The Diagnosis and Management of Gestational Diabetes Mellitus in the Context of the COVID-19 Pandemic

Use of the Japanese gestational diabetes mellitus diagnostic strategy during the COVID-19 pandemic in Japan: A questionnaire survey

AIM

Some concerns exist that diagnosis of gestational diabetes mellitus (GDM) may be missed when the simplified diagnostic criteria of the Japanese Society of Diabetes and Pregnancy (JSDP) for GDM (published during the COVID-19 pandemic) are used. Moreover, limited data is available regarding how widespread these diagnostic criteria are used when managing GDM during the COVID-19 pandemic. Therefore, this study aimed to determine how GDM diagnosis has changed during the COVID-19 pandemic in Japan.

METHODS

The changes in GDM diagnosis during the COVID-19 pandemic were investigated using an online questionnaire to 2159 obstetric facilities in Japan. The questionnaire collected data on facility type, awareness of Japanese GDM diagnostic strategies, modifications to diagnostic methods for early and late GDM, and opinions on GDM management, with the pandemic divided into seven periods.

RESULTS

We received responses from 593 facilities (27%). Approximately 90% of the facilities did not change their diagnostic process for early GDM or late GDM (occurring after 24 weeks gestation). However, during the COVID-19 pandemic, 19 facilities discontinued the use of 75-g oral glucose tolerance tests before 24 weeks of gestation, and 17 facilities discontinued it after 24 weeks of gestation, instead using the aforementioned Japanese GDM diagnostic strategy.

CONCLUSIONS

Although a limited number of facilities modified their diagnostic method in response to the COVID-19 pandemic, this study demonstrated that those that adjusted their diagnostic method primarily used the Japanese COVID-19 GDM strategy by the JSDP.

COVID-19, Pregnancy, and Diabetes Mellitus

During the severe acute respiratory distress virus coronavirus type 2 (SARS-CoV-2) pandemic, many women were infected during their pregnancies. The SARS-CoV-2-induced coronavirus disease 19 (COVID-19) has an impact on maternal health and pregnancy outcomes; peripartum and perinatal morbidity and mortality are increased. Pregnancy is considered a risk factor for severe COVID-19 course. Additional risk factors during pregnancy are diabetes mellitus, gestational diabetes mellitus (GDM), and obesity. Systemic inflammation can lead to severe metabolic dysregulation with ketoacidosis. The endocrine pancreas is a target organ for SARS-CoV-2 and the fetal risk depends on inflammation of the placenta. Up to now there is no evidence that SARS-CoV-2 infection during pregnancy leads to permanent diabetes in mothers or their offspring via triggering autoimmunity or beta cell destruction. The frequently observed increased prevalence of GDM compared to the years before the pandemic is most likely due to changed lifestyle during lockdown. Furthermore, severe COVID-19 may be associated with the development of GDM due to worsening of glucose tolerance. Vaccination with a mRNA vaccine is safe and highly effective to prevent infection and to reduce hospitalization. Registries support offering evidence-based recommendations on vaccination for pregnant women. Even with the current omicron virus variant, there are increased risks for symptomatic and unvaccinated pregnant women.

Employing fasting plasma glucose to safely limit the use of oral glucose tolerance tests in pregnancy: a pooled analysis of four Norwegian studies

Background/objective

There is no international consensus about the optimal approach to screening and diagnosis of gestational diabetes mellitus (GDM). Fasting plasma glucose (FPG) has been proposed as an alternative universal screening test to simplify the diagnosis of GDM. We investigate the ability of the FPG to predict a 2-hour glucose value below the cut-off for GDM, thereby "ruling out" the necessity of a full OGTT and assess the proportion of GDM-related complications associated with the identified FPG level.

Materials and methods

This study included secondary data from four Norwegian pregnancy cohorts (2002-2013), encompassing 2960 women universally screened with late mid-pregnancy 75g OGTT measuring FPG and 2-hour glucose. For a range of FPG thresholds, we calculated sensitivity to predict elevated 2-hour glucose, number of OGTTs needed and percentage of GDM cases missed, applying modified World Health Organization (WHO) 2013 criteria (2013WHO) and 2017 Norwegian criteria (2017Norwegian). We analyzed pregnancy outcomes for women above and below our selected threshold.

Results

The prevalence of GDM was 16.6% (2013WHO) and 10.1% (2017Norwegian). A FPG threshold of 4.7 mmol/L had a sensitivity of 76% (2013WHO) and 80% (2017Norwegian) for detecting elevated 2-hour glucose, with few missed GDM cases (2.0% of those ruled out and 7.5% of all GDM cases for 2013WHO, and 1.1% of those ruled out and 7% of all GDM cases for 2017Norwegian). When excluding women with FPG <4.7mmol/l and those with GDM based on FPG, only 24% (2013WHO) and 29% (2017Norwegian) would require OGTT. Women with FPG <4.7mmol/l, including missed GDM cases, had low risk of large-for-gestational-age newborns, cesarean section and operative vaginal delivery.

Conclusion

A FPG threshold of 4.7mmol/l as a first step when screening for GDM could potentially eliminate the need for OGTT in 70-77% of pregnancies. Women with FPG below this threshold appear to carry low risk of GDM-associated adverse pregnancy outcomes.

Performance of glycated hemoglobin A1c for the diagnosis of gestational diabetes mellitus during the SARS-CoV-2 pandemic in Belgium (2020-2021)

OBJECTIVES

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, health care access was restricted. To reduce the risk of maternal SARS-CoV-2 infection, simplified screening recommendations for gestational diabetes mellitus (GDM) have been suggested, leading to glycated hemoglobin A1c (HbA1c) being proposed as an alternative to the oral glucose tolerance test (OGTT). This study aimed to assess the optimal HbA1c cutoff to confirm GDM diagnosis according to IADPSG/WHO2013 guidelines.

METHODS

In this retrospective study, 3361 pregnancies were followed at the hospital of Mouscron and the Cliniques Universitaires St Luc in Brussels (2020-2021). GDM was universally screened in the third trimester of gestation. The ROC curve was used to evaluate the diagnostic performance of HbA1c with OGTT as the reference. Sensitivity, specificity and likelihood ratios for different HbA1c thresholds were calculated.

RESULTS

In total, 312 women were selected due to HbA1c analysis in addition to OGTT, and 149 had GDM. The area under the ROC curve for GDM detection by HbA1c was 0.73 (95% CI 0.68-0.79, p < 0.0001). The cutoff value chosen as a possible threshold was HbA1c 5.5% (37 mmol/mol). The sensitivity, specificity, positive and negative likelihood ratios for this cutoff were 12.0%, 99.4%, 20 and 0.88, respectively. The Fagan nomogram test showed a posttest GDM probability of approximately 70%, corresponding to a 10-fold higher pretest probability. An HbA1c ≥ 5.5% (37 mmol/mol) would have avoided OGTT in 18% of women with GDM. These women with an HbA1c ≥ 5.5% had significantly higher rates of family history of diabetes, older age, higher BMI and higher blood glucose levels (fasting, 1 h and 2 h) at OGTT.

CONCLUSION

Our results are consistent with the literature concerning the diagnostic ability of GDM through HbA1c ≥ 5.5%.

Knowledge on gestational diabetes mellitus and associated factors among pregnant women attending antenatal care clinics of North Shewa zone public hospitals, Oromia region, Central Ethiopia: a cross-sectional study

BACKGROUND

Globally, the prevalence of gestational diabetes mellitus (GDM) is currently rising. Assessing GDM knowledge and taking various public health actions will help pregnant women know more about the condition, resulting in its prevention.

OBJECTIVE

To assess pregnant women's knowledge of GDM and associated factors at antenatal care clinics of public hospitals in the North Shewa zone, Oromia region, Central Ethiopia.

DESIGN

Cross-sectional study.

SETTING

Five public hospitals of North Shewa zone, Oromia regional state, Central Ethiopia.

PARTICIPANTS

A total of 417 pregnant women.

METHODS

A face-to-face interview was conducted. A 13-items tool was used to measure GDM knowledge. Multivariable binary logistic regression was fitted to identify factors associated with the knowledge of GDM. The adjusted OR (AOR) with 95% CI and a p<0.05 was used to determine statistical significance.

RESULTS

Overall, 48% (95% CI 43.4% to 52.8%) of pregnant women had sufficient knowledge about GDM. The level of sufficient knowledge for GDM risk factors, screening/treatment and its consequences were 48%, 54.4% and 99%, respectively. Age group 15-24 years (AOR 3.49, 95% CI 1.05 to 11.59), attending secondary and above education (AOR 4.27, 95% CI 1.29 to 14.070, women whose partners attended primary school (AOR 3.83, 95% CI 1.36 to 10.78), history of GDM (AOR 3.36, 95% CI 1.68 to 6.71), history of hypertension (AOR 2.42, 95% CI 1.21 to 4.84), receiving preconception care (AOR 3.02, 95% CI 1.74 to 5.22) and being multigravida (AOR 3.19, 95% CI 1.52 to 6.67) were factors significantly associated with sufficient knowledge about GDM.

CONCLUSION

Overall, more than half of pregnant women have insufficient knowledge about GDM. Significant association between GDM knowledge and women's age, women's and partners' educational status, preconception care, history of GDM and hypertension, and the number of pregnancies were detected. Therefore, to increase pregnant women's GDM knowledge, health education programmes in the community and healthcare facilities should target the identified factors.

Clinicians' perspectives on gestational diabetes screening during the global COVID-19 pandemic in Australia

AIM

There is no international consensus for the screening and diagnosis of gestational diabetes mellitus (GDM). In March 2020, modified screening and diagnostic recommendations were rapidly implemented in Queensland, Australia, in response to the COVID-19 pandemic. How clinicians perceived and used these changes can provide insights to support high-quality clinical practice and provide lessons for future policy changes. The aim of this study was to understand clinicians' perceptions and use of COVID-19 changes to GDM screening and diagnostic recommendations.

METHODS

Queensland healthcare professionals responsible for diagnosing or caring for women with GDM were recruited for semi-structured telephone interviews. Data analysis of transcribed interviews used inductive reflexive thematic analysis.

RESULTS

Seventeen interviews were conducted with the following participants: six midwives/nurses, three endocrinologists, two general practitioners, two general practitioners/obstetricians, two diabetes educators, one dietitian and one obstetrician. Three themes emerged: communication and implementation, perceptions and value of evidence and diversity in perceptions of GDM screening. Overall, clinicians welcomed the rapid changes during the initial uncertainty of the pandemic, but as COVID-19 became less of a threat to the Queensland healthcare system, some questioned the underlying evidence base. In areas where GDM was more prevalent, clinicians more frequently worried about missed diagnoses, whereas others who felt that overdiagnosis had occurred in the past continued to support the changes.

CONCLUSIONS

These findings highlight the challenges to changing policy when clinicians have diverse (and often strongly held) views.

Validation of Insurance Billing Codes for Monitoring Antenatal Screening

BACKGROUND

Prevalence statistics for pregnancy complications identified through screening such as gestational diabetes usually assume universal screening. However, rates of screening completion in pregnancy are not available in many birth registries or hospital databases. We validated screening-test completion by comparing public insurance laboratory and radiology billing records with medical records at three hospitals in British Columbia, Canada.

METHODS

We abstracted a random sample of 140 delivery medical records (2014-2019), and successfully linked 127 to valid provincial insurance billings and maternal-newborn registry data. We compared billing records for gestational diabetes screening, any ultrasound before 14 weeks gestational age, and Group B streptococcus screening during each pregnancy to the gold standard of medical records by calculating sensitivity and specificity, positive predictive value, negative predictive value, and prevalence with 95% confidence intervals (CIs).

RESULTS

Gestational diabetes screening (screened vs. unscreened) in billing records had a high sensitivity (98% [95% CI = 93, 100]) and specificity (>99% [95% CI = 86, 100]). The use of specific glucose screening approaches (two-step vs. one-step) were also well characterized by billing data. Other tests showed high sensitivity (ultrasound 97% [95% CI = 92, 99]; Group B streptococcus 96% [95% CI = 89, 99]) but lower negative predictive values (ultrasound 64% [95% CI = 33, 99]; Group B streptococcus 70% [95% CI = 40, 89]). Lower negative predictive values were due to the high prevalence of these screening tests in our sample.

CONCLUSIONS

Laboratory and radiology insurance billing codes accurately identified those who completed routine antenatal screening tests with relatively low false-positive rates.

SARS-CoV-2 Infection: A Clinical and Histopathological Study in Pregnancy

During pregnancy, SARS-CoV-2 infection is associated with several adverse outcomes, including an increased risk of pre-eclampsia, preterm delivery, hypertensive disorders, gestational diabetes, and fetal growth restriction related to the development of placenta vascular abnormalities. We analyzed human placenta from full-term, uncomplicated pregnancies with SARS-CoV-2 infection during the first, second, or third trimesters of gestation. We studied, by the immunohistochemistry technique, the expression of CD34 and podoplanin (PDPN) as markers of vasculogenesis to find any differences. As secondary outcomes, we correlated maternal symptoms with placental histological alterations, including fibrin deposits, lymphocyte infiltration in the villi, edema, and thrombi. Our results showed a PDPN expression around the villous stroma as a plexiform network around the villous nucleus of fetal vessels; significant down-regulation was observed in the villous stroma of women infected during the third trimester. CD34 showed no changes in expression levels. During SARS-CoV-2 infection, the most common maternal symptoms were fever, anosmia, ageusia and asthenia, and the majority were treated with paracetamol, corticosteroids and azithromycin. Patients that required multiple symptomatic treatments evidenced a large amount of fibrin deposition in the villi. Certainly, PDPN plays a key role in healthy placental vasculogenesis and thus in its proper physiology, and SARS-CoV-2 surely alters its normal expression. Further studies are necessary to understand what mechanisms are being altered to try to avoid possible complications for both the mother and fetus in terms of the contagions that will still occur.

Maternal and Perinatal Outcomes During the COVID-19 Epidemic in Pregnancies Complicated by Gestational Diabetes

Introduction

Gestational diabetes (GDM) is one of the most common complications in pregnancy, with a prevalence that continues to rise. At the time of the COVID-19 epidemic, immediate reorganisation and adjustment of the system was needed. Telemedicine support was offered in order to provide high-quality treatment to pregnant women. However, the success of the treatment is unknown. We therefore aimed to evaluate COVID-19 epidemic effects on pregnancy outcomes in GDM.

Methods

The maternal outcomes (insulin treatment, gestational weight gain, caesarean section, hypertensive disorders) and perinatal outcomes (rates of large and small for gestational age, preterm birth and a composite child outcome) of women visiting a university hospital diabetes clinic from March to December 2020 were compared with those treated in the same period in 2019.

Results

Women diagnosed with GDM during the COVID-19 epidemic (n=417), were diagnosed earlier (23.9 [11.7-26.0] vs. 25.1 [21.8-26.7] gestational week), had higher fasting glucose (5.2 [5.0-5.4] vs. 5.1 [4.8-5.3] mmol/l) and earlier pharmacological therapy initiation, and had achieved lower HbA1c by the end of followup (5.1% (32.2 mmol/mol) [4.9% (30.1 mmol/mol)-5.4% (35.0 mmol/mol)] vs. 5.2% (33.3 mmol/mol) [5.0% (31.1 mmol/mol) - 5.4%·(35.5 mmol/mol)], p<0.001) compared to a year before (n=430). No significant differences in perinatal outcomes were found.

Conclusions

Although GDM was diagnosed at an earlier gestational age and higher fasting glucose concentration was present at the time of diagnosis, the COVID-19 epidemic did not result in worse glucose control during pregnancy or worse pregnancy outcomes in Slovenia.

Double jeopardy-pregnancy and birth during a catastrophic bushfire event followed by a pandemic lockdown, a natural experiment

BACKGROUND

From November 2019 to January 2020, eastern Australia experienced the worst bushfires in recorded history. Two months later, Sydney and surrounds were placed into lockdown for six weeks due to the COVID-19 pandemic, followed by ongoing restrictions. Many pregnant women at this time were exposed to both the bushfires and COVID-19 restrictions.

OBJECTIVE

To assess the impact of exposure to bushfires and pandemic restrictions on perinatal outcomes.

METHODS

The study included 60 054 pregnant women who gave birth between November 2017 and December 2020 in South Sydney. Exposure cohorts were based on conception and birthing dates: 1) bushfire late pregnancy, born before lockdown; 2) bushfires in early-mid pregnancy, born during lockdown or soon after; 3) conceived during bushfires, lockdown in second trimester; 4) conceived after bushfires, pregnancy during restrictions. Exposure cohorts were compared with pregnancies in the matching periods in the two years prior. Associations between exposure cohorts and gestational diabetes, preeclampsia, hypertension, stillbirth, mode of birth, birthweight, preterm birth and small for gestational age were assessed using generalised estimating equations, adjusting for covariates.

RESULTS

A decrease in low birth weight was observed for cohort 1 (aOR 0.81, 95%CI 0.69, 0.95). Conversely, cohort 2 showed an increase in low birth weight, and increases in prelabour rupture of membranes, and caesarean sections (aOR 1.18, 95%CI 1.03, 1.37; aOR 1.21, 95%CI 1.07, 1.37; aOR 1.10 (1.02, 1.18) respectively). Cohort 3 showed an increase in unplanned caesarean sections and high birth weight babies (aOR 1.15, 95%CI 1.04, 1.27 and aOR 1.16, 95%CI 1.02, 1.31 respectively), and a decrease in gestational diabetes mellitus was observed for both cohorts 3 and 4.

CONCLUSION

Pregnancies exposed to both severe climate events and pandemic disruptions appear to have increased risk of adverse perinatal outcomes beyond only experiencing one event, but further research is needed.

Gestational Diabetes Mellitus—Recent Literature Review

Gestational diabetes mellitus (GDM), which is defined as a state of hyperglycemia that is first recognized during pregnancy, is currently the most common medical complication in pregnancy. GDM affects approximately 15% of pregnancies worldwide, accounting for approximately 18 million births annually. Mothers with GDM are at risk of developing gestational hypertension, pre-eclampsia and termination of pregnancy via Caesarean section. In addition, GDM increases the risk of complications, including cardiovascular disease, obesity and impaired carbohydrate metabolism, leading to the development of type 2 diabetes (T2DM) in both the mother and infant. The increase in the incidence of GDM also leads to a significant economic burden and deserves greater attention and awareness. A deeper understanding of the risk factors and pathogenesis becomes a necessity, with particular emphasis on the influence of SARS-CoV-2 and diagnostics, as well as an effective treatment, which may reduce perinatal and metabolic complications. The primary treatments for GDM are diet and increased exercise. Insulin, glibenclamide and metformin can be used to intensify the treatment. This paper provides an overview of the latest reports on the epidemiology, pathogenesis, diagnosis and treatment of GDM based on the literature.

Impact of Remote Monitoring Technologies for Assisting Patients With Gestational Diabetes Mellitus: A Systematic Review

Introduction: In Chile, 1 in 8 pregnant women of middle socioeconomic level has gestational diabetes mellitus (GDM), and in general, 5–10% of women with GDM develop type 2 diabetes after giving birth. Recently, various technological tools have emerged to assist patients with GDM to meet glycemic goals and facilitate constant glucose monitoring, making these tasks more straightforward and comfortable.

Objective: To evaluate the impact of remote monitoring technologies in assisting patients with GDM to achieve glycemic goals, and know the respective advantages and disadvantages when it comes to reducing risk during pregnancy, both for the mother and her child.

Methods: A total of 188 articles were obtained with the keywords “gestational diabetes mellitus,” “GDM,” “gestational diabetes,” added to the evaluation levels associated with “glucose level,” “glycemia,” “glycemic index,” “blood sugar,” and the technological proposal to evaluate with “glucometerm” “mobile application,” “mobile applications,” “technological tools,” “telemedicine,” “technovigilance,” “wearable” published during the period 2016–2021, excluding postpartum studies, from three scientific databases: PUBMED, Scopus and Web of Science. These were managed in the Mendeley platform and classified using the PRISMA method.

Results: A total of 28 articles were selected after elimination according to inclusion and exclusion criteria. The main measurement was glycemia and 4 medical devices were found (glucometer: conventional, with an infrared port, with Bluetooth, Smart type and continuous glucose monitor), which together with digital technology allow specific functions through 2 identified digital platforms (mobile applications and online systems). In four articles, the postprandial glucose was lower in the Tele-GDM groups than in the control group. Benefits such as improved glycemic control, increased satisfaction and acceptability, maternal confidence, decreased gestational weight gain, knowledge of GDM, and other relevant aspects were observed. There were also positive comments regarding the optimization of the medical team’s time.

Conclusion: The present review offers the opportunity to know about the respective advantages and disadvantages of remote monitoring technologies when it comes to reducing risk during pregnancy. GDM centered technology may help to evaluate outcomes and tailor personalized solutions to contribute to women’s health. More studies are needed to know the impact on a healthcare system.

Fasting plasma glucose level to guide the need for an OGTT to screen for gestational diabetes mellitus

AIMS

To determine the fasting plasma glucose (FPG) level at which an oral glucose tolerance test (OGTT) could be avoided to screen for gestational diabetes (GDM) and to evaluate the characteristics of women across this FPG threshold.

METHODS

A multi-centric prospective cohort study with 1843 women receiving universal screening for GDM with a 75 g OGTT.

RESULTS

In the total population, GDM prevalence was 12.5% (231). A FPG < 78 mg/dL was the cut-off with best trade-off to limit the number of missed GDM cases [44 (19.0%)] with a negative predictive value of 97.3% (95% CI 96.5-98.0) for GDM, while avoiding 52.2% OGTTs. Compared to GDM with FPG ≥ 78 mg/dL [187 (81.0%)], GDM women with FPG < 78 mg/dL had a significantly lower BMI (27.1 ± 4.5 vs. 29.6 ± 5.2 kg/m², p = 0.003), less insulin resistance [Matsuda: 0.4 (0.4-0.7) vs. 0.3 (0.2-0.5), p < 0.001] and better β-cell function [ISSI-2: 0.13 (0.08-0.25) vs. 0.09 (0.04-0.15), p = 0.004]. Compared to NGT women (1612) with FPG ≥ 78 mg/dL [846 (52.5%)], NGT with FPG < 78 mg/dL [766 (47.5%)] had a significantly lower BMI (26.0 ± 3.9 vs. 27.8 ± 4.7 kg/m², p < 0.001), less insulin resistance [Matsuda: 0.7 (0.5-0.9) vs. 0.5 (0.4-0.7), p < 0.001], better β-cell function [ISSI-2: 0.17 (0.10-0.30) vs. 0.12 (0.07-0.21), p < 0.001], and less often large-for-gestational age infants [9.2 (70) vs. 16.2% (136), p < 0.001].

CONCLUSIONS

FPG < 78 mg/dL can be used to limit the number of OGTTs when screening for GDM. Women with FPG < 78 mg/dL had a better metabolic profile and in NGT women also less fetal overgrowth.

Clinical Outcomes Following a Change in Gestational Diabetes Mellitus Diagnostic Criteria Due to the COVID-19 Pandemic: A Case-Control Study

Background: Due to COVID-19, many centres adopted a change to the diagnosis of GDM. Methods: A case-control study of antenatal patients between 1 April and 30 June in 2019 and 2020 looking at detection rates of GDM, use of medication, obstetric, and fetal outcomes. Results: During COVID-19, the rate of positive GDM tests approximately halved (20% (42/210) in 2020 vs. 42.2% (92/218) in 2019, (p < 0.01)) with higher rates of requirement for insulin at diagnosis (21.4% (2020) vs. 2.2% (2019); p < 0.01), and at term (31% (2020) vs. 5.4% (2019); p < 0.01). and metformin at diagnosis (4.8% (2020) vs. 1.1% (2019); p < 0.01), and at term (14.3% (2020) vs. 7.6% (2019) p < 0.01), with no differences in birth outcomes. Conclusions: There was likely an underdiagnosis of GDM while women at a higher risk of hyperglycaemia were correctly identified. The GTT should be maintained as the gold-standard test where possible, with provisions made for social distancing during testing if required.

Correlation of body composition in early pregnancy on gestational diabetes mellitus under different body weights before pregnancy

OBJECTIVE

The prediction of gestational diabetes mellitus (GDM) by body composition-related indicators in the first trimester was analyzed under different body mass index (BMI) values before pregnancy.

METHODS

This was a retrospective analysis of pregnant women who were treated, had documented data, and received regular perinatal care at the Third Affiliated Hospital of Zhengzhou University from January 1, 2021, to December 31, 2021. Women with singleton pregnancies who did not have diabetes before pregnancy were included. In the first trimester (before the 14th week of pregnancy), bioelectric impedance assessment (BIA) was used to analyze body composition-related indicators such as protein levels, mineral levels, fat volume, and the waist-hip fat ratio. The Pearman's correlation coefficient was used to evaluate the linear relationship between the continuous variables and pre-pregnancy body mass index (BMI). In the univariate body composition analysis, the association with the risk of developing GDM was included in a multivariate analysis using the relative risk and 95% confidence interval obtained from logarithmic binomial regression, and generalized linear regression was used for multivariate regression analysis. Furthermore, the area under the curve (AUC) was calculated by receiver operating characteristic (ROC) curves. The optimal cutoff value of each risk factor was calculated according to the Youden Index.

RESULTS

In a retrospective study consisting of 6698 pregnant women, we collected 1109 cases of gestational diabetes. Total body water (TBW), protein levels, mineral levels, bone mineral content (BMC), body fat mass (BFM), soft lean mass (SLM), fat-free mass (FMM), skeletal muscle mass (SMM), percent body fat (PBF), the waist-hip ratio (WHR), the visceral fat level (VFL), and the basal metabolic rate (BMR) were significantly higher in the GDM group than in the normal group (P<0.05). Under the pre-pregnancy BMI groupings, out of 4157 pregnant women with a BMI <24 kg/m², 456 (10.97%) were diagnosed with GDM, and out of 2541 pregnant women with a BMI ≥24 kg/m², 653 (25.70%) were diagnosed with GDM. In the generalized linear regression model, it was found that in all groups of pregnant women, pre-pregnancy BMI, age, gestational weight gain (GWG) in the first trimester, and weight at the time of the BIA had a certain risk for the onset of GDM. In Model 1, without adjusting for confounders, the body composition indicators were all positively correlated with the risk of GDM. In Model 3, total body water, protein levels, mineral levels, bone mineral content, soft lean mass, fat-free mass, skeletal muscle mass, and the basal metabolic rate were protective factors for GDM. After Model 4 was adjusted for confounders, only the waist-hip ratio was positively associated with GDM onset. Among pregnant women with a pre-pregnancy BMI <24 kg/m², the body composition-related indicators in Model 2 were all related to the onset of GDM. In Model 3, total body water, soft lean mass, fat-free mass, and the basal metabolic rate were negatively correlated with GDM onset. In the body composition analysis of among women with a pre-pregnancy BMI ≥ 24 kg/m², only Model 1 and Model 2 were found to show positive associations with GDM onset. In the prediction model, in the basic data of pregnant women, the area under the receiver operating characteristic curve predicted by gestational weight gain for GDM was the largest (0.795), and its cutoff value was 1.415 kg. In the body composition results, the area under the receiver operating characteristic curve of body fat mass for predicting GDM risk was larger (0.663) in all pregnant women.

CONCLUSIONS

Through this retrospective study, it was found that the body composition-related indicators were independently associated with the onset of GDM in both the pre-pregnancy BMI <24 kg/m² and pre-pregnancy BMI ≥24 kg/m² groups. Body fat mass, the visceral fat level, and the waist-hip ratio had a higher correlation with pre-pregnancy BMI. Total body water, protein levels, mineral levels, bone mineral content, soft lean mass, fat-free mass, skeletal muscle mass, and the basal metabolic rate were protective factors for GDM after adjusting for some confounders. In all pregnant women, the waist-hip ratio was found to be up to 4.562 times the risk of GDM development, and gestational weight gain had the best predictive power for GDM. Gestational weight gain in early pregnancy, body fat mass, and the waist-hip ratio can assess the risk of GDM in pregnant women, which can allow clinicians to predict the occurrence of GDM in pregnant women as early as possible and implement interventions to reduce adverse perinatal outcomes.

New strategy for diagnosing abnormal glucose tolerance before 24 gestational weeks during the coronavirus disease 2019 pandemic

The Japanese abnormal glucose tolerance before 24 gestational weeks diagnostic strategy in the evolving coronavirus disease 2019 pandemic published by the Japanese Society of Diabetes and Pregnancy.

Impact of the Gestational Diabetes Diagnostic Criteria during the Pandemic: An Observational Study

OBJECTIVE

To analyze the effect of applying alternative diagnostic criteria for gestational diabetes mellitus (GDM) during the COVID-19 pandemic on GDM prevalence and obstetrical and perinatal outcomes, in comparison to usual diagnostic approaches.

METHODS

Data from women referred to GDM diagnosis from 1 September to 30 November 2019 were retrospectively collected (2019-group). The same data from the same period in 2020 were prospectively collected (2020-group). In both cases, a two-step diagnostic approach was used, the first step being a screening test (1 h 50 goral glucose tolerance test, OGTT). In 2019 it was followed by a 100 gr OGTT for diagnosis. In 2020, this was replaced by a blood test for the measurement of plasma glucose and HbA1c, according to alternative GDM diagnostic criteria during the COVID-19 pandemic.

RESULTS

From 237 women in the 2019 group, 40 (16.9%) were diagnosed with GDM, while from 255 women in the 2020 group, 37 (14.5%) had GDM (p = 0.470). More women in the 2020 group, in comparison to the 2019 group, were nulligravid (41.9% vs. 47.2%, p = 0.013), had a personal history of GDM (11.4% vs. 4.6%, p = 0.013) and had macrosomia in previous pregnancies (10.2% vs. 2.1%, p = 0.001). Obstetrical and perinatal outcomes were similar when comparing women with GDM to non-GDM women in the 2019 and 2020 groups and between GDM women and non-GDM women.

CONCLUSION

In a Spanish population, GDM prevalence during the COVID-19 pandemic using the alternative diagnostic criteria was similar to that found in 2019 using the usual diagnostic criteria. Despite women referred for GDM diagnosis during the pandemic having more GDM risk factors, obstetrical and perinatal outcomes were comparable to those observed before the pandemic.

SARS-CoV-2 in diabetic pregnancies: a systematic scoping review

BACKGROUND

Currently, we suffer from an increasing diabetes pandemic and on the other hand from the SARS-CoV-2 pandemic. Already at the beginning of the SARS-CoV-2 pandemic, it was quickly assumed that certain groups are at increased risk to suffer from a severe course of COVID-19. There are serious concerns regarding potential adverse effects on maternal, fetal, and neonatal outcomes. Diabetic pregnancies clearly need special care, but clinical implications as well as the complex interplay of diabetes and SARS-CoV-2 are currently unknown. We summarized the evidence on SARS-CoV-2 in diabetic pregnancies, including the identification of novel potential pathophysiological mechanisms and interactions as well as clinical outcomes and features, screening, and management approaches.

METHODS

We carried out a systematic scoping review in MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection in September 2020.

RESULTS

We found that the prognosis of pregnant women with diabetes mellitus and COVID-19 may be associated with potential underlying mechanisms such as a simplified viral uptake by ACE2, a higher basal value of pro-inflammatory cytokines, being hypoxemic as well as platelet activation, embolism, and preeclampsia. In the context of "trans-generational programming" and COVID-19, life-long consequences may be "programmed" during gestation by pro-inflammation, hypoxia, over- or under-expression of transporters and enzymes, and epigenetic modifications based on changes in the intra-uterine milieu. COVID-19 may cause new onset diabetes mellitus, and that vertical transmission from mother to baby might be possible.

CONCLUSIONS

Given the challenges in clinical management, the complex interplay between COVID-19 and diabetic pregnancies, evidence-based recommendations are urgently needed. Digital medicine is a future-oriented and effective approach in the context of clinical diabetes management. We anticipate our review to be a starting point to understand and analyze mechanisms and epidemiology to most effectively treat women with SARS-COV-2 and diabetes in pregnancy.

An Update on Screening Strategies for Gestational Diabetes Mellitus: A Narrative Review

Gestational diabetes mellitus (GDM) is a frequent medical complication during pregnancy. Screening and diagnostic practices for GDM are inconsistent across the world. This narrative review includes data from 87 observational studies and randomized controlled trials (RCTs), and aims to give an overview of the current evidence on screening strategies and diagnostic criteria for GDM. Screening in early pregnancy remains controversial and studies show conflicting results on the benefit of screening and treatment of GDM in early pregnancy. Implementing the one-step "International Association of Diabetes and Pregnancy Study Groups" (IADPSG) screening strategy at 24-28 weeks often leads to a substantial increase in the prevalence of GDM, without conclusive evidence regarding the benefits on pregnancy outcomes compared to a two-step screening strategy with a glucose challenge test (GCT). In addition, RCTs are needed to investigate the impact of treatment of GDM diagnosed with IADPSG criteria on long-term maternal and childhood outcomes. Selective screening using a risk-factor-based approach could be helpful in simplifying the screening algorithm but carries the risk of missing significant proportions of GDM cases. A two-step screening method with a 50g GCT and subsequently a 75g oral glucose tolerance test (OGTT) with IADPSG could be an alternative to reduce the need for an OGTT. However, to have an acceptable sensitivity to screen for GDM with the IADPSG criteria, the threshold of the GCT should be lowered from 7.8 to 7.2 mmol/L. A pragmatic approach to screen for GDM can be implemented during the COVID-19 pandemic, using fasting plasma glucose (FPG), HbA1c or even random plasma glucose (RPG) to reduce the number of OGTTs needed. However, usual guidelines and care should be resumed as soon as the COVID pandemic is controlled.

Performance of guidelines for the screening and diagnosis of gestational diabetes mellitus during the COVID-19 pandemic: A scoping review of the guidelines and diagnostic studies evaluating the recommended testing strategies

Aim

The COVID-19 pandemic has necessitated less resource-intensive testing guidelines to identify gestational diabetes mellitus (GDM). We performed a scoping review of the international evidence reporting the ability of diagnostic tests recommended during the pandemic to accurately identify patients with GDM, compared to pre-pandemic reference standards, and associated test and clinical outcomes.

Methods

A comprehensive search of the literature was carried out in Embase, LitCovid, Cochrane Covid-19 study register, and medRxiv on 14^th June 2021.

Results

145 unique citations were returned; after screening according to pre-specified inclusion criteria by title and abstract and then full text, 13 studies involving 40,836 pregnant people and an additional 52,884 instances of OGTT were included. Thresholds defined in the Australian pandemic guideline appear adequate to identify most GDM cases; false negative cases appeared at lower risk of hyperglycaemia-in-pregnancy(HIP)-related events. For UK and Canadian guidelines, a larger proportion would be misdiagnosed as non-GDM; these false negative cases had broadly equivalent HIP-related event rates as true positives.

Conclusions

The OGTT remains the most effective test to identify abnormal glucose processing in pregnancy, supporting the prompt return to standard guidelines post-pandemic. Cohort studies investigating the impact of the change in guidelines on GDM pregnancies and associated outcomes are needed.

Diabetes in pregnancy 100 years after the discovery of insulin: Hot topics and open questions to be addressed in the coming years

By making it possible for women with diabetes to achieve their family planning goals, the discovery of insulin ushered in the field of diabetes in pregnancy. The ensuing century has witnessed tremendous advances, with clinical focus on preconception planning and maternal glycemic control making successful pregnancy an achievable goal. Currently, the global epidemic of overweight/obesity has led to maternal hyperglycemia now affecting one in every six pregnancies worldwide, prompting intense research interest. Topics of particular interest include (i) the optimal approach to diagnosing gestational diabetes mellitus (GDM); (ii) the emergence of GDM as a chronic metabolic disorder identifying future risk of non-communicable disease; (iii) the transgenerational impact of maternal glycemia as per the Developmental Origins of Health and Disease; and (iv) the application of new technology for optimizing clinical management. These topics have raised exciting questions such as (i) whether the treatment of diabetes in pregnancy can impact growth/development in childhood, (ii) whether GDM can be prevented, and (iii) whether the diagnosis of GDM could facilitate the prevention of type 2 diabetes and cardiovascular disease. Indeed, this field may be on the precipice of a golden era of new concepts and evidence to optimize the health of mother and child.

Screening for Gestational Diabetes during the COVID-19 Pandemic-Current Recommendations and Their Consequences

Gestational diabetes mellitus (GDM) is recognized as one of the most common medical complications of pregnancy that can lead to significant short-term and long-term risks for the mother and the fetus if not detected early and treated appropriately. Current evidence suggests that, with the use of appropriate screening programs for GDM, those women diagnosed and treated have reduced perinatal morbidity. It has been implied that, when screening for GDM, there should be uniformity in the testing used and in further management. This paper summarizes and compares current screening strategies proposed by international bodies and discusses application in the context of the COVID-19 pandemic.

Screening for Gestational Diabetes Mellitus in Early Pregnancy: What Is the Evidence?

The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. This has a significant effect on the health of the mother and offspring. There is no doubt that screening for GDM between 24 and 28 weeks is important to reduce the risk of adverse pregnancy outcomes. However, there is no consensus about diagnosis and treatment of GDM in early pregnancy. In this narrative review on the current evidence on screening for GDM in early pregnancy, we included 37 cohort studies and eight randomized controlled trials (RCTs). Observational studies have shown that a high proportion (15–70%) of women with GDM can be detected early in pregnancy depending on the setting, criteria used and screening strategy. Data from observational studies on the potential benefit of screening and treatment of GDM in early pregnancy show conflicting results. In addition, there is substantial heterogeneity in age and BMI across the different study populations. Smaller RCTs could not show benefit but several large RCTs are ongoing. RCTs are also necessary to determine the appropriate cut-off for HbA1c in pregnancy as there is limited evidence showing that an HbA1c ≥6.5% has a low sensitivity to detect overt diabetes in early pregnancy.

Limiting the Use of Oral Glucose Tolerance Tests to Screen for Hyperglycemia in Pregnancy during Pandemics

We aimed to evaluate each proposal of Australian–New Zealand Societies to limit the number of oral glucose tolerance tests (OGTTs) to diagnose hyperglycemia in pregnancy (HIP) during the coronavirus disease 2019 (COVID-19) pandemic. At our university hospital (2012–2016), we retrospectively applied in 4245 women who had OGTT between 22 and 30 weeks of gestation (reference standard: WHO criteria) the proposals in which OGTT is performed only in high-risk women; in all (Option 1) or high-risk (Option 1-Sel) women with fasting plasma glucose (FPG) 4.7–5.0 mmol/L; in all (Option 2) or high-risk (Option 2-Sel) women without history of HIP and with FPG 4.7–5.0 mmol/L. We also tested FPG measurement alone in all high-risk women. Measuring FPG alone had a sensitivity of 49% (95% confidence interval 45–54) applying universal screening. Option 2 appeared to have the best balance considering the needed OGTT (17.3%), sensitivity (72% (67–76)) and rates of a composite outcome (true negative cases: 10.6%, false positive cases: 24.4%; true positive cases: 19.5%; false negative cases: 10.2%). Consideration of a history of HIP and measuring first FPG can avoid more than 80% of OGTTs and identify women with the highest risk of adverse HIP-related events.

Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic

The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1^st March 2020 and 15^th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24–28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.

A Review of the Current Status of Gestational Diabetes Mellitus in Australia-The Clinical Impact of Changing Population Demographics and Diagnostic Criteria on Prevalence

The current status of gestational diabetes mellitus in Australia reveals an almost quadrupling prevalence over the last decade. A narrative review of the current Australian literature reveals unique challenges faced by Australian maternity clinicians when addressing this substantial disease burden in our diverse population. Rising rates of maternal overweight and obesity, increasing maternal age and the diversity of ethnicity are key epidemiological impactors, overlaid by the 2015 changes in screening and diagnostic parameters. Our vast land mass and the remote location of many at risk women requires innovative and novel ideas for pathways to diagnose and effectively manage women with gestational diabetes mellitus. By modifying and modernizing models of care for women with gestational diabetes mellitus, we have the ability to address accessibility, resource management and our acute response to global events such as the COVID 19 pandemic. With continuing research, education and robust discourse, Australia is well placed to meet current and future challenges in the management of gestational diabetes mellitus.

The Oral Glucose Tolerance Test-Is It Time for a Change?-A Literature Review with an Emphasis on Pregnancy

Globally, gestational diabetes (GDM) is increasing at an alarming rate. This increase is linked to the rise in obesity rates among women of reproductive age. GDM poses a major global health problem due to the related micro- and macro-vascular complications of subsequent Type 2 diabetes and the impact on the future health of generations through the long-term impact of GDM on both mothers and their infants. Therefore, correctly identifying subjects as having GDM is of utmost importance. The oral glucose tolerance test (OGTT) has been the mainstay for diagnosing gestational diabetes for decades. However, this test is deeply flawed. In this review, we explore a history of the OGTT, its reproducibility and the many factors that can impact its results with an emphasis on pregnancy.

[Screening for gestational diabetes due to of the COVID-19 pandemic]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that causes coronavirus disease in 2019 (COVID-19). Currently, there is no evidence that pregnant women are more vulnerable to COVID-19. All concerns and anticipated risks are related to the potential impact of COVID-19 on perinatal outcomes, so pregnant women require special attention in relation to the preventive measures, diagnosis and treatment of a new coronavirus disease. Women with gestational diabetes mellitus (GDM) belong to the group of high perinatal risk and need timely medical assistance. During the COVID-19 pandemic, there is a necessity in temporary changes of approaches to diagnosing GSD and pregnancy care before and after delivery in women with GSD. The purpose of our review is to present and analyze all available GSD screening recommendations, updated and published in various countries in response to the coronavirus pandemic, at the time of publication of this article. It seems that there is no single universal strategy to achieve a reasonable balance. In this regard, it is necessary to develop new national algorithms for GSD screening, taking into account both demographic factors and the features and capabilities of our health system. We believe that the knowledge and experience achieved as a result of these changes will lead to the revision and improvement of national and international recommendations.

Testing for gestational diabetes during the COVID-19 pandemic. An evaluation of proposed protocols for the United Kingdom, Canada and Australia

AIMS

We assessed how altered diagnostic processes and criteria for gestational diabetes mellitus (GDM) recommended by the United Kingdom (UK), Canada and Australia for use during the COVID-19 pandemic would affect both GDM frequency and related adverse outcomes.

METHODS

Secondary analysis of 5974 HAPO study women with singleton pregnancies who underwent 75 g OGTTs and HbA1c assays between 24 and 32 weeks' gestation and who received no treatment for GDM.

RESULTS

All post COVID-19 modified pathways reduced GDM frequency - UK (81%), Canada (82%) and Australia (25%). Canadian women whose GDM would remain undetected post COVID-19 (missed GDMs) displayed similar rates of pregnancy complications to those with post COVID-19 GDM. Using UK modifications, the missed GDM group were at slightly lower risk whilst the women missed using the Australian modifications were at substantially lower risk.

CONCLUSIONS

The modifications in GDM diagnosis proposed for the UK, Canada and Australia result in differing reductions of GDM frequency. Each has both potential benefits in terms of reduction in potential exposure to COVID-19 and costs in terms of missed opportunities to influence pregnancy and postpartum outcomes. These factors should be considered when deciding which protocol is most appropriate for a particular context.

Diagnosis and principles of management of gestational diabetes mellitus in the prevailing COVID-19 pandemic

BACKGROUND

Limited medical facilities are available due to Covid-19 pandemic. Nevertheless, all efforts should be made in planning judicial and possible methods of delivering health care, particularly to pregnant woman with GDM. GDM may play a crucial role in the increasing prevalence of diabetes and obesity and also may be the origin of cardiometabolic diseases.

METHODS

It is mandatary to diagnose and care pregnant woman with GDM. The test suggested to diagnose GDM has to be evidence based and in this regard "a single test procedure" evaluated meets this requirement. This doable test has been accepted by the Diabetes in Pregnancy Study Group India (DIPSI) and approved by MHFW-GOI, WHO, International Diabetes Federation, and International Federation of Obstetricians and Gynecologists. MHFW-GOI also recommends testing at first antenatal visit and then at 24-28 weeks of gestation. This opportunity can also be utilized for performing ultrasonography for assessing fetal development.

RESULT

The first-line management is MNT and life style modifications. Non-responders may require insulin or OHA. The target glycemic control is FPG ~ 5.0 mmol/dl (90 mg/dl) and 2 h PPPG ~ 6.7 mmol/dl (120 mg/dl). The goal is to obtain newborns birth weight appropriate for gestational age between 2.5 and 3.5 kg, a step to prevent offspring developing diabetes.

CONCLUSION

The essential precaution required during COVID pandemic is to wear face mask, avoid crowded places, and maintain social distancing. Finally, the economical and evidence based "single test procedure" of DIPSI is most appropriate for screening during the COVID pandemic.

Gestational diabetes mellitus testing in the COVID-19 pandemic: The problems with simplifying the diagnostic process

Background

Multiple professional bodies have temporarily revised recommendations for gestational diabetes mellitus (GDM) testing during the COVID‐19 pandemic to reduce person‐to‐person contact. The current Australian temporary criteria advise that if the fasting glucose is ≤4.6 mmol/L, then no glucose tolerance test (GTT) is required.

Aims

The aim of this study is to examine the extent of underdiagnosis of GDM using a fasting glucose ≤4.6 mmol/L as a cut‐off to determine that a GTT is not necessary.

Materials and Methods

De‐identified data from pregnant women having a GTT test in the Illawarra area during a six‐year period was used to determine the number of women with GDM and the proportion of positive cases that would be missed for different fasting glucose values.

Results

There were 16 522 results identified and GDM was diagnosed in 12.2%. The majority of women were more than 30 years of age (85.2%) and diagnosed at ≥20 weeks gestation (81.1%). Of those diagnosed with GDM, 29% had a fasting glucose of ≤4.6 mmol/L and would have been missed.

Conclusions

Our results show that using a fasting glucose of 4.6 mmol/L or less would miss nearly a third of women who would otherwise be diagnosed with GDM.