Determinants of fetal growth at different periods of pregnancies complicated by gestational diabetes mellitus or impaired glucose tolerance

Fetal abdominal obesity in women with one value abnormality on diagnostic test for gestational diabetes mellitus

Previous studies have shown that fetal abdominal obesity (FAO) was already observed at the time of gestational diabetes mellitus (GDM) diagnosis and persisted until delivery despite management in older and/or obese women. In this study, we investigated whether fetuses of women with milder hyperglycemia than GDM have accelerated abdominal growth, leading to adverse pregnancy outcomes. We retrospectively reviewed the medical records of 7,569 singleton pregnant women who were universally screened using a 50-g glucose challenge test (GCT) and underwent a 3-h 100-g oral glucose tolerance test (OGTT) if GCT result was ≥140mg/dL. GDM, one value abnormality (OVA), and normal glucose tolerance (NGT, NGT1: GCT negative, NGT2: GCT positive & OGTT negative) were diagnosed using Carpenter-Coustan criteria. With fetal biometry data measured simultaneously with 50-g GCT, relative fetal abdominal overgrowth was investigated by assessing the fetal abdominal overgrowth ratios (FAORs) of the ultrasonographically estimated gestational age (GA) of abdominal circumference(AC) per actual GA by the last menstruation period(LMP), biparietal diameter(BPD) or femur length(FL), respectively. FAO was defined as FAOR ≥90th percentile The FAORs of GA-AC/GA-LMP and GA-AC/GA-BPD were significantly higher in OVA subjects compared to NGT subjects but not in NGT2 subjects. Although the frequency of FAO in OVA (12.1%) was between that of NGT (9.6%) and GDM (18.3%) without statistically significant difference, the prevalence of large for gestational age at birth and primary cesarean delivery rates were significantly higher in OVA (9.8% and 29.7%) than in NGT (5.1% and 21.5%, p<0.05). Particularly, among OVA subjects with FAO, the prevalence (33.3% and 66.7%) was significantly higher than in those without FAO (9.7% and 24.2%, p<0.05). The degree of fetal abdominal growth acceleration in OVA subjects was intermediate between that of NGT and GDM subjects. OVA subjects with FAO at the time of GDM diagnosis were strongly associated with adverse pregnancy outcomes.

Maternal Hypertriglyceridemia in Gestational Diabetes: A New Risk Factor?

Elevated maternal triglycerides (TGs) have been associated with excessive fetal growth. However, the role of maternal lipid profile is less studied in gestational diabetes mellitus (GDM). We aimed to study the association between maternal lipid profile in the third trimester and the risk for large-for-gestational-age (LGA) newborns in women with GDM. We performed an observational and retrospective study of pregnant women with GDM who underwent a lipid profile measurement during the third trimester. We applied a logistic regression model to assess predictors of LGA. A total of 100 singleton pregnant women with GDM and third-trimester lipid profile evaluation were included. In the multivariate analysis, pre-pregnancy BMI (OR 1.19 (95% CI 1.03-1.38), p = 0.022) and hypertriglyceridemia (OR 7.60 (1.70-34.10), p = 0.008) were independently associated with LGA. Third-trimester hypertriglyceridemia was found to be a predictor of LGA among women with GDM, independently of glycemic control, BMI, and pregnancy weight gain. Further investigation is needed to confirm the role of TGs in excessive fetal growth in GDM pregnancies.

Adverse pregnancy outcomes among women in Norway with gestational diabetes using three diagnostic criteria

INTRODUCTION

The aim of this study was to examine the risk of adverse perinatal outcomes in women diagnosed with GDM by the World Health Organization (WHO) 1999 criteria, and in those retrospectively identified by the Norwegian-2017 and WHO-2013 criteria but not by WHO-1999 criteria. We also examine the effect of maternal overweight/obesity and ethnicity.

MATERIAL AND METHODS

We used pooled data from four Norwegian cohorts (2002-2013), encompassing 2970 mother-child pairs. Results from universally offered 75-g oral glucose tolerance tests measuring fasting plasma glucose (FPG) and 2-hour glucose (2HG) were used to assign women into three diagnostic groups: Diagnosed and treated by WHO-1999 (FPG≥7.0 or (2HG ≥7.8 mmol/L), identified by WHO-2013 (FPG ≥5.1 or 2HG ≥8.5 mmol/L), and identified by Norwegian-2017 criteria (FPG ≥5.3 or 2HG ≥9.0 mmol/L). Perinatal outcomes included large-for-gestational-age (LGA) infants, cesarean section, operative vaginal delivery, preterm birth and preeclampsia.

RESULTS

Compared to the non-GDM group, women diagnosed with GDM by either of the three criteria had an increased risk of large-for-gestational-age infants (adjusted odds ratios (OR) 1.7-2.2). Those identified by the WHO-2013 and Norwegian-2017 criteria but not diagnosed and treated by WHO-1999 criteria had an additional increased risk of cesarean section (OR 1.36, 95% CI 1.02,1.83 and 1.44, 95% CI 1.03,2.02, respectively) and operative vaginal delivery (OR 1.35, 95% CI 1.1,1.7 and 1.5, 95% CI 1.1,2.0, respectively). The proportions of LGA neonates and cesarean section were higher for women with GDM in both normal-weight and overweight/obese women. Asians had a lower risk of delivering large-for-gestational-age infants than Europeans applying national birthweight references, but maternal glucose values were similarly positively associated with birthweight in all ethnic groups.

CONCLUSIONS

Women who met the WHO-2013 and Norwegian-2017 criteria, but were not diagnosed by the WHO-1999 criteria and therefore not treated, had an increased risk of LGA, cesarean section and operative vaginal delivery compared to women without GDM.

Maternal body mass index and risk of fetal overgrowth in women with gestational diabetes Mellitus in Southeast China: a retrospective cohort study

BACKGROUND

To investigate the relationship between body mass index (BMI) changes and large for gestational age (LGA) in women with gestational diabetes mellitus (GDM).

METHODS

A retrospective cohort study including 10,486 women with GDM was conducted. A dose‒response analysis of BMI changes and the occurrence of LGA was performed. Binary logistic regressions were performed to assess crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Receiver operating characteristic (ROC) curves and areas under the curve (AUCs) were used to assess the ability of BMI changes to predict LGA.

RESULTS

The probability of LGA increased with increasing BMI. The risk of LGA increased across the BMI change quartiles. The BMI change remained positively associated with the risk of LGAafter stratification analysis. The AUC was 0.570 (95% CI: 0.557 ~ 0.584)in the entire study population, and the best optimal predictive cut-off value was 4.922, with a sensitivity of 0.622 and a specificity of 0.486. The best optimal predictive cut-off value decreased from the underweight group to the overweight and obese group.

CONCLUSIONS

BMI changes are related to the risk of LGA and may be a useful predictor of the incidence of LGA in singleton pregnant women with GDM.

Role of cord blood IGF-1 and maternal HbA1c levels to predict interventricular septal hypertrophy among infants of diabetic mothers: A case-control study

BACKGROUND

Infants of diabetic mothers (IDMs) develop interventricular septal hypertrophy (ISH) (> 6 mm) [1]. The proportion of IDMs developing ISH varies from country to country. Maternal HbA1c and cord blood Insulin-like growth factor-1 (IGF-1) levels have been found useful to predict ISH.

METHODS

This was a case-control study of term neonates of diabetic mothers (cases) and of non-diabetic mothers (controls) to evaluate echocardiographic (ECHO) differences among cases and controls and to find the correlation of interventricular septal thickness (IVS) thickness with maternal HbA1C and cord blood IGF-1 levels.

RESULTS

Of 32 cases and 34 controls (mean gestational age 37.7 ± 0.9 weeks), 15 (46.8 %) cases, no control developed ISH. Septal thickness was more (6 ± 0.15 cm vs 3 ± 0.06 cm; p = 0.027) in cases than controls. Functional ECHO parameters including left ventricle ejection fraction were comparable (p = 0.9) among the two groups. Maternal HbA1C levels were higher (6.5 % ± 1.3 vs 3.6 % ± 0.7; p = 0.001) with a positive correlation with IVS (Pearson's coefficient 0.784, p < 0.001). Cord blood IGF1 levels were too higher in cases (99.1 ± 6.09 ng/ml vs 37.1 ± 2.99 ng/ml; p < 0.001) with moderate correlation with IVS thickness (Pearson's coefficient 0.402; p = 0.00). Receiver operator curve analysis showed, that at a cut-off of 72 ng/ml, cord blood IGF1 predicted ISH with 72 % sensitivity; 88 % specificity and at a cut-off of 7.35 %, maternal HbA1c predicted ISH with sensitivity; specificity of 93.8 % and 72.1 % respectively.

CONCLUSION

ISH was present in 46.8 % in cases as compared to none in controls. IVS thickness correlated well with maternal HbA1C and moderately with cord blood IGF-1 levels. Functional parameters on ECHO were unaffected by maternal diabetic control. At the cut-off of maternal HbA1c of 7.35 % and cord blood IGF-1 of 72 ng /ml, babies need to be monitored clinically with ECHO to look for ISH.

The association between an oral glucose tolerance test performed at term pregnancy and obstetric outcomes

Aims

Assessing the value of oral glucose tolerance test performed at term pregnancy in identifying obstetric complications.

Methods

Retrospective cohort study of women with a normal 50 g glucose challenge test who also had an oral glucose tolerance test at term (defined as at or after 37 weeks of gestation). Comparison between the pathological and normal oral glucose tolerance test groups was performed.

Results

The mean glucose in the glucose challenge test of women in the normal oral glucose tolerance test (n = 256) group was lower than that in the pathological oral glucose tolerance test (N = 16) group (105 ± 17 mg/dl (5.8 ± 0.9 mmol/l) vs 117 ± 13 mg/dl (6.5 ± 0.7 mmol/l), p = 0.007). Relevant obstetrical complications did not differ significantly between the groups. Of note, in the pathological oral glucose tolerance test group only one woman delivered a macrosomic infant.

Conclusions

A pathological oral glucose tolerance test performed at term was unable to identify women at risk for impaired glucose metabolism-related obstetric complications and is therefore of limited clinical value and seems to be unjustified.

Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review

AIMS

Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia.  METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized.

RESULTS

Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed.

CONCLUSIONS

There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.

Longitudinal Associations of Plasma Phospholipid Fatty Acids in Pregnancy with Neonatal Anthropometry: Results from the NICHD Fetal Growth Studies-Singleton Cohort

Despite increasing interest in the health effects of polyunsaturated FAs (PUFAs), their roles in fetal and neonatal growth remain understudied. Within the NICHD Fetal Growth Studies—Singleton Cohort, we prospectively investigated the associations of individual and subclasses of plasma phospholipid PUFAs at gestational weeks (GW) 10−14, 15−26, 23−31, and 33−39 with neonatal anthropometric measures as surrogates for fetal growth among 107 women with gestational diabetes mellitus (GDM) and 214 non-GDM controls. Multivariable weighted linear regression models estimated the associations between plasma phospholipid PUFAs and neonatal anthropometric measures. Adjusted beta coefficients for phospholipid docosahexaenoic acid (DHA) per standard deviation (SD) increase at GW 23−31 in association with birthweight z-score, neonatal length, and neonatal fat mass were 0.25 (95% CI: 0.08−0.41), 0.57 (0.11−1.03) cm, and 54.99 (23.57−86.42) g, respectively; all false discovery rates (FDRs) < 0.05. Estimated Δ5-desaturase activity per SD increase at GW 33−39 but not at other time points was positively associated with birthweight z-score: 0.29 (95% CI: 0.08−0.33); neonatal length: 0.61 (0.29−0.94) cm; and neonatal fat mass: 32.59 (8.21−56.96) g; all FDRs < 0.05. Longitudinal analysis showed consistent results. Our findings suggest that mid-to-late pregnancy presented as critical windows for primarily diet-derived DHA and Δ5-desaturase activity in relation to neonatal anthropometric measures.

Third trimester HbA1c and the association with large-for-gestational-age neonates in women with gestational diabetes

Objective

To evaluate the association between HbA1c levels measured in the third trimester and the risk for large for gestational age (LGA) in neonates of mothers affected by gestational diabetes mellitus (GDM). Secondarily, we aimed to identify an ideal cut-off for increased risk of LGA amongst pregnant women with GDM.

Methods

Observational retrospective review of singleton pregnant women with GDM evaluated in a diabetes and pregnancy clinic of a tertiary and academic hospital. From January/2011 to December/2017, 1,085 pregnant women underwent evaluation due to GDM, of which 665 had an HbA1c test in the third trimester. A logistic regression model was performed to evaluate predictors of LGA. A receiver-operating-characteristic (ROC) curve was used to evaluate the predictive ability of third trimester HbA1c for LGA identification.

Results

A total of 1,085 singleton pregnant women were evaluated during the study period, with a mean age of 32.9 ± 5.3 years. In the multivariate analysis, OGTT at 0 minutes (OR: 1.040; CI 95% 1.006-1.076, p = 0.022) and third trimester HbA1c (OR: 4.680; CI 95% 1.210-18.107, p = 0.025) were associated with LGA newborns. Using a ROC curve to evaluate the predictive ability of third trimester HbA1c for LGA identification, the optimal HbA1c cut-off point was 5.4% where the sensitivity was 77.4% and the specificity was 71.7% (AUC 0.782; p < 0.001).

Conclusion

Few studies in the Mediterranean population have evaluated the role of HbA1c in predicting neonatal complications in women with GDM. A third trimester HbA1c > 5.4% was found to have good sensitivity and specificity for identifying the risk of LGA.

Prenatal metal mixtures and fetal size in mid-pregnancy in the MADRES study

BACKGROUND

Fetal growth is predictive of health later in life. Both toxic and essential metals influence fetal growth, but most studies have focused on these elements individually and used birth weight as an indicator of fetal growth. The objective of the current study was to investigate the impact of a mixture of metals on fetal size in mid-pregnancy in a predominately lower income Hispanic pregnancy cohort in Los Angeles.

METHODS

For our primary analysis, we focused on six elements that have previously been associated individually with fetal size, including arsenic (As), barium (Ba), cadmium (Cd), mercury (Hg), molybdenum (Mo), and tin (Sn), measured in maternal urine samples collected in early pregnancy (median: 12.4 weeks gestation). In an exploratory analysis, we additionally included cobalt (Co), nickel (Ni), antimony (Sb), and thallium (Tl). Using covariate-adjusted Bayesian Kernel Machine Regression (BKMR) as our main mixture modeling approach, we examined the impact of these metals on fetal biometry measures obtained between 18 and 22 weeks gestation, with a focus on estimated fetal weight (EFW).

RESULTS

BKMR identified Mo and Ba as the mixture components that contributed most to associations with EFW. Linear associations were observed for both metals. An increase in Mo from the 25th to 75th percentile was associated with a 0.114 (95% credible interval (CI): 0.019, 0.247) SD higher EFW, equivalent to a 7.4 g difference. Similar associations were observed between Mo and the other fetal measures evaluated. In contrast, an increase in Ba from the 25th to 75th percentile was associated with a -0.076 (95% CI: 0.217, 0.066) SD lower EFW, equivalent to a 4.9 g difference. Similar inverse associations were observed for Ba in relation to abdominal circumference and biparietal diameter. BKMR also identified a possible interaction between Ba and Mo in relation to head circumference, suggesting that the positive associations between Mo and this outcome may be attenuated at high levels of Ba, which was consistent with findings from linear regression (P_interaction = 0.03). In an exploratory analysis accounting for a larger mixture of metals, Mo and Ba consistently contributed most to associations with EFW. An inverse association was also identified between Sb and EFW.

CONCLUSIONS

Our results suggest that Mo may promote fetal growth, while Ba and Sb may reduce fetal growth, in this population.

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

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

The Predictive Ability of Two Triglyceride-Associated Indices for Gestational Diabetes Mellitus and Large for Gestational Age Infant Among Chinese Pregnancies: A Preliminary Cohort Study

BACKGROUND/AIMS

To investigate the potential of maternal first-trimester triglyceride (TG) to high-density lipoprotein cholesterol (TG/HDL-c) ratio, triglyceride glucose index (TyG) and total cholesterol (TC)/HDL-c to predict the risk of later gestational diabetes mellitus (GDM) and large for gestational age (LGA) newborn in Chinese women.

METHODS

We included 352 women with a singleton pregnancy, who were followed up prospectively from the first prenatal visit until delivery. Fasting glucose and plasma lipid profiles including TG, TC, HDL-c, and low-density lipoprotein cholesterol (LDL-c) were measured in the first trimester. A binary logistic regression analysis was performed to determine the odds ratios (ORs) and 95% confidence intervals (CIs) of GDM and LGA according to tertiles of those indices, respectively. Receiver-operating characteristic curve (ROC) and areas under the curve (AUC) were employed to evaluate the ability of those indices to predict the risk of GDM and LGA infants, and differences in the AUC values between them were compared.

RESULTS

Women with the top tertile of TG/HDL-c or TyG other than TC/HDL-c had a significantly higher risk of GDM (ORTG/HDL-c=2.388, 95% CI 1.026-5.467; ORTyG=3.535, 95% CI 1.483-8.426, respectively) and LGA infant delivery (ORTG/HDL-c=3.742, 95% CI 1.114-12.569; ORTyG=3.011, 95% CI 1.012-8.962, respectively) than women with the lowest tertile of TG/HDL-c or TyG after adjusting for confounders. The AUC of TG/HDL-c and TyG to detect GDM was 0.664 (95% CI 0.595-0.733) and 0.686 (95% CI 0.615-0.756), respectively, and that to detect LGA was 0.646 (95% CI 0.559-0.734) and 0.643 (95% CI 0.552-0.735), respectively (all P < 0.01). There were no statistical differences between TG/HDL-c and TyG in the ability of predicting the risk of GDM or LGA infants.

CONCLUSION

Maternal first-trimester TG/HDL-c and TyG are both good indicators in predicting the risk of later GDM and LGA newborn, and it may be useful to evaluate them in early pregnancy.

First-trimester fasting glycemia as a predictor of gestational diabetes (GDM) and adverse pregnancy outcomes

AIMS

Studies to prevent gestational diabetes (GDM) have shown the best results when lifestyle measures have been applied early in pregnancy. We aimed to investigate whether first-trimester fasting plasma glucose (FPG) could predict GDM risk and adverse pregnancy outcomes.

METHODS

A retrospective analysis of prospectively collected data from singleton pregnancies who were attended at our hospital between 2008 and 2018 (n = 27,198) was performed. We included patients with a recorded first-trimester FPG and complete pregnancy data (n = 6845). Patients under 18, with pregestational diabetes or reproductive techniques, were excluded. First-trimester FPG was evaluated as a continuous variable and divided into quartiles. GDM was diagnosed by NDDG criteria. The relationship between first- and second-trimester glucose > 92 mg/dL was also investigated. The relationship between FPG and pregnancy outcomes was assessed in 6150 patients who did not have GDM.

RESULTS

Maternal age was 34.2 ± 3.9 years, BMI 23.1 ± 3.7 kg/m² and mean FPG 83.0 ± 7.3 mg/dL. Glucose quartiles were: ≤ 78, 79-83, 84-87 and ≥ 88 mg/dL. First-trimester FPG predicted the risk of GDM (7%, 8%, 10.2% and 16% in each quartile, p < 0.001) and the risk of second-trimester glucose > 92 mg/dL (2.6%, 3.8%, 6.3% and 11.4% in each quartile, p < 0.001). FPG was significantly associated with LGA (8.2%, 9.3%, 10% and 11.7% in each quartile, p = 0.011) but not with other obstetrical outcomes. In a multivariate analysis including age, BMI, tobacco use, number of pregnancies and weight gained during pregnancy, first-trimester FPG was an independent predictor of LGA.

CONCLUSIONS

First-trimester FPG is an early marker of GDM and LGA.

Factors associated with macrosomia, hypoglycaemia and low Apgar score among Fijian women with gestational diabetes mellitus

Background

Gestational diabetes mellitus (GDM) in Fiji is a serious public health issue. However, there are no recent studies on GDM among pregnant women in Fiji. The aim of this study was to examine prevalence of, and sociodemographic factors associated with adverse neonatal outcomes among Fijian women with GDM.

Methods

We used cross-sectional data of 255 pregnant women with GDM who gave birth to singleton infants at Colonial War Memorial Hospital (CWMH) in Suva city. Women underwent testing for GDM during antenatal clinic visits and were diagnosed using modified International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Multivariable logistic regression analysis was used to investigate factors associated with neonatal outcomes.

Results

Women with a previous baby weighing > 4 kg were 6.08 times more likely to experience neonatal macrosomia (Adjusted odds ratio (AOR) = 6.08; 95%CI: 2.46, 15.01). Compared to unmarried women, the odds of macrosomia among married women reduced by 71% (AOR = 0.29; 95%CI: 0.11, 0.77). Compared with delivery before 38 weeks of gestation, the infants of women who delivered between 38 and 41 weeks of gestation were 62 and 86% less likely to experience neonatal hypoglycaemia and Apgar score < 7 at 5 mins, respectively. The offspring of women who were overweight and obese had higher odds of neonatal hypoglycaemia. Late booking in gestation (≥28 weeks) was significantly associated with Apgar score < 7 at 5 min (AOR = 7.87; 95%CI: 1.11, 55.75). Maternal pre-eclampsia/pregnancy induced hypertension was another factor associated with low Apgar score in infants.

Conclusions

The study found high rates of adverse neonatal outcomes among off springs of Fijian women with GDM and showed that interventions targeting pregnant women who are overweight, had a previous baby weighing > 4 kg, had pre-eclampsia, delivered before 38 weeks of gestation, and those who booked later than 13 weeks in gestation, are needed to improve pregnancy outcomes.

Increased risk of neonatal complications or death among neonates born small for gestational age to mothers with gestational diabetes

AIMS

To evaluate if neonatal complications or death were poorer for neonates born small for gestational age (SGA) than for those born with adequate weight or large for gestation age (LGA) to women with gestational diabetes mellitus (GDM).

METHODS

Retrospective analysis of the clinical outcomes of neonates born to 3413 women with GDM. The prevalence of neonatal hypoglycaemia, hypocalcaemia, hyperbilirubinemia, polycythaemia, and death was compared among three birthweight groups: SGA, adequate, and LGA. A two-sided chi-squared or Fisher's exact test was used for between-group comparisons. A forward multiple logistic regression was performed to determine the odds ratio (OR) associated with SGA.

RESULTS

Neonatal complications were more frequent in the SGA group (20.1%) than in the adequate (9.9%) or LGA (15.2%) groups. There were four deaths (1.6%) in the SGA group compared to one in the LGA (0.4%) and six in the adequate (0.2%) groups (P = 0.002). SGA was a risk factor for neonatal complications or death (OR. 2.122; 95% confidence interval, 1.552-2.899), independent of maternal age, weight gain, fasting glucose, glycaemic control, gestational hypertension, pre-eclampsia, smoking, or neonatal prematurity.

CONCLUSION

SGA birthweight is an important risk factor for neonatal complications or death among neonates born to mothers with GDM.

The relationship of hyperlipidemia with maternal and neonatal outcomes in pregnancy: A cross-sectional study

Background

Concentrations of plasma lipids levels during pregnancy clearly increases. According to some studies, dyslipidemia is effective in the incidence of preeclampsia and insulin resistance. Objective: This study aimed to examine the relationship between hyperlipidemia and maternal and neonatal outcomes in pregnant women.

Materials and Methods

This is a cross-sectional study which was conducted on two groups of pregnant women with hyperlipidemia and normal ones to assess maternal and neonatal outcomes. Maternal data including gestational age, mother's age, body mass index, and maternal weight gain during pregnancy, gestational diabetes mellitus, preeclampsia, cholestasis, and delivery method. Also, birth weight and Apgar score were gathered as the neonatal outcomes.

Results

The results showed that the prevalence of abnormal lipid parameters increased with increasing gestational age. In pregnant women with dyslipidemia in combination with increased triglyceride, cholesterol and Low-density lipoprotein, and decreased High-density lipoprotein, the incidence rates of gestational diabetes (p < 0.001), preeclampsia (p < 0.001), cholestasis (p = 0.041), fetal growth retardation (p < 0.001), and macrosomia (p < 0.001) were statistically higher.

Conclusion

Dyslipidemia was associated with some adverse effects of pregnancy and harmful fetal outcomes. Therefore, it seems that adding laboratory assessment of lipid profiles before and during pregnancy can be effective in early diagnosis of dyslipidemia.

THE ASSOCIATION OF GESTATIONAL WEIGHT GAIN AND ADVERSE PREGNANCY OUTCOMES IN WOMEN WITH GESTATIONAL DIABETES MELLITUS

Objective: To explore the association of excessive gestational weight gain (GWG) defined by the Institute of Medicine (IOM) targets and adverse perinatal outcomes in gestational diabetes mellitus (GDM) pregnancies, and whether a modified target might be related to a lower rate of adverse perinatal outcomes for GDM. Methods: This retrospective cohort study involved 1,138 women of normal glucose tolerance (NGT) and 1,200 women with GDM. Based on the IOM target, pregnancies were classified to appropriate GWG (aGWG), inadequate GWG, and excessive GWG (eGWG). Modified GWG targets included: upper limit of IOM target minus 1 kg (IOM-1) or 2 kg (IOM-2), both upper and lower targets minus 1 kg (IOM-1-1) or 2 kg (IOM-2-2). Results: The proportions of women achieving eGWG were 26.3% in NGT and 31.2% in GDM (P = .036); in comparison, for aGWG NGT, the risks of large for gestational age (LGA) were significantly higher in eGWG NGT (adjusted odds ratio [OR] 1.47; 95% confidence interval [CI] 1.02 to 2.13), aGWG GDM (adjusted OR 1.42; 95% CI 1.03 to 1.95), and eGWG GDM (adjusted OR 2.70; 95% CI 1.92 to 3.70). GDM pregnancies gaining aGWG based on the modified GWG targets (IOM-2, IOM-1-1, and IOM-2-2) had a lower prevalence of LGA and macrosomia delivery than that for similar pregnancies using the original IOM target (all P<.05). Conclusion: For aGWG GDM according to the IOM target, adhering to a more stringent weight control was associated with decreased adverse outcomes. A tighter IOM target might help to reduce the prevalence of adverse pregnancy outcomes. Abbreviations: aGWG = appropriate gestational weight gain; BG = blood glucose; BMI = body mass index; CI = confidence interval; eGWG = excessive gestational weight gain; GDM = gestational diabetes mellitus; GW = gestational weeks; GWG = gestational weight gain; HbA1c = hemoglobin A1c; iGWG = inadequate gestational weight gain; IOM = Institute of Medicine; LGA = large for gestational age; NGT = normal glucose tolerance; NICU = neonatal intensive care unit; OGTT = oral glucose tolerance test; OR = odds ratio; PARp = partial population attributable risks; SGA = small for gestational age.

Level of maternal triglycerides is a predictor of fetal macrosomia in non-obese pregnant women with gestational diabetes mellitus

BACKGROUND

The role of maternal serum triglycerides (TGs) in the development of fetal macrosomia in different subgroups of body mass index (BMI) has received little attention. The aim of this study was to determine the association between the level of maternal TGs and fetal macrosomia in Iranian pregnant women of different BMI subgroups with gestational diabetes mellitus (GDM).

METHODS

This cohort study was conducted on 305 pregnant women with GDM referred for glucose control to Kowsar Hospital in Qazvin, Iran. Level of TGs was measured on the 24th-28th weeks of pregnancy. The ROC curve of the level of TGs was depicted in BMI subgroups to predict fetal macrosomia. Logistic regression analysis was used to determine the risk of macrosomia per 1-SD increase in the level of TGs.

RESULTS

The prevalence of hypertriglyceridemia did not significantly differ across BMI subgroups. Macrosomia was more prevalent in obese women (32.2%) than overweight (19.1%) and normal weight (11.1%) women (P < 0.05). A 1-SD increase in the level of TG was associated with 4.2 and 1.9 times increased risk of macrosomia in normal weight (P < 0.01) and overweight (P < 0.01) women, respectively. Serum level of TGs was not associated with macrosomia in any adjustment models in obese women. The area under the curve of the level of TGs for macrosomia was 0.828 (95% CI: 0.712-0.911, P < 0.001) and 0.711 (95% CI: 0.639-0.775, P < 0.001) in normal weight and overweight women, respectively.

CONCLUSION

Hypertriglyceridemia was a predictor of macrosomia in non-obese women. More studies on different ethnicities and lifestyles are necessary to determine the association between the level of maternal TG and fetal macrosomia in BMI subgroups.

Biomarkers for Macrosomia Prediction in Pregnancies Affected by Diabetes

Large birthweight, or macrosomia, is one of the commonest complications for pregnancies affected by diabetes. As macrosomia is associated with an increased risk of a number of adverse outcomes for both the mother and offspring, accurate antenatal prediction of fetal macrosomia could be beneficial in guiding appropriate models of care and interventions that may avoid or reduce these associated risks. However, current prediction strategies which include physical examination and ultrasound assessment, are imprecise. Biomarkers are proving useful in various specialties and may offer a new avenue for improved prediction of macrosomia. Prime biomarker candidates in pregnancies with diabetes include maternal glycaemic markers (glucose, 1,5-anhydroglucitol, glycosylated hemoglobin) and hormones proposed implicated in placental nutrient transfer (adiponectin and insulin-like growth factor-1). There is some support for an association of these biomarkers with birthweight and/or macrosomia, although current evidence in this emerging field is still limited. Thus, although biomarkers hold promise, further investigation is needed to elucidate the potential clinical utility of biomarkers for macrosomia prediction for pregnancies affected by diabetes.

Maternal overweight is not an independent risk factor for increased birth weight, leptin and insulin in newborns of gestational diabetic women: observations from the prospective 'EaCH' cohort study

BACKGROUND

Both gestational diabetes mellitus (GDM) as well as overweight/obesity during pregnancy are risk factors for detrimental anthropometric and hormonal neonatal outcomes, identified to 'program' adverse health predispositions later on. While overweight/obesity are major determinants of GDM, independent effects on critical birth outcomes remain unclear. Thus, the aim of the present study was to evaluate, in women with GDM, the relative/independent impact of overweight/obesity vs. altered glucose metabolism on newborn parameters.

METHODS

The prospective observational 'Early CHARITÉ (EaCH)' cohort study primarily focuses on early developmental origins of unfavorable health outcomes through pre- and/or early postnatal exposure to a 'diabetogenic/adipogenic' environment. It includes 205 mother-child dyads, recruited between 2007 and 2010, from women with treated GDM and delivery at the Clinic of Obstetrics, Charité - Universitätsmedizin Berlin, Germany. Recruitment, therapy, metabolite/hormone analyses, and data evaluation were performed according to standardized guidelines and protocols. This report specifically aimed to identify maternal anthropometric and metabolic determinants of anthropometric and critical hormonal birth outcomes in 'EaCH'.

RESULTS

Group comparisons, Spearman's correlations and unadjusted linear regression analyses initially confirmed that increased maternal prepregnancy body-mass-index (BMI) is a significant factor for elevated birth weight, cord-blood insulin and leptin (all P < 0.05). However, consideration of and adjustment for maternal glucose during late pregnancy showed that no maternal anthropometric parameter (weight, BMI, gestational weight gain) remained significant (all n.s.). In contrast, even after adjustment for maternal anthropometrics, third trimester glucose values (fasting and postprandial glucose at 32nd and 36th weeks' gestation, HbA1c in 3rd trimester and at delivery), were clearly positively associated with critical birth outcomes (all P < 0.05).

CONCLUSIONS

Neither overweight/obesity nor gestational weight gain appear to be independent determinants of increased birth weight, insulin and leptin. Rather, 3rd trimester glycemia seems to be crucial for respective neonatal outcomes. Thus, gestational care and future research studies should greatly consider late pregnancy glucose in overweight/obese women with or without GDM, for evaluation of critical causes and interventional strategies against 'perinatal programming of diabesity' in the offspring.

The Emerging Role of Biomarkers in the Diagnosis of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is a common complication of pregnancy; its rising incidence is a result of increased maternal obesity and older maternal age together with altered diagnostic criteria identifying a greater proportion of pregnant women with GDM. Its consequences are far-reaching, associated with poorer maternal and neonatal outcomes compared to non-GDM pregnancies, and GDM has implications for metabolic health in both mother and offspring. Objective markers to identify women at high risk for the development of GDM are useful to target therapy and potentially prevent its development. Established clinical risk factors for GDM include overweight/obesity, age, ethnicity, and family history of diabetes, though they lack specificity for its development. The addition of biomarkers to predictive models of GDM may improve the ability to identify women at risk of GDM prior to its development. These biomarkers reflect the pathophysiologic mechanisms of GDM involving insulin resistance, chronic inflammation, and altered placental function. In addition, the role of epigenetic changes in GDM pathogenesis highlights the complex interplay between genetic and environmental factors, potentially offering further refinement of the prediction of GDM risk. In this review, we will discuss the clinical challenges associated with the diagnosis of GDM and its current pathophysiologic basis, giving rise to potential biomarkers that may aid in its identification. While not yet validated for clinical use, we explore the possible clinical role of biomarkers in the future. We also explore novel diagnostic tools, including high throughput methodologies, that may have potential future application in the identification of women with GDM.

Genetic and Environmental Influences on Fetal Growth Vary during Sensitive Periods in Pregnancy

Aberrant fetal growth is associated with morbidities and mortality during childhood and adult life. Although genetic and environmental factors are known to influence in utero growth, their relative contributions over pregnancy is unknown. We estimated, across gestation, the genetic heritability, contribution of shared environment, and genetic correlations of fetal growth measures (abdominal circumference (AC), humerus length (HL), femur length (FL), and estimated fetal weight (EFW)) in a prospective cohort of dichorionic twin gestations recruited through the NICHD Fetal Growth Studies. Structural equation models were fit at the end of first trimester, during mid-gestation, late second trimester, and third trimester of pregnancy. The contribution of fetal genetics on fetal size increased with gestational age, peaking in late second trimester (AC = 53%, HL = 57%, FL = 72%, EFW = 71%; p < 0.05). In contrast, shared environment explained most of phenotypic variations in fetal growth in the first trimester (AC = 50%, HL = 54%, FL = 47%, EFW = 54%; p < 0.05), suggesting that the first trimester presents an intervention opportunity for a more optimal early fetal growth. Genetic correlations between growth traits (range 0.34–1.00; p < 0.05) were strongest at the end of first trimester and declined with gestation, suggesting that different fetal growth measures are more likely to be influenced by the same genes in early pregnancy.

Are the Institute of Medicine weight gain targets applicable in women with gestational diabetes mellitus?

AIMS/HYPOTHESIS

Our aim was to study the relationship between excessive gestational weight gain (GWG) according to Institute of Medicine (IOM) targets and perinatal outcomes, and examine whether modifying targets may improve outcomes in women with gestational diabetes mellitus (GDM).

METHODS

This was a retrospective cohort study of all GDM pregnancies from 1992 to 2013. ORs were calculated for associations between excessive GWG (EGWG) using IOM targets and adverse pregnancy outcomes. ORs were then adjusted for maternal age, gestational age at diagnosis, prepregnancy BMI, gravidity, parity, ethnicity, antenatal fasting blood glucose level (BGL), 2 h BGL and HbA_1c. BMI was categorised into underweight (<18.5 kg/m²), healthy weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²) and obese (≥30 kg/m²). Large for gestational age (LGA) was defined as birthweight above the 90th percentile, small for gestational age (SGA) was birthweight below the 10th percentile, macrosomia was birthweight >4000 g, and preterm delivery was delivery prior to 37 weeks' gestation. Modified GWG targets were derived by: (1) subtracting 2 kg from the upper IOM target only; (2) subtracting 2 kg from both upper and lower targets; (3) using the interquartile range of maternal GWG of women with infants who were appropriate for gestational age per BMI category; and (4) restricting GWG to 0-4 kg in women with BMI ≥35 kg/m².

RESULTS

Among 3095 GDM pregnancies, only 31.7% had GWG within IOM guidelines. Adjusted ORs for women who exceeded GWG were Caesarean section (1.5; 95% CI 1.2, 1.9), LGA (1.8; 95% CI 1.4, 2.4) and macrosomia (2.3; 95% CI 1.6, 3.3); there was a lower risk of SGA (adjusted OR 0.5; 95% CI 0.3, 0.7).

CONCLUSIONS/INTERPRETATION

EGWG according to IOM targets was associated with Caesarean section, LGA and macrosomia. Modification of IOM criteria, including more restrictive targets, did not improve perinatal outcomes.

An Unbiased Lipidomics Approach Identifies Early Second Trimester Lipids Predictive of Maternal Glycemic Traits and Gestational Diabetes Mellitus

OBJECTIVE

To investigate the relationship between early second trimester serum lipidomic variation and maternal glycemic traits at 28 weeks and to identify predictive lipid biomarkers for gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

Prospective study of 817 pregnant women (discovery cohort, n = 200; validation cohort, n = 617) who provided an early second trimester serum sample and underwent an oral glucose tolerance test (OGTT) at 28 weeks. In the discovery cohort, lipids were measured using direct infusion mass spectrometry and correlated with OGTT results. Variable importance in projection (VIP) scores were used to identify candidate lipid biomarkers. Candidate biomarkers were measured in the validation cohort using liquid chromatography-mass spectrometry and tested for associations with OGTT results and GDM status.

RESULTS

Early second trimester lipidomic variation was associated with 1-h postload glucose levels but not with fasting plasma glucose levels. Of the 13 lipid species identified by VIP scores, 10 had nominally significant associations with postload glucose levels. In the validation cohort, 5 of these 10 lipids had significant associations with postload glucose levels that were independent of maternal age and BMI, i.e., TG(51.1), TG(48:1), PC(32:1), PCae(40:3), and PCae(40:4). All except the last were also associated with maternal GDM status. Together, these four lipid biomarkers had moderate ability to predict GDM (area under curve [AUC] = 0.71 ± 0.04, P = 4.85 × 10-7) and improved the prediction of GDM by age and BMI alone from AUC 0.69 to AUC 0.74.

CONCLUSIONS

Specific early second trimester lipid biomarkers can predict maternal GDM status independent of maternal age and BMI, potentially enhancing risk factor-based screening.

Pregnancy and Infants' Outcome: Nutritional and Metabolic Implications

Pregnancy is a complex period of human growth, development, and imprinting. Nutrition and metabolism play a crucial role for the health and well-being of both mother and fetus, as well as for the long-term health of the offspring. Nevertheless, several biological and physiological mechanisms related to nutritive requirements together with their transfer and utilization across the placenta are still poorly understood. In February 2009, the Child Health Foundation invited leading experts of this field to a workshop to critically review and discuss current knowledge, with the aim to highlight priorities for future research. This paper summarizes our main conclusions with regards to maternal preconceptional body mass index, gestational weight gain, placental and fetal requirements in relation to adverse pregnancy and long-term outcomes of the fetus (nutritional programming). We conclude that there is an urgent need to develop further human investigations aimed at better understanding of the basis of biochemical mechanisms and pathophysiological events related to maternal-fetal nutrition and offspring health. An improved knowledge would help to optimize nutritional recommendations for pregnancy.

Antenatal dietary and lifestyle advice for women who are overweight or obese and the effect on fetal growth and adiposity: the LIMIT randomised trial

OBJECTIVE

To report the influence of maternal overweight and obesity on fetal growth and adiposity and effects of an antenatal dietary and lifestyle intervention among these women on measures of fetal growth and adiposity as secondary outcomes of the LIMIT Trial.

DESIGN

Randomised controlled trial.

SETTING

Public maternity hospitals in metropolitan Adelaide, South Australia.

POPULATION

Pregnant women with a body mass index ≥ 25 kg/m(2), and singleton gestation between 10(+0) and 20(+0) weeks.

METHODS

Women were randomised to Lifestyle Advice or continued Standard Care and offered two research ultrasound scans at 28 and 36 weeks of gestation.

MAIN OUTCOME MEASURES

Ultrasound measures of fetal growth and adiposity.

RESULTS

For each fetal body composition parameter, mean Z-scores were substantially higher when compared with population standards. Fetuses of women receiving Lifestyle Advice demonstrated significantly greater mean mid-thigh fat mass, when compared with fetuses of women receiving Standard Care (adjusted difference in means 0.17; 95% CI 0.02-0.32; P = 0.0245). While subscapular fat mass increased between 28 and 36 weeks of gestation in fetuses in both treatment groups, the rate of adipose tissue deposition slowed among fetuses of women receiving Lifestyle Advice, when compared with fetuses of women receiving Standard Care (P = 0.0160). No other significant differences were observed.

CONCLUSIONS

These findings provide the first evidence of changes to fetal growth following an antenatal dietary and lifestyle intervention among women who are overweight or obese.

Accelerated Fetal Growth Prior to Diagnosis of Gestational Diabetes Mellitus: A Prospective Cohort Study of Nulliparous Women

OBJECTIVE

To determine whether fetal overgrowth precedes the diagnosis of gestational diabetes mellitus (GDM) and to quantify the interrelationships among fetal overgrowth, GDM, and maternal obesity.

RESEARCH DESIGN AND METHODS

We conducted a prospective cohort study of unselected nulliparous women and performed ultrasonic measurement of the fetal abdominal circumference (AC) and head circumference (HC) at 20 and 28 weeks of gestational age (wkGA). Exposures were diagnosis of GDM ≥28 wkGA and maternal obesity. The risk of AC >90th and HC-to-AC ratio <10th percentile was modeled using log-binomial regression, adjusted for maternal characteristics.

RESULTS

Of 4,069 women, 171 (4.2%) were diagnosed with GDM at ≥28 wkGA. There was no association between fetal biometry at 20 wkGA and subsequent maternal diagnosis of GDM. However, at 28 wkGA, there was an increased risk of AC >90th percentile (adjusted relative risk 2.05 [95% CI 1.37-3.07]) and HC-to-AC ratio <10th percentile (1.97 [1.30-2.99]). Maternal obesity showed similar associations at 28 wkGA (2.04 [1.62-2.56] and 1.46 [1.12-1.90], respectively). The combination of GDM and obesity was associated with an approximately fivefold risk of AC >90th (4.52 [2.98-6.85]) and approximately threefold risk of HC-to-AC ratio <10th percentile (2.80 [1.64-4.78]) at 28 wkGA. Fetal AC >90th percentile at 28 weeks was associated with an approximately fourfold risk of being large for gestational age at birth.

CONCLUSIONS

Diagnosis of GDM is preceded by excessive growth of the fetal AC between 20 and 28 wkGA, and its effects on fetal growth are additive with the effects of maternal obesity.

Diagnosis of more gestational diabetes lead to better pregnancy outcomes: Comparing the International Association of the Diabetes and Pregnancy Study Group criteria, and the Carpenter and Coustan criteria

AIMS/INTRODUCTION

The International Association of the Diabetes and Pregnancy Study Group (IADPSG) criteria for gestational diabetes are associated with increased prevalence. However, it remains unknown if intervention for more women with gestational diabetes mellitus by the IADPSG criteria results in better pregnancy outcomes than adopting the Carpenter and Coustan (C&C) criteria in Asian populations.

MATERIALS AND METHODS

This was a retrospective cohort study. A total of 1,840 women, 952 subjects by the IADPSG criteria and 888 subjects by the C&C criteria, who delivered singletons in 2011 in a single tertiary center, were included in the study. The same therapeutic interventions were offered to women with gestational diabetes mellitus by the two criteria. Maternal and neonatal outcomes were evaluated.

RESULTS

Adopting the IADPSG criteria increased the prevalence of gestational diabetes mellitus diagnosis to 13.44%, compared with 2.59% by the C&C criteria. The diagnosis was made 3 weeks earlier by the IADPSG criteria (27 vs 30.5 weeks, P < 0.0001). Adopting the IADPSG criteria was associated with reduced risk of primary cesarean section (adjusted odds ratio 0.79, 95% confidence interval 0.63-0.998, P < 0.05) and having any one of the adverse fetal outcomes (adjusted odds ratio 0.79, 95% confidence interval 0.64-0.998, P < 0.05), including birthweight >90th percentile, jaundice, admission to neonatal intensive care unit, birth trauma, neonatal hypoglycemia and fetal death.

CONCLUSIONS

Adopting the IADPSG criteria is associated with improved pregnancy outcomes, at the expense of increased prevalence of gestational diabetes mellitus diagnosis.

Does maternal body mass index influence treatment effect in women with mild gestational diabetes?

OBJECTIVE

The aim of the article is to determine whether maternal body mass index (BMI) influences the beneficial effects of diabetes treatment in women with gestational diabetes mellitus (GDM).

STUDY DESIGN

Secondary analysis of a multicenter randomized treatment trial of women with GDM. Outcomes of interest were elevated umbilical cord c-peptide levels (> 90th percentile 1.77 ng/mL), large for gestational age (LGA) birth weight (> 90th percentile), and neonatal fat mass (g). Women were grouped into five BMI categories adapted from the World Health Organization International Classification of normal, overweight, and obese adults. Outcomes were analyzed according to treatment group assignment.

RESULTS

A total of 958 women were enrolled (485 treated and 473 controls). Maternal BMI at enrollment was not related to umbilical cord c-peptide levels. However, treatment of women in the overweight, Class I, and Class II obese categories was associated with a reduction in both LGA birth weight and neonatal fat mass. Neither measure of excess fetal growth was reduced with treatment in normal weight (BMI < 25 kg/m(2)) or Class III (BMI ≥ 40 kg/m(2)) obese women.

CONCLUSION

There was a beneficial effect of treatment on fetal growth in women with mild GDM who were overweight or Class I and Class II obese. These effects were not apparent for normal weight and very obese women.

Maternal obesity and occurrence of fetal macrosomia: a systematic review and meta-analysis

OBJECTIVE

To determine a precise estimate for the contribution of maternal obesity to macrosomia.

DATA SOURCES

The search strategy included database searches in 2011 of PubMed, Medline (In-Process & Other Non-Indexed Citations and Ovid Medline, 1950-2011), and EMBASE Classic + EMBASE. Appropriate search terms were used for each database. Reference lists of retrieved articles and review articles were cross-referenced.

METHODS OF STUDY SELECTION

All studies that examined the relationship between maternal obesity (BMI ≥30 kg/m(2)) (pregravid or at 1st prenatal visit) and fetal macrosomia (birth weight ≥4000 g, ≥4500 g, or ≥90th percentile) were considered for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Data regarding the outcomes of interest and study quality were independently extracted by two reviewers. Results from the meta-analysis showed that maternal obesity is associated with fetal overgrowth, defined as birth weight ≥ 4000 g (OR 2.17, 95% CI 1.92, 2.45), birth weight ≥4500 g (OR 2.77,95% CI 2.22, 3.45), and birth weight ≥90% ile for gestational age (OR 2.42, 95% CI 2.16, 2.72).

CONCLUSION

Maternal obesity appears to play a significant role in the development of fetal overgrowth. There is a critical need for effective personal and public health initiatives designed to decrease prepregnancy weight and optimize gestational weight gain.

Using estimated fetal weight from ultrasonography at 18 to 22 weeks to predict gestational diabetes mellitus and newborn macrosomia

OBJECTIVES

To determine if fetal macrosomia in the second trimester predicts the onset of gestational diabetes mellitus (GDM) or large for gestational age (LGA) birth weight.

METHODS

We performed a case-control study using data from the Diabetes in Pregnancy Clinic in our tertiary care hospital. Cases were women with GDM requiring insulin (n = 65) or controlled with diet (n = 65). Control subjects were women who screened negative for GDM at 24 to 28 weeks' gestation (n = 131). Estimated fetal weight (EFW) was determined by ultrasound at 18 to 22 weeks.

RESULTS

Estimated fetal weight that was one standard deviation (70 g) higher at 18 to 22 weeks was not associated with subsequent GDM (adjusted OR [aOR] 1.00, 95% confidence intervals 0.61 to 1.66), but was associated with a 231 g (95% CI 128 g to 334 g) increase in birth weight and increased odds of LGA (aOR 4.02, 95% CI 1.76 to 9.19) after adjusting for gestational age at the time of estimating fetal weight, maternal age, parity, BMI and GDM treatment.

CONCLUSION

EFW at 18 to 22 weeks did not predict the onset of GDM, but did predict LGA.

Antenatal predictors and body composition of large-for-gestational-age newborns: perinatal health outcomes

OBJECTIVE

To compare body composition of large-for-gestational-age (LGA) with appropriate-for-gestational-age (AGA) newborns and to identify antenatal predictors of LGA.

STUDY DESIGN

This cross-sectional study included 536 term, singleton infants. Anthropometric measurements were performed within 48 h of birth and included determination of body fat percentage (%BF) by air displacement plethysmography. Associations were investigated using logistic regression.

RESULT

LGA infants had greater %BF (P<0.001) compared with AGA infants. Significant predictors of LGA infants included parity (odds ratio (OR)=1.98, (95% confidence interval (CI) 1.00, 4.02)), paternal height (OR=1.08, (95% CI 1.03, 1.14)), maternal pregravid weight (65 to 74.9 kg: OR=2.77, (95% CI 1.14, 7.06)) and gestational weight gain (OR=1.09, 95% CI (1.03, 1.16)). Gestational diabetes mellitus was not associated with LGA infants (P=0.598).

CONCLUSION

Paternal height, parity, maternal pregravid weight and gestational weight gain were strongly associated with LGA infants. These results may allow early prediction and potential modification, thereby optimising clinical outcomes.

Prevalence of macrosomia and its risk factors in china: a multicentre survey based on birth data involving 101,723 singleton term infants

BACKGROUND

Macrosomia, defined as a birthweight at least 4000 g, is a public health problem because of its adverse influences on maternal and neonatal outcomes. Studies show that there is an increasing prevalence of macrosomia births in developing countries. However, information on the epidemiology of macrosomia is limited in China. This study aimed to determine the prevalence and geographic variability of macrosomia in China and risk factors that can be targeted for intervention.

METHODS

A hospital-based, cross-sectional survey was conducted in 14 provinces in China, covering a wide range of geographic areas. The medical records of 101,723 singleton term infants born in 39 hospitals during 2011 were reviewed. Multiple logistic regression analysis was used to examine the associations between demographic characteristics and the risk of macrosomia.

RESULTS

The total prevalence of macrosomia was 7.3%. The prevalence varied between provinces, ranging from 4.1% to 13.4%. The prevalence of macrosomia in northern China (8.5%) was significantly higher than that in southern China (5.6%). Logistic regression analyses showed that risk of macrosomia was positively associated with maternal age, pre-pregnant body mass index (BMI), gravidity, parity, maternal height, gestational weight gain (GWG), gestational diabetes mellitus (GDM), and male fetal sex. Maternal BMI, gestational week, and GWG were the three risk factors most strongly associated with macrosomia.

CONCLUSIONS

The prevalence of macrosomia varied dramatically between different areas of China. High pre-pregnancy BMI and GWG represent main modifiable risk factors for macrosomia and need more attention from health care providers.

Being macrosomic at birth is an independent predictor of overweight in children: results from the IDEFICS study

Fetal macrosomia is a risk factor for the development of obesity late in childhood. We retrospectively evaluated the relationship between maternal conditions associated with fetal macrosomia and actual overweight/obesity in the European cohort of children participating in the IDEFICS study. Anthropometric variables, blood pressure and plasma lipids and glucose were measured. Socio-demographic data, medical history and perinatal factors, familiar and gestational history, maternal and/or gestational diabetes were assessed by a questionnaire. Variables of interest were reported for 10,468 children (M/F = 5,294/5,174; age 6.0 ± 1.8 years, M ± SD). The sample was divided in four groups according to child birth weight (BW) and maternal diabetes: (1) adequate for gestational age offspring (BW between the 10th and 90th percentiles for gestational age) of mothers without diabetes (AGA-ND); (2) adequate for gestational age offspring of mothers with diabetes (AGA-D); (3) macrosomic offspring (BW > 90th percentile for gestational age) of mothers without diabetes (Macro-ND); (4) macrosomic offspring of mothers with diabetes (Macro-D). Children macrosomic at birth showed significantly higher actual values of body mass index, waist circumference, and sum of skinfold thickness. In both boys and girls, Macro-ND was an independent determinant of overweight/obesity, after the adjustment for confounders [Boys: OR = 1.7 95 % CI (1.3;2.2); Girls: OR = 1.6 95 % CI (1.3;2.0)], while Macro-D showed a significant association only in girls [OR = 2.6 95 % CI (1.1;6.4)]. Fetal macrosomia, also in the absence of maternal/gestational diabetes, is independently associated with the development of overweight/obesity during childhood. Improving the understanding of fetal programming will contribute to the early prevention of childhood overweight/obesity.

First trimester maternal lipid levels and serum markers of small- and large-for-gestational age infants

OBJECTIVE

To investigate if first trimester lipids, sonographic parameters and serum markers are related to small- and large-for-gestational age (SGA, LGA) infants.

METHODS

This study was conducted at Baskent University Adana Research Center between December 2009 and July 2011 and enrolled 433 women. Blood samples were drawn to measure fasting blood glucose, serum triglycerides, cholesterol, very low-density lipoprotein, low-density lipoprotein, high-density lipoprotein, fβ-hCG and pregnancy associated protein-A (PAPP-A) at the first trimester. Crown rump length and nuchal translucency were measured as suggested by the fetal medicine foundation.

RESULTS

LGA group was significantly taller (p = 0.016) and SGA group had significantly greater BMI (0.025). SGA fetuses were born at a significantly earlier gestational age (p = 0.001). Univariate analysis revealed that LGA group had significantly lower cholesterol (p = 0.038) and LDL levels (p = 0.041). PAPP-A was significantly lower in SGA Group compared with LGA Group (0.027). After controlling for age, parity, height, pre-pregnant BMI, weight gain during pregnancy and fasting blood sugar, none of the lipids, serum markers or sonographic parameters was related to LGA. PAPP-A was the only parameter significantly associated with SGA after multivariate analysis (p = 0.008).

CONCLUSION

PAPP-A was significantly associated with SGA after controlling for confounders.

Higher fetal insulin resistance in Chinese pregnant women with gestational diabetes mellitus and correlation with maternal insulin resistance

OBJECTIVE

The aim of this study was to determine the effect of gestational diabetes mellitus (GDM) on fetal insulin resistance or β-cell function in Chinese pregnant women with GDM.

MEASUREMENTS

Maternal fasting blood and venous cord blood samples (reflecting fetal condition) were collected in 65 well-controlled Chinese GDM mothers (only given dietary intervention) and 83 control subjects. The insulin, glucose and proinsulin concentrations of both maternal and cord blood samples were measured, and the homeostasis model assessment of insulin resistance (HOMA-IR) and the proinsulin-to-insulin ratios (an indicator of fetal β-cell function) were calculated in maternal and cord blood respectively.

RESULTS

Both maternal and fetal levels of insulin, proinsulin and HOMA-IR but not proinsulin-to-insulin ratios were significantly higher in the GDM group than in the control group (maternal insulin, 24.8 vs. 15.4 µU/mL, P = 0.004, proinsulin, 23.3 vs. 16.2 pmol/L, P = 0.005, and HOMA-IR, 5.5 vs. 3.5, P = 0.041, respectively; fetal: insulin, 15.1 vs. 7.9 µU/mL, P<0.001, proinsulin, 25.8 vs. 15.1 pmol/L, P = 0.015, and HOMA-IR, 2.8 vs. 1.4, P = 0.017, respectively). Fetal HOMA-IR but not proinsulin-to-insulin ratios was significantly correlated to maternal HOMA-IR (r = 0.307, P = 0.019), in the pregnant women with GDM.

CONCLUSIONS

Fetal insulin resistance was higher in Chinese pregnant women with GDM than control subjects, and correlated with maternal insulin resistance.

HbA(1c) and birthweight in women with pre-conception type 1 and type 2 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

To investigate clinical and sociodemographic predictors of birthweight in singletons born to women with type 1 or type 2 diabetes.

METHODS

Normally formed singleton live births and intrapartum stillbirths, born to women with pre-conception diabetes during 1996-2008, were identified from the population-based Northern Diabetes in Pregnancy Survey (n = 1,505). Associations between potential predictors and birthweight were analysed by multiple regression.

RESULTS

Potentially modifiable independent predictors of increase in birthweight were pre-pregnancy care (adjusted regression coefficient [b] = 87.1 g; 95% CI 12.9, 161.3), increasing third-trimester HbA(1c) ≤7% (53 mmol/mol) (b = 310.5 g per 1% [11 mmol/mol]; 95% CI 246.3, 374.7) and increasing maternal BMI (b = 9.5 g per 1 kg/m(2); 95% CI 3.5, 15.5). Smoking during pregnancy (b = -145.1 g; 95% CI -231.4, -58.8), later gestation at first antenatal visit (b = -15.0 g; 95% CI -26.9, -3.0) and higher peri-conception HbA(1c) (b = -48.2 g; 95% CI -68.8, -27.6) were independently associated with birthweight reduction. Pre-pregnancy nephropathy (b = -282.7 g; 95% CI -461.8, -103.6) and retinopathy (b = -175.5 g; 95% CI -269.9, -81.0) were independent non-modifiable predictors of reduced birthweight, while greater maternal height was a non-modifiable predictor of increasing birthweight (b = 17.8 g; 95% CI 12.3, 23.2). Other predictors of birthweight increase were male sex, multiparity and increasing gestational age at delivery. Type or duration of diabetes, socioeconomic status and ethnicity were not associated with continuous birthweight.

CONCLUSIONS/INTERPRETATION

Poor glycaemic control before and throughout pregnancy is associated with abnormal fetal growth, with increasing peri-conception HbA(1c) predicting weight reduction and increasing third-trimester HbA(1c) predicting increased birthweight. Women with microvascular complications of diabetes may require increased surveillance to detect fetal growth restriction.

Effect of maternal anthropometry and metabolic parameters on fetal growth

OBJECTIVE

The aim of this study was to determine the effect of maternal anthropometry and metabolic parameters on neonatal anthropometry.

MATERIALS AND METHODS

This observational cross-sectional study was conducted from January 2008 to June 2009 at a single tertiary care center. Maternal anthropometry and metabolic parameters like fasting serum insulin, lipid profile, and random blood glucose were estimated in 50 pregnant women at term. Detailed anthropometry of the neonates was performed.

RESULTS

Large for gestational age (LGA) babies had higher maternal body mass index (BMI), fasting serum insulin, and cord blood insulin levels, and lower maternal high density lipoprotein (HDL) compared to appropriate for gestational age (AGA) group (P < 0.001). Among the maternal parameters, BMI, gestational age, fasting serum insulin, and random blood sugar (RBS) had significant positive correlation, while HDL had negative correlation with birth weight (P < 0.05). However, only maternal BMI was the significant predictor of neonatal birth weight on multiple regression analysis (ß = 0.340, P = 0.01).

CONCLUSION

The BMI of glucose-tolerant mother is more important than metabolic parameters in determining the birth weight of term babies.

Premixed insulin aspart 30 (BIAsp 30) versus premixed human insulin 30 (BHI 30) in gestational diabetes mellitus: a randomized open-label controlled study

A randomized, open-label, parallel study was conducted to assess the efficacy and safety of premixed insulin aspart 30 (biphasic insulin aspart [BIAsp] 30) in managing gestational diabetes mellitus (GDM). A total of 323 women with GDM registered at a single center in India were randomly assigned to receive 6 U of either BIAsp 30 (Group A) or premixed human insulin (biphasic human insulin [BHI] 30; Group B) in a 1:1 ratio. Subjects performed home glucose monitoring and visited their care provider twice a month. The primary outcome was the degree of neonatal macrosomia (neonatal birth weight >90th percentile). Groups A and B were demographically comparable at study entry. Before labor onset, Groups A and B achieved similar degrees of fasting plasma glucose and postprandial plasma glucose control (92.97 ± 14.44 vs. 95.43 ± 18.96 and 127.59 ± 28.99 vs. 126.98 ± 29.89, respectively; both p = NS). Neonatal macrosomia frequency was 6.3% in Group A and 6.9% in Group B; however, this difference was not statistically significant. By last visit, the required insulin dose was significantly lower for Group A than Group B (19.83 ± 15.75 IU vs. 26.34 ± 23.15 IU, respectively; p = 0.006). BIAsp 30 was noninferior to BHI 30, producing comparable fetal outcomes when administered during pregnancy. Based on final doses, BIAsp 30 may offer greater treat-to-target potential for pregnant women.

Fetal growth versus birthweight: the role of placenta versus other determinants

Introduction

Birthweight is used as an indicator of intrauterine growth, and determinants of birthweight are widely studied. Less is known about determinants of deviating patterns of growth in utero. We aimed to study the effects of maternal characteristics on both birthweight and fetal growth in third trimester and introduce placental weight as a possible determinant of both birthweight and fetal growth in third trimester.

Methods

The STORK study is a prospective cohort study including 1031 healthy pregnant women of Scandinavian heritage with singleton pregnancies. Maternal determinants (age, parity, body mass index (BMI), gestational weight gain and fasting plasma glucose) of birthweight and fetal growth estimated by biometric ultrasound measures were explored by linear regression models. Two models were fitted, one with only maternal characteristics and one which included placental weight.

Results

Placental weight was a significant determinant of birthweight. Parity, BMI, weight gain and fasting glucose remained significant when adjusted for placental weight. Introducing placental weight as a covariate reduced the effect estimate of the other variables in the model by 62% for BMI, 40% for weight gain, 33% for glucose and 22% for parity. Determinants of fetal growth were parity, BMI and weight gain, but not fasting glucose. Placental weight was significant as an independent variable. Parity, BMI and weight gain remained significant when adjusted for placental weight. Introducing placental weight reduced the effect of BMI on fetal growth by 23%, weight gain by 14% and parity by 17%.

Conclusion

In conclusion, we find that placental weight is an important determinant of both birthweight and fetal growth. Our findings indicate that placental weight markedly modifies the effect of maternal determinants of both birthweight and fetal growth. The differential effect of third trimester glucose on birthweight and growth parameters illustrates that birthweight and fetal growth are not identical entities.

[Gestational diabetes]

Gestational diabetes is one of the most common complications during pregnancy. Its incidence has increased in recent decades. This is partly due to improved screening strategies and more stringent diagnostic criteria. Using the updated diagnostic thresholds, it is expected that 5-10% at least of all pregnant women will be diagnosed with diabetes mellitus. The rationale for the novel blood glucose criteria are data from prospective studies reporting an increase of fetal and maternal complications even when the blood glucose is only slightly increased. For the first time, solid evidence now exists for the diagnosis and treatment of gestational diabetes.

Third trimester plasma adiponectin and leptin in gestational diabetes and normal pregnancies

The aim of this study was to compare pregnant women with and without gestational diabetes (GDM) with regard to third trimester adiponectin, leptin and insulin resistance, as well as to investigate their relation to fetal growth and macrosomia. 134 pregnant women were enrolled in the study: 86 with GDM and 48 controls. Maternal plasma adiponectin, leptin, fasting insulin, glucose and fetal biometry were measured between 27 and 32 weeks of gestation. Birthweight and delivery data were also assessed. Adiponectin in GDM patients was lower when compared to non-diabetic women while mean leptin concentration was not different. In GDM group only mothers' weight gain until third trimester was significantly different between the groups of patients with normal and accelerated fetal growth. No correlation of adiponectin and leptin with fetal growth was shown. Mothers' weight gain until third trimester and mean fasting glucose between 33 and 34 weeks of gestation were associated with neonatal macrosomia. There were no differences in adiponectin and leptin between mothers of macrosomic and non-macrosomic neonates. Fetal growth seems not to be related to third trimester adiponectin and leptin concentrations, while increased third trimester fasting glucose may be an independent risk factor of macrosomia.

Maternal body mass index and the risk of fetal and infant death: a cohort study from the North of England

BACKGROUND

Early pregnancy obesity (body mass index, BMI, ≥ 30 kg/m(2)) carries significant health implications. This cohort study investigates the association between early pregnancy BMI and the risk of fetal and infant death in pregnancies not affected by congenital anomalies or pre-gestational diabetes.

METHODS

Data on singleton pregnancies delivered during 2003-2005 at five hospitals were linked with data from three regional registers: the Northern Perinatal Mortality Survey, the Northern Diabetes in Pregnancy Survey and the Northern Congenital Abnormality Survey. Logistic regression models were used to determine the crude and adjusted odds ratios (aOR) of a spontaneous fetal death (≥ 20 weeks gestation) and infant death (aged up to 1 year), among underweight (BMI <18.5 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese women compared with women of recommended BMI (18.5-24.9 kg/m(2)).

RESULTS

Obese women were at significantly increased risks of both fetal death [aOR = 2.32 (95% confidence interval: 1.64-3.28), P< 0.001] and infant death [aOR = 1.97 (1.13-3.45), P= 0.02]. Continuous analyses revealed a V-shaped relationship between BMI and the risk of fetal and infant death, with a minimum risk at 23 kg/m(2), and significantly increased risk thereafter for both fetal death [aOR, per unit = 1.07 (1.05-1.10), P< 0.001] and infant death [aOR, per unit = 1.06 (1.02-1.10), P= 0.007]. No significant excess risks, however, were identified for either maternal underweight [fetal death: aOR = 0.98 (0.42-2.25), P= 0.96; infant death: aOR = 1.89 (0.73-4.88), P= 0.19] or maternal overweight [fetal death: aOR = 1.34 (0.94-1.89), P= 0.10; infant death: aOR = 1.35 (0.79-2.32), P= 0.27] as categories. Except for higher rates of pre-eclampsia among stillbirths, no specific cause of death could explain the increased odds of fetal and infant death among the obese.

CONCLUSIONS

Early pregnancy obesity is significantly associated with fetal and infant death, independent of the known relationships with congenital anomalies and maternal pre-gestational diabetes.

Increased fat mass and cardiac septal hypertrophy in newborn infants of mothers with well-controlled diabetes during pregnancy

BACKGROUND

Improved glycaemic control during pregnancy in mothers with type 1 diabetes (T1DM) and gestational diabetes (GDM) has resulted in a marked reduction of perinatal mortality and morbidity, but the prevalence of macrosomia is usually high.

OBJECTIVE

We used non-invasive anthropometric methods to estimate the body composition and the thickness of the interventricular heart septum in 18 infants of mothers with well-controlled T1DM, 10 infants of mothers with GDM and 28 infants of healthy control mothers matched for gestational age and mode of delivery.

METHODS

Skinfold measurements were obtained with a Harpenden calliper within 48 h after delivery. Echocardiography was also performed to measure the thickness of the interventricular septum. Cord blood was sampled for assays of C-peptide, leptin and IGF-I.

RESULTS

The rates of macrosomia (gestational age-adjusted birth weight >2 standard deviation score, SDS) were 56 and 30% in infants of mothers with T1DM and GDM, respectively, compared to 10% in control infants. The body fat content was 40% (0.2 kg) higher and the interventricular heart septum thickness was increased by 20% in both groups of infants of diabetic mothers. We found no associations between maternal levels of HbA1c during pregnancy and body composition or interventricular heart septum thickness. Cord levels of C-peptide and leptin were significantly higher in infants of T1DM mothers than in control infants. Cord leptin level was associated with birth weight SDS and percent body fat in infants of T1DM mothers. IGF-I was associated with percent body fat in infants of GDM mothers and control mothers. A multiple-regression analysis showed that 50% of the variation in body weight SDS could be determined, with IGF-I, leptin and C-peptide as independent variables.

CONCLUSION

Both fat mass and cardiac septal thickness are increased in newborn infants of women with T1DM and GDM in spite of efforts to achieve good glycaemic control during pregnancy.

Effect of a low glycaemic index diet on blood glucose in women with gestational hyperglycaemia

AIM

The objectives of this pilot study were to determine the feasibility and effect on glycaemic control of a low-glycaemic-index (GI) diet in women with gestational diabetes or impaired glucose tolerance of pregnancy.

METHODS

participants, recruited from the Diabetes-in-Pregnancy Clinic of an inner-city teaching hospital serving a predominantly non-Caucasian population, were randomized to a low-GI (n=23) or control (n=24) diet and followed from 28 weeks gestation until delivery. Self-monitored-blood-glucose (SMBG), maternal and infant weight were collected from medical charts. Dietary intakes were assessed using diet records and questionnaires.

RESULTS

diet GI on control (58, 95% CI: 56,60) was significantly higher than on low-GI (49, 95% CI: 47,51; p=0.001). Glycaemic control improved on both diets, but more postprandial glucose values were within target on low-GI (58.4% of n=1891) than control (48.7% of n=1834; p<0.001). SMBG post-breakfast was directly related to pre-pregnancy BMI in the control, but not the low-GI group (BMI*diet interaction; p=0.021). Participants accepted the study foods and were willing to consume them post-intervention.

CONCLUSIONS

a low-GI diet was feasible and acceptable in this sample and facilitated control of postprandial glucose. A larger study is needed to determine the effect of a low-GI diet on maternal and infant outcomes.

Screening for hyperglycaemia in pregnancy: Consensus and controversy

Policy decisions on whether to implement screening programmes depend on whether the proposed programmes meet a set of criteria laid down by the World Health Organization. Screening for hyperglycaemia in pregnancy (HGP) does not meet all the criteria. However the case for screening has been strengthened by a number of recent developments, including: rising prevalence of HGP because of increasing maternal age and BMI; the results of the Hyperglycaemia and Adverse Pregnancy Outcomes study, showing that adverse effects of HGP are seen over a wider range of plasma glucose levels than previously thought; two large trials which showed the benefits of treating lesser degrees of HGP; trials showing that metformin and glibenclamide were effective and safe alternatives to immediate insulin in those without good control on lifestyle measures alone. However uncertainties remain around the threshold for treatment, and on the best screening strategy.