Increased risk of hypertension after gestational diabetes mellitus: findings from a large prospective cohort study

Characterization of human placental fetal vessels in gestational diabetes mellitus

Gestational diabetes mellitus is one of the most common complications during pregnancy. Its prevalence is rapidly increasing worldwide. Gestational diabetes mellitus is leading to an elevated risk for the development of endothelial dysfunction and cardiovascular diseases both in the mother and the child in later life. The underlying pathophysiological mechanisms are not well-understood. Therefore, we aimed to characterize the endothelial function in fetal placental vessels from mothers with gestational diabetes mellitus. In this study, we distinguished between insulin-treated and diet-controlled gestational diabetes mothers and compared them to a normoglycemic control group. The clinical data confirmed pre-conceptional overweight as a risk factor in women with insulin-treated gestational diabetes mellitus. The insulin-treated gestational diabetes group was also characterized by a recent family history of diabetes compared to mothers of the control or diet-controlled gestational diabetes group. Analyses of blood serum from umbilical cords suggested a reduced fetal insulin metabolism in the insulin-treated gestational diabetes group. Vascular function analysis in fetal placental vessels revealed an altered substance P-induced vasorelaxation in vessels from patients with insulin-dependent gestational diabetes. Inhibition of nitric oxide synthase affected only fetal vessel segments from the control group or diet-controlled gestational diabetes group, but not from insulin-dependent gestational diabetes. Finally, we found a significantly decreased substance P receptor (TACR1) mRNA expression in fetal vessel segments from patients with insulin-treated gestational diabetes. In conclusion, we provide evidence that different pathophysiological mechanisms might be responsible for the development of insulin-treated versus diet-controlled gestational diabetes. Only in fetal vessels from patients with insulin-treated gestational diabetes were we able to detect an endothelial dysfunction and a reduced fetal insulin conversion. This provides novel insights into the pathophysiology of the subtypes of gestational diabetes.

Associations of prognostic nutritional index with risk of all-cause and cardiovascular disease mortalities in persons with gestational diabetes mellitus: A NHANES-based analysis

OBJECTIVE

To investigate relationships between prognostic nutritional index (PNI) during pregnancy and risk of all-cause mortality (ACM) and cardiovascular disease (CVD) mortality in persons with gestational diabetes mellitus (GDM).

METHODS

A cross-sectional study was conducted using NHANES data from 2007 to 2018, and weighted Cox regression models were established. Restricted cubic spline analysis was used to unveil associations of PNI with risk of ACM and CVD mortalities in individuals with GDM. Receiver operating characteristic curve was employed for determination of threshold value for association of PNI with mortality. Sensitivity analysis was performed to verify the stability of the results.

RESULTS

734 GDM individuals and 7987 non-GDM individuals were included in this study. In GDM population, after adjusting for different categorical variables, PNI was significantly negatively correlated with ACM risk. Subgroup analysis showed that among GDM populations with no physical activity, moderate physical activity, parity of 1 or 2, negative correlation between PNI and risk of ACM was stronger than other subgroups. Sensitivity analysis results showed stable negative correlations between PNI and ACM and CVD mortality of total population, and between PNI and ACM of GDM.

CONCLUSION

In individuals with GDM, PNI was negatively correlated with ACM risk, especially in populations with no physical activity, moderate physical activity, and parity of 1 or 2. PNI = 50.75 may be an effective threshold affecting ACM risk in GDM, which may help in risk assessment and timely intervention for individuals with GDM.

Patterns of Gestational Hypertension or Preeclampsia Across 2 Pregnancies in Relationship to Chronic Hypertension Development: A Retrospective Cohort Study

BACKGROUND

Gestational hypertension (GHTN) and preeclampsia are established risk indicators for chronic hypertension. While recurrence is associated with a greater risk, it is unclear whether there are differences in risk when these gestational complications occur for the first time in an earlier pregnancy versus first occurrence in a subsequent one. We hypothesized that the absence of recurrence reflects a transition toward a lower hypertension risk trajectory, whereas a new occurrence in a later pregnancy indicates a transition toward elevated risk.

METHODS AND RESULTS

We analyzed linked data in Quebec, Canada, from public health care insurance administrative databases and birth, stillbirth, and death registries. Our retrospective cohort study included mothers with 2 singleton deliveries between April 1990 and December 2012. The primary exposure was patterns of GHTN or preeclampsia across 2 pregnancies (GHTN/preeclampsia in neither, first only, second only, or both). The outcome was incident chronic hypertension. We performed an adjusted multivariable Cox regression analysis. Among 431 980 women with 2 singleton pregnancies, 27 755 developed hypertension during the follow-up period. Compared with those without GHTN/preeclampsia, those with GHTN/preeclampsia only in the first pregnancy had a 2.7-fold increase in hazards (95% CI, 2.6-2.8), those with GHTN/preeclampsia only in the second had a 4.9-fold increase (95% CI, 4.6-5.1), and those with GHTN/preeclampsia in both pregnancies experienced a 7.3-fold increase (95% CI, 6.9-7.6). Patterns and estimates were similar when we considered GHTN and preeclampsia separately.

CONCLUSIONS

The magnitude of hypertension risk is associated with the number and sequence of GHTN/preeclampsia-affected pregnancies. Considering both allows more personalized risk estimates.

Female-specific risk factors for cardiovascular disease: an update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. While it was previously believed that men have greater susceptibility to CVD, recent research suggests that women face an increased risk of CVD after the onset of menopause, primarily due to the loss of the protective effects of estrogens. Premature ovarian insufficiency (POI), polycystic ovarian syndrome (PCOS), and gestational factors, such as gestational diabetes mellitus (GDM), recurrent pregnancy loss, preterm delivery, and preeclampsia, are specific reproductive disorders that may contribute to an elevated risk of CVD at earlier ages, i.e., before the onset of menopause. This suggests that women with these conditions should be closely monitored for CVD risk factors even before reaching menopause. Such early intervention may help reduce the incidence of CVD and improve overall cardiovascular health in this population. The precise pathophysiological mechanism underlying the development of CVD in women with menopause, premature POI, PCOS, and gestational factors remains elusive. This review article seeks to elucidate the latest research on the relationship between these conditions and CVD in women, aiming to explore the underlying pathogenic mechanisms contributing to this association.

Association Between Gestational Diabetes Mellitus and Hypertension: A Systematic Review and Meta-Analysis of Cohort Studies With a Quantitative Bias Analysis of Uncontrolled Confounding

BACKGROUND

Whether individuals with gestational diabetes mellitus (GDM) had an increased risk of hypertension remains unclear. We conducted a systematic literature review and meta-analysis to examine the association between GDM and hypertension and performed a quantitative bias analysis to quantify the impact of uncontrolled confounding due to antenatal psychological stress.

METHODS

We searched databases (PUBMED, EMBASE, and Web of Science) through 2022/11. Eligible studies were cohort studies that reported the association of GDM with hypertension. We assessed the risk of bias using the Newcastle-Ottawa Scale for cohort studies. We pooled adjusted risk ratios with 95% CIs using a random effects model. We performed the quantitative bias analysis using the bias formula.

RESULTS

We included 15 cohort studies, with a total of 3 959 520 (GDM, 175 378; non-GDM, 3 784 142) individuals. During the follow-up of 2 to 20 years, 106 560 cases of hypertension were reported. We found that GDM was associated with a higher risk of hypertension (pooled risk ratio, 1.78 [95% CI, 1.47, 2.17]). The risk ratio was lower among cohorts assessing incident (1.58 [95% CI, 1.29, 1.95]) than prevalent hypertension (2.60 [95% CI, 2.40, 2.83]). However, other subgroup analyses showed no differences. The quantitative bias analysis revealed that if the uncontrolled confounder of antenatal psychological stress was additionally adjusted, the positive association between GDM and hypertension would attenuate slightly (≤18%) but remains positive.

CONCLUSIONS

Limitations of this study included residual confounding and discrepancies in GDM and hypertension ascertainments. Our findings indicate that GDM is positively associated with hypertension after the index pregnancy.

Do WHO criteria for gestational diabetes fit a rural population in Tanzania? - A follow-up study assessing mother and child health six years after a pregnancy diagnosed with gestational diabetes

AIMS AND METHODS

In low- and middle- income countries (LMICs) consequences of gestational diabetes (GDM) is understudied. Using a prospective cohort of mothers (n = 197)and children (n = 251), from rural north-eastern Tanzania, we assessed prediabetes and type 2 diabetes (T2D) prevalence six years after a pregnancy with/without GDM.

RESULTS

The prevalence of prediabetes (49.4 % vs. 46.4 %) orT2D (20.0 % vs. 16.1 %), p ≥ 0.36, based on fasting plasma glucose (FPG) or HbA1clevels (prediabetes: 16.9 % vs. 13.8 % and T2D 1.2 % vs. 0 %, p = 0.47), andcardio-metabolic health parameters,weresimilar between women with/without previous GDM. These results were supported by similar perinatal outcomes and child health at follow-up.The overall prevalence ofprediabetes/T2D was high, but no differences in other cardio-metabolic risk markers were observed in women with prediabetes/T2D compared to women with normal glucose tolerance.

CONCLUSIONS

Despite high prevalence of GDM amongTanzanian women, the diagnosis was not associated with adverse pregnancy outcomes, nor with increased risk of prediabetes or T2D at follow-up. FPG and HbA1c may be poor markers for diabetes in this population, and further follow-up studies with longer time intervals are warranted to evaluate which GDM diagnostic criteria are most optimal for women in rural Tanzania and similar LMIC settings.

Gestational diabetes-related gut microbiome dysbiosis is not influenced by different Asian ethnicities and dietary interventions: a pilot study

Gut microbiome dysbiosis contributes to the pathophysiology of both gestational diabetes mellitus (GDM) and its associated adverse outcomes in the woman and offspring. Even though GDM prevalence, complications, and outcomes vary among different ethnic groups, limited information is available about the influence of ethnicity on gut microbiome dysbiosis in pregnancies complicated by GDM. This pilot prospective cohort study examined the impact of ethnicity on gut dysbiosis in GDM among three Asian ethnic groups (Chinese, Malay, Indian) living in Singapore, and investigated the potential modulatory roles of diet and lifestyle modifications on gut microbiome post-GDM diagnosis. Women with GDM (n = 53) and without GDM (n = 16) were recruited. Fecal samples were collected at 24-28- and 36-40-weeks' gestation and analyzed by targeted 16S rRNA gene-based amplicon sequencing. Permutational multivariate analysis of variance (PERMANOVA) analysis was performed to evaluate differences between groups. Differentially abundant taxa were identified by DeSeq2 based analysis. Functional prediction was performed using the phylogenetic investigation of communities by reconstruction of unobserved states (PICRUSt2). Among women with GDM, gut microbiome from different ethnicities harbored common microbial features. However, among those without GDM, there was contrasting microbiome composition between ethnic groups. Microbial members such as Collinsella, Blautia, Ruminococcus, Ruminococcus gnavus, Ruminococcus torques, and Eubacterium hallii groups were differentially enriched (p < 0.05) in women with GDM compared to those without. Among women with GDM, no differences in alpha- and beta- diversity were observed when comparing 24-28 weeks' samples with 36-40 weeks' samples, a period covering intense dietary and lifestyle modification, suggesting an inability to modulate gut microbiota through classic GDM management. Women with GDM have a distinct gut microbiome profile which harbours common features across different Asian ethnic groups, consistent with the notion that specific microbes are involved in the pathogenesis of insulin resistance, pro-inflammatory conditions, and other metabolic dysregulation known to be present in GDM.

Genetic and inflammatory factors underlying gestational diabetes mellitus: a review

Gestational diabetes mellitus (GDM) poses a significant global health concern, impacting both maternal and fetal well-being. Early detection and treatment are imperative to mitigate adverse outcomes during pregnancy. This review delves into the pivotal role of insulin function and the influence of genetic variants, including SLC30A8, CDKAL1, TCF7L2, IRS1, and GCK, in GDM development. These genetic variations affect beta-cell function and insulin activity in crucial tissues, such as muscle, disrupting glucose regulation during pregnancy. We propose a hypothesis that this variation may disrupt zinc transport, consequently impairing insulin production and secretion, thereby contributing to GDM onset. Furthermore, we discussed the involvement of inflammatory pathways, such as TNF-alpha and IL-6, in predisposing individuals to GDM. Genetic modulation of these pathways may exacerbate glucose metabolism dysregulation observed in GDM patients. We also discussed how GDM affects cardiovascular disease (CVD) through a direct correlation between pregnancy and cardiometabolic function, increasing atherosclerosis, decreased vascular function, dyslipidemia, and hypertension in women with GDM history. However, further research is imperative to unravel the intricate interplay between inflammatory pathways, genetics, and GDM. This understanding is pivotal for devising targeted gene therapies and pharmacological interventions to rectify genetic variations in SLC30A8, CDKAL1, TCF7L2, IRS1, GCK, and other pertinent genes. Ultimately, this review offers insights into the pathophysiological mechanisms of GDM, providing a foundation for developing strategies to mitigate its impact.

The Risk of Hypertension and Diabetes Mellitus According to Offspring's Birthweight in Women With Normal Body Mass Index: A Nationwide Population-Based Study

BACKGROUND

Maladaptation to vascular, metabolic, and physiological changes during pregnancy can lead to fetal growth disorders. Moreover, adverse outcomes during pregnancy can further increase the risk of cardiovascular and metabolic diseases in mothers. Delivering a large-for-gestational-age (LGA) baby may indicate a pre-existing metabolic dysfunction, whereas delivering a small-for-gestational-age (SGA) baby may indicate a pre-existing vascular dysfunction. This study aims to assess the risk of hypertension (HTN) and diabetes mellitus (DM) in women with normal body mass index (BMI) scores who did not experience gestational DM or hypertensive disorders during pregnancy based on the offspring's birthweight.

METHODS

This retrospective nationwide study included women with normal BMI scores who delivered a singleton baby after 37 weeks. Women with a history of DM or HTN before pregnancy and those with gestational DM or hypertensive disorders, were excluded from the study. We compared the risk of future maternal outcomes (HTN and DM) according to the offspring's birthweight. Multivariate analyses were performed to estimate the hazard ratio (HR) for the future risk of HTN or DM.

RESULTS

A total of 64,037 women were included in the analysis. Of these, women who delivered very LGA babies (birthweight > 97th percentile) were at a higher risk of developing DM than those who delivered appropriate-for-gestational-age (AGA) babies (adjusted HR = 1.358 [1.068-1.727]), and women who delivered very SGA babies (birthweight < 3rd percentile) were at a higher risk of developing HTN than those who delivered AGA babies (adjusted HR = 1.431 [1.181-1.734]), even after adjusting for age, parity, gestational age at delivery, fetal sex, maternal BMI score, and a history of smoking.

CONCLUSION

These findings provide a novel support for the use of the offspring's birthweight as a predictor of future maternal diseases such as HTN and DM.

Psychometric evaluation of a novel tool for assessing gestational diabetes and hypertension care: knowledge, attitudes, and practices of midwives and nurses

While standardized assessment of knowledge, attitudes, and practices (KAP) related to gestational diabetes and hypertension is possible with a valid tool, existing research remains limited. This prospective validation study aimed to develop and validate a novel tool to assess the KAP of midwives and obstetric nurses. We included 125 midwives and obstetric nurses who routinely care for patients with gestational diabetes and hypertension. The tool demonstrated good internal consistency (Cronbach's alpha): knowledge (0.729, 95% CI, 0.654-0.776), attitude (0.756, 95% CI, 0.690-0.814), and practices (0.925, 95% CI, 0.905-0.943). Difficulty indices (d) ranged from 0.38 to 0.99 (knowledge), 0.41 to 0.99 (attitudes), and 0.41 to 0.93 (practices), indicating appropriate item difficulty. Discrimination indices (D) confirmed items could differentiate between respondents with low and high knowledge levels (D range: 0.02-0.77 for knowledge, 0.06-0.64 for attitudes, 0.20-0.84 for practices). The robust psychometric properties of this tool support its use in future research on KAP related to diabetes and gestational hypertension management in midwives and nurses. This instrument has the potential to be valuable in various settings, including baseline assessment before educational programs or evaluation of learning outcomes after interventions.

Association of parity with the prevalence of hypertension in Japan: The Tohoku Medical Megabank Community-based cohort study

This study investigated the association of parity with hypertension prevalence in Japanese women while considering a clinical history of hypertensive disorders of pregnancy (HDP) and menopausal status. This cross-sectional study included 30,530 Japanese women (6700 premenopausal; 23 830 postmenopausal). The association between parity and the prevalence of hypertension was evaluated using a multiple logistic regression model with possible confounders. In premenopausal women, no statistically significant association between parity and hypertension prevalence was found. When not adjusted for current body mass index (BMI), a linear graded association was observed between parity and the prevalence of hypertension in postmenopausal women. However, the association between parity and hypertension prevalence in postmenopausal women was attenuated after adjustment for current BMI. Both current BMI and a clinical history of HDP were significantly associated with a high risk of hypertension in both premenopausal and postmenopausal women. Our results also suggest that continuous surveillance and preventive measures for hypertension should be provided for women with HDP and high parity.

The Fit After Baby randomized controlled trial: An mHealth postpartum lifestyle intervention for women with elevated cardiometabolic risk

BACKGROUND

Postpartum women with overweight/obesity and a history of adverse pregnancy outcomes are at elevated risk for cardiometabolic disease. Postpartum weight loss and lifestyle changes can decrease these risks, yet traditional face-to-face interventions often fail. We adapted the Diabetes Prevention Program into a theory-based mobile health (mHealth) program called Fit After Baby (FAB) and tested FAB in a randomized controlled trial.

METHODS

The FAB program provided 12 weeks of daily evidence-based content, facilitated tracking of weight, diet, and activity, and included weekly coaching and gamification with points and rewards. We randomized women at 6 weeks postpartum 2:1 to FAB or to the publicly available Text4baby (T4B) app (active control). We measured weight and administered behavioral questionnaires at 6 weeks, and 6 and 12 months postpartum, and collected app user data.

RESULTS

81 eligible women participated (77% White, 2% Asian, 15% Black, with 23% Hispanic), mean baseline BMI 32±5 kg/m2 and age 31±5 years. FAB participants logged into the app a median of 51/84 (IQR 25,71) days, wore activity trackers 66/84 (IQR 43,84) days, logged weight 17 times (IQR 11,24), and did coach check-ins 5.5/12 (IQR 4,9) weeks. The COVID-19 pandemic interrupted data collection for the primary 12-month endpoint, and impacted diet, physical activity, and body weight for many participants. At 12 months postpartum women in the FAB group lost 2.8 kg [95% CI -4.2,-1.4] from baseline compared to a loss of 1.8 kg [95% CI -3.8,+0.3] in the T4B group (p = 0.42 for the difference between groups). In 60 women who reached 12 months postpartum before the onset of the COVID-19 pandemic, women randomized to FAB lost 4.3 kg [95% CI -6.0,-2.6] compared to loss in the control group of 1.3 kg [95% CI -3.7,+1.1] (p = 0.0451 for the difference between groups).

CONCLUSIONS

There were no significant differences between groups for postpartum weight loss for the entire study population. Among those unaffected by the COVID pandemic, women randomized to the FAB program lost significantly more weight than those randomized to the T4B program. The mHealth FAB program demonstrated a substantial level of engagement. Given the scalability and potential public health impact of the FAB program, the efficacy for decreasing cardiometabolic risk by increasing postpartum weight loss should be tested in a larger trial.

Hypertensive pregnancy complications and maternal characteristics as predictors of cardiovascular health within ten years after delivery

OBJECTIVE

To identify the combination of maternal characteristics in women with hypertensive disorders of pregnancy (HDP) associated with hypertensive and other cardiovascular diseases (CVDs) within ten years following delivery. The aim is to understand who should receive the most intensive primary cardiovascular disease prevention.

STUDY DESIGN

A prospective cohort study.

MAIN OUTCOME

The population was the FINNPEC cohort (2008-2011), including women with (n = 1837) and without (n = 847) HDP. The main exposures were maternal hypertensive pregnancy complications linked with maternal pregnancy data from hospital records. The outcomes were hypertensive diseases and other CVDs (International Classification of Diseases, Tenth Revision).

RESULTS

Women with de novo pre-eclampsia (PE) had an elevated risk for hypertensive diseases within ten years following delivery. The risk of CVD was increased in women with superimposed PE and chronic hypertension (CHT) only. Women with de novo PE and hypertensive diseases were more often primiparous (41.4% vs. 23.0%, p = 0.020), had gestational diabetes (GDM) (31.0% vs. 11.7%, p = 0.002), and higher pre-pregnancy body mass index (BMI) (28.7 ± 5.8 vs. 24.6 ± 4.8 kg/m2, p = 0.001), compared with women who remained normotensive. Women with superimposed PE with CVD had more likely early-onset PE, preterm delivery and were older than women without later CVD.

CONCLUSIONS

Healthcare professionals should target early prevention of CVDs in women with chronic hypertension during pregnancy; of those who developed superimposed PE prior to 34th weeks of gestation and who delivered preterm. Women with de novo PE who are overweight/obese, primiparous, and with concurrent GDM need regular blood pressure monitoring.

Oral Glucose Tolerance Test in Pregnancy and Subsequent Maternal Hypertension

OBJECTIVE

The aim of the study is to evaluate whether values and the shape of the glucose curve during the oral glucose tolerance test (OGTT) in pregnancy identify women at risk of developing hypertension (HTN) later in life.

STUDY DESIGN

This category includes the secondary analysis of a follow-up from a mild gestational diabetes mellitus (GDM) study that included a treatment trial for mild GDM (n = 458) and an observational cohort of participants with abnormal 1-hour glucose loading test only (normal OGTT, n = 430). Participants were assessed at a median of 7 (IQR 6-8) years after their index pregnancy, and trained staff measured their blood pressure (systolic blood pressure [SBP]; diastolic blood pressure [DBP]). The association between values and the shape of the glucose curve during OGTT in the index pregnancy and the primary outcome defined as elevated BP (SBP ≥120, DBP ≥80 mm Hg, or receiving anti-HTN medications), and secondary outcome defined as stage 1 or higher (SBP ≥130, DBP ≥80 mm Hg, or receiving anti-HTN medications) at follow-up were evaluated using multivariable regression, adjusting for maternal age, body mass index, and pregnancy-associated hypertension during the index pregnancy.

RESULTS

There was no association between fasting, 1-hour OGTT, and the outcomes. However, the 2-hour OGTT value was positively associated (adjusted odds ratio [aRR] per 10-unit increase 1.04, 95% CI 1.01-1.08), and the 3-hour was inversely associated (aRR per 10-unit increase 0.96, 95% CI 0.93-0.99) with the primary outcome. When the shape of the OGTT curve was evaluated, a monophasic OGTT response (peak at 1 hour followed by a decline in glucose) was associated with increased risk of elevated BP (41.3vs. 23.5%, aRR 1.66, 95% CI 1.17-2.35) and stage 1 HTN or higher (28.5 vs. 14.7%, aRR 1.83, 95% CI 1.15-2.92), compared with a biphasic OGTT response.

CONCLUSION

Among persons with mild GDM or lesser degrees of glucose intolerance, the shape of the OGTT curve during pregnancy may help identify women who are at risk of HTN later in life, with biphasic shape to be associated with lower risk.

KEY POINTS

· The shape of the Oral Glucose Tolerance Test curve may help identify patients who are at risk of having elevated BP or HTN 5 to 10 years following pregnancy.. · The 2-hour Oral Glucose Tolerance Test values is positively associated with elevated BP 5 to 10 years following pregnancy.. · This supports the concept of pregnancy as a window to future health and represents a potential novel biomarker for maternal cardiovascular health screening..

Association of Gestational Diabetes With Subsequent Long-Term Risk of Mortality

Importance

Gestational diabetes has been associated with numerous chronic diseases. However, few studies have examined the association of gestational diabetes with long-term mortality risk.

Objective

To investigate the associations between gestational diabetes and long-term risks of total and cause-specific mortality.

Design, Setting, and Participants

This cohort study analyzed participants of the Nurses' Health Study II who were followed for 30 years (1989-2019). Participants included US female nurses aged 25 to 42 years who reported at least 1 pregnancy (≥6 months) at 18 years or older across their reproductive life span. Data were analyzed from May 1, 2022, to May 25, 2023.

Exposure

Gestational diabetes across the reproductive life span.

Main Outcomes and Measures

Hazard ratios (HRs with 95% CIs) for total and cause-specific mortality were estimated by Cox proportional hazards regression models.

Results

A total of 91 426 parous participants were included, with a mean (SD) age of 34.9 (4.7) years and a body mass index of 24.1 (4.7) at baseline. During a follow-up period of 2 609 753 person-years, 3937 deaths were documented, including 255 deaths from cardiovascular disease and 1397 from cancer. Participants with a history of gestational diabetes had a higher crude mortality rate than those without a history of gestational diabetes (1.74 vs 1.49 per 1000 person-years; absolute difference = 0.25 per 1000 person-years). The corresponding HR for total mortality was 1.28 (95% CI, 1.13-1.44), which did not materially change after additional adjustment for potential confounders and lifestyle factors during the reproductive life span (HR, 1.25; 95% CI, 1.11-1.41). The association persisted regardless of the subsequent development of type 2 diabetes and was more robust among participants who adopted less healthy lifestyles; experienced gestational diabetes in 2 or more pregnancies (HR, 1.48; 95% CI, 0.99-2.19); had gestational diabetes both in the initial and subsequent pregnancies (HR, 1.71; 95% CI, 1.11-2.63); and concurrently reported hypertensive disorders in pregnancy (HR, 1.80; 95% CI, 1.21-2.67), preterm birth (HR, 2.46; 95% CI, 1.66-3.64), or low birth weight (HR, 2.11; 95% CI, 1.21-3.68). Cause-specific mortality analyses revealed that gestational diabetes was directly associated with the risk of mortality due to cardiovascular disease (HR, 1.59; 95% CI, 1.03-2.47). Additionally, gestational diabetes was inversely associated with cancer mortality (HR, 0.76; 95% CI, 0.59-0.98); however, it was only evident among participants who later developed type 2 diabetes.

Conclusions and Relevance

Results of this cohort study suggest that participants who reported a history of gestational diabetes exhibited a small but elevated risk of subsequent mortality over 30 years. The findings emphasize the importance of considering gestational diabetes as a critical factor in later-life mortality risk.

Continuous glucose monitoring-derived glycemic metrics and adverse pregnancy outcomes among women with gestational diabetes: a prospective cohort study

Background

Continuous glucose monitoring (CGM) has shown potential in improving maternal and neonatal outcomes in individuals with type 1/2 diabetes, but data in gestational diabetes mellitus (GDM) is limited. We aimed to explore the relationship between CGM-derived metrics during pregnancy and pregnancy outcomes among women with GDM.

Methods

We recruited 1302 pregnant women with GDM at a mean gestational age of 26.0 weeks and followed them until delivery. Participants underwent a 14-day CGM measurement upon recruitment. The primary outcome was any adverse pregnancy outcome, defined as having at least one of the outcomes: preterm birth, large-for-gestational-age (LGA) birth, fetal distress, premature rupture of membranes, and neonatal intensive care unit (NICU) admission. The individual outcomes included in the primary outcome were considered as secondary outcomes. We conducted multivariable logistic regression to evaluate the association of CGM-derived metrics with these outcomes.

Findings

Per 1-SD difference in time above range (TAR), glucose area under the curve (AUC), nighttime mean blood glucose (MBG), daytime MBG, and daily MBG was associated with higher risk of any adverse pregnancy outcome, with odds ratio: 1.22 (95% CI 1.08-1.36), 1.22 (95% CI 1.09-1.37), 1.18 (95% CI 1.05-1.32), 1.21 (95% CI 1.07-1.35), and 1.22 (95% CI 1.09-1.37), respectively. Time in range, TAR, AUC, nighttime MBG, daytime MBG, daily MBG, and mean amplitude of glucose excursions were positively associated, while time blow range was inversely associated with the risk of LGA. Additionally, higher value for TAR was associated with higher risk of NICU admission. We further summarized the potential thresholds of TAR (2.5%) and daily MBG (4.8 mmol/L) to distinguish individuals with and without any adverse pregnancy outcome.

Interpretation

The CGM-derived metrics may help identify individuals at higher risk of adverse pregnancy outcomes. These CGM biomarkers could serve as potential new intervention targets to maintain a healthy pregnancy status among women with GDM.

Funding

National Key R&D Program of China, National Natural Science Foundation of China, and Westlake Laboratory of Life Sciences and Biomedicine.

Focus on Metformin: Its Role and Safety in Pregnancy and Beyond

Metformin is used worldwide in the treatment of type 2 diabetes and has been used in the treatment of diabetes in pregnancy since the 1970s. It is highly acceptable to patients due to its ease of administration, cost and adverse effect profile. It is effective in reducing macrosomia, large-for-gestational-age infants and reduces maternal weight gain. Despite its many advantages, metformin has been associated with reductions in foetal size and has been associated with an increase in infants born small-for-gestational-age in certain cohorts. In this article, we review its efficacy, adverse effects and long-term follow-up before, during and after pregnancy for both mother and infant. We also evaluate the other forms of treatment for gestational diabetes, including oral therapies, insulin therapy and emerging treatments.

Metabolic alteration of circulating steroid hormones in women with gestational diabetes mellitus and the related risk factors

Background

Abnormally changed steroid hormones during pregnancy are closely related to the pathological process of gestational diabetes mellitus (GDM). Our aim was to systematically profile the metabolic alteration of circulating steroid hormones in GDM women and screen for risk factors.

Methods

This study was a case-control study with data measured from 40 GDM women and 70 healthy pregnant women during their 24-28 gestational weeks. 36 kinds of steroid hormones, including 3 kinds of corticosteroids, 2 kinds of progestins, 5 kinds of androgens and 26 kinds of downstream estrogens in serum were systematically measured using a combined sensitive UPLC-MS/MS method. The flux of different metabolic pathways of steroid hormones was analyzed. Logistic regression and ROC curve model analyses were performed to identify potential steroid markers closely associated with GDM development.

Results

Serum corticosteroids, progestins and almost all the estrogen metabolites via 16-pathway from parent estrogens were higher in GDM women compared with healthy controls. Most of the estrogen metabolites via 4-pathway and more than half of the metabolites via 2-pathway were not significantly different. 16α-hydroxyestrone (16OHE1), estrone-glucuronide/sulfate (E1-G/S) and the ratio of total 2-pathway estrogens to total estrogens were screened as three indicators closely related to the risk of GDM development. The adjusted odds ratios of GDM for the highest quartile compared with the lowest were 72.22 (95% CI 11.27-462.71, P _trend <0.001) for 16OHE1 and 6.28 (95% CI 1.74-22.71, P _trend <0.05) for E1-G/S. The ratio of 2-pathway estrogens to total estrogens was negatively associated with the risk of GDM.

Conclusion

The whole metabolic flux from cholesterol to downstream steroid hormones increased in GDM condition. The most significant changes were observed in the 16-pathway metabolism of estrogens, rather than the 2- or 4-pathway or other types of steroid hormones. 16OHE1 may be a strong marker associated with the risk for GDM.

Prediction of pre-eclampsia in diabetic pregnant women

Background & objectives

Gestational or preexisting diabetes is one of the risk factors of pre-eclampsia. Both are responsible for higher maternal and fetal complications. The objective was to study clinical risk factors of pre-eclampsia and biochemical markers in early pregnancy of women with diabetes mellitus (DM)/gestational diabetes mellitus (GDM) for the development of pre-eclampsia.

Methods

The study group comprised pregnant women diagnosed with GDM before the 20 wk of gestation and DM before pregnancy and the control group had age-, parity- and period of gestation-matched healthy women. Sex hormone-binding globulin (SHBG), insulin-like growth factor-I (IGF-I) and 25-hydroxy vitamin D [25(OH)D] levels and the polymorphism of these genes was evaluated at recruitment.

Results

Out of 2050 pregnant women, 316 (15.41%) women (296 had GDM and 20 DM before pregnancy) were included in the study group. Of these, 96 women (30.38%) in the study group and 44 (13.92%) controls developed pre-eclampsia. Multivariate logistic regression analysis indicated those who belonged to the upper middle and upper class of socio-economic status (SES) were likely to be at 4.50 and 6.10 times higher risk of developing pre-eclampsia. The risk of getting pre-eclampsia among those who had DM before pregnancy and pre-eclampsia in their previous pregnancy was about 2.34 and 4.56 times higher compared to those who had no such events, respectively. The serum biomarkers [SHBG, IGF-I and 25(OH)D] were not found to be useful in predicting pre-eclampsia in women with GDM. To predict risk of development of pre-eclampsia, the fitted risk model by backward elimination procedure was used to calculate a risk score for each patient. Receiver operating characteristic (ROC) curve for pre-eclampsia showed that area under the curve was 0.68 (95% confidence interval: 0.63-0.73); P<0.001.

Interpretation & conclusions

The findings of this study suggested that pregnant women with diabetes were at a higher risk for pre-eclampsia. SES, history of pre-eclampsia in previous pregnancy and pre-GDM were found to be the risk factors.

Adverse pregnancy outcomes and future risk of heart failure

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death in women. Women with history of adverse pregnancy outcomes (APOs) have approximately two-fold risk of future CVD, but until recently the association with future heart failure (HF) was unclear. Here, we summarize evidence for associations of APOs with HF, potential underlying mechanisms, and future directions for clinical translation.

RECENT FINDINGS

Women with history of hypertensive disorders of pregnancy (HDPs) have roughly two-fold risk of future HF compared with other parous women even after accounting for interval development of coronary artery disease. The HDPs portend heightened risk of HF with both reduced and preserved ejection fraction. Gestational diabetes mellitus (GDM) and other APOs such as preterm delivery, small-for-gestational-age delivery, and placental abruption may also confer additional risk for HF development. Possible underlying mechanisms linking APOs to HF include shared upstream risk factors and genetics, accelerated development of cardiometabolic risk factors postpartum, persistent endothelial and microvascular dysfunction, and impaired natriuretic peptide signaling.

SUMMARY

History of APOs, including HDPs and GDM, confer increased risk for development of HF years after delivery. Further research is needed to define strategies to optimize prepregnancy and postpartum cardiovascular health toward HF prevention.

Validation of Algorithms to Identify Gestational Diabetes From Population-level Health-care Administrative Data

OBJECTIVES

Our aim in this study was to determine the test characteristics of algorithms using hospitalization and physician claims data to predict gestational diabetes (GDM).

METHODS

Using population-level health-care administrative data, we identified all pregnant women in Ontario in 2019. The presence of GDM was determined based on glucose screening laboratory results. Algorithms using hospitalization records and/or physician claims were tested against this "gold standard." The selected algorithm was applied to administrative data records from 1999 to 2019 to determine GDM prevalence in each year.

RESULTS

Identifying GDM based on either a diabetes mellitus code on the delivery hospitalization record, OR at least 1 physician claim with a diabetes diagnosis code with a 90-day lookback before delivery yielded a sensitivity of 95.9%, a specificity of 99.2% and a positive predictive value of 87.6%. The prevalence of GDM increased from 4.2% of pregnancies in 1999 to 12.0% in 2019.

CONCLUSION

Algorithms using hospitalization or physician claims administrative data can accurately identify GDM.

Gender Differences and Cardiometabolic Risk: The Importance of the Risk Factors

Metabolic syndrome (Mets) is a clinical condition characterized by a cluster of major risk factors for cardiovascular disease (CVD) and type 2 diabetes: proatherogenic dyslipidemia, elevated blood pressure, dysglycemia, and abdominal obesity. Each risk factor has an independent effect, but, when aggregated, they become synergistic, doubling the risk of developing cardiovascular diseases and causing a 1.5-fold increase in all-cause mortality. We will highlight gender differences in the epidemiology, etiology, pathophysiology, and clinical expression of the aforementioned Mets components. Moreover, we will discuss gender differences in new biochemical markers of metabolic syndrome and cardiovascular risk.

Trends, Predictors, and Outcomes of Cardiovascular Complications at Delivery Associated With Gestational Diabetes: A National Inpatient Sample Analysis (2004-2019)

Background Gestational diabetes (GD) is associated with increased risk of long-term cardiovascular complications. However, data on acute peripartum cardiovascular complications are not well established. Hence, we aimed to investigate the association of GD with acute cardiovascular outcomes at the time of delivery admission. Methods and Results We used data from the National Inpatient Sample (2004-2019). International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) codes were used to identify delivery hospitalizations and GD diagnosis. A total of 63 115 002 weighted hospitalizations for deliveries were identified, of which 3.9% were among individuals with GD (n=2 435 301). The prevalence of both GD and obesity increased during the study period (P trends<0.01). Individuals with GD versus those without GD had a higher prevalence of obesity, hypertension, and dyslipidemia. After adjustment for age, race or ethnicity, comorbidities, insurance, and income, GD remained independently associated with cardiovascular complications including preeclampsia (adjusted odds ratio [aOR], 1.97 [95% CI, 1.96-1.98]), peripartum cardiomyopathy (aOR, 1.15 [1.08-1.22]), acute kidney injury (aOR, 1.16 [1.11-1.21]), stroke (aOR, 1.15 [1.09-1.23]), and arrhythmias (aOR, 1.48 [1.46-1.50]), compared with no GD. Moreover, delivery hospitalizations among individuals with GD were associated with increased length (3 versus 2 days, P<0.01) and cost of hospitalization ($4909 versus $3682, P<0.01). Even in the absence of preeclampsia, GD was associated with elevated cardiovascular risk. Conclusions Individuals with GD had a higher risk of preeclampsia, peripartum cardiomyopathy, acute kidney injury, stroke, and arrhythmias during delivery hospitalizations. As rates of GD are increasing globally, efforts to improve preconception cardiometabolic health and prevent GD may represent important strategies to improve peripartum maternal outcomes and mitigate long-term cardiovascular risk.

Gestational diabetes mellitus and hypertensive disorder of pregnancy play as spouse-pair risk factors of diabetes and hypertension: Insights from Tehran Lipid and Glucose Study

BACKGROUND

Complicated pregnancies by gestational diabetes mellitus (GDM) and hypertensive disorder of pregnancy (HDP) are relatively common worldwide. The evidence is still inconclusive regarding the role of GDM and HDP as spousal risk factor of diabetes (DM) and hypertension (HTN). This study aimed to determine the spousal risk of development of DM and/or HTN in the context of GDM and/or HDP.

METHODS

This population-based cohort study involved couples who participated in Tehran Lipid and Glucose Study. A total of 3650 pairs of spouses were identified, and among them, 2820 met the inclusion criteria. Included participants, followed up 3-year intervals visits from 1999 to 2018. All pairs underwent standard data collection. GDM and HDP were the main exposure of interest in females, and DM and HTN were the main outcomes in both females and their spouses. Cox proportional hazard regression models were used for both females and their spouses, adjusting for age, consanguinity, waist-to-height ratio, physical activity, smoking, and parity.

RESULTS

Of 2820 females, 558 (19.79 %) had histories of GDM or HDP, and 72 (2.55 %) experienced both. Among females who experienced GDM and HDP, 24 (33 %) and 31 (33 %) developed DM and HTN during the follow-up. The corresponding numbers were 89 (16 %) and 191 (34 %) for those who experienced GDM or HPD, and 274 (13 %) and 623 (28 %) for the non-risk factors group. The incidences of DM were 9 (12 %), 100 (18 %), and 373 (17 %) for males whose spouses experienced both GDM and HDP, either one or none of them, respectively. Among males in these groups, 20 (28 %), 150 (27 %), and 630 (29 %) developed HTN, respectively. Females who never had history of GDM and HDP have 34 % (95 % CI: 21, 45) less hazard of being diabetic than their spouses if they have the same age and waist to hip ratio. In cases with histories of both GDM and HDP, the risk of females increases to 3.05 (95 % CI: 1.43, 6.52) times of their spouses. Also, females who had experienced GDM (HR: 3.51, 95 % CI: 2.23, 5.53), or HDP (HR: 2.80, 95 % CI: 1.72, 4.56) were at higher risk of developing DM compared with females who never had GDM or HDP. We found that females with neither GDM nor HDP were more likely than males to be hypertensive in the future by the hazard ratio of 1.21 (95 % CI: 1.06, 1.39).

CONCLUSIONS

Complicated pregnancies by GDM and/or HDP were associated with increased risk of development DM and HTN in later life of females and their spouses. Further studies are required to confirm these results. Preventive care programs should be considered pregnancy complications as couple-based risk factors for subsequent DM and HTN.

Long-term cardiovascular outcomes of gestational diabetes mellitus: a prospective UK Biobank study

BACKGROUND

Previous studies showed that gestational diabetes mellitus (GDM) can be a risk factor for subsequent atherosclerotic cardiovascular disease. However, there is a paucity of information regarding diverse cardiovascular outcomes in elderly women after GDM. In the current study, we examined whether women with a history of GDM have an increased risk for long-term overall cardiovascular outcomes.

METHODS

Among the UK participants, we included 219,330 women aged 40 to 69 years who reported at least one live birth. The new incidence of diverse cardiovascular outcomes was compared according to GDM history by multivariable Cox proportional hazard models. In addition, causal mediation analysis was performed to examine the contribution of well-known risk factors to observed risk.

RESULTS

After enrollment, 13,094 women (6.0%) developed new overall cardiovascular outcomes. Women with GDM history had an increased risk for overall cardiovascular outcomes [adjusted HR (aHR) 1.36 (95% CI 1.18-1.55)], including coronary artery disease [aHR 1.31 (1.08-1.59)], myocardial infarction [aHR 1.65 (1.27-2.15)], ischemic stroke [aHR 1.68 (1.18-2.39)], peripheral artery disease [aHR 1.69 (1.14-2.51)], heart failure [aHR 1.41 (1.06-1.87)], mitral regurgitation [aHR 2.25 (1.51-3.34)], and atrial fibrillation/flutter [aHR 1.47 (1.18-1.84)], after adjustment for age, race, BMI, smoking, early menopause, hysterectomy, prevalent disease, and medication. In mediation analysis, overt diabetes explained 23%, hypertension explained 11%, and dyslipidemia explained 10% of the association between GDM and overall cardiovascular outcome.

CONCLUSIONS

GDM was associated with more diverse cardiovascular outcomes than previously considered, and conventional risk factors such as diabetes, hypertension, and dyslipidemia partially contributed to this relationship.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Exposure to metal mixtures and hypertensive disorders of pregnancy: A nested case-control study in China

Exposure to metals has been linked with the risk of hypertensive disorders of pregnancy (HDP), but little is known about the potential effects of exposure to metal mixtures. Thus, our study aimed to investigated the impact of a complex mixture of metals on HDP, especially the interactions among metal mixtures. We did a population-based nested case-control study from October 2013 to October 2016 in Wuhan, China, including 146 HDP cases and 292 controls. Plasma concentrations of Aluminum (Al), Barium (Ba), Cobalt (Co), Copper (Cu), Lead (Pb), Mercury (Hg), Molybdenum (Mo), Nickel (Ni), Selenium (Se), Strontium (Sr), Thallium (Tl), and Vanadium (V) were measured and collected between 10 and 16 gestational weeks. We employed quantile g-computation, conditional logistic regression models, and Bayesian Kernel Machine Regression (BKMR) to assess the association of individual metals and metal mixtures with HDP risk. In the quantile g-computation, the OR for a joint tertile increase in plasma concentrations was 3.67 (95% CI: 1.70, 7.91). Hg contributed the largest positive weights and followed by Al, Ni, and V. In conditional logistic regression models, concentrations of Hg, Al, Ni, and V were significantly associated with the risk of HDP (p-FDR < 0.05). Compared to the lowest tertiles, the ORs (95% CI) for the highest tertiles of these four metals were 2.67 (1.44, 4.95), 3.09 (1.70, 5.64), 5.31 (2.68, 10.53), and 4.52 (2.26, 9.01), respectively. In the BKMR analysis, we observed a linear positive association between Hg, Al, V, and HDP, and a nonlinear relationship between Ni and HDP. A potential interaction between Al and V was also identified. We found that exposure to metal mixtures in early pregnancy, both individually and as a mixture, was associated with the risk of HDP. Potential interaction effects of Al and V on the risk of HDP may exist.

Gestational Diabetes Mellitus Among Asians - A Systematic Review From a Population Health Perspective

Objective

Since Asians are particularly vulnerable to the risk of gestational diabetes mellitus (GDM), the lifecourse health implications of which are far beyond pregnancy, we aimed to summarize the literature to understand the research gaps on current GDM research among Asians.

Methods

We systematically searched the articles in PubMed, Web of Science, Embase, and Scopus by 30 June 2021 with keywords applied on three topics, namely "GDM prevalence in Asians", "GDM and maternal health outcomes in Asians", and "GDM and offspring health outcomes in Asians".

Results

We observed that Asian women (natives and immigrants) are at the highest risk of developing GDM and subsequent progression to type 2 diabetes among all populations. Children born to GDM-complicated pregnancies had a higher risk of macrosomia and congenital anomalies (i.e. heart, kidney and urinary tract) at birth and greater adiposity later in life.

Conclusion

This review summarized various determinants underlying the conversion between GDM and long-term health outcomes in Asian women, and it might shed light on efforts to prevent GDM and improve the lifecourse health in Asians from a public health perspective.

Systematic Review Registration

Prospero, CRD42021286075.

Lifestyle behaviors and cardiovascular risk profiles among parous women by gestational diabetes status, 2007-2018

BACKGROUND AND AIMS

Women with prior gestational diabetes mellitus (GDM) are at elevated risk of type 2 diabetes mellitus and cardiovascular disease. We compared cardiometabolic risk factors among parous U.S. women ages 20-44 by history of GDM.

METHODS AND RESULTS

Using data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018, 3537 parous women were classified by self-reported GDM history. We compared anthropometric measures, glycemia, blood pressure, lipids, lifestyle factors, cardiovascular health, and cardiometabolic disease prevalence by GDM status. NHANES survey design was taken into account. Women without history of GDM were younger and, after adjusting for age, race/ethnicity, and education, had more favorable cardiometabolic risk factor profiles for measures of anthropometry, glycemia, diabetes, many lipids, physical activity, diet, and overall cardiovascular health than women with history of GDM. Many patterns persisted after further adjustment for lifestyle factors. In analyses stratified by race/ethnicity, many patterns persisted, though there were key differences. Hypertension prevalence differed by GDM history only among Hispanic women. In women of other race/ethnicity, there was no difference in healthy eating or body mass index by GDM history. In non-Hispanic Black women, there was no difference in healthy eating by GDM history.

CONCLUSION

Among parous U.S. women ages 20-44, those with history of GDM had less favorable cardiometabolic risk factor profiles than those without history of GDM. This highlights the importance of continued efforts to develop and test multilevel interventions to improve cardiometabolic risk factors among reproductive-age women with a history of GDM.

Association of glucose metabolism and blood pressure during pregnancy with subsequent maternal blood pressure

The goal of this study was to examine associations of measures of maternal glucose metabolism and blood pressure during pregnancy with blood pressure at follow-up in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) cohort. The HAPO Follow-Up Study included 4747 women who had a 75-g oral glucose tolerance test (OGTT) at ~28 weeks' gestation. Of these, 4572 women who did not have chronic hypertension during their pregnancy or other excluding factors, had blood pressure evaluation 10-14 years after the birth of their HAPO child. Primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), and hypertension (SBP ≥ 140 and/or DBP ≥ 90 or treatment for hypertension) at follow-up. Blood pressure during pregnancy was associated with all blood pressure outcomes at follow-up independent of glucose and insulin sensitivity during pregnancy. The sum of glucose z-scores was associated with blood pressure outcomes at follow-up but associations were attenuated in models that included pregnancy blood pressure measures. Associations with SBP were significant in adjusted models, while associations with DBP and hypertension were not. Insulin sensitivity during pregnancy was associated with all blood pressure outcomes at follow-up, and although attenuated after adjustments, remained statistically significant (hypertension OR 0.79, 95%CI 0.68-0.92; SBP beta -0.91, 95% CI -1.34 to -0.49; DBP beta -0.50, 95% CI -0.81 to -0.19). In conclusion, maternal glucose values at the pregnancy OGTT were not independently associated with maternal blood pressure outcomes 10-14 years postpartum; however, insulin sensitivity during pregnancy was associated independently of blood pressure, BMI, and other covariates measured during pregnancy.

Clinical Characteristics, Outcomes, and Progression to Type 2 Diabetes in Women with Hyperglycemia in Pregnancy

CONTEXT

Women with hyperglycemia in pregnancy (HIP) are at increased risk of developing type 2 diabetes (T2D).

AIM

The present study intended to study the incidence of postpartum diabetes among HIP women and predict its risk factors.

SETTINGS AND DESIGN

This was a prospective observational study done on 178 women with HIP diagnosed after the first trimester, attending the tertiary care hospitals between December 2018 and March 2020.

MATERIALS AND METHODS

Demographics, clinical variables, and feto-maternal outcomes were recorded. The postpartum glycemic status was determined using a 75 g oral glucose tolerance test (OGTT) at 1 and 6 months.

STATISTICAL ANALYSIS

All analyses were performed with SPSS software (version 21.0).

RESULTS

The mean age of women with HIP was 30.2 ± 6.1 years, with 38% having a family history of diabetes. Eighty percent of the women delivered full-term babies and 71.3% underwent a cesarean section. Gestational hypertension was present in 21.9% of patients. Macrosomia was present in 4.6% of the babies, hypoglycemia in 6.7%, and spontaneous abortion occurred in 7.7%. Postpartum OGTT at 6 months was completed by 76.4% of participants. The incidence of diabetes and glucose intolerance postpartum was 11.7 and 16.2%, respectively at 6 months. Logistic regression analysis showed that maternal obesity, diagnosis of HIP at an earlier trimester (<24 weeks), need for insulin treatment during pregnancy, signs of insulin resistance and fasting and 2-h plasma glucose >100 (>5.6 mmol/L) and >195 mg/dL (>10.9 mmol/L), respectively, and glycated hemoglobin > 6.5% (>48 mmol/mol) increased the risk of having postpartum diabetes significantly.

CONCLUSION

The incidence of postpartum glucose intolerance in women with HIP is high. Prospective diabetes evaluation is required and intervention should be considered in women with HIP who have obesity, diagnosis of HIP at an earlier trimester, signs of insulin resistance, and require insulin treatment during pregnancy.

Meal Timing and Glycemic Control during Pregnancy-Is There a Link?

Hyperglycemia during pregnancy and gestational diabetes mellitus (GDM) constitute an important public health problem due to their prevalence and long-term health consequences both for the mother and offspring. Results from studies in rodents and some clinical investigations suggest that meal time manipulation may be a potential lifestyle approach against conditions involving perturbations in glucose homeostasis (e.g., hyperglycemia, insulin resistance, diabetes, etc.). The purpose of this review is to summarize and critically evaluate the current literature on the role of meal timing and daily nutrient distribution on glycemic control during pregnancy. Only a small number of mostly observational studies have assessed the role of meal timing in glucose homeostasis during pregnancy. Food consumption earlier in the day and short-term fasting with adequate nutrient intake may improve glycemic control during the second and third trimester of gestation. Considering that the field of chrononutrition is still in its infancy and many questions remain unanswered, future prospective and carefully designed studies are needed to better understand the role of meal timing in metabolic homeostasis and maternal and fetal health outcomes during pregnancy.

Current progress in metabolomics of gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is one of the most common metabolic disorders of pregnancy and can cause short- and long-term adverse effects in both pregnant women and their offspring. However, the etiology and pathogenesis of GDM are still unclear. As a metabolic disease, GDM is well suited to metabolomics study, which can monitor the changes in small molecular metabolites induced by maternal stimuli or perturbations in real time. The application of metabolomics in GDM can be used to discover diagnostic biomarkers, evaluate the prognosis of the disease, guide the application of diet or drugs, evaluate the curative effect, and explore the mechanism. This review provides comprehensive documentation of metabolomics research methods and techniques as well as the current progress in GDM research. We anticipate that the review will contribute to identifying gaps in the current knowledge or metabolomics technology, provide evidence-based information, and inform future research directions in GDM.

Intertwined disparities: Applying the maternal-infant dyad lens to advance perinatal health equity

Differences in the quality of delivery hospital care contribute to persistent, intertwined racial and ethnic disparities in both maternal and infant health. Despite the shared causal pathways and overlapping burden of maternal and infant health disparities, little research on perinatal quality of care has addressed obstetric and neonatal care jointly to improve outcomes and reduce health inequities for the maternal-infant dyad. In this paper, we review the role of hospital quality in shaping perinatal health outcomes, and investigate how a framework that considers the mother-infant dyad can enhance our understanding of the full burden of obstetric and neonatal disparities on health and society. We conclude with a discussion of how integrating a maternal-infant dyad lens into research and clinical intervention to improve quality of care can move the needle on disparity reduction for both women and infants around the time of birth and throughout the life course.

Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association

This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman's later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.

Gestational Diabetes History and Glucose Tolerance After Pregnancy Associated With Coronary Artery Calcium in Women During Midlife: The CARDIA Study

BACKGROUND

Gestational diabetes (GD) leads to earlier onset and heightened risk of type 2 diabetes, a strong risk factor for cardiovascular disease (CVD). However, it is unclear whether attaining normoglycemia can ameliorate the excess CVD risk associated with GD history. This study sought to evaluate GD history and glucose tolerance after pregnancy associated with coronary artery calcification (CAC) in women, a manifestation of atherosclerotic CVD and a predictor of CVD clinical events.

METHODS

Data were obtained from the CARDIA study (Coronary Artery Risk Development in Young Adults), a US multicenter, community-based prospective cohort of young Black (50%) and White adults aged 18 to 30 years at baseline (1985-1986). The sample included 1133 women without diabetes at baseline, who had ≥1 singleton births (n=2066) during follow-up, glucose tolerance testing at baseline and up to 5 times during 25 years (1986-2011), GD status, and CAC measurements obtained from 1 or more follow up examinations at years 15, 20, and 25 (2001-2011). CAC was measured by noncontrast cardiac computed tomography; dichotomized as Any CAC (score>0) or No CAC (score=0). Complementary log-log models for interval-censored data estimated adjusted hazard ratios of CAC and 95% confidence intervals for GD history and subsequent glucose tolerance groups (normoglycemia, prediabetes, or incident diabetes) on average 14.7 years after the last birth adjusted for prepregnancy and follow-up covariates.

RESULTS

Of 1133 women, 139 (12.3%) reported GD and were 47.6 years of age (4.8 SD) at follow-up. CAC was present in 25% (34/139) of women with GD and 15% (149/994) of women with no GD. In comparison with no GD/normoglycemia, adjusted hazard ratios (95% CIs) were 1.54 (1.06-2.24) for no GD/prediabetes and 2.17 (1.30-3.62) for no GD/incident diabetes, and 2.34 (1.34-4.09), 2.13 (1.09-4.17), and 2.02 (0.98-4.19) for GD/normoglycemia, GD/prediabetes, and GD/incident diabetes, respectively (overall P=0.003).

CONCLUSIONS

Women without previous GD showed a graded increase in the risk of CAC associated with worsening glucose tolerance. Women with a history of GD had a 2-fold higher risk of CAC across all subsequent levels of glucose tolerance. Midlife atherosclerotic CVD risk among women with previous GD is not diminished by attaining normoglycemia.

The Efficacy of an Intensive Lifestyle Modification Program on Psychosocial Outcomes among Rural Women with Prior Gestational Diabetes Mellitus: Six Months Follow-Up of a Randomized Controlled Trial

Women with prior gestational diabetes mellitus (GDM) are at a higher risk of type 2 diabetes and other health issues after delivery. They may have a lower quality of life (QoL), experience more medical-related stress, and need more support than those without it. This study aimed to examine the six-month efficacy of an intensive lifestyle modification program on perceived stress, social support, and QoL among women with prior GDM in rural China. A total of 320 women with prior GDM were randomly assigned to an intervention group (n = 160) and a control group (n = 160). Participants in the intervention group received an intensive lifestyle modification (ILSM) program, including a series of six biweekly face-to-face sessions and five biweekly phone sessions delivered by trained local health workers. The control group received the usual care. Data about perceived stress, social support, QoL, and HbA1c were collected at baseline, at three months, and at six-month follow-ups. Generalized estimating equation analysis was used to assess the efficacy of the intervention. There were significant improvements in the psychological domain (β = 0.479 ± 0.153, p = 0.002) and environmental domain (β = 0.462 ± 0.145, p = 0.001) of QoL over six months; there were significant group effects (β = −0.718 ± 0.280, p = 0.010) and time effects (β = 0.453 ± 0.211, p = 0.032) in physiological domain, and there were significant group effects in the social relations domain (β = −0.669 ± 0.321, p = 0.037). The ILSM group had a more pronounced downward trend in HbA1c than the control group (β = −0.050 ± 0.026, p = 0.059). The ILSM program can help women with GDM improve their psychological and environmental domain of QoL. It can be recommended as a form of health promotion for improving QoL among women with prior GDM in rural primary care settings in developing countries.

Trends in National Canadian Guideline Recommendations for the Screening and Diagnosis of Gestational Diabetes Mellitus over the Years: A Scoping Review

Canada's largest national obstetric and diabetology organizations have recommended various algorithms for the screening of gestational diabetes mellitus (GDM) over the years. Though uniformity across recommendations from clinical practice guidelines (CPGs) is desirable, historically, national guidelines from Diabetes Canada (DC) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) have differed. Lack of consensus has led to variation in screening approaches, rendering precise ascertainment of GDM prevalence challenging. To highlight the reason and level of disparity in Canada, we conducted a scoping review of CPGs released by DC and the SOGC over the last thirty years and distributed a survey on screening practices among Canadian physicians. Earlier CPGs were based on expert opinion, leading to different recommendations from these organizations. However, as a result of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, disparities between DC and the SOGC no longer exist and many Canadian physicians have adopted their recent recommendations. Given that Canadian guidelines now recommend two different screening programs (one step vs. two step), lack of consensus on a single diagnostic threshold continues to exist, resulting in differing estimates of GDM prevalence. Our scoping review highlights these disparities and provides a step forward towards reaching a consensus on one unified threshold.

Gestational Diabetes Mellitus: Predictive Value of Fetal Growth Measurements by Ultrasonography at 22-24 Weeks: A Retrospective Cohort Study of Medical Records

Early intervention of gestational diabetes mellitus (GDM) is effective in reducing pregnancy disorders. Fetal growth, measured by routine ultrasound scan a few weeks earlier before GDM diagnosis, might be useful to identify women at high risk of GDM. In the study, generalized estimating equations were applied to examine the associations between ultrasonic indicators of abnormal fetal growth at 22–24 weeks and the risk of subsequent GDM diagnosis. Of 44,179 deliveries, 8324 (18.8%) were diagnosed with GDM between 24 and 28 weeks. At 22–24 weeks, fetal head circumference (HC) < 10th, fetal femur length (FL) < 10th, and estimated fetal weight (EFW) < 10th percentile were associated with 13% to 17% increased risks of maternal GDM diagnosis. Small fetal size appeared to be especially predictive of GDM among women who were parous. Fetal growth in the highest decile of abdominal circumference (AC), HC, FL and EFW was not associated with risk of subsequent GDM. The observed mean difference in fetal size across gestation by GDM was small; there was less than 1 mm difference for AC, HC, and FL, and less than 5 g for EFW before 24 weeks. Despite similar mean fetal growth among women who were and were not later diagnosed with GDM, mothers with fetuses in the lowest decile of HC, FL and EFW at 22–24 weeks tended to have higher risk of GDM.

Gestational Diabetes: Importance of Follow-up Screening for the Benefit of Long-term Health

Gestational diabetes mellitus (GDM) is the most common obstetric metabolic disorder. Long-term health consequences, including type 2 diabetes, metabolic syndrome, and cardiovascular disease, are common with GDM. Postpartum glucose screening is recommended for women with a prior GDM pregnancy. Rates of postpartum screening compliance remain low. Interventions ranging from appointment reminder systems to personalized chronic disease education are being used, emphasizing future chronic disease risk for patients with a history of GDM. With these practice changes, clinicians can more thoroughly engage in the early identification, intervention, and prevention of chronic disease for women with a history of GDM.

Changes in Cardiometabolic Risk Factors Before and After Gestational Diabetes: A Prospective Life-Course Analysis in CARDIA Women

OBJECTIVE

This study hypothesized that both preconception and postchildbearing patterns of cardiometabolic risk factors may be different for women with gestational diabetes mellitus (GDM) compared with women without GDM.

METHODS

Among 1,302 (51% black) women in the Coronary Artery Risk Development in Young Adults (CARDIA) study with births and followed for 30 years, this study evaluated changes in cardiometabolic factors (BMI, waist circumference [WC], lipids, blood pressure) during prechildbearing (prior to the first postbaseline birth) and postchildbearing periods (after the last birth) by GDM status using piecewise linear mixed models adjusted for sociodemographics, parity, and time-varying covariates.

RESULTS

Compared with women who did not develop GDM, weight and WC increases in women who developed GDM (n = 152, 12%) were faster (BMI difference: +0.12 kg/m² /y, P = 0.04; WC difference: +0.28 cm/y, P = 0.04) during the prechildbearing period, accounting for covariates. This translated to an average of 1.3 kg of excess weight gain across 4 years among women with subsequent GDM versus non-GDM births. In contrast, slopes after childbearing did not differ by GDM status, nor were there other cardiometabolic differences.

CONCLUSIONS

Women with GDM exhibited an increasing prepregnancy pattern of weight gain and central adiposity. Absolute postchildbearing weight was also higher in GDM-affected women, but the slope of gain after GDM was not.

Development and Modification of a Mobile Health Program to Promote Postpartum Weight Loss in Women at Elevated Risk for Cardiometabolic Disease: Single-Arm Pilot Study

BACKGROUND

Pregnancy complications in combination with postpartum weight retention lead to significant risks of cardiometabolic disease and obesity. The majority of traditional face-to-face interventions have not been effective in postpartum women. Mobile technology enables the active engagement of postpartum women to promote lifestyle changes to prevent chronic diseases.

OBJECTIVE

We sought to employ an interactive, user-centered, and participatory method of development, evaluation, and iteration to design and optimize the mobile health (mHealth) Fit After Baby program.

METHODS

For the initial development, a multidisciplinary team integrated evidence-based approaches for health behavior, diet and physical activity, and user-centered design and engagement. We implemented an iterative feedback and design process via 3 month-long beta pilots in which postpartum women with cardiometabolic risk factors participated in the program and provided weekly and ongoing feedback. We also conducted two group interviews using a structured interview guide to gather additional feedback. Qualitative data were recorded, transcribed, and analyzed using established qualitative methods. Modifications based on feedback were integrated into successive versions of the app.

RESULTS

We conducted three pilot testing rounds with a total of 26 women. Feedback from each pilot cohort informed changes to the functionality and content of the app, and then a subsequent pilot group participated in the program. We optimized the program in response to feedback through three iterations leading to a final version.

CONCLUSIONS

This study demonstrates the feasibility of using an interactive, user-centered, participatory method of rapid, iterative design and evaluation to develop and optimize a mHealth intervention program for postpartum women.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02384226; https://www.clinicaltrials.gov/ct2/show/NCT02384226.

Glycated albumin in pregnancy: reference intervals establishment and its predictive value in adverse pregnancy outcomes

Background

Many efforts have been focused on the alternative glycemic marker glycated albumin (GlyA) and its application in pregnancy during which profound physiological changes take place. Our objective was to determine the reference intervals (RIs) of GlyA in healthy Chinese pregnant women and to assess the predictive value of serum GlyA in adverse pregnancy outcomes.

Methods

Totally 421 healthy subjects including 137 in the first trimester, 152 in the second trimester, and 132 in the third trimester were enrolled from March to July 2019, for the purpose of establishing the trimester-specific RIs of GlyA. In addition, 67 pregnant women diagnosed with GDM were enrolled at 24–28 weeks of gestation. The diagnostic value of GlyA for GDM patients was evaluated and compared with that of fasting plasma glucose (FPG) at 24–28 weeks of gestation. The association between GlyA in the late pregnancy and the adverse pregnancy outcomes was analyzed with the data collected from January to June 2018 at our hospital.

Results

The estimated RIs of GlyA in present study were 11.26–15.10%, 10.04–13.50%, and 9.76–13.09% in the first, second, and third trimesters respectively. The areas under receiver operating characteristic (ROC) curves were 0.503 for GlyA and 0.705 for FPG. More importantly, the GlyA level in the third trimester was not more elevated in the patients with adverse pregnancy outcomes including large for gestational age (LGA), preterm delivery, hypertension and preeclampsia (PE). The exception was made with the GDM patients who suffered from postpartum hemorrhage and had significantly higher GlyA levels than the control group.

Conclusions

Our results showed that the GlyA was continuously decreased as the gestational age went up. The GlyA testing has limited value in diagnosing GDM and predicting adverse pregnancy outcomes.

Gestational diabetes and long-term risk for dyslipidemia: a population-based historical cohort study

OBJECTIVES

To assess the course of lipid levels over time in postpartum women according to gestational diabetes status, taking into account potential confounders, such as comorbid conditions and body weight.

METHODS

The data for the present analysis were collected from a 2.3 million member integrated care provider in Israel. Included were all female members aged 15-50 years who performed a 50 g glucose challenge test (GCT) between March 1995 and May 2009. We collected all follow-up lipid consecration tests performed from date of delivery following the GCT (index date) until April 2017. Data analysis was performed for each lipid component individually (triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C)) and the effects of the several risk factors (history of gestational diabetes mellitus (GDM), age at delivery, obesity status and smoking status) were investigated using general linear model taking into account potential confounders.

RESULTS

A total of 160 527 women (6.1 million person-years of actual follow-up) were eligible for the analysis, including 10 234 women with GDM (6.4% of the entire cohort). During the study follow-up period, a total of 2.1 million lipid tests were performed. When adjusting for follow-up time, age at index date, body mass index status, and smoking status, GDM was associated with a 1.8-fold risk (95% CI 1.73 to 1.88) for dyslipidemia defined by TG, 1.45-fold risk (95% CI 1.38 to 1.52) for dyslipidemia defined by LDL-C, and 1.44-fold risk (95% CI 1.39 to 1.50) for dyslipidemia defined by HDL-C.

DISCUSSION

The results of this retrospective cohort analysis indicate that gestational diabetes confers added risk for developing hyperlipidemia post partum, particularly dyslipidemia defined by TG, as compared with women with normal glucose tolerance.

Gestational diabetes prevention and treatment: a protocol for developing core outcome sets

INTRODUCTION

Selective reporting bias, inconsistency in the chosen outcomes between trials and irrelevance of the chosen outcomes for women, limit the efficiency and value of research for prevention and treatment of gestational diabetes mellitus (GDM). One way to address these challenges is to develop core outcome sets (COSs).

METHODS AND ANALYSIS

The aim of this manuscript is to present a protocol for a study to develop COSs for GDM prevention and treatment. This is a three-phase project consisting of (1) a systematic review of the literature to create two lists of outcomes that have been reported in trials and systematic reviews of trials of interventions for the prevention and treatment of GDM, (2) a three-round, web-based e-Delphi survey with key stakeholders to prioritise these outcomes and (3) a consensus meeting to resolve any remaining disagreements and to agree on two COSs.

ETHICS AND DISSEMINATION

Ethical approval to conduct this study was obtained from the ethics committee at Galway University Hospitals on 13 December 2018 (Reference: C.A.2078). We will disseminate our research findings through peer-reviewed, open access publications and present at international conferences to reach a wide range of knowledge users.

Increased risk of non-alcoholic fatty liver disease in women with gestational diabetes mellitus: A population-based cohort study, systematic review and meta-analysis

AIMS

Non-Alcoholic Fatty Liver Disease (NAFLD) is one of the leading causes of liver transplantation in the West. This study seeks to examine whether women with gestational diabetes mellitus (GDM) are at increased risk of developing NAFLD compared to women without GDM.

METHODS

We conducted a population-based retrospective matched-controlled cohort study utilising The Health Improvement Network (THIN), a large primary care database representative of the United Kingdom population, between 01/01/1990 to 31/05/2016 followed by systematic review of available literature. The study population included 9640 women with GDM and 31,296 controls without GDM, matched for age, body mass index (BMI) and time of pregnancy. All study participants were free from NAFLD diagnosis at study entry. Patients with GDM and patients developing NAFLD were identified by clinical codes.

RESULTS

The median (range) follow-up duration was similar in women with and without GDM (2.95 (1.21-6.01) vs 2.85 (1.14-5.75) years respectively). Unadjusted incidence rate ratio (IRR) for NAFLD development in women with vs without GDM was 3.28 (95% CI 2.14-5.02), which remained significant after adjustment for wide range of potential confounders (IRR 2.70; 95% CI 1.744-4.19). The risk of NAFLD in GDM remained high (IRR 2.46: 95% CI 1.51-4.00) despite women being censored after they developed type 2 diabetes. The meta-analysis of 3 studies (including the current study) showed increased NAFLD risk in women with vs without GDM (OR 2.60; 95% CI 1.90-3.57, I₂ = 0%). As our study is based on routine clinical diagnosis of NAFLD, this study could potentially have underestimated the risk of NAFLD development.

CONCLUSIONS

Women with GDM are at increased risk of developing NAFLD in their later life compared to women without GDM regardless of the development of type 2 diabetes. Clinicians should have a low threshold to investigate women with history of GDM for the presence of NAFLD. Further studies to identify screening strategies are needed.

VCAM-1, ICAM-1 and selectins in gestational diabetes mellitus and the risk for vascular disorders

Aim: Levels of VCAM-1, ICAM-1 and selectins in gestational diabetes mellitus (GDM) subjects are an indication of endothelial dysfunction predicting the future metabolic consequence via metabolic memory effect. Materials & methods: This cross-sectional study was conducted in 92 pregnant women and serum endothelial cell adhesion molecules were measured using Randox biochip analyzer. Results: Significantly elevated serum level of VCAM-1 was found in GDM subjects and in greater than equal to one parity categorized GDM group when compared with control. The correlation of parity and P-selectin was statistically significant in GDM subjects. Conclusion: Elevated levels of endothelial cell adhesion molecules in GDM women indicate an imbalance in vascular function. Transient hyperglycemia during pregnancy may induce persistent modifications to the memory cells and GDM subjects are more prone to develop future consequences.