Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021

Discovery of novel 6-(piperidin-1-ylsulfonyl)-2H-chromenes targeting α-glucosidase, α-amylase, and PPAR-γ: Design, synthesis, virtual screening, and anti-diabetic activity for type 2 diabetes mellitus

A new series of 2H-chromene-based sulfonamide derivatives 3-12 has been synthesized and characterized using different spectroscopic techniques. The synthesized 2H-chromenes were synthesized by reacting activated methylene with 5-(piperidin-1-ylsulfonyl)salicylaldehyde through one-step condensation followed by intramolecular cyclization. Virtual screening of the designed molecules on α-glucosidase enzymes (PDB: 3W37 and 3A4A) exhibited good binding affinity suggesting that these derivatives may be potential α-glucosidase inhibitors. In-vitro α-glucosidase activity was conducted firstly at 100 µg/mL, and the results demonstrated good inhibitory potency with values ranging from 90.6% to 96.3% compared to IP = 95.8% for Acarbose. Furthermore, the IC50 values were determined, and the designed derivatives exhibited inhibitory potency less than 11 µg/mL. Surprisingly, two chromene derivatives 6 and 10 showed the highest potency with IC50 values of 0.975 ± 0.04 and 0.584 ± 0.02 µg/mL, respectively, compared to Acarbose (IC50 = 0.805 ± 0.03 µg/mL). Moreover, our work was extended to evaluate the in-vitro α-amylase and PPAR-γ activity as additional targets for diabetic activity. The results exhibited moderate activity on α-amylase and potency as PPAR-γ agonist making it a multiplet antidiabetic target. The most active 2H-chromenes 6 and 10 exhibited significant activity to PPAR-γ with IC50 values of 3.453 ± 0.14 and 4.653 ± 0.04 µg/mL compared to Pioglitazone (IC50 = 4.884±0.29 µg/mL) indicating that these derivatives improve insulin sensitivity by stimulating the production of small insulin-sensitive adipocytes. In-silico ADME profile analysis indicated compliance with Lipinski's and Veber's rules with excellent oral bioavailability properties. Finally, the docking simulation was conducted to explain the expected binding mode and binding affinity.

Maternal Dietary Carbohydrate and Pregnancy Outcomes: Quality over Quantity

Dietary nutrition plays a crucial role in determining pregnancy outcomes, with poor diet being a major contributor to pregnancy metabolic syndrome and metabolic disorders in offspring. While carbohydrates are essential for fetal development, the excessive consumption of low-quality carbohydrates can increase the risk of pregnancy complications and have lasting negative effects on offspring development. Recent studies not only highlighted the link between carbohydrate intake during pregnancy, maternal health, and offspring well-being, but also suggested that the quality of carbohydrate foods consumed is more critical. This article reviews the impacts of low-carbohydrate and high-carbohydrate diets on pregnancy complications and offspring health, introduces the varied physiological effects of different types of carbohydrate consumption during pregnancy, and emphasizes the importance of both the quantity and quality of carbohydrates in nutritional interventions during pregnancy. These findings may offer valuable insights for guiding dietary interventions during pregnancy and shaping the future development of carbohydrate-rich foods.

Metformin Use in the First Trimester of Pregnancy and Risk for Nonlive Birth and Congenital Malformations: Emulating a Target Trial Using Real-World Data

BACKGROUND

Metformin is a first-line pharmacotherapy for type 2 diabetes, but there is limited evidence about its safety in early pregnancy.

OBJECTIVE

To evaluate the teratogenicity of metformin use in the first trimester of pregnancy.

DESIGN

In an observational cohort of pregnant women with pregestational type 2 diabetes receiving metformin monotherapy before the last menstrual period (LMP), a target trial with 2 treatment strategies was emulated: insulin monotherapy (discontinue metformin treatment and initiate insulin within 90 days of LMP) or insulin plus metformin (continue metformin and initiate insulin within 90 days of LMP).

SETTING

U.S. Medicaid health care administration database (2000 to 2018).

PARTICIPANTS

12 489 pregnant women who met the eligibility criteria.

MEASUREMENTS

The risk and risk ratio of nonlive births, live births with congenital malformations, and congenital malformations among live births were estimated using standardization to adjust for covariates.

RESULTS

A total of 850 women were in the insulin monotherapy group and 1557 in the insulin plus metformin group. The estimated risk for nonlive birth was 32.7% under insulin monotherapy (reference) and 34.3% under insulin plus metformin (risk ratio, 1.02 [95% CI, 1.01 to 1.04]). The estimated risk for live birth with congenital malformations was 8.0% (CI, 5.7% to 10.2%) under insulin monotherapy and 5.7% (CI, 4.5% to 7.3%) under insulin plus metformin (risk ratio, 0.72 [CI, 0.51 to 1.09]).

LIMITATION

Possible residual confounding by glycemic control and body mass index.

CONCLUSION

Compared with switching to insulin monotherapy, continuing metformin and adding insulin in early pregnancy resulted in little to no increased risk for nonlive birth among women receiving metformin before pregnancy. Under conventional statistical criteria, anything between a 49% decrease and a 9% increase in risk for congenital malformations was highly compatible with our data.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Physical Activity during Pregnancy and Risk of Gestational Diabetes Mellitus: A Meta-Review

BACKGROUND

Nowadays, pregnant women require more individualized attention in their assistance process during pregnancy. One of the aspects that requires the most focus is the suitability of carrying out physical activity. The objective of this meta-review is to find out the effects of physical activity during pregnancy on the incidence of GDM compared to women who do not perform physical activity.

METHODS

A search was conducted in Cochrane, CSIC, Ebscohost, Proquest, Pubmed, Scielo, and Scopus. The search focused on systematic reviews and meta-analyses published in the last five years. The AMSTAR-2 scale was used as a quality assessment tool for the final sample.

RESULTS

A total of 18 systematic reviews and meta-analyses were included. Sixteen of them found out that physical activity during pregnancy has preventive effects for GDM compared with women who lacked physical activity. Among the studies, we found a reduction in the risk of GDM of between 24% and 38% and odds ratios ranging between 0.39 and 0.83 calculated for a 95% CI. Only two studies did not find statistically significant effects. Other variables such as type and duration of physical activity, overweight and obesity, gestational age, etc., were also considered.

CONCLUSIONS

Physical activity prevents the incidence of GDM. The main characteristics that enhance this preventive effect are starting at the initial stages of pregnancy and maintaining during the whole pregnancy as well as combining strength and aerobic exercise at a low to moderate intensity.

An automated insulin delivery system from pregestational care to postpartum in women with type 1 diabetes. Preliminary experience with telemedicine in 6 patients

INTRODUCTION

The use of most commercially available automated insulin delivery (AID) systems is off-label in pregnancy. However, an increasing number of women with type 1 diabetes (T1D) use such devices throughout pregnancy and delivery. We analysed the data of six women with T1D from a single centre (Diabetology Outpatient Clinic of District-63/Asl Salerno, Italy) who were able to start and maintain AID therapy with the MiniMed™ 780G (Medtronic, Minneapolis, MN, USA) throughout the pregestational care period, pregnancy, delivery, and postpartum.

METHODS

We retrospectively collected data from six patients with T1D who received training and initiation on use of the MiniMed™ 780G and attended follow-up visits throughout pregnancy (these visits were virtual because of the COVID-19 pandemic). All patients maintained their devices in the closed-loop setting throughout pregnancy and during labour and delivery. We analysed data from the pregestational phase to the first 30 days postpartum.

RESULTS

All patients achieved the recommended metabolic goals before conception [median time in range (TIR) of 88% for 70-180 mg/dL; median pregnancy-specific TIR 63-140 mg/dL (ps-TIR) of 66% and maintained the ps-TIR until delivery (median ps-TIR 83%). All patients had slightly better metrics during the night than during the day, with a very low time below range of < 63 mg/dL. Optimal glycaemic values were also maintained on the day of labour and delivery (median ps-TIR 92.5%) and in the first 30 days postpartum, with no severe hypoglycaemia. The only neonatal complications were jaundice in one child and an interatrial defect in another child.

CONCLUSION

In our well-selected and trained patients, use of the MiniMed™ 780G helped to achieve and maintain ps-metrics from the pregestational period to delivery despite the fact that the algorithm is not set to achieve the ambitious glycaemic values recommended for pregnancy.

Hypertriglyceridemia-Induced Acute Pancreatitis-The Milky Way Constellation-The Seven-Year Experience of a Large Tertiary Centre

(1) Background: Hypertriglyceridemia (HTG) is a well-known metabolic condition associated with an increased risk of acute pancreatitis. In this study, we tried to establish whether there are any significant disparities concerning recurrence rate, intensive care unit (ICU) admission, hospital (ICU and total) length of stay (LoS), morphology, severity and age between HTG-induced acute pancreatitis and any other known cause of pancreatitis (OAP). (2) Methods: The research was a retrospective unicentric cohort study, using information from the Bucharest Acute Pancreatitis Index (BUC-API) registry, a database of 1855 consecutive cases of acute pancreatitis. (3) Results: We found a weak association between HTG-AP and recurrence. The HTG-AP patients were younger, with a median of 44.5 years, and had a longer ICU stay than the OAP patients. In addition, we identified that the HTG-AP patients were more likely to develop acute peripancreatic fluid collection (APFC), to be admitted in ICU, to have a more severe course of disease and to be cared for in a gastroenterology ward. (4) Conclusions: Hypertriglyceridemia-induced APs have a more severe course. The typical patient with HTG-AP is a middle-aged male, with previous episodes of AP, admitted in the gastroenterology ward, with a longer ICU stay and longer length of hospitalization, more likely to evolve in a severe acute pancreatitis (SAP) and with a higher probability of developing APFC.

A retrospective study comparing the results of continuous glucose monitoring to self-blood glucose monitoring for pregnant women with type 1 diabetes mellitus

BACKGROUND

Type 1 diabetes mellitus (T1DM) is associated with adverse maternal and fetal outcomes. Continuous glucose monitoring (CGM) during pregnancy is associated with better glycemic control in women with T1DM. However, no clear benefits have been demonstrated in reducing adverse feto-maternal outcomes in pregnant women with T1DM.

DESIGN AND METHODS

This is a retrospective, single-center study of pregnant women with T1DM to evaluate the impact of CGM use on glycemic control and feto-maternal outcomes in pregnant women with T1DM.

RESULTS

Of 265 women with T1DM, 92 (34.7%) used CGM, and 173 (65.3%) were managed with capillary blood glucose (CBG) monitoring. The mean (SD) age and BMI at the first visit were 29.4 (4.7) years and 27.2 (5.2) kg/m2, respectively. The mean (SD) HbA1c at the first-trimester visit was 63 (1) mmol/mol, and in the last trimester was 51 (1%). There was no difference in the mean changes in HbA1c between the two groups. Women using CGM had lower insulin requirements (1.02 + 0.37 vs. 0.87 + 0.04 units/kg, p = 0.01). The two groups had no significant differences in maternal or fetal outcomes.

CONCLUSION

CGM use in pregnant T1DM women is not associated with improved fetomaternal outcomes.

Maternal Education Level Among People with Diabetes and Associated Adverse Outcomes

OBJECTIVE

The aim of the study is to determine the relation between education and adverse outcomes in individuals with pregestational or gestational diabetes.

STUDY DESIGN

This population-based cohort study, using the U.S. vital statistics datasets, evaluated individuals with pregestational or gestational diabetes who delivered between 2016 and 2019. The primary outcome was composite neonatal adverse outcome including any of the following: large for gestational age (LGA), Apgar's score 6 hours, neonatal seizure, or neonatal death. The secondary outcome was composite maternal adverse outcomes including any of the following: admission to intensive care unit, transfusion, uterine rupture, or unplanned hysterectomy. Multivariable analysis was used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CIs).

RESULTS

Of 15,390,962 live births in the United States, 858,934 (5.6%) were eligible for this analysis. Compared with individuals with a college education and above, the risk of composite neonatal adverse outcome was higher in individuals with some college (aRR = 1.08, 95% CI = 1.07-1.09), high school (aRR = 1.06, 95% CI = 1.04-1.07), and less than high school (aRR = 1.05, 95% CI = 1.03-1.07) education. The components of composite neonatal adverse outcome that differed significantly between the groups were LGA, Apgar's score 6 hours. Infant death differed when stratified by education level. An increased risk of composite maternal adverse outcome was also found with a lower level of education.

CONCLUSION

Among individuals with diabetes, lower education was associated with a modestly higher risk of adverse neonatal and maternal outcomes.

KEY POINTS

· Education levels were associated with adverse outcomes among individuals with diabetes.. · Lower education is associated with multiple neonatal complications, including infant death.. · Individuals with varying levels of education are at higher risk for adverse maternal outcomes..

Predictors and Trends in First-Trimester Hemoglobin A1c Screening in New York City, 2009 to 2017

Glycated hemoglobin is an adjunct tool in early pregnancy to assess glycemic control. We examined trends and maternal predictors for those who had A1c screening in early pregnancy using hospital discharge and vital registry data between 2009 and 2017 linked with the New York City A1C Registry (N = 798,312). First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017. The likelihood of screening became less targeted to high-risk patients over time, with a decrease in mean A1c values from 5.8% (95% confidence interval [CI]: 5.8, 5.9) to 5.3 (95% CI: 5.3, 5.4). The prevalence of gestational diabetes mellitus increased while testing became less discriminate for those with high-risk factors, including pregestational type 2 diabetes, chronic hypertension, obesity, age over 40 years, as well as Asian or Black non-Hispanic race/ethnicity. KEY POINTS: · First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017 in New York City.. · The likelihood of screening became less targeted to high-risk patients over time.. · The prevalence of gestational diabetes mellitus increased, while testing became less discriminate..

Continuous Glucose Monitoring Feedback in the Subsequent Development of Gestational Diabetes: A Pilot, Randomized, Controlled Trial in Pregnant Women

OBJECTIVE

 This study evaluated the effects of receiving glucose feedback from continuous glucose monitoring (CGM) by intermittent scanning (unblinded group), and CGM with masked feedback (blinded group) in the subsequent development of gestational diabetes mellitus (GDM).

STUDY DESIGN

 This was a prospective, single-center, pilot, randomized controlled trial including n = 206 pregnant women in the first trimester of pregnancy with no prior diagnosis of type 1 or type 2 diabetes. The participants were randomized into the unblinded group or blinded group and wore the CGM in the first trimester of pregnancy (9-13 weeks), the second trimester of pregnancy (18-23 weeks), and late-second to early-third trimester (24-31 weeks). The primary outcome was GDM rate as diagnosed by the 75-g oral glucose tolerance test (OGTT) at 24 to 28 weeks.

RESULTS

 Over 47 months, 206 pregnant women were enrolled at 9 to 13 weeks. The unblinded group had a higher prevalence of women who developed GDM (21.5 vs. 14.9%; p > 0.05), compared to the blinded group. In the unblinded group compared to the blinded group, plasma glucose values were higher at 1 hour (median 7.7 [interquartile range {IQR}: 6.3-9.2] vs. 7.5 [6.3-8.7]) and 2 hours (6.3 [5.8-7.7] vs. 6.2 [5.3-7.2]), but lower at 0 hour (4.2 [4.0-4.5] vs. 4.3 [4.1-4.6]; p > 0.05). All these differences were not statistically significant.

CONCLUSION

 Glucose feedback from CGM wear in the first to the third trimester of pregnancy without personalized patient education failed to alter GDM rate.

KEY POINTS

· Continuous glucose monitoring (CGM) is feasible for use in pregnant women.. · No significant difference in gestational diabetes rates with or without CGM feedback.. · Future clinical trials should incorporate CGM education and personalized guidance to enhance study outcomes..

Evaluation of preadipocyte factor-1 (Pref-1) level in cord blood of newborns born by mothers with gestational diabetes mellitus (GDM)

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common metabolic complication, which leads to short and long-term consequences in both mother and fetus exposed to hyperglycemia. The aetiology of this condition is proposed to be based on the dysfunction of the adipose tissue, which is characterised by the aberrant generation of adipokines. One of them is preadipocyte factor-1 (Pref-1), which could mediate controlling the adaptation of the maternal metabolism to pregnancy.

AIMS

The study aims to examine the level of Pref-1 in the cord blood of healthy pregnant women's neonates and fetuses born to mothers with GDM.

MATERIALS AND METHODS

Cord blood samples were collected from 30 newborns of mothers with GDM and 40 newborns of healthy pregnant women. Pref-1 concentrations were measured with an ELISA kit.

RESULTS

Fetal Pref-1 concentrations were significantly lower in newborns of mothers with GDM compared to the normal pregnancy group children (5.32 ± 0.29 vs. 7.38 ± 0.53; p < 0.001). Mothers with GDM had a significantly higher index of BMI before pregnancy, maternal gestational weight gain, and maternal fasting glucose. In-depth analysis through multiple variant linear regression revealed a significant association between fetal serum Pref-1 levels, exposure to GDM, and gestational age.

CONCLUSION

These findings contribute valuable insights into maternal-fetal health and pave the way for more targeted and effective clinical interventions.

Impact of Mediterranean diet in lowering risk of gestational diabetes mellitus: A cross-sectional study

INTRODUCTION AND OBJECTIVES

The prevalence of gestational diabetes is increasing, and the Mediterranean diet is highly recommended for health. The objective of this study is to determine the relationship between adherence to the Mediterranean diet and gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

In this cross-sectional study the presence of GDM is the dependent variable, and socio-demographic and anthropometric characteristics and adherence to the Mediterranean diet are the independent variables in this study, which was carried out in pregnant women who were 24-28 weeks pregnant and had Oral Glucose Tolerance Test (OGTT). Adherence to the Mediterranean diet was evaluated with the Mediterranean Diet Adherence Scale (MEDAS). Data were collected through face-to-face interviews, weight and height measurements of the pregnant women were made, and the diagnosis of GDM was made with OGTT.

RESULTS

Two hundred and seven pregnant women participated in the study and 85 of them (41.1%) were diagnosed as GDM. According to Logistic Regression models, age (OR: 1.088, 95% CI: 1.031-1.149) and infertility treatment (OR: 4.570, 95% CI: 1.443-14.474) significantly increased the occurrence of GDM, while adherence to the Mediterranean diet (OR: 0.683, 95% CI: 0.568-0.820) significantly reduced the risk.

CONCLUSIONS

Nearly two-fifths of pregnant women were diagnosed with GDM while only one-fourth complied with a Mediterranean diet. The increase in the frequency of GDM should be carefully monitored. It may be useful to detect risky pregnant women at the time of the first diagnosis, to measure their glucose levels, and to give suggestions about the Mediterranean diet in the early period.

Safety of GLP-1 Receptor Agonists and Other Second-Line Antidiabetics in Early Pregnancy

Importance

Increasing use of second-line noninsulin antidiabetic medication (ADM) in pregnant individuals with type 2 diabetes (T2D) may result in fetal exposure, but their teratogenic risk is unknown.

Objective

To evaluate periconceptional use of second-line noninsulin ADMs and whether it is associated with increased risk of major congenital malformations (MCMs) in the infant.

Design, Setting, and Participants

This observational population-based cohort study used data from 4 Nordic countries (2009-2020), the US MarketScan Database (2012-2021), and the Israeli Maccabi Health Services database (2009-2020). Pregnant women with T2D were identified and their live-born infants were followed until up to 1 year after birth.

Exposure

Periconceptional exposure was defined as 1 or more prescription fill of sulfonylureas, dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and sodium-glucose cotransporter 2 (SGLT2) inhibitors, or insulin (active comparator) from 90 days before pregnancy to end of first trimester.

Main Outcomes and Measures

Relative risks (RRs) and 95% CIs for MCMs were estimated using log-binomial regression models, adjusting for key confounders in each cohort and meta-analyzed.

Results

Periconceptional exposure to second-line noninsulin ADMs differed between countries (32, 295, and 73 per 100 000 pregnancies in the Nordics, US, and Israel, respectively), and increased over the study period, especially in the US. The standardized prevalence of MCMs was 3.7% in all infants (n = 3 514 865), 5.3% in the infants born to women with T2D (n = 51 826), and among infants exposed to sulfonylureas was 9.7% (n = 1362); DPP-4 inhibitors, 6.1% (n = 687); GLP-1 receptor agonists, 8.3% (n = 938); SGLT2 inhibitors, 7.0% (n = 335); and insulin, 7.8% (n = 5078). Compared with insulin, adjusted RRs for MCMs were 1.18 (95% CI, 0.94-1.48), 0.83 (95% CI, 0.64-1.06), 0.95 (95% CI, 0.72-1.26), and 0.98 (95% CI, 0.65-1.46) for infants exposed to sulfonylureas, DPP-4 inhibitors, GLP-1 receptor agonists, and SGLT2 inhibitors, respectively.

Conclusions and Relevance

Use of second-line noninsulin ADMs is rapidly increasing for treatment of T2D and other indications, resulting in an increasing number of exposed pregnancies. Although some estimates were imprecise, results did not indicate a large increased risk of MCMs above the risk conferred by maternal T2D requiring second-line treatment. Although reassuring, confirmation from other studies is needed, and continuous monitoring will provide more precise estimates as data accumulate.

Effect of artificial pancreas system use on glycaemic control among pregnant women with type 1 diabetes mellitus: A meta-analysis of randomized controlled trials

AIM

To assess the efficacy of artificial pancreas systems (APS) use among pregnant women with type 1 diabetes mellitus (T1DM) by conducting a meta-analysis.

METHODS

We searched five databases, including EMBASE, Web of Science, PubMed, Cochrane Library and SCOPUS, for literature on APS use among pregnant women with T1DM before October 9, 2023. The primary endpoint was 24-hour time in range (TIR; 3.5-7.8 mmol/L). Secondary endpoints included glycaemic metrics for 24-hour (mean blood glucose [MBG], time above range [TAR], time below range [TBR]), and overnight TIR and TBR.

RESULTS

We identified four randomized controlled trials involving 164 participants; one study with 16 participants focused on overnight APS use, and the other three focused on 24-hour APS use. Compared with standard care, APS exhibited a favourable effect on 24-hour TIR (standard mean difference [SMD] = 0.53, 95% confidence interval [CI] 0.25, 0.80, P < 0.001), overnight TIR (SMD = 0.67, 95% CI 0.39, 0.95, P < 0.001), and overnight TBR (<3.5 mmol/L; SMD = -0.49, 95% CI -0.77, -0.21 P < 0.001), while there was no significant difference in 24-hour TAR, 24-hour TBR, or MBG between the two groups. We further conducted subgroup analyses after removing the trial focused on overnight APS use and showed that 24-hour APS use reduced not only the 24-hour TIR (SMD = 0.41, 95% CI 0.12, 0.71; P = 0.007) but also the 24-hour TBR (<2.8 mmol/L; SMD = -0.77, 95% CI -1.32, -0.23, P = 0.006).

CONCLUSION

Our findings suggest that APS might improve 24-hour TIR and overnight glycaemic control, and 24-hour APS use also significantly reduced 24-hour TBR (2.8 mmol/L) among pregnant women with T1DM.

Predictors of anxiety among pregnant women with gestational diabetes mellitus and their partners: The mediating role of marital satisfaction

AIMS

This study aims to examine the prevalence of anxiety symptoms and identify predictors of anxiety among pregnant women with gestational diabetes mellitus and their partners and explore the mediating role of marital satisfaction between maternal and paternal anxiety.

DESIGN

A cross-sectional study was conducted in Guangzhou, China, from July 2021 to May 2022.

METHODS

A total of 306 dyads of pregnant women with gestational diabetes mellitus and their partners completed the State-Trait Anxiety Inventory, Locke-Wallace Marital Adjustment Test and the socio-demographic and clinical data sheet.

RESULTS

The prevalence of anxiety symptoms was 32.4% and 36.6% in pregnant women with gestational diabetes mellitus and their partners, respectively. The predictors of maternal anxiety were paternal anxiety, maternal marital satisfaction, maternal monthly salary, fasting glucose value and 1-h glucose value. By contrast, the predictors of paternal anxiety were maternal anxiety, paternal marital satisfaction and paternal monthly salary. Moreover, the relationship between maternal and paternal anxiety was mediated by marital satisfaction.

CONCLUSIONS

The anxiety symptoms of pregnant women with gestational diabetes mellitus and their partners influence each other, and this relationship was mediated by marital satisfaction. Every couple should be screened for anxiety symptoms and treated as a team rather than focusing solely on the pregnant woman.

The Role of the Glycemic Index and Glycemic Load in the Dietary Approach of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is a common metabolic disorder that often develops during pregnancy, characterized by glucose intolerance and insulin resistance (IR). To ensure the well-being of both the mother and the fetus, the body undergoes multiple metabolic and immunological changes that result in peripheral IR and, under certain hereditary or acquired abnormalities, GDM in predisposed women. The adverse short- and long-term effects of GDM impact both the mother and the fetus. Nutrition seems to play an important role to prevent GDM or improve its evolution. An emphasis has been given to the proportion of carbohydrates (CHO) relative to protein and lipids, as well as dietary patterns, in GDM. The effects of CHO on postprandial glucose concentrations are reflected in the glycemic index (GI) and glycemic load (GL). Diets rich in GI and GL may induce or exacerbate IR, whereas diets low in GI and GL appear to enhance insulin sensitivity and improve glycemic control. These positive outcomes may be attributed to direct interactions with insulin and glucose homeostasis or indirect effects through improved body composition and weight management. This comprehensive narrative review aims to explore the significance of nutrition, with a focus on the critical evaluation of GI and GL in the dietary management of women with GDM.

Promoting healthy eating in early pregnancy in individuals at risk of gestational diabetes mellitus: does it improve glucose homeostasis? A study protocol for a randomized control trial

Background

Healthy eating during pregnancy has favorable effects on glycemic control and is associated with a lower risk of gestational diabetes mellitus (GDM). According to Diabetes Canada, there is a need for an effective and acceptable intervention that could improve glucose homeostasis and support pregnant individuals at risk for GDM.

Aims

This unicentric randomized controlled trial (RCT) aims to evaluate the effects of a nutritional intervention initiated early in pregnancy, on glucose homeostasis in 150 pregnant individuals at risk for GDM, compared to usual care.

Methods

Population: 150 pregnant individuals ≥18 years old, at ≤14 weeks of pregnancy, and presenting ≥1 risk factor for GDM according to Diabetes Canada guidelines. Intervention: The nutritional intervention initiated in the first trimester is based on the health behavior change theory during pregnancy and on Canada's Food Guide recommendations. It includes (1) four individual counseling sessions with a registered dietitian using motivational interviewing (12, 18, 24, and 30 weeks), with post-interview phone call follow-ups, aiming to develop and achieve S.M.A.R.T. nutritional objectives (specific, measurable, attainable, relevant, and time-bound); (2) 10 informative video clips on healthy eating during pregnancy developed by our team and based on national guidelines, and (3) a virtual support community via a Facebook group. Control: Usual prenatal care. Protocol: This RCT includes three on-site visits (10-14, 24-26, and 34-36 weeks) during which a 2-h oral glucose tolerance test is done and blood samples are taken. At each trimester and 3 months postpartum, participants complete web-based questionnaires, including three validated 24-h dietary recalls to assess their diet quality using the Healthy Eating Food Index 2019. Primary outcome: Difference in the change in fasting blood glucose (from the first to the third trimester) between groups. This study has been approved by the Ethics Committee of the Centre de recherche du CHU de Québec-Université Laval.

Discussion

This RCT will determine whether a nutritional intervention initiated early in pregnancy can improve glucose homeostasis in individuals at risk for GDM and inform Canadian stakeholders on improving care trajectories and policies for pregnant individuals at risk for GDM.

Clinical trial registration

https://clinicaltrials.gov/study/NCT05299502, NCT05299502.

Family planning behaviours among women with diabetes mellitus: a scoping review

INTRODUCTION

Diabetes mellitus in pregnancies is associated with adverse outcomes both for the mothers and babies. Postponing pregnancy in unoptimized conditions and stabilisation of glucose should be prioritized. This scoping review is aimed to determine the scope and at the same time map the types of evidence available that is related to family planning behaviours among women with diabetes mellitus, with a particular focus on their factors which influence family planning usage and subsequently enable the identification of knowledge gaps in preventing unintended pregnancies among this high-risk population.

METHODS

This scoping review is guided by the methodological framework by Arksey and O'Malley's and Prisma-ScR checklist. PubMed, EBSCO and OVID were searched for empirical studies between 2000 and February 2022 using the search terms "family planning", "contraceptive" and "diabetes mellitus". Data were summarized according to the study characteristics and levels of factors influencing family planning behaviours.

RESULTS

Thirty-five articles that met the eligibility criteria included 33 quantitative studies, one qualitative study and one mixed-methods study. The prevalence of family planning methods used by women with diabetes mellitus varied ranging from 4.8 to 89.8% among the studied population. Women with diabetes mellitus were reported to be less likely to utilise any family planning methods compared to women without diabetes mellitus.

CONCLUSIONS

Most of the evidence to date on family planning behaviours among women with diabetes mellitus focuses on the role of individual level sociodemographic factors. Few studies focused on exploring determinants at multiple levels. In this review we found that there is limited evidence on disease control and pregnancy intention in relation to their family planning practices. Future studies with more clinical and contextual factors are needed to guide the strengthening of family planning services for high-risk group women specifically for women with diabetes mellitus.

Maternal-placental axis and its impact on fetal outcomes, metabolism, and development

Maternal obesity could impact offspring's health. During "critical period" such as pregnancy insults have a significant role in developing chronic diseases later in life. Literature has shown that diet can play a major role in essential metabolic and development processes on fetal outcomes. Moreover, the placenta, an essential organ developed in pregnancy, seems to have its functions impaired based on pre-gestational and gestational nutritional status. Specifically, a high-fat diet has been shown as a potential nutritional insult that also affects the maternal-placental axis, which is involved in offspring development and outcome. Moreover, some classes of nutrients are associated with pregnancy complications such as reduced intake of micronutrients and diabetes, preeclampsia, and preterm delivery. Thus, we will summarize the current literature on maternal environment factors that impacts the placental development and consequently the fetal an offspring health, or the maternal-placental axis, and this on fetal outcomes, metabolism, and development.

Do glycaemic treatment targets affect the perinatal mental health status of women with gestational diabetes? - Data from the TARGET Trial

BACKGROUND

Gestational diabetes mellitus is associated with perinatal mental disorders. Effective management may reduce this risk, but there is little evidence on effects of different glycaemic treatment targets. We assessed whether tight glycaemic treatment targets compared with less-tight targets reduce the risk of poor mental health outcomes in women with gestational diabetes.

METHODS

This was a secondary analysis of data from women who consented to complete perinatal mental health questionnaires as participants in the TARGET Trial, a stepped-wedge cluster randomized trial in 10 hospitals in New Zealand. All hospitals initially used less tight glycaemic targets for management of gestational diabetes and were sequentially randomized, in clusters of two at 4-monthly intervals, to using tighter glycaemic targets. Data were collected from 414 participants on anxiety (6-item Spielberger State Anxiety scale), depression (Edinburgh Postnatal Depression Scale), and health-related quality of life (36-Item Short-Form General Health Survey) at the time of diagnosis (baseline), 36 weeks of gestation, and 6 months postpartum. The primary outcome was composite poor mental health (any of anxiety, vulnerability to depression, or poor mental health-related quality of life). Generalized linear mixed models were used to determine the main treatment effect with 95% confidence intervals using an intention-to-treat approach.

RESULTS

We found no differences between randomised glycaemic target groups in the primary outcome at 36 weeks' (relative risk (RR): 1.07; 95% confidence interval 0.58, 1.95) and 6 months postpartum (RR: 1.03; 0.58, 1.81). There were similarly no differences in the components of the primary outcome at 36 weeks' [anxiety (RR: 0.85; 0.44, 1.62), vulnerability to depression (RR: 1.10; 0.43, 2.83), or poor mental health-related quality of life (RR: 1.05; 0.50, 2.20)] or at 6 months postpartum [anxiety (RR:1.21; 0.59, 2.48), vulnerability to depression (RR:1.41; 0.53, 3.79), poor mental health-related quality of life (RR: 1.11; 0.59, 2.08)].

CONCLUSION

We found no evidence that adoption of tighter glycaemic treatment targets in women with gestational diabetes alters their mental health status at 36 weeks' gestation and at 6 months postpartum.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12615000282583 (ANZCTR-Registration). Date of registration: 25 March 2015.

Effect of individualised nutritional intervention on the postpartum nutritional status of patients with gestational diabetes mellitus and the growth and development of their offspring: a quasi-experimental study

This study explored the effect of individualised nutritional intervention on the postpartum nutritional status of patients with the growth and development of their offspring. This study included pregnant women with gestational diabetes mellitus (GDM) at Hangzhou Women's Hospital in 2019. At 42 days after childbirth, the HbA1c (95% CI: 0.44-0.56%, p < 0.001), the FPG (95% CI: 0.01-0.26 mmol/L, p < 0.05), 2HPG (95% CI: -0.01-0.73 mmol/L, p < 0.05) and TCH (95% CI: -0.34-0.00 mmol/L, p < 0.05) level of the control group were 0.14, 0.36, and 0.17 mmol/L higher than in the intervention group. There were no differences in TG and HGB between the two groups (all p > 0.05). There were significant differences in the number of macrosomia and neonatal weight between the two groups (both p < 0.05). Differences in WHZ after childbirth were not statistically significant between the two groups (all p > 0.05). Individualised nutritional intervention could improve blood glucose levels 42 days after childbirth and reduce macrosomia incidence in pregnant women with GDM.Impact statementWhat is already known on this subject? Individualised nutrition intervention can improve blood glucose status and complications during pregnancy, thus improving pregnancy outcomes.What the results of this study add? Individual nutrition intervention improved the blood glucose and nutritional status of patients at 42 days postpartum, but there was no difference in the growth and development indicators of their offspring at 0-24 months.What the implications are of these findings for clinical practice and/or further research? Improve nutritional intervention programs for gestational diabetes, improve blood glucose during pregnancy and postpartum, to improve pregnancy outcomes and reduce the occurrence of type 2 diabetes and other metabolic diseases; Extend the monitoring range of the growth and development of the offspring of gestational diabetes, find the problems and timely carry out the nutritional intervention, to improve the development of the offspring.

Achieving comparability in glycemic control between antidiabetic treatment strategies in pregnancy when using real world data

PURPOSE

Healthcare utilization databases often lack information on glycemic control, a key confounder when studying the safety of antidiabetic treatments, since patients with worse control are channeled to second-line agents, in particular insulin, versus first-line agents such as metformin. We evaluated whether adjustment for measured characteristics attains balance in glycemic control when comparing antidiabetic treatment strategies in pregnant women with pregestational type 2 diabetes (T2DM).

METHODS

In a US insurance claims database, we identified 3360 women with T2DM pregnant between 2004 and 2015, of whom a subset of 996 had data on hemoglobin A1c (HbA1c ) levels. We selected insulin only as the comparator group and used propensity score (PS)-matching on comorbidities and proxies of diabetes severity, but not on HbA1c , to adjust for confounding. We used standardized differences (st.diff) to assess balance in claims-based covariates and mean HbA1c (% ± SD) in the subset.

RESULTS

There were imbalances in claims-based covariates before PS-matching, with smaller differences when both treatment strategies included insulin. After PS-matching, balance was achieved in most claims-based covariates (st.diff <0.1). Mean HbA1c was similar before and after PS-matching when both treatments included insulin (e.g., 7.1 ± 1.5 vs. 7.7 ± 1.8 and 7.1 ± 1.5 vs. 7.5 ± 1.7, respectively, for metformin + insulin vs. insulin only). Differences in mean HbA1c remained after PS-matching when non-insulin treatments were compared to treatments including insulin (e.g., 6.3 ± 1.1 vs. 7.6 ± 1.7 for metformin only vs. insulin only).

CONCLUSIONS

Balance in both claims-based characteristics and glycemic control was attained after restricting the population to women with T2DM and comparing treatment strategies indicated for patients with similar diabetes severity. When comparing treatment strategies with versus without insulin, differences in glycemic control persisted after PS-matching even when balance was attained for other measured characteristics.

Maternal and fetal outcomes in a retrospective cohort of obstetrical patients that used an insulin pump paired with a continuous glucose monitor

OBJECTIVE

To assess maternal and neonatal outcomes in pregnant pregestational diabetic patients using a continuous subcutaneous insulin infusion (CSII) pump paired with a continuous glucose monitor (CGM).

METHODS

This retrospective cohort study included 55 patients who delivered within one healthcare system from October 2019 to October 2022 with pregestational diabetes managed using CSII pumps paired with CGM. Maternal blood glucose (BG) data were analyzed for the two-week period preceding delivery. The percentage of time spent at a BG level of less than 140 mg/dL was recorded and compared between patients with and without obstetric and neonatal morbidities.

RESULTS

Patients who delivered with severe preeclampsia (S. PreE) had a significantly lower mean percentage of time spent at BG < 140 mg/dL than those who did not (S. PreE 15/55, 63.1% ± 19.0 vs. 40/55, 73.6% ± 13.8; p = 0.03). Mothers who had a preterm birth (PTB) had a significantly lower mean percentage of time spent at BG < 140 mg/dL than those who delivered at term (PTB 35/55, 66.4% ± 16.4 vs 20/55, 78.3% ± 11.9; p = 0.006). The mean percentage of time spent at a BG < 140 mg/dL among mothers of neonates with respiratory distress syndrome (RDS) was significantly lower than those without RDS (RDS present 13/55, 59.7% ± 20.4 vs 42/55, 74.1% ± 12.7; p = 0.003). There was a significant correlation between a greater neonatal birth weight percentile and worse time spent at BG < 140 mg/dL (r = - 0.31; p = 0.02). No other significant differences were observed between the groups.

CONCLUSION

Improved blood glucose levels in pregestational diabetic patients using a CSII pump and CGM is associated with reduced maternal and neonatal morbidity as well as lower birth weight percentile neonates. Future studies are needed to clarify how much time each day a patient needs to spend below a given blood sugar, how long this blood glucose should be maintained, and what specific blood glucose target should be selected.

Self-monitoring of blood glucose two-weekly versus weekly in gestational diabetes on nutrition therapy: A randomized trial

OBJECTIVE

To evaluate 4-point per day self-monitoring of blood glucose (SMBG) every 2 weeks compared with every week.

METHODS

A total of 104 patients with lifestyle-controlled gestational diabetes (GDMA1) were randomized to 2-weekly or weekly 4-point per day (fasting on awakening and 2-h post-meals) SMBG. Primary outcome was the change in glycated hemoglobin (HbA1c) level from enrollment to 36 weeks of pregnancy across trial arms. The non-inferiority margin was an HbA1c increase of 0.2%.

RESULTS

The mean difference for change in HbA1c from enrollment to 36 weeks was 0.003% (95% confidence interval [CI] -0.098% to +0.093%), within the 0.2% non-inferiority margin. The change in HbA1c level increased significantly within both trial arms-0.275% ± 0.241% (P < 0.001) in 2-weekly arm versus 0.277% ± 0.236% (P < 0.001) in the weekly arm. Participants randomized to 2-weekly SMBG were significantly less likely to receive anti-glycemic treatment-5/52 (9.6%) versus 14/50 (28.0%) (relative risk 0.34, 95% CI 0.13-0.88; P = 0.017). All secondary outcomes-maternal weight gain, preterm delivery, cesarean delivery, birthweight, and neonatal admission-were not significantly different.

CONCLUSIONS

In GDMA1, 2-weekly is non-inferior to weekly SMBG on the change in HbA1c level. Two-weekly SMBG appeared to be adequate for monitoring women with GDMA1.

CLINICAL TRIAL REGISTRATION

This study was registered in ISRCTN registry on March 25, 2022 with trial identification number: ISRCTN13404790 (https://doi.org/10.1186/ISRCTN13404790). The first participant was recruited on April 12, 2022.

The Cohort of Indonesian Preterm Infants for Long-term Outcomes (CIPTO) study: a protocol

BACKGROUND

Indonesia has high numbers of preterm birth, i.e., around 600,000 preterm births annually. It imposes a significant burden on the Indonesia's healthcare system. Indonesia therefore requires its own evidence-based reference to manage premature neonates and ex-preterm infants who subsequently survived. No long-term study on preterm infants in Indonesia has been conducted, therefore we aim to evaluate growth and development on ex-preterm infants until the pre-pubertal stage.

METHODS

We at the Cipto Mangunkusumo General Hospital (CMGH) designed a prospective cohort study of preterm infants, i.e., the Cohort of Indonesian Preterm Infants for Long-term Outcomes (CIPTO) study. At least 500 subjects will be recruited with an estimation of two-year recruitment (i.e., the recruitment phase will be completed before 2024). The CIPTO study will observe long-term outcomes of ex-preterm infants, primarily on growth and developmental milestones until 8 years old. Aims of this study are to determine the ex-preterm outcomes and to generate an evidence-based reference of preterm care for ensuring optimum outcomes. The pre-specified long-term outcomes in this study are survival rates, growth outcomes, neurodevelopmental outcomes, feeding behavior, as well as hearing and vision impairments. Growth and neurodevelopmental outcomes will be assessed at 0, 2, 4, 6, 9, 12, 15, 18 and 24 months of corrected age as well as at 3, 4, 5, 6, 7 and 8 years old.

DISCUSSION

The CIPTO study is the first prospective cohort in Indonesia focusing on preterm infants born at the CMGH. With a follow up until 8 years old, this study may provide useful insights to generate an evidence-based, Indonesia's health care reference in managing premature infants and ensuring the optimum outcomes of ex-preterm infants.

Reproductive care in Thai women with diabetes mellitus: a descriptive cross-sectional study

BACKGROUND

Pre-existing diabetes mellitus (DM) is a challenging pregnancy complication as poor glycemic control is associated with adverse maternal and fetal outcomes. In this study, we aimed to investigate DM-related knowledge, attitudes, preconception care practices, and contraceptive prevalence in women with DM.

METHODS

This descriptive cross-sectional survey was conducted among reproductive-aged Thai women receiving DM treatment at King Chulalongkorn Memorial Hospital between August 1, 2021, and June 30, 2022. Patients with DM who were not pregnant or trying to conceive and could be contacted via the phone were included and a validated self-administered questionnaire was distributed electronically.

RESULTS

A total of 238 participants were included in the final analysis, yielding 69.4% response rates. The mean (standard deviation) score for knowledge of pregnancy planning and pregnancy-related risks was 6.8 (3.5) out of 15. Only about half of the participants had discussed pregnancy planning with their physicians. Multivariable analysis showed that younger age at DM diagnosis, non-Buddhism, married, higher education, and medical personnel were significantly associated with higher knowledge scores. Women aged > 45 years and those with higher practice scores had significantly higher adjusted odds of using highly effective contraception; the most common methods included male condoms and combined oral contraceptive pills. There was an unmet need for contraception in 9.5% of women with DM.

CONCLUSIONS

Although highly effective contraception is safe for patients with DM, only about half of our participants used tier one or two contraceptives or had received consultation regarding preconception planning. There was a notable gap in care coordination among specialists; integrating reproductive healthcare into DM therapy would improve access to preconception care.

Effectiveness of Telemedicine in Managing Diabetes in Pregnancy: A Systematic Review and Meta-Analysis

BACKGROUND

Strict monitoring of blood glucose during pregnancy is essential for ensuring optimal maternal and neonatal outcomes. Telemedicine could be a promising solution for supporting diabetes management; however, an updated meta-analysis is warranted. This study assesses the effects of telemedicine solutions for managing gestational and pregestational diabetes.

METHODS

PubMed, EMBASE, Cochrane Library Central Register of Controlled Trials, and CINAHL were searched up to October 14, 2020. All randomized trials assessing the effects of telemedicine in managing diabetes in pregnancy relative to any comparator without the use of telemedicine were included. The primary outcome was infant birth weight. A meta-analysis comparing the mean difference (MD) in birth weight across studies was applied, and subgroup and sensitivity analyses were performed. The revised Cochrane tool was applied to assess the risk of bias, and the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From a total of 18 studies, ten (totaling 899 participants) were used to calculate the effect on infant birth weight. The results nonsignificantly favored the control (MD of 19.34 g; [95% confidence interval, CI -47.8; 86.47]), with moderate effect certainty. Heterogeneity was moderate (I2 = 37.39%). Statistically significant secondary outcomes included differences in two-hour glucose tolerance postpartum (gestational diabetes; two studies: standardized mean difference 9.62 mg/dL [95% CI: 1.95; 17.28]) that favored the control (GRADE level, very low) and risk of shoulder dystocia (four studies: log odds -1.34 [95% CI: -2.61; -0.08]) that favored telemedicine (GRADE, low).

CONCLUSIONS

No evidence was found to support telemedicine as an alternative to usual care when considering maternal and fetal outcomes. However, further research is needed, including economic evaluations.

The Incidence and Management of Type 2 Diabetes Mellitus After Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) refers to a transient state of impaired glucose tolerance that develops during pregnancy, affecting a significant proportion of expectant mothers globally. This review aimed to comprehensively examine the subsequent incidence and management of type 2 diabetes mellitus (T2DM) in women who have previously experienced GDM. The transition from GDM to T2DM is a well-recognized continuum, with affected women facing an increased risk of developing T2DM postpartum. Several studies have demonstrated that women with a history of GDM face a substantially higher risk of developing T2DM compared to normoglycemic pregnant women. The long-term consequences of developing T2DM following GDM are significant, as it not only affects the health of the mother but also poses risks to the offspring. The most common risk factors associated with the progression of GDM to T2DM include pregnancy at an advanced age, insulin treatment during pregnancy, and delivering an overweight baby. As GDM women are at higher risk of developing T2DM, effective management strategies such as lifestyle changes, postpartum care, breastfeeding, screening tests, and gaining awareness of risk are crucial to mitigate the risk of T2DM in this population. The current review was conducted to guide healthcare providers and women with a history of GDM about the potential risks of T2DM and management strategies to prevent the condition. This review provides a summary of evidence on the incidence rate of T2DM in GDM patients, its associated risk factors, and approaches to mitigate this challenge.

Significance of Umbilical Cord Leptin Profile during Pregnancy in Gestational Diabetes Mellitus-A Systematic Review and Meta-Analysis

BACKGROUND

The literature provides limited evidence of cord blood leptin levels in gestational diabetes mellitus (GDM), with contradictory and inconsistent results with respect to their possible implications for maternal, perinatal, and future complications.

METHODS

MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched in order to investigate the state of evidence on the association of leptin profile in cord blood during perinatal complications in GDM. We critically assessed the risk of bias using the Newcastle-Ottawa scale. Meta-analyses were performed, and heterogeneity and publication bias were analyzed.

RESULTS

sixteen primary-level studies were included, recruiting 573 GDM and 1118 control pregnant women. Cord blood leptin levels were significantly higher in GDM participants compared to controls (standardized mean difference [SMD] = 0.59, 95% confidence intervals (CI) = 0.37 to 0.80, p < 0.001). All subgroups also maintained significant differences stratified by continents (Asia: SMD = 0.91, 95% CI = 0.45 to 1.37, p < 0.001; Europe: SMD = 0.38, 95% CI = 0.20 to 0.56, p < 0.001), analysis technique (ELISA: SMD = 0.70, 95% CI = 0.44 to 0.97, p < 0.001; RIA: SMD = 0.30, 95% CI = 0.11 to 0.49, p = 0.002), and sample source (plasma: SMD = 0.71, 95% CI = 0.33 to 1.09, p < 0.001; serum: SMD = 0.55, 95% CI = 0.34 to 0.77, p < 0.001).

CONCLUSION

Cord blood leptin levels were significantly higher in GDM compared to controls. Further research is needed to clarify its role as a predictive biomarker of subsequent metabolic diseases in mothers with GDM and offspring.

Issues and challenges in diabetic neuropathy management: A narrative review

Diabetic neuropathy (DN) is a devastating disorder with an increasing prevalence globally. This epidemic can pose a critical burden on individuals and com-munities, subsequently affecting the productivity and economic output of a country. With more people living a sedentary lifestyle, the incidence of DN is escalating worldwide. Many researchers have relentlessly worked on ways to combat this devastating disease. Their efforts have given rise to a number of commercially available therapies that can alleviate the symptoms of DN. Unfortunately, most of these therapies are only partially effective. Worse still, some are associated with unfavorable side effects. This narrative review aims to highlight current issues and challenges in the management of DN, especially from the perspective of molecular mechanisms that lead to its progression, with the hope of providing future direction in the management of DN. To improve the approaches to diabetic management, the suggested resolutions in the literature are also discussed in this review. This review will provide an in-depth understanding of the causative mechanisms of DN, apart from the insights to improve the quality and strategic approaches to DN management.

Self-management of type 2 diabetes mellitus in pregnancy and breastfeeding experiences among women in Thailand: Study protocol

Women with type 2 diabetes mellitus are at a higher risk of pregnancy complications. Although traditional beliefs and practices influence diabetes management and breastfeeding, recommendations integrating Thai cultural beliefs in maternal care are lacking. The purpose of this study is to describe diabetes self-management in pregnancy and breastfeeding experiences in women with preexisting type 2 diabetes mellitus from Thailand. A convergent parallel mixed-methods study will be conducted. Data will be collected from 20 pregnant women with preexisting type 2 diabetes mellitus in Thailand who are either primigravida or multigravida, aged 20-44 years old, speak the Thai language, and provide consent. The National Institute on Minority Health and Health Disparities Framework's sociocultural and behavioral domains guides the research aims. Data will be collected two times. The first time is during pregnancy (T1); study participants will complete questionnaires and engage in an interview about diabetes self-management, breastfeeding confidence, and breastfeeding intention. The second time is at 4-6 weeks postpartum (T2); study participants will be interviewed about their breastfeeding experiences. We will review and extract maternal health outcomes including body mass index, gestational weight gain, and glycated hemoglobin for T1 as well as fasting plasma glucose for T2. Qualitative data will be analyzed using directed content analysis. Quantitative data will be analyzed using descriptive statistics. Data sources will be triangulated with relative convergence in the results. This proposed study is significant because the findings will be used as a preliminary guide to developing a culturally tailored approach to enhance health outcomes of Thai women with diabetes in pregnancy and postpartum periods.

Predicting insulin use among women with gestational diabetes diagnosed in oral glucose tolerance test

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common complications affecting pregnant women. While most women will achieve adequate glycemic levels with diet and exercise, some will require pharmacological treatment to reach and maintain glucose levels between the desired thresholds. Identifying these patients early in pregnancy could help direct resources and interventions.

METHODS

This retrospective cohort of women with GDM diagnosed with an abnormal 75g-OGTT presents data from 869 patients (724 in the diet group and 145 in the insulin group). Univariate logistic regression was used to compare the groups, and multivariable logistic regression was used to identify independent factors associated with the need for insulin. A log-linear function was used to estimate the probability of requiring pharmacological treatment.

RESULTS

Women in the insulin group had higher pre-pregnancy BMI index (29.8 vs 27.8 kg/m², odds ratio [OR] 1.06, 95% confidence interval [CI] 1.03-1.09), more frequent history of previous GDM (19.4% vs. 7.8%, OR 2.84, 95% CI 1.59-5.05), were more likely to have chronic hypertension (31.7% vs. 23.2%, OR 1.54, 95% CI 1.04-2.27), and had higher glucose levels at all three OGTT points. Multivariable logistic regression final model included age, BMI, previous GDM status, and the three OGTT values as predictors of insulin requirement.

CONCLUSIONS

We can use regularly collected data from patients (age, BMI, previous GDM status, and the three OGTT values) to calculate the risk of a woman with GDM diagnosed in OGTT needing insulin. Identifying patients with a greater risk of requiring pharmacological treatment could help healthcare services to better allocate resources and offer closer follow-up to high-risk patients.

Self-monitoring of blood glucose levels among pregnant individuals with gestational diabetes: a systematic review and meta-analysis

Introduction

The World Health Organization (WHO) recommends treatment and management of gestational diabetes (GD) through lifestyle changes, including diet and exercise, and self-monitoring blood glucose (SMBG) to inform timely treatment decisions. To expand the evidence base of WHO's guideline on self-care interventions, we conducted a systematic review of SMBG among pregnant individuals with GD.

Setting

Following PRISMA guidelines, we searched PubMed, CINAHL, LILACS, and EMBASE for publications through November 2020 comparing SMBG with clinic-based monitoring during antenatal care (ANC) globally.

Primary and secondary outcome measures

We extracted data using standardized forms and summarized maternal and newborn findings using random effects meta-analysis in GRADE evidence tables. We also reviewed studies on values, preferences, and costs of SMBG.

Results

We identified 6 studies examining SMBG compared to routine ANC care, 5 studies on values and preferences, and 1 study on costs. Nearly all were conducted in Europe and North America. Moderate-certainty evidence from 3 randomized controlled trials (RCTs) showed that SMBG as part of a package of interventions for GD treatment was associated with lower rates of preeclampsia, lower mean birthweight, fewer infants born large for gestational age, fewer infants with macrosomia, and lower rates of shoulder dystocia. There was no difference between groups in self-efficacy, preterm birth, C-section, mental health, stillbirth, or respiratory distress. No studies measured placenta previa, long-term complications, device-related issues, or social harms. Most end-users supported SMBG, motivated by health benefits, convenience, ease of use, and increased confidence. Health workers acknowledged SMBG's convenience but were wary of technical problems. One study found SMBG by pregnant individuals with insulin-dependent diabetes was associated with decreased costs for hospital admission and length of stay.

Conclusion

SMBG during pregnancy is feasible and acceptable, and when combined in a package of GD interventions, is generally associated with improved maternal and neonatal health outcomes. However, research from resource-limited settings is needed.

Systematic Review Registration

PROSPERO CRD42021233862.

A Pilot Study of Dietetic, Phenotypic, and Genotypic Features Influencing Hypertensive Disorders of Pregnancy in Women with Pregestational Diabetes Mellitus

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and perinatal morbimortality. Dietetic, phenotypic, and genotypic factors influencing HDP were analyzed during a nutrigenetic trial in Rio de Janeiro, Brazil (2016-2020). Pregnant women with pregestational diabetes mellitus (n = 70) were randomly assigned to a traditional or DASH diet group. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured during prenatal visits and HDP were diagnosed using international criteria. Phenotypic data were obtained from medical records and personal interviews. Genotyping for FTO and ADRB2 polymorphisms used RT-PCR. Linear mixed-effect models and time-to-event analyses were performed. The variables with significant effect on the risk for progression to HDP were: black skin color (adjusted hazard ratio [aHR] 8.63, p = 0.01), preeclampsia in previous pregnancy (aHR 11.66, p < 0.01), SBP ≥ 114 mmHg in the third trimester (aHR 5.56, p 0.04), DBP ≥ 70 mmHg in the first trimester (aHR 70.15, p = 0.03), mean blood pressure > 100 mmHg (aHR 18.42, p = 0.03), and HbA1c ≥ 6.41% in the third trimester (aHR 4.76, p = 0.03). Dietetic and genotypic features had no significant effect on the outcome, although there was limited statistical power to test both.

MIDO GDM: an innovative artificial intelligence-based prediction model for the development of gestational diabetes in Mexican women

Given the barriers to early detection of gestational diabetes mellitus (GDM), this study aimed to develop an artificial intelligence (AI)-based prediction model for GDM in pregnant Mexican women. Data were retrieved from 1709 pregnant women who participated in the multicenter prospective cohort study 'Cuido mi embarazo'. A machine-learning-driven method was used to select the best predictive variables for GDM risk: age, family history of type 2 diabetes, previous diagnosis of hypertension, pregestational body mass index, gestational week, parity, birth weight of last child, and random capillary glucose. An artificial neural network approach was then used to build the model, which achieved a high level of accuracy (70.3%) and sensitivity (83.3%) for identifying women at high risk of developing GDM. This AI-based model will be applied throughout Mexico to improve the timing and quality of GDM interventions. Given the ease of obtaining the model variables, this model is expected to be clinically strategic, allowing prioritization of preventative treatment and promising a paradigm shift in prevention and primary healthcare during pregnancy. This AI model uses variables that are easily collected to identify pregnant women at risk of developing GDM with a high level of accuracy and precision.

Feto-placental endothelial dysfunction in Gestational Diabetes Mellitus under dietary or insulin therapy

OBJECTIVE

Gestational diabetes mellitus (GDM) is a serious complication in pregnancy. Despite controlling the plasma glucose levels with dietary intervention (GDM-D) or insulin therapy (GDM-I), children born of diabetic mothers suffer more long-term complications from childhood to early adulthood. Placental circulation and nutrient exchange play a vital role in fetal development. Additionally, placental endothelial function is an indicator of vascular health, and plays an important role in maintaining placental circulation for nutrient exchange. This study was conducted to assess changes in fetal endothelial dysfunction in GDM under different interventions during pregnancy.

METHODS

The primary human umbilical vein endothelial cells (HUVECs) were obtained from normal pregnant women (n = 11), GDM-D (n = 14), and GDM-I (n = 12) patients. LC-MS/MS was used to identify differentially expressed proteins in primary HUVECs among the three groups, after which Bioinformatics analysis was performed. Glucose uptake, ATP level, apoptosis, and differentially expressed proteins were assessed to investigate changes in energy metabolism.

RESULTS

A total of 8174 quantifiable proteins were detected, and 142 differentially expressed proteins were identified after comparing patients with GDM-D/GDM-I and healthy controls. Of the 142, 64 proteins were upregulated while 77 were downregulated. Bioinformatics analysis revealed that the differentially expressed proteins were involved in multiple biological processes and signaling pathways related to cellular processes, biological regulation, and metabolic processes. According to the results from KEGG analysis, there were changes in the PI3K/AKT signaling pathway after comparing the three groups. In addition, there was a decrease in glucose uptake in the GDM-I (P < 0.01) group. In GDM-I, there was a significant decrease in the levels of glucose transporter 1 (GLUT1) and glucose transporter 3 (GLUT3). Moreover, glucose uptake was significantly decreased in GDM-I, although in GDM-D, there was only a decrease in the levels of GLUT1. ATP levels decreased in GDM-I (P < 0.05) and apoptosis occurred in both the GDM-D and GDM-I groups. Compared to the normal controls, the levels of phosphate AKT and phosphate AMPK over total AKT and AMPK were reduced in the GDM-I group.

CONCLUSION

In summary, endothelial dysfunction occurred in pregnancies with GDM even though the plasma glucose levels were controlled, and this dysfunction might be related to the degree of glucose tolerance. The energy dysfunction might be related to the regulation of the AKT/AMPK/mTOR signaling pathway.

Experiences of Preconception Counseling among Pregnant Women with Preexisting Diabetes: Opportunities to Improve Patient-Centered Care

Available research suggests that patients with diabetes do not regularly receive preconception counseling, but information on patients' experiences of counseling is scant. We conducted a qualitative study involving semi-structured interviews with 22 patients between October 2020 and February 2021. Pregnant patients with preexisting diabetes were recruited from a specialty diabetes and pregnancy clinic at a large academic medical center in Northern California. Interviews were transcribed, coded, and analyzed using an inductive and deductive content analysis approach. A total of 27% reported they did not have any pregnancy-related discussions with a health care provider before pregnancy. Of those that did, many sought out counseling; this was often connected to how "planned" the pregnancy was. Few participants, nearly all with type 1 diabetes, reported having a formal preconception care visit. Participants described receiving information mostly about the risks associated with diabetes and pregnancy. While participants who sought out counseling generally reported their providers were supportive of their desire for pregnancy, there were a few exceptions, notably all among patients with type 2 diabetes. The varied experiences of participants indicate gaps in the delivery of pre-pregnancy counseling to patients with diabetes and suggest counseling may vary based on diabetes type. There are opportunities to improve the patient-centeredness of counseling.

Establishing Trimester-Specific Haemoglobin A1c Reference Intervals in Pregnant Women: A retrospective study of healthy South Asian women with normal pregnancy outcomes

Objectives

This study aimed to define trimester-specific haemoglobin A1c (HbA1c) reference intervals in healthy, pregnant South Asian women.

Methods

This retrospective study was conducted at St. Stephen's Hospital, Delhi, India, between January 2011 and December 2016. Healthy pregnant women were compared to a control group of healthy non-pregnant women. Pregnant participants had term deliveries of babies with appropriate gestational weights. The HbA1c levels were calculated in terms of non-parametric 2.5 and 97.5 percentiles for women in first (T1), second (T2) and third (T3) trimester groups. Statistical tests were used to obtain the normal HbA1c reference values and were considered significant when P <0.05.

Results

This study included a total of 1,357 healthy pregnant women and a control group of 67 healthy, non-pregnant women. Pregnant women had a median HbA1c of 4.8% (4-5.5%) or 32 mmol/mol (20-39 mmol/mol); non-pregnant women had a median HbA1c of 5.1% (4-5.7%) or 29 mmol/mol (20-37 mmol/mol; P <0.001). The HbA1c levels for the T1, T2 and T3 groups were 4.9% (4.1-5.5%) or 30 mmol/mol (21-37 mmol/mol), 4.8% (4.5-5.3%) or 29 mmol/mol (20-34 mmol/mol) and 4.8% (3.9-5.6%) or 29 mmol/mol (19-38 mmol/mol), respectively. The HbA1c values were significant when comparing T1 versus T2 (P <0.001), T1 versus T3 (P = 0.002) and T1 versus the non-pregnant group (P = 0.001). However, T2 versus T3 was not significant (P = 0.111).

Conclusion

Compared to non-pregnant women, HbA1c levels were lower in pregnant women, despite women in the T2 and T3 groups having a higher body mass index than the women in the T1 and non-pregnant groups. Further research is recommended to understand the factors responsible and validate these findings.

Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes

IMPORTANCE

Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening.

OBJECTIVE

To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022.

MAIN OUTCOMES AND MEASURES

Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively.

RESULTS

A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum.

CONCLUSIONS AND RELEVANCE

In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

Effect of cognitive behavior therapy (CBT) on lowering of blood glucose levels in gestational diabetes mellitus (GDM) patients: study protocol for a prospective, open-label, randomized controlled trial

BACKGROUND

Gestational diabetes mellitus (GDM) is a common perinatal condition. Convincing evidence has shown that hyperglycemia and other chronic comorbidities of diabetes during the prenatal period increase maternal and fetal risk. Several guidelines have identified lifestyle management as the first-line therapy in GDM patients. To improve the efficacy of lifestyle intervention, cognitive behavior therapy (CBT) is proposed as a solution to improve clinical outcomes. The objective of this trial is to determine the efficacy in treating hyperglycemia of mobile-based CBT interventions in GDM patients, compared with conventional face-to-face interventions.  METHODS: This trial is designed as a prospective randomized controlled trial, which enrolled the patients diagnosed with GDM in First People's Hospital of Kunshan affiliated with Jiangsu University from September 2021 to March 2023 with a 3-month follow-up. The specific randomization method was established and implemented through the central randomization system of EDC clinical trials. The percentage of all blood glucose levels collected within the normal range between the two groups at baseline, during the intervention period, and postpartum infant and maternal outcomes will be measured. Summary statistics for continuous variables will include the number of subjects, mean, median, SD, or the standard error, minimum, and maximum. The chi-square test, t test, and paired-sample t test were used for statistical analysis of differences between groups.

DISCUSSION

This trial investigates the effects of mobile-based CBT intervention on blood glucose levels in GDM patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100048527) [registered: 2021/07/09].

The combination of type 1 diabetes and eating disorder during pregnancy

The problem of eating disorders currently holds a special place in clinical practice. Bulimia nervosa is one of the main forms of eating disorders, characterized by the difficulty in its treatment and a long, recurrent course. Eating disorders are common in patients with type 1 diabetes mellitus (T1D), especially in adolescent girls.

In this article, we present a clinical case of a patient with T1D and bulimia nervosa, which developed before the manifestation of T1D and progressed against its background. The patient is overly concerned with controlling body weight, specifically restricted the intake of carbohydrates, forcibly caused vomiting. During pregnancy fasting ketonuria («low-carb ketone») was repeatedly detected. The minimum weight was 37 kg (BMI 15.2 kg/m2). Particular interest of this case is the course of pregnancy, which ended in the antenatal death. The possible cause could be the restriction on carbohydrate food and prolonged stay in ketosis, that might lead to the development of pregnancy pathology. Additional examination also revealed multiple complications of diabetes and recurrent depressive disorder, which requires conjoint monitoring by an endocrinologist and a psychiatrist.

Combination of T1D and eating disorder in a pregnant patient should be considered as an atypical course of the disease.

Diabetic foot ulcers: Classification, risk factors and management

Diabetic foot ulceration is a devastating complication of diabetes that is associated with infection, amputation, and death, and is affecting increasing numbers of patients with diabetes mellitus. The pathogenesis of foot ulcers is complex, and different factors play major roles in different stages. The refractory nature of foot ulcer is reflected in that even after healing there is still a high recurrence rate and amputation rate, which means that management and nursing plans need to be considered carefully. The importance of establishment of measures for prevention and management of DFU has been emphasized. Therefore, a validated and appropriate DFU classification matching the progression is necessary for clinical diagnosis and management. In the first part of this review, we list several commonly used classification systems and describe their application conditions, scope, strengths, and limitations; in the second part, we briefly introduce the common risk factors for DFU, such as neuropathy, peripheral artery disease, foot deformities, diabetes complications, and obesity. Focusing on the relationship between the risk factors and DFU progression may facilitate prevention and timely management; in the last part, we emphasize the importance of preventive education, characterize several of the most frequently used management approaches, including glycemic control, exercise, offloading, and infection control, and call for taking into account and weighing the quality of life during the formulation of treatment plans. Multidisciplinary intervention and management of diabetic foot ulcers (DFUs) based on the effective and systematic combination of these three components will contribute to the prevention and treatment of DFUs, and improve their prognosis.

Transition From Pediatric to Adult Care for Individuals With Type 1 Diabetes: Opportunities and Challenges

OBJECTIVES

Type 1 diabetes (T1D) is a chronic disease with patients across the age spectrum that has high potential for morbidity and mortality. Unfortunately, patients transitioning from pediatric to adult care continue to demonstrate worsened glycemic control in part due to lack of understanding of transition of care best practices.

METHODS

This review highlights the impact of existing transition of care interventions, assessment tools, and other recently published strategies for providers to consider to improve care of adolescent and young adult (AYA) patients with T1D in both hospital- and clinic-based settings.

RESULTS

Many barriers impact patients with T1D during the transition period and disparities by race, sex, insurance status, and comorbid illness persist. As diabetic care continues to evolve and the prevalence of adolescents and young adults living with T1D increases, an intentional approach to transition of care is more pressing than ever. While current literature on transition of care models is limited, many show promise in improving clinic attendance and decreasing hospitalization. There are critical discussions that providers should lead with AYA patients to improve their outcomes and increase diabetes self-management, such as re-addressing carbohydrate counseling, sleep hygiene, and reproductive planning.

CONCLUSION

While further research on transition of care is needed, many care models offer the promise of improved T1D outcomes, enhancements in our approach to care, and increased value for our health care system at large.

Flexible treatment of gestational diabetes mellitus adjusted according to intrauterine fetal growth versus treatment according to strict maternal glycemic parameters: a randomized clinical trial

INTRODUCTION

To compare the conventional treatment of gestational diabetes mellitus (GDM) with flexible treatment according to the measurement of fetal abdominal circumference (AC) in daily clinical practice.

RESEARCH DESIGN AND METHODS

Two hundred and sixty pregnant women diagnosed with GDM before week 34 were randomly placed in two groups: a control group, treated according to maternal capillary glycemia, and an experimental group, treated according to ultrasound parameters of fetal growth. The glycemic targets in the control group were blood glucose levels when fasting and 1 hour postprandial (<95/140 mg/dL). In the experimental group, glycemic targets depended on the percentile (p) of fetal AC: if AC p <75th, then blood glucose targets when fasting and at 1 hour postprandial were <120/180 mg/dL; and if AC p ≥75th, then the glycemic targets were <80/120 mg/dL. The follow-up of both groups was scheduled according to the GDM protocol of our diabetes and gestation unit.

RESULTS

The study was completed by 246 pregnant women, 125 in the control group and 121 in the experimental group. In the experimental group, insulin treatment and neonatal hypoglycemia were significantly lower (p=0.018 and p 0.035, respectively). No differences were observed in large and small infants according to gestational age. However, macrosomic infants were less frequent in the experimental group, although this difference did not reach statistical significance. In terms of gestation complications, the type of delivery and its complications and the rest of the neonatal complications analyzed, no significant differences were observed.

CONCLUSIONS

The treatment of flexible GDM according to the measurement of fetal AC is safe for the mother and the fetus and almost halves the number of pregnant women who require insulin treatment, without increasing the number of ultrasound checks or medical visits.

Prediction of large-for-gestational-age infant by fetal growth charts and hemoglobin A1c level in pregnancy complicated by pregestational diabetes

OBJECTIVES

To compare the ability of three fetal growth charts (Fetal Medicine Foundation (FMF), Hadlock and National Institutes of Child Health and Human Development (NICHD) race/ethnicity-specific) to predict large-for-gestational age (LGA) at birth in pregnant individuals with pregestational diabetes, and to determine whether inclusion of hemoglobin A1c (HbA1c) level improves the predictive performance of the growth charts.

METHODS

This was a retrospective analysis of individuals with Type-1 or Type-2 diabetes with a singleton pregnancy that resulted in a non-anomalous live birth. Fetal biometry was performed between 28 + 0 and 36 + 6 weeks of gestation. The primary exposure was suspected LGA, defined as estimated fetal weight ≥ 90^th percentile using the Hadlock (Formula C), FMF and NICHD growth charts. The primary outcome was LGA at birth, defined as birth weight ≥ 90^th percentile, using 2017 USA natality reference data. The performance of the three growth charts to predict LGA at birth, alone and in combination with HbA1c as a continuous measure, was assessed using the area under the receiver-operating-characteristics curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

Of 358 assessed pregnant individuals with pregestational diabetes (34% with Type 1 and 66% with Type 2), 147 (41%) had a LGA infant at birth. Suspected LGA was identified in 123 (34.4%) by the Hadlock, 152 (42.5%) by the FMF and 152 (42.5%) by the NICHD growth chart. The FMF growth chart had the highest sensitivity (77% vs 69% (NICHD) vs 63% (Hadlock)) and the Hadlock growth chart had the highest specificity (86% vs 76% (NICHD) and 82% (FMF)) for predicting LGA at birth. The FMF growth chart had a significantly higher AUC (0.79 (95% CI, 0.74-0.84)) for LGA at birth compared with the NICHD (AUC, 0.72 (95% CI, 0.68-0.77); P < 0.001) and Hadlock (AUC, 0.75 (95% CI, 0.70-0.79); P < 0.01) growth charts. Prediction of LGA improved for all three growth charts with the inclusion of HbA1c measurement in comparison to each growth chart alone (P < 0.001 for all); the FMF growth chart remained more predictive of LGA at birth (AUC, 0.85 (95% CI, 0.81-0.90)) compared with the NICHD (AUC, 0.79 (95% CI, 0.73-0.84)) and Hadlock (AUC, 0.81 (95% CI, 0.76-0.86)) growth charts.

CONCLUSIONS

The FMF fetal growth chart had the best predictive performance for LGA at birth in comparison with the Hadlock and NICHD race/ethnicity-specific growth charts in pregnant individuals with pregestational diabetes. Inclusion of HbA1c improved further the prediction of LGA for all three charts. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Barriers and facilitators to diabetes screening and prevention after a pregnancy complicated by gestational diabetes

OBJECTIVE

Gestational diabetes mellitus (GDM) is increasing in the United States, with higher rates among minoritized racial and ethnic populations and lower income populations. GDM increases risk for type 2 diabetes (T2DM), and postpartum diabetes screening and prevention are imperative. This qualitative study examines barriers and facilitators to postpartum T2DM screening and prevention among non-privately insured individuals with a history of GDM in a state prior to Medicaid expansion.

METHODS

Thirty-six non-privately insured women with a history of GDM completed semi-structured interviews. Four focus groups and seven interviews were conducted with 30 nurse practitioners, physicians, physician assistants, nurses and registered dietitians from Federally Qualified Health Centers in St. Louis, MO. Interviews and focus groups were audio-recorded and transcribed. Data were analyzed using an integrative thematic analysis informed by the socio-ecological model.

RESULTS

Barriers and facilitators to T2DM screening and prevention occur across multiple environments (society, healthcare system, interpersonal, and individual). Societal barriers include insurance issues, unemployment, and lack of transportation, childcare, safe housing, and healthy food access, while facilitators include government sponsored programs and community organizations. Healthcare system barriers include care fragmentation, scheduling policies and time constraints while facilitators include care coordination, pregnancy support groups, and education materials. Interpersonal barriers include negative care experiences, cultural differences, communication challenges, competing priorities, and lack of a social support network, while facilitators include family and friend support and positive care experiences. Individual barriers include health complications and unhealthy food and exercise patterns, while facilitators include child wellbeing, empowered attitudes and healthy food and exercise patterns.

CONCLUSIONS

The socioecological model highlights the societal and systemic determinants that encompass individual and interpersonal factors affecting postpartum T2DM screening and prevention. This framework can inform multi-level interventions to increase postpartum T2DM screening and prevention in this high-risk population, including policy changes to alleviate higher-level barriers.

Carbohydrate Intake and Closed-Loop Insulin Delivery System during Two Subsequent Pregnancies in Type 1 Diabetes

Carbohydrate intake is one of the main determinants of glycemic control. In pregnancy, achievement of tight glycemic control is of utmost importance; however, data on the role of hybrid closed-loop systems (HCLs) in pregnancy are scarce. Therefore, we aimed to assess glycemic control achieved through the use of HCLs, and its association with carbohydrate intake in type 1 diabetes pregnancy. We included data from women with a sensor-augmented pump (SAP) during their first pregnancy and HCL use during the subsequent pregnancy. Student's paired t-test was used to compare data between both pregnancies. Six women were identified, with age 30.2 ± 3.6 vs. 33.0 ± 3.6 years, diabetes duration 23 ± 5 vs. 26 ± 5 years, and baseline HbA1c 6.7 ± 0.7% (50.1 ± 7.7 mmol/mol) vs. 6.3 ± 0.6% (45.2 ± 6.5 mmol/moll) in the first and second pregnancies, respectively. Time with glucose in the range 3.5-7.8 mmol/L was 69.1 ± 6.7 vs. 78.6 ± 7.4%, p = 0.045, with the HCLs compared to SAP. Higher meal frequency, but not the amount of carbohydrate consumption, was associated with more time spent in the target range and lower glycemic variability. HCLs and meal frequency were associated with better glycemic control in a small series of pregnant women with type 1 diabetes. Whether this translates to better perinatal outcomes remains to be seen.

Associations of Maternal Fructosamine before Delivery in Gestational Diabetes Mellitus Pregnancies with Neonatal Glucometabolic Disorders

Background

The offspring of pregnant women with gestational diabetes mellitus (GDM) are vulnerable to be glucometabolic disorders. However, to date, few current studies focused on the associations of maternal accumulated glucose exposure before delivery with neonatal glucometabolic disorders and large for gestational age (LGA) infants. This study is aimed at exploring the associations of maternal fructosamine (FMN) before delivery in GDM pregnant women with neonatal glucometabolic disorders in the first 3 days of life and LGA infants.

Methods

The study subjects were the GDM pregnant women, who gave birth in our hospital from September 1, 2018 to January 31, 2021, and their newborns. The maternal FMN adjusted by serum albumin (FMNALB) before delivery was selected as exposure factors. A multivariate logistical regression model was used to calculate the odds ratios (OR) for neonatal glucometabolic disorders, hypoglycemia needing intervention (<2.6 mmol/L), and glucose intolerance (>7.0 mmol/L) in the first 3 days and LGA infants.

Results

In GDM pregnant women, the newborns in the maternal FMNALB ≥ 75th percentile (≥5.89 mmol/g) group had higher risks in neonatal glucometabolic disorders (aOR 2.50, 95% CI 1.34-4.65, P = 0.004) and hypoglycemia (aOR 2.18, 95% CI 1.16-4.10, P = 0.016). However, FMNALB ≥ 75th percentile seemed to be not predictive of the glucose intolerance (aOR 1.76, 95% CI 0.82-3.79, P = 0.149) and LGA (aOR 1.56, 95% CI 0.81-3.02, P = 0.185). Further, in the sensitivity analysis, the newborns in the maternal FMNALB ≥ 90th percentile (≥6.40 mmol/g) group also had higher risks in neonatal glucometabolic disorders (aOR 5.70, 95% CI 2.18-14.89, P < 0.001) and hypoglycemia (aOR 3.72, 95% CI 1.48-9.31, P = 0.005).

Conclusions

The maternal FMNALB before delivery in GDM pregnant women was a useful biomarker to identify the offspring with high risk of neonatal glucometabolic disorders. However, the association between maternal FMNALB and the risk of LGA infants was not so strong.

Intrapartum and early postpartum glycemic profiles in women with gestational diabetes mellitus: an observational study

BACKGROUND

Data on the glycemic profile of pregnant women with gestational diabetes mellitus (GDM) during the perinatal period are sparse. This study described the intrapartum and early postpartum glucose profiles among pregnant women with GDM, and analyzed factors potentially affecting glycemic parameters during the period.

METHODS

This was a prospective observational study conducted from March 2020 to November 2021. Pregnant women with GDM receiving lifestyle interventions alone during pregnancy and matched women with non-diabetic pregnancies (NDPs) were enrolled from among patients admitted to the obstetrics department for childbirth. Glucose monitoring was performed via a flash glucose monitoring (FGM) system on admission, and glucose readings during labor and early postpartum were analyzed. The clinical characteristics and FGM-based parameters of participants in the two groups were compared.

RESULTS

A total of 124 participants (mean age: 29.5 ± 3.5 years, 92 [74.2%] primipara) were included in the final analysis. A total of 17,571 glucose readings were retrieved. There were no significant differences in clinical characteristics between the GDM (n = 60) and NDP (n = 64) groups. The average glucose level was 92.2 mg/dL, and the level was higher in the GDM group (95.5 ± 12.1 mg/dL vs. 89.1 ± 13.4 mg/dL, P = 0.008) during the intrapartum and early postpartum periods. The data were split into the intrapartum period (from the start of labor to delivery of the placenta) and the early postpartum period (within 24 h after placental delivery) for analysis. During intrapartum, women with GDM exhibited glycemic profiles and fluctuations similar to those in the NDP group. However, women with GDM had higher postpartum glucose levels (97.7 ± 13.4 mg/dL vs. 90.8 ± 15.3 mg/dL, P = 0.009), a longer time spent >140 mg/dL (8.7 ± 9.3% vs. 5.9 ± 10.3%, P = 0.011), and greater glycemic fluctuations than those with NDP. Postpartum hyperglycemia in GDM might be associated with high parity and postprandial glucose abnormalities in GDM screening tests.

CONCLUSION

Compared to those with normoglycemia, pregnant women with GDM receiving lifestyle interventions alone had similar intrapartum glucose profiles but higher early postpartum glucose levels and greater glucose variability, providing evidence for modification of the current perinatal glucose monitoring strategy for GDM.

TRIAL REGISTRATION

ChiCTR.org.cn, ChiCTR2000030972.