnancy complications in a large sample from China. Additionally, since obesity and assisted reproductive technology (ART) are common in women with PCOS, we also aimed to determine whether both of these factors increased the complication incidence for women with PCOS. A retrospective cohort study that included 1357 pregnant women with PCOS and 6940 without PCOS was performed. Our results indicated women with PCOS had higher incidence of gestational diabetes mellitus (GDM), hypertension, postpartum haemorrhage, preterm birth, macrosomia and cervical incompetence. Additionally, obesity was associated with an increased incidence of hypertension and GDM in women with PCOS generally. ART did not result in an increase in the obstetric complication rate in women with PCOS. In conclusion, PCOS appeared to result in an increased risk of adverse pregnancy complications. Obesity may further increase the risks of hypertension and GDM among women with PCOS. However, ART did not increase the risk of pregnancy complications, which suggests that ART is a relatively safe and effective method to address infertility problems in women with PCOS.IMPACT STATEMENTWhat is already known on this subject? There are several studies evaluating the associations of PCOS with the risk of pregnancy complications. However, reports about the risk of pregnancy complications between PCOS women with and without obesity or ART are limited.What do the results of this study add? PCOS appeared to increase the risk of adverse pregnancy complications, including GDM, pregnancy-induced hypertension, postpartum haemorrhage, preterm birth, macrosomia and cervical incompetence. Obesity further increased the risks of hypertension and GDM in women with PCOS, but it did not increase the incidence of macrosomia and postpartum haemorrhage. Additionally, ART did not increase the risk of adverse pregnancy complications among women with PCOS, except for postpartum haemorrhage.What are the implications of these findings for clinical practice and/or further research? This study contributes to the literature because it showed that PCOS independently increased the risk of adverse pregnancy complications in a large sample of patients. Second, obesity is a high risk factor for adverse complications in pregnant women with PCOS. Third, ART is a relatively safe and effective method for addressing infertility problems for women with PCOS.

The risk factors of gestational diabetes mellitus in patients with polycystic ovary syndrome: What should we care

ABSTRACT

The influencing factors of gestational diabetes mellitus (GDM) in the polycystic ovary syndrome (PCOS) patients remain unclear, we aimed to investigate the risk factors of GDM in patients with PCOS, to provide reliable evidence for the prevention and treatment of GDM in PCOS patients.PCOS patients treated in our hospital from January 1, 2019 to October 31, 2020 were included. The personal and clinical treatment details of GDM and no GDM patients were analyzed. Logistic regressions were performed to analyze the factors influencing the occurrence of GDM.A total of 196 PCOS patients were included, the incidence of GDM in patients with PCOS was 23.98%. There were significant differences in the age, body mass index, insulin resistance index, fasting insulin, testosterone, androstenedione, and sex hormone-binding protein between GDM and no GDM patients with PCOS (all P < .05), and no significant differences in the family history of GDM, the history of adverse pregnancy, and multiple pregnancies were found (all P > .05). Age ≥30 years (odds ratio (OR) 2.418, 95% confidence interval (CI) 1.181-3.784), body mass index ≥24 kg/m2 (OR 1.973, 95%CI 1.266-3.121), insulin resistance index ≥22.69 (OR 2.491, 95%CI 1.193-4.043), fasting insulin ≥22.71 mIU/L (OR 2.508, 95%CI 1.166-5.057), testosterone ≥2.85 nmol/L (OR 1.821, 95%CI 1.104-2.762), androstenedione ≥6.63 nmol/L (OR 1.954, 95%CI 1.262-2.844), sex hormone-binding protein <64.22 nmol/L (OR 1.497, 95%CI 1.028-2.016) were the independent risk factors of GDM in patients with PCOS (all P < .05). The incidence of preeclampsia, premature delivery, premature rupture of membranes, polyhydramnios, and postpartum hemorrhage in the GDM group was significantly higher than that of the no-GDM group (all P < .05). There was no significant difference in the incidence of oligohydramnios between the 2 groups (P = .057).The incidence of GDM in PCOS patients is high, and the measures targeted at the risk factors are needed to reduce the occurrence of GDM in patients with PCOS.

No impact of gestational diabetes mellitus on pregnancy complications in women with PCOS, regardless of GDM criteria used

Polycystic ovary syndrome (PCOS) is characterized by the presence of insulin resistance, and women with PCOS have high prevalence of gestational diabetes (GDM). Both conditions have been associated with increased risk for pregnancy complications such as preterm birth, preeclampsia and increased offspring birth weight. We aimed to estimate the prevalence of GDM in women with PCOS using both previous and new diagnostic criteria, and to analyse whether the risk of pregnancy complications increased with the presence of GDM. In addition, we aimed to assess the response to metformin treatment in PCOS women with GDM. We performed post-hoc analysis of three prospective, double blinded studies of altogether 791 pregnant women with PCOS randomized to either metformin or placebo treatment from first trimester to delivery. Glucose data allowing GDM classification after previous (WHO 1999) and new (WHO 2013 and Norwegian 2017) diagnostic criteria were available for 722 of the women. Complications such as preeclampsia, late miscarriage and preterm birth, birth weight and gestational age were correlated to the presence of GDM and metformin treatment. The prevalence of GDM was 28.3% (WHO 1999), 41.2% (WHO 2013) and 27.2% (Norwegian 2017). Having GDM already in first trimester associated with increased risk for late miscarriage (p<0.01). Having GDM according to newer criteria correlated to increased maternal age and BMI (p<0.001). Otherwise, having GDM (any criteria) correlated neither to the development of preeclampsia, nor to birth weight z-score or the proportion of offspring being large for gestational weight. Maternal age and BMI, parity and gestational weight gain, but not GDM or metformin treatment, were determinants for birth weight z-score. Conclusion: in pregnant women with PCOS, having GDM did not increase the risk for other pregnancy complications except for an increased risk for late miscarriage among those with GDM already in the first trimester.

Fundamental Concepts and Novel Aspects of Polycystic Ovarian Syndrome: Expert Consensus Resolutions

Polycystic ovary syndrome (PCOS) is a very common endocrine and metabolic disorder with the involvement of both genetic and environmental factors. Although much has been clarified on its pathogenesis, diagnosis, clinical manifestations, and therapy, there are still areas of uncertainty. To address fundamental concepts, novel aspects and hypotheses, and future perspectives, including the possible additional benefits of treatment with nutraceuticals, an expert consensus panel formed by endocrinologists and gynecologists was established. After an independent review of the literature, the panel convened electronically on February 3, 2020, and six resolutions were created, debated, and agreed upon discussion, and finally approved in their final form in a consensus livestream meeting held on April 15. The summary of the resolutions are: (1) PCOS is a well-established medical condition that negatively affects reproduction, general health, sexual health, and quality of life; (2) the symptoms and signs of PCOS appear early in life especially in female newborns from PCOS carriers; (3) women with PCOS have significantly increased risk of pregnancy-related complications including gestational diabetes mellitus; (4) a male PCOS equivalent exists, and it may impact on metabolic health and probably on reproduction; (5) the evidence supports that medical therapy for PCOS is effective, rational, and evidence-based; (6) the evidence supports a major research initiative to explore possible benefits of nutraceutical therapy for PCOS. The proposed resolutions may be regarded as points of agreement based on the current scientific evidence available.

Normal Gestational Weight Gain Protects From Large-for-Gestational-Age Birth Among Women With Obesity and Gestational Diabetes

Background: Pre-pregnancy obesity, excess gestational weight gain (GWG), and gestational diabetes (GDM) increase fetal growth. Our aim was to assess whether normal GWG is associated with lower risk for a large-for-gestational-age (LGA; over the 90th percentile of birth weight for sex and gestational age) infant and lower birth weight standard deviation (SD) score in the presence of GDM and maternal obesity.

Methods: This multicenter case-control study is part of the Finnish Gestational Diabetes (FinnGeDi) Study and includes singleton pregnancies of 1,055 women with GDM and 1,032 non-diabetic controls. Women were divided into 12 subgroups according to their GDM status, pre-pregnancy body mass index (BMI; kg/m²), and GWG. Non-diabetic women with normal BMI and normal GWG (according to Institute of Medicine recommendations) served as a reference group.

Results: The prevalence of LGA birth was 12.2% among women with GDM and 6.2% among non-diabetic women (p < 0.001). Among all women, normal GWG was associated with lower odds of LGA [odds ratio (OR) 0.57, 95% CI: 0.41–0.78]. Among women with both obesity and GDM, the odds for giving birth to a LGA infant was 2.25-fold (95% CI: 1.04–4.85) among those with normal GWG and 7.63-fold (95% CI: 4.25–13.7) among those with excess GWG compared with the reference group. Compared with excess GWG, normal GWG was associated with 0.71 SD (95% CI: 0.47–0.97) lower birth weight SD score among women with GDM and obesity. Newborns of normal weight women with GDM and normal GWG had 0.28 SD (95% CI: 0.05–0.51) lower birth weight SD scores compared with their counterparts with excess GWG. In addition, in the group of normal weight non-diabetic women, normal GWG was associated with 0.46 SD (95% CI: 0.30–0.61) lower birth weight SD scores compared with excess GWG.

Conclusion: GDM, obesity, and excess GWG are associated with higher risk for LGA infants. Interventions aiming at normal GWG have the potential to lower LGA rate and birth weight SD scores even when GDM and obesity are present.

Perinatal outcome of in vitro fertilization pregnancies in women with polycystic ovary syndrome by pregravid BMI

OBJECTIVES

Given the adverse effects of either polycystic ovary syndrome (PCOS) or overweight/obesity, one could speculate that patients with both would fare worse than others. We sought to evaluate the relationship between pregravid BMI and pregnancy complications in PCOS patients conceived by assisted reproductive techniques (ART).

METHODS

Maternal and fetal/neonatal outcomes of singleton pregnancies after assisted reproduction in women with and without PCOS were compared by pregravid body mass index (BMI, <24.9 vs. ≥25 kg/cm²).

RESULTS

The study population comprised 185 with a BMI <24.9 kg/cm² including 39 (21%) with PCOS and 146 (79%) without. We also included 84 patients with BMI ≥25 kg/cm², involving 34 (40.5%) with PCOS and 50 (59.5%) without. PCOS (total 73 patients) was significantly more common among overweight/obese patients, OR 2.5 (95% CI 1.4, 4.4). Neonates >4,000 g were born only to the overweight/obese mothers in the PCOS group. A higher incidence of gestational diabetes, chronic hypertension, and gestational hypertension was related to pregravid overweight/obesity rather than PCOS.

CONCLUSIONS

In this specific subgroup of patients conceived after assisted reproduction, pregravid BMI>25 kg/cm² rather than PCOS itself appears to be associated with GDM and hypertensive disorders.

Increased risk markers in women with polycystic ovary syndrome and gestational diabetes mellitus during mid-pregnancy

Objective

This study aimed to investigate application of the urine albumin-to-creatinine ratio (ACR), serum beta 2-microglobulin (β2-MG), and cystatin C as risk markers in a cohort of women with polycystic ovary syndrome (PCOS) for the incidence of gestational diabetes mellitus (GDM).

Methods

In this cross-sectional study, we analyzed 312 pregnant women with PCOS and classified them as those with and without GDM. For all participants, elbow venous blood and clean middle urine were collected in the morning after 8 hours of an empty stomach.

Results

Logistic regression analysis showed that the ACR, urine β2-MG levels, and serum cystatin C levels were important markers for women with PCOS concomitant with GDM. Receiver operating characteristic curve analysis showed that the area under the curve of CysC was 0.81 with the threshold based on >0.93 and that of β2-MG was 0.72 with the threshold based on >1.25.

Conclusions

Increased levels of β2-MG and cystatin C and a high ACR might be risk factors for Chinese women with PCOS and GDM during mid-pregnancy.

Polycystic ovary syndrome as an independent risk factor for gestational diabetes and hypertensive disorders of pregnancy: a population-based study on 9.1 million pregnancies

STUDY QUESTION

Does polycystic ovary syndrome (PCOS) confer an independent risk for the development of gestational diabetes mellitus (GDM), gestational hypertension (GHTN) and preeclampsia (PEC) based on analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database.

SUMMARY ANSWER

After controlling for all potential confounding effects, women with PCOS are at a 2-fold higher risk of developing GDM, a 50% increased risk for the development of GHTN and a 30% increased risk of developing PEC than women without PCOS.

WHAT IS KNOWN ALREADY

Currently, there is evidence of an increased prevalence of maternal pregnancy complications in women with PCOS. However, there remain significant gaps in understanding how PCOS affects the development of GDM, GHTN and PEC. This is most likely due to the complex, multifactorial etiology of PCOS, its range of potential confounders for pregnancy complications and the variable methodology of studies that have been conducted. To date, the largest meta-analysis on this subject includes 11 565 women with PCOS analyzed for their risk of GDM and 5896 patients analyzed for their risk of PEC.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based study utilizing data from the HCUP-NIS over 11 years from 2004 to 2014. A dataset of all deliveries between 2004 and 2014 inclusively was created. Within this group, all deliveries to women with PCOS were identified as part of the study group (n = 14 882), and the remaining deliveries were categorized as non-PCOS births and comprised the reference group (n = 9 081 906).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The HCUP-NIS is the largest inpatient sample database in the USA and is comprised of hospital inpatient stays submitted by hospitals throughout the entire country. Each year, the database provides information relating to 7 million inpatient stays, including patient characteristics, diagnosis and procedures. The data are representative of ∼20% of admissions to US hospitals across 48 states and the District of Columbia.

MAIN RESULTS AND THE ROLE OF CHANCE

At baseline, more pregnant women with PCOS were obese (22.3% vs. 3.5%, P < 0.001), had chronic hypertension (HTN) (8.4% vs. 1.8%, P < 0.001), had pregestational diabetes (4.1% vs. 0.9%, P < 0.001) and had treated thyroid disease (12.6% vs. 2.4%, P < 0.001). Women with PCOS were also more likely to have undergone IVF treatment (2.4% vs. 0.1%, P < 0.001), have multi-gestation pregnancies (5.9% vs. 1.5%, P < 0.001), and more multiple gestations (MGs) in the PCOS group were the result of IVF treatment than the non-PCOS groups (12.3% vs. 2.3%, P < 0.001). In all pregnancies, women with PCOS were more likely to develop gestational diabetes (adjusted odds ratio (aOR) 2.19, 95% CI 2.02-2.37), pregnancy associated HTN (aOR 1.38, 95% CI 1.27-1.50, P < 0.001), GHTN (aOR 1.47, 95% CI 1.31-1.64), PEC (aOR 1.29, 95% CI 1.14-1.45) and superimposed PEC (aOR 1.29, 95% CI 1.04-1.59) after controlling for confounding effects (age, race, income level, insurance type, obesity, IVF use, previous cesarean section, chronic HTN, pregestational diabetes, thyroid disease, MG, smoking and recreational drug use). Odds ratios were comparable between all pregnancies and singleton pregnancies only. In women pregnant with multiple fetuses, PCOS only conferred a statistically significant increased risk of developing GDM (aOR 2.33, 95% CI 1.92-2.83, P < 0.001). However, there was a trend toward an increased risk for developing pregnancy associated HTN (aOR 1.92, 95% CI 0.99-1.42, P = 0.058).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective analysis utilizing an administrative database which relies on the accuracy and consistency of the individuals coding the data. There are known limitations in how accurately hospital coding is able to capture perinatal conditions and complications, making it difficult to know with certainty that such events are accurate.

WIDER IMPLICATIONS OF THE FINDINGS

Pregnant women with PCOS are at increased risk of adverse complications in pregnancy even when they do not present with other coexisting metabolic conditions. Furthermore, it is important to also consider the risk of all other coexisting metabolic conditions frequently encountered in PCOS women, as these risks are additive and place women with PCOS at significantly increased risk for adverse complications in pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Obesity and the Risk of Infertility, Gestational Diabetes, and Type 2 Diabetes in Polycystic Ovary Syndrome

This review describes the relationship between obesity and the most common reproductive (infertility) and metabolic (gestational diabetes mellitus [GDM] and type 2 diabetes mellitus [T2DM]) consequences in polycystic ovary syndrome (PCOS). It also describes the vital role of lifestyle management for PCOS. PCOS is a heterogeneous endocrine disorder common in reproductive-age women. Consensus on the exact etiological mechanisms of PCOS is unreached. Overweight or obesity is present in at least 60% of the PCOS population, but the condition occurs irrespective of BMI, with excess BMI increasing both the prevalence and severity of clinical features. Use of lifestyle therapies (nutrition, physical activity, and/or behavioral) for the prevention and management of excess weight gain, infertility, GDM, and T2DM is a vital component of best-practice PCOS care. Lifestyle management is recommended for all women with PCOS as the first-line treatment with or without medications. Due to a lack of high-quality trials demonstrating the efficacy of specific lifestyle approaches, PCOS lifestyle recommendations are as those for the general population. This review summarizes current knowledge relating to obesity and its impact on fertility, GDM, and T2DM. It also summarizes the lifestyle recommendations to best manage these conditions in women with PCOS and obesity.

Polycystic Ovarian Syndrome and Fertility

Polycystic ovary syndrome (PCOS) is a common endocrinopathy that has been associated with impaired fertility. This chapter reviews the underlying pathophysiology of PCOS and the associated fertility barriers of the condition. Psychologic concerns, hypothalamic-pituitary, ovarian, and mitochondria dysfunction, obesity, and the role of vitamin D in PCOS are considered with respect to fertility. Lastly, pregnancy risk factors associated with PCOS are also reviewed.

Resistance to the Insulin and Elevated Level of Androgen: A Major Cause of Polycystic Ovary Syndrome

PCOS has a wide range of negative impacts on women's health and is one of the most frequent reproductive systemic endocrine disorders. PCOS has complex characteristics and symptom heterogeneity due to the several pathways that are involved in the infection and the absence of a comm14on cause. A recent study has shown that the main etiology and endocrine aspects of PCOS are the increased level of androgen, which is also known as "hyperandrogenemia (HA)" and secondly the "insulin resistance (IR)". The major underlying cause of the polycystic ovary is these two IR and HA, by initiating the disease and its severity or duration. As a consequence, study on Pathogenesis is crucial to understand the effect of "HA" and "IR" on the pathophysiology of numerous symptoms linked to PCOS. A deep understanding of the pattern of the growth in PCOS for HA and IR can help ameliorate the condition, along with adjustments in nutrition and life, as well as the discovery of new medicinal products. However, further research is required to clarify the mutual role of IR and HA on PCOS development.

Inositols in PCOS

(1) Background: Myoinositol (MI) and D-chiro-inositol (DCI) are involved in a number of biochemical pathways within oocytes having a role in oocyte maturation, fertilization, implantation, and post-implantation development. Both inositols have a role in insulin signaling and hormonal synthesis in the ovaries. (2) Methods: Literature search (with key words: inositols, myo-inositol, d-chiro-inositol, PCOS) was done in PubMed until Sept. 2020 and 197 articles were identified, of which 47 were of clinical trials (35 randomized controlled trials). (3) Results: Many studies have demonstrated that in patients with polycystic ovarian syndrome (PCOS) MI treatment improved ovarian function and fertility, decreased the severity of hyperandrogenism including acne and hirsutism, positively affected metabolic aspects, and modulated various hormonal parameters deeply involved in the reproductive axis function and ovulation. Thus treating with MI has become a novel method to ameliorate PCOS symptoms, improve spontaneous ovulation, or induce ovulation. The current review is focused on the effects of MI and DCI alone or in combination with other agents on the pathological features of PCOS with focus on insulin resistance and adverse metabolic outcomes. (4) Conclusions: The available clinical data suggest that MI, DCI, and their combination in physiological ratio 40:1 with or without other compound could be beneficial for improving metabolic, hormonal, and reproductive aspects of PCOS.

Genetic construction between polycystic ovarian syndrome and type 2 diabetes

Polycystic ovarian syndrome (PCOS) in reproductive-aged women is identified to be one of the endocrine disorders. This heterogeneous disorder is categorized through oligo-anovulation and hyperandrogenemia. National institutes of health and Rotterdam criterions were used to diagnose PCOS women. Type 2 Diabetes (T2D) is one of the complications in PCOS which is connected through insulin resistance (IR), which is a condition in which liver, muscles and fat infrequently respond to the hormones, and this leads to extreme IR and consequently leads to T2D disease. PCOS is inherited by the autosomal dominant mode of inheritance and may also with the different intricate patterns. Till now, many studies have been performed in PCOS with the genes identified by T2D and till now no studies have shown the similar genetic association and pathophysiology between both the diseases. So, the current review aims to investigate the genetic relation between PCOS and T2D and why both the diseases cannot be reverted. In this review, published data were screened with the T2D related genes and single nucleotide polymorphisms in PCOS women. The case-control, hospital-based and meta-analysis molecular studies disclosed both positive and negative connotations. Genetically, no relationship has been established between PCOS and T2D. Maximum studies have shown as PCOS women had developed T2D later in life because as a risk-factor, but none of the studies documented T2D women having developed PCOS as a risk factor. Apart from this, the disease PCOS is developed in women with reproductive age and T2D develops in both the men and women during adulthood. This review concludes as there is a genetic relation only in between PCOS and T2D, but not with T2D to PCOS and further it cannot be explicitly reverted from T2D to PCOS.

Impact of comorbid polycystic ovarian syndrome and gestational diabetes mellitus on pregnancy outcomes: a retrospective cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) have been associated with adverse maternal and neonatal outcomes, but the evidence on the impact of coexistent PCOS and GDM is rather limited and inconclusive. We investigated the impact of comorbid PCOS on pregnancy outcomes among women with GDM.

METHODS

This retrospective cohort study included women diagnosed with GDM on 75 g oral glucose tolerance test on routine antenatal screening tests at Liverpool Hospital between February 2015 and January 2019. Women were then grouped into those with and without PCOS based on the Rotterdam criteria. The demographic details, clinical data and pregnancy outcomes were compared between the two groups.

RESULTS

Among the 1545 women with GDM included in the study, there were 326 women with PCOS. Women with GDM and PCOS (GDM⁺PCOS⁺) were younger (29.5 years vs 31.5 years, p < 0.001), more likely to be primigravidae (31.9% vs 20%, p < 0.001), as well as of Caucasian descent (37.4% vs 21.7%, p < 0.001). PCOS was an independent risk factor for the development of preeclampsia on regression analysis (OR 2.06, p = 0.021). Women with PCOS and GDM had a higher body mass index (31.5 kg/m² vs 27.7 kg/m², p < 0.001), significant gestational weight gain (12.6 kg vs 11.5 kg, p = 0.016), and more frequent use of pharmacotherapies to manage their GDM (57.7% vs 45.2%, p < 0.001). There was no statistically significant difference in the rates of adverse neonatal outcomes in both the groups.

CONCLUSION

Among women with GDM, PCOS was an independent risk factor for the development of preeclampsia and significant gestational weight gain, warranting vigilant monitoring of blood pressure, blood glucose levels and body weight, and implementing timely interventions to improve obstetric and neonatal outcomes.

Gestational Diabetes Mellitus: A Harbinger of the Vicious Cycle of Diabetes

Gestational diabetes mellitus (GDM), characterized by a transitory form of diabetes induced by insulin resistance and pancreatic β-cell dysfunction during pregnancy, has been identified as one of the major obstacles in achieving improved maternal and child health. Approximately 9-25% of pregnancies worldwide are impacted by the acute, long-term, and transgenerational health complications of this disease. Here, we discuss how GDM affects longstanding maternal and neonatal outcomes, as well as health risks that likely persist into future generations. In addition to the current challenges in the management and diagnosis of and the complications associated with GDM, we discuss current preclinical models of GDM to better understand the underlying pathophysiology of the disease and the timely need to increase our scientific toolbox to identify strategies to prevent and treat GDM, thereby advancing clinical care.

Fundamental Concepts and Novel Aspects of Polycystic Ovarian Syndrome: Expert Consensus Resolutions

Polycystic ovary syndrome (PCOS) is a very common endocrine and metabolic disorder with the involvement of both genetic and environmental factors. Although much has been clarified on its pathogenesis, diagnosis, clinical manifestations, and therapy, there are still areas of uncertainty. To address fundamental concepts, novel aspects and hypotheses, and future perspectives, including the possible additional benefits of treatment with nutraceuticals, an expert consensus panel formed by endocrinologists and gynecologists was established. After an independent review of the literature, the panel convened electronically on February 3, 2020, and six resolutions were created, debated, and agreed upon discussion, and finally approved in their final form in a consensus livestream meeting held on April 15. The summary of the resolutions are: (1) PCOS is a well-established medical condition that negatively affects reproduction, general health, sexual health, and quality of life; (2) the symptoms and signs of PCOS appear early in life especially in female newborns from PCOS carriers; (3) women with PCOS have significantly increased risk of pregnancy-related complications including gestational diabetes mellitus; (4) a male PCOS equivalent exists, and it may impact on metabolic health and probably on reproduction; (5) the evidence supports that medical therapy for PCOS is effective, rational, and evidence-based; (6) the evidence supports a major research initiative to explore possible benefits of nutraceutical therapy for PCOS. The proposed resolutions may be regarded as points of agreement based on the current scientific evidence available.

Associations between pre-pregnancy body mass index and gestational weight gain with pregnancy outcomes in women with polycystic ovary syndrome

BACKGROUND

The influence of pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) on perinatal outcomes of women with polycystic ovary syndrome (PCOS) remains unclear. Therefore, we explored how the above indicators influence pregnancy outcomes in women with PCOS.

METHODS

A retrospective study was conducted involving the baseline characteristics, laboratory data, and pregnancy outcomes of 722 pregnant women with PCOS. Subjects were grouped in a way to find out risks in their pregnancy outcomes. Multivariable logistic regression analysis was performed to investigate how BMI and GWG were associated with perinatal outcomes.

RESULTS

Among women with PCOS, underweight increased the risk of small for gestational age (SGA) (OR 12.35, 95% CI 3.56-42.82), but reduced the risk of large for gestational age (LGA). Overweight but not obese women were more susceptible to developing preeclampsia (PE) than women with normal weight. In PCOS women with BMI < 25 kg/m² before pregnancy, inadequate GWG was a protective factor for gestational hypertension (GH) and postpartum hemorrhage (PPH), excessive GWG exhibited a positive correlation with LGA. But in PCOS women with BMI ≥ 25 kg/m², excessive GWG increased the probability of undergoing a cesarean section. Inadequate GWG did not reduce the likelihood of LGA in women with BMI ≥ 25 kg/m², and excessive GWG did not reduce the probability of SGA in women with BMI < 25 kg/m².

CONCLUSION

The impacts of pre-pregnancy BMI, GWG on maternal and infant outcomes among PCOS women are similar to reported results in general pregnant women. However, some unique trends were also observed in PCOS women. While the underweight factor significantly increased the risk of SGA birth, overweight but not obesity was correlated with the risk of PE. Inadequate GWG was a protective factor for GH and PPH only in women with pregestational BMI < 25 kg/m². Inadequate GWG did not reduce the probability of LGA in women with BMI ≥ 25 kg/m², and similarly, excessive GWG did not reduce the probability of SGA in women with BMI < 25 kg/m². Overall, these findings indicate that women with PCOS should begin weight management before pregnancy.

Maternal abdominal subcutaneous fat thickness as a simple predictor for gestational diabetes mellitus

Background To date, only a limited number of studies have evaluated the importance of abdominal subcutaneous fat thickness (ASFT) on gestational diabetes mellitus (GDM) screening. The aim of this study was to investigate the effectiveness of ASFT measurement during routine obstetric ultrasound performed between 24 and 28 weeks of gestation in predicting cases with GDM. Methods This prospective comparative study was conducted on 50 cases with GDM and 50 cases without GDM in the GDM screening program at 24-28 gestational weeks between January 2018 and May 2018. The most accurate ASFT cut-off point values were determined for the prediction of cases with GDM by performing receiver operator characteristic (ROC) curve analysis. Results The ASFT was higher in those with GDM compared to those without GDM (P < 0.05). For an ASFT cut-off point value of 18.1 mm for the prediction of cases with GDM, the sensitivity, specificity, negative and positive predictive values were 72.0%, 60.0%, 64.2% and 68.1%, respectively. The risk of GDM increased 3.86-fold in those with ASFT level >18.1 mm (P = 0.001). Conclusion The ASFT value measured by routine obstetric ultrasound performed at 24-28 weeks of gestation was found to be significantly higher in patients with GDM in comparison to those without GDM. However, further multi-centered and comprehensive prospective studies are required to better demonstrate this relationship.

[Risk factors analysis of gestational diabetes mellitus based on International Association of Diabetes Pregnancy Study Groups criteria]

OBJECTIVE

To study the risk factors for gestational diabetes mellitus (GDM).

METHODS

This retrospective case-control study was conducted among women registered at the Department of Obstetrics of West China Second University Hospital between March, 2016 and May, 2018. The women were divided into case group (GDM) and control group (Non- GDM) according to the diagnosis of GDM based on the International Association of Diabetes Pregnancy Study Groups (IADPSG) criteria. The data including age, education level, ethnicity and other socio-demographic data, as well as the gestational week, parity, polycystic ovary syndrome, family history of diabetes, fat mass, total body water, minerals and other clinical characteristics were collected. Univariate Logistic regression analysis was performed and the variables with statistical difference and clinical significance were included in multivariate Logistic regression analysis to identify the risk factors of GDM.

RESULTS

A total of 3608 pregnant women were included in the study. Univariate logistic analysis revealed that age, previous GDM, intracellular/extracellular water, fat mass, arm circumference, skeletal muscle mass were risk factors for GDM. Multivariate logistic analysis showed that age, previous GDM, family history of DM, and an arm circumference ≥28.5 cm were independent risk factors for GDM after controlling pre-pregnancy BMI. The risk of GDM in pregnant women aged 30-35 years and 36 years or older was 1.883 (P < 0.001) and 2.883 (P < 0.001) times of that in women aged 20-29 years, respectively. Women with a history of GDM had a 6.604 (P < 0.001) greater risk of developing GDM than women without a history of GDM. Compared with those without a family history of diabetes, those with a family history of diabetes were 2.518 times more likely to develop GDM (P < 0.001). Compared with those with an arm circumference no greater than 25.5 cm, pregnant women with an arm circumference over 28.5 cm had an increased risk of GDM by 2.815 times (P < 0.001). High fat free mass was a protective factor for GDM, and compared with a fat free mass below 35.1 kg, a fat free mass over 40.1 kg was associated with a lowered risk of GDM by 0.515 times (P < 0.001).

CONCLUSIONS

The onset of GDM was affected by multiple factors. Age, history of GDM, family history of diabetes, and a large arm circumference are all independent risk factors of GDM and should be controlled to reduce the incidence of GDM.

Early pregnancy metabolic factors associated with gestational diabetes mellitus in normal-weight women with polycystic ovary syndrome: a two-phase cohort study

BACKGROUND

Polycystic ovary syndrome (PCOS) has been consistently associated with subsequent gestational diabetes mellitus (GDM). Women with PCOS showed a high prevalence of obesity, which raises the question regarding the role of obesity or PCOS pe ser in development of GDM. In this study we conducted a 2-phase study to compare the risk of GDM and its associated early pregnancy metabolic factors in women with and without PCOS, stratified by pre-pregnancy body mass index (BMI).

METHODS

A 2-phase design was used in this study. The initial phase of the study included 566 age- and pre-pregnancy BMI-matched singleton pregnant women (242 with and 324 without PCOS). Risk of GDM and associated early-pregnancy risk factors were explored between women with and without PCOS, after stratification by pre-pregnancy BMI. Stratified analysis was conducted in normal weight (pre-pregnancy BMI < 25 kg/m²) and overweight/obese (pre-pregnancy BMI ≥ 25 kg/m²) groups. Subsequently, the findings was confirmed in a separate cohort study with 18,106 participants (877 with and 17,229 without PCOS).

RESULTS

Overall, prevalence of GDM is higher in women with PCOS. Results from the initial study showed that in normal-weight subjects, there is a significant increase in GDM prevalence in PCOS women than non-PCOS women (26.5% vs. 16.2%, p = 0.02). Additionally, normal-weight PCOS women showed higher triglycerides levels (1.51 ± 0.84 mmol/L vs. 1.30 ± 0.75 mmol/L, p = 0.02), lower SHBG levels (277.8 ± 110.2 nmol/L vs. 330.5 ± 180.4 nmol/L, p = 0.001) and a possible trend towards higher insulin resistance (LogHoMA-IR 0.70 ± 0.55 vs. 0.57 ± 0.57, p = 0.05) during early pregnancy. However, in overweight/obese group, no difference in risk of GDM was observed between PCOS and non-PCOS subjects (p = 0.7). Results from the independent cohort confirmed the risk for GDM associated with PCOS in normal weight women (p < 0.0001).

CONCLUSION

Consistent findings from the 2-phase study showed an increased risk of GDM in normal-weight, but not overweight/obese PCOS women. Analysis of early-pregnancy risk factors of GDM suggested that the pathogenesis of GDM in normal weight and overweight/obese women with PCOS may be different.

Antidiabetic medication use during pregnancy: an international utilization study

OBJECTIVE

Diabetes in pregnancy and consequently the need for treatment with antidiabetic medication (ADM) has become increasingly prevalent. The prevalence and patterns of use of ADM in pregnancy from 2006 onward in seven different countries was assessed.

RESEARCH DESIGN AND METHODS

Data sources included individually linked data from the nationwide health registers in Denmark (2006-2016), Finland (2006-2016), Iceland (2006-2012), Norway (2006-2015), Sweden (2006-2015), state-wide administrative and claims data for New South Wales, Australia (2006-2012) and two US insurance databases: Medicaid Analytic eXtract (MAX; 2006-2012, public) and IBM MarketScan (2012-2015, private). The prevalence of ADM use was calculated as the proportion of pregnancies with at least one filled prescription of an ADM in the 90 days before pregnancy or within the three trimesters of pregnancy.

RESULTS

Prevalence of any ADM use in 5 279 231 pregnancies was 3% (n=147 999) and varied from under 2% (Denmark, Norway, and Sweden) to above 5% (Australia and US). Insulin was the most used ADM, and metformin was the most used oral hypoglycemic agent with increasing use over time in all countries. In 11.4%-62.5% of pregnancies with prepregnancy use, ADM (primarily metformin) was discontinued. When ADM treatment was initiated in late pregnancy for treatment of gestational diabetes mellitus, insulin was most often dispensed, except in the US, where glibenclamide was most often used.

CONCLUSIONS

Prevalence and patterns of use of ADM classes varied between countries and over time. While insulin remained the most common ADM used in pregnancy, metformin use increased significantly over the study period.

Abnormal irisin level in serum and endometrium is associated with metabolic dysfunction in polycystic ovary syndrome patients

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive-age women. Irisin is considered to play a role in metabolic disorder and PCOS. However, correlation between irisin and metabolic disorder in PCOS is not clear.

MATERIAL AND METHODS

This is a prospective study. Forty patients with PCOS and thirty patients without PCOS were recruited for in vitro fertilization and embryo transfer (IVF-ET). All PCOS women fulfilled all three Rotterdam consensus criteria. In each group, patients were also divided into obese and nonobese patients, and patients with or without dyslipidaemia.

RESULTS

Serum irisin level in PCOS patients was significantly reduced. Irisin level in obese PCOS patients was significantly lower than in nonobese PCOS patients. Irisin level in PCOS patients with dyslipidaemia was significantly higher than in PCOS patients with normal blood lipid profile. In both PCOS and control patients, serum irisin level was negatively correlated with body weight and waist-hip ratio (WHR). Moreover, serum irisin level was positively correlated with body fat rate, BAI, fasting plasma glucose (FPG) and HOMA-IR in PCOS patients. In addition, serum irisin level was positively correlated with HOMA-IR in control patients. In PCOS patients, body weight and HOMA-IR could predict the level of irisin. In control patients, body mass index (BMI) could predict the level of irisin. Expression of irisin in PCOS patients was lower than that in control patients. However, there was no significant difference of irisin expression between the subdivided groups in PCOS and control patients.

CONCLUSIONS

Taken together, the present findings enriched the knowledge about the role of irisin in metabolic dysfunction in PCOS patients.