Prediction of gestational diabetes mellitus in the first trimester: comparison of C-reactive protein, fasting plasma glucose, insulin and insulin sensitivity indices

Gestational Diabetes and C-Reactive Protein/Albumin Ratio in Pregnancy: A Prospective Study

PURPOSE

The C-reactive protein/albumin ratio (CAR) has been reported as a novel inflammatory marker to assess inflammation. The aim of this study was to compare the levels of CAR as a inflammatory marker in gestational diabetes mellitus (GDM) and non GDM patients.

MATERIALS AND METHODS

Eight hundred ten pregnant women who applied to our hospital for routine antenatal screening were included in this prospective case-control study. The patients were divided into two groups, as positive and negative diagnosis of GDM. CAR between groups was compared as the primary outcome using statistical methods.

RESULTS

The CAR value was significantly higher in pregnancies with GDM compared to healthy controls [1.07 (0.43-1.89) vs. 0.37 (0.12-0.68), p<0.0001]. The Spearman's correlation analysis revealed that the CAR value had a significant positive correlation with all three steps of 75 gr oral glucose tolerance test (p<0.0001 for each) and neutrophil to lymphocyte ratio value (p=0.011).

CONCLUSION

Considering that laboratory testing is very simple and inexpensive, CAR is an independent predictor that is clinically easy to use for the development of GDM. This report is the first to show the role of CAR in GDM. However, further studies with larger sample sizes are needed to generalize this comment.

Physical Activity and High-Sensitivity C-Reactive Protein in Pregnancy: Does It Matter during Leisure or Work?

INTRODUCTION

Physical activity (PA), regardless of domain, is recommended for pregnant individuals in clinical guidelines, but limited evidence is available for work-related PA. This study aimed to examine the associations of occupational (OPA) and leisure-time PA (LTPA) with plasma high-sensitivity C-reactive protein (hs-CRP), a risk marker for adverse pregnancy outcomes, among pregnant individuals.

METHODS

This longitudinal study included 257 workers in the fetal growth cohort. OPA/LTPA and hs-CRP were measured in each trimester. OPA/LTPA was divided into high and low groups by the median level. Multivariable linear regressions were applied to estimate the adjusted geometric mean differences of hs-CRP (mg·L-1) comparing high versus low OPA/LTPA in each trimester and the changes in OPA/LTPA over pregnancy.

RESULTS

OPA was positively associated with hs-CRP (high: 5.14 vs low: 3.59; P value: 0.001) in the first trimester, particularly for standing/walking or walking fast, regardless of carrying things. LTPA was negatively associated with hs-CRP in the second (high: 3.93 vs low: 5.08; 0.02) and third trimesters (high: 3.30 vs low: 4.40; 0.046). Compared with the low OPA + high LTPA group, hs-CRP was higher in both the high OPA + high LTPA and high OPA + low LTPA groups in the first trimester, and in the high OPA + low LTPA group only in the third trimester. The change in OPA during pregnancy was positively associated with hs-CRP, whereas the change in LTPA was negatively associated with hs-CRP from the second to the third trimester.

CONCLUSIONS

In pregnant individuals, LTPA was negatively associated with hs-CRP, whereas OPA was positively associated with hs-CRP. More research on OPA's health impact among pregnant individuals is needed, and guidelines may consider the potential unfavorable influence of OPA on pregnant individuals.

Associations of ozone exposure with gestational diabetes mellitus and glucose homeostasis: Evidence from a birth cohort in Shanghai, China

BACKGROUND

Associations between individual exposure to ozone (O₃) and gestational diabetes mellitus (GDM) have rarely been investigated, and critical windows of O₃ exposure for GDM have not been identified.

OBJECTIVES

We aimed to explore the associations of gestational O₃ exposure with GDM and glucose homeostasis as well as to identify the potential critical windows.

METHODS

A total of 7834 pregnant women were included. Individual O₃ exposure concentrations were evaluated using a high temporal-spatial resolution model. Each participant underwent an oral glucose tolerance test (OGTT) to screen for GDM between 24 and 28 gestational weeks. Multiple logistic and multiple linear regression models were used to estimate the associations of O₃ with GDM risks and with blood glucose levels of OGTT, respectively. Distributed lag nonlinear models (DLNMs) were used to estimate the critical windows of O₃ exposure for GDM.

RESULTS

Nearly 13.29 % of participants developed GDM. After controlling for covariates, we observed increased GDM risks per IQR increment of O₃ exposure in the first trimester (OR = 1.738, 95 % CI: 1.002-3.016) and the first two trimesters (OR = 1.576, 95 % CI: 1.005-2.473). Gestational O₃ exposure was positively associated with increased fasting blood glucose (the first trimester: β = 2.964, 95 % CI: 1.529-4.398; the first two trimesters: β = 1.620, 95 % CI: 0.436-2.804) and 2 h blood glucose (the first trimester: β = 6.569, 95 % CI: 1.775-11.363; the first two trimesters: β = 6.839, 95 % CI: 2.896-10.782). We also observed a concentration-response relationship of gestational O₃ exposure with GDM risk, as well as fasting and 2 h blood glucose levels. Additionally, 5-10 gestational weeks was identified as a critical window of O₃ exposure for GDM development.

CONCLUSION

In summary, we found that gestational O₃ exposure disrupts glucose homeostasis and increases the risk of GDM in pregnant women. Furthermore, 5-10 gestational weeks could be a critical window for the effects of O₃ exposure on GDM.

Serum afamin levels in predicting gestational diabetes mellitus and preeclampsia: A systematic review and meta-analysis

OBJECTIVES

The association between biomarkers and the risk of gestational diabetes mellitus (GDM) or preeclampsia (PE) has been extensively studied. However, there is still a lack of convenient, specific, and sensitive indicators for early identification of GMD and PE. Therefore, we conducted a meta-analysis of published articles to investigate the value of afamin circulating levels in the early diagnosis of GDM and PE.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for English studies published before November 16, 2022, that examined the association between afamin and GDM or PE. In addition, we searched Clinicaltrials.gov for the relevant completed and ongoing clinical trials. Pooled standard mean differences (SMDs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs) were used to compare the levels of afamin in different groups.

RESULTS

Eleven studies were included in our analysis (N = 3047 participants: 1195 GDM, 1407 non-GDM, 195 PE, and 250 non-PE). Subgroup analysis based on different blood collection periods found that the plasma afamin levels in pregnant women with GDM in the first trimester were significantly higher than those in healthy pregnant women (SMD = 0.481, 95% CI: 0.280-0.682), but the analysis showed the opposite results in the second and late stages (SMD = 0.292, 95% CI: -0.092-0.676). The plasma afamin levels of pregnant women with PE in the first trimester (SMD = 0.808, 95% CI: 0.558-1.059) and second/third trimesters (SMD = 0.904, 95% CI: 0.570-1.239) were significantly higher than those in healthy pregnant women.

CONCLUSION

The plasma afamin levels in pregnant women with GDM in the first trimester were significantly higher than those in healthy pregnant women, but the analysis showed the opposite results in the second and third trimesters. The plasma afamin levels in pregnant women with PE in the first, second, and third trimesters were significantly higher than those in healthy pregnant women. Additional large-scale prospective studies are desired to verify these findings, and it is recommended that afamin should be included as a routine diagnostic test for women with GDM and PE.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=339171, identifier CRD42022339171.

Predictive and Prognostic Value of Plasma Zonulin for Gestational Diabetes Mellitus in Women at 24-28 Weeks of Gestation

OBJECTIVE

We aimed to examine the predictive and prognostic value of plasma zonulin for gestational diabetes mellitus (GDM) in women at 24-28 weeks of gestation.

METHODS

This retrospective study was carried out with pregnant women with GDM (n=98) and normal glucose tolerance (control group) (n=132). GDM was diagnosed according to American Diabetes Association (ADA) criteria with a one-step 75-g OGTT at 24-28 gestational weeks. Their serum zonulin levels measured during one-step 75-g OGTT and perinatal outcomes were compared, and the cut-off value of plasma zonulin for the prediction of GDM was calculated with receiver operating characteristic curve analysis.

RESULTS

Plasma zonulin level was significantly higher in women with GDM compared to controls (28.8±24.9 and 7.3±11.3 ng/mL, respectively). According to logistic regression analysis, plasma zonulin levels and GDM were statistically significant. The plasma zonulin cut-off value was>45.2 ng/mL. The rate of cesarean section, the rate of meconium in the amniotic fluid, and the need for admission to the neonatal intensive care unit significantly differed between women with GDM and controls.

CONCLUSION

In pregnant women with GDM, plasma zonulin increases, and with the cut-off level of>45.2 ng/mL, it can predict GDM with values of sensitivity and specificity levels significantly higher in pregnant women with GDM, suggesting that it can be used as a tool for its screening and early diagnosis.

Maternal metabolic factors and the association with gestational diabetes: A systematic review and meta-analysis

Gestational diabetes (GDM) is associated with several adverse outcomes for the mother and child. Higher levels of individual lipids are associated with risk of GDM and metabolic syndrome (MetS), a clustering of risk factors also increases risk for GDM. Metabolic factors can be modified by diet and lifestyle. This review comprehensively evaluates the association between MetS and its components, measured in early pregnancy, and risk for GDM. Databases (Cumulative Index to Nursing and Allied Health Literature, PubMed, Embase, and Cochrane Library) were searched from inception to 5 May 2021. Eligible studies included ≥1 metabolic factor (waist circumference, blood pressure, fasting plasma glucose (FPG), triglycerides, and high-density lipoprotein cholesterol), measured at <16 weeks' gestation. At least two authors independently screened potentially eligible studies. Heterogeneity was quantified using I² . Data were pooled by random-effects models and expressed as odds ratio and 95% confidence intervals (CIs). Of 7213 articles identified, 40 unique articles were included in meta-analysis. In analyses adjusting for maternal age and body mass index, GDM was increased with increasing FPG (odds ratios [OR] 1.92; 95% CI 1.39-2.64, k = 7 studies) or having MetS (OR 2.52; 1.65, 3.84, k = 3). Women with overweight (OR 2.17; 95% CI 1.89, 2.50, k = 12) or obesity (OR 4.34; 95% CI 2.79-6.74, k = 9) also were at increased risk for GDM. Early pregnancy assessment of glucose or the MetS, offers a potential opportunity to detect and treat individual risk factors as an approach towards GDM prevention; weight loss for pregnant women with overweight or obesity is not recommended. Systematic review registration: PROSPERO CRD42020199225.

Use of oral glucose tolerance testing and HbA1c at 6-14 gestational weeks to predict gestational diabetes mellitus in high-risk women

PURPOSE

To study the prediction of gestational diabetes mellitus (GDM) in high-risk pregnant women by testing fasting blood glucose, 1-h(1hPG) and 2-h plasma glucose (2hPG) after an oral glucose tolerance test, and glycated hemoglobin (HbA1c) in early pregnancy (6-14 weeks).

METHODS

We recruited 1311 pregnant women at high risk for diabetes from the Obstetrics Clinic of Daxing District People's Hospital between June 2017 and December 2019. The tests performed during the first trimester included fasting blood glucose (FPG), HbA1c, and 75-g oral glucose tolerance test (OGTT) with 1hPG and 2hPG. Seventy-three pregnant women diagnosed with pregestational diabetes mellitus (PGDM) early in pregnancy and 36 who were missed in the second trimester were excluded. A total of 1202 women were followed up until 24-28 weeks for GDM. The receiver operating characteristic (ROC) and area under the ROC curve (AUC) were calculated to determine the predictive values of FPG, 1hPG, 2hPG, and HbA1c for GDM in early pregnancy in high-risk pregnant women.

RESULTS

The AUC for 1hPG for the prediction of GDM in high-risk pregnant women was greater than those for FPG, 2hPG, and HbA1c. All differences were significant. The AUCs for the predictive values of FPG, 1hPG, 2hPG, and HbA1c in high-risk pregnant women were 0.63, 0.76, 0.71, and 0.67, respectively. The prevalence of PGDM among pregnant women at high risk of diabetes was 5.6%.

CONCLUSION

First-trimester levels of FPG, 1hPG, 2hPG, and HbA1c in high-risk women are significant predictors of GDM, with 1hPG having the most significant predictive value.

An explainable machine learning-based clinical decision support system for prediction of gestational diabetes mellitus

Gestational Diabetes Mellitus (GDM), a common pregnancy complication associated with many maternal and neonatal consequences, is increased in mothers with overweight and obesity. Interventions initiated early in pregnancy can reduce the rate of GDM in these women, however, untargeted interventions can be costly and time-consuming. We have developed an explainable machine learning-based clinical decision support system (CDSS) to identify at-risk women in need of targeted pregnancy intervention. Maternal characteristics and blood biomarkers at baseline from the PEARS study were used. After appropriate data preparation, synthetic minority oversampling technique and feature selection, five machine learning algorithms were applied with five-fold cross-validated grid search optimising the balanced accuracy. Our models were explained with Shapley additive explanations to increase the trustworthiness and acceptability of the system. We developed multiple models for different use cases: theoretical (AUC-PR 0.485, AUC-ROC 0.792), GDM screening during a normal antenatal visit (AUC-PR 0.208, AUC-ROC 0.659), and remote GDM risk assessment (AUC-PR 0.199, AUC-ROC 0.656). Our models have been implemented as a web server that is publicly available for academic use. Our explainable CDSS demonstrates the potential to assist clinicians in screening at risk patients who may benefit from early pregnancy GDM prevention strategies.

Early Identification of the Maternal, Placental and Fetal Dialog in Gestational Diabetes and Its Prevention

Gestational diabetes mellitus (GDM) complicates between 5 and 12% of pregnancies, with associated maternal, fetal, and neonatal complications. The ideal screening and diagnostic criteria to diagnose and treat GDM have not been established and, currently, diagnostic use with an oral glucose tolerance test occurs late in pregnancy and produces poor reproducibility. Therefore, in recent years, significant research has been undertaken to identify a first-trimester biomarker that can predict GDM later in pregnancy, enable early intervention, and reduce GDM-related adverse pregnancy outcomes. Possible biomarkers include glycemic markers (fasting glucose and hemoglobin A1c), adipocyte-derived markers (adiponectin and leptin), pregnancy-related markers (pregnancy-associated plasma protein-A and the placental growth factor), inflammatory markers (C-reactive protein and tumor necrosis factor-α), insulin resistance markers (sex hormone-binding globulin), and others. This review summarizes current data on first-trimester biomarkers, the advantages, and the limitations. Large multi-ethnic clinical trials and cost-effectiveness analyses are needed not only to build effective prediction models but also to validate their clinical use.

Early Gestational Diabetes Mellitus: Diagnostic Strategies and Clinical Implications

Preexisting diabetes mellitus (DM) should be ruled out early in pregnancy in those at risk. During screening, a significant proportion of women do not reach the threshold for overt DM but fulfill the criteria used for diagnosing conventional gestational DM (cGDM). There is no consensus on the management of pregnancies with intermediate levels of hyperglycemia thus diagnosed. We have used the term early gestational DM (eGDM) for this condition and reviewed the currently available literature. Fasting plasma glucose (FPG), oral glucose tolerance test, and glycated hemoglobin (HbA1c) are the commonly employed screening tools in early pregnancy. Observational studies suggest that early pregnancy FPG and Hba1c correlate with the risk of cGDM and adverse perinatal outcomes. However, specific cut-offs, including those proposed by the International Association of the Diabetes and Pregnancy Study Group, do not reliably predict the development of cGDM. Emerging data, though indicate that FPG ≥ 92 mg/dL (5.1 mmol/L), even in the absence of cGDM, signals the risk for perinatal complication. Elevated HbA1c, especially a level ≥ 5.9%, also correlates with the risk of cGDM and worsened outcome. HbA1c as a diagnostic test is however besieged with the usual caveats that occur in pregnancy. The studies that explored the effects of intervention present conflicting results, including a possibility of fetal malnutrition and small-for-date baby in the early treatment group. Diagnostic thresholds and glycemic targets in eGDM may differ, and large multicenter randomized controlled trials are necessary to define the appropriate strategy.

The role of complement factor H in gestational diabetes mellitus and pregnancy

BACKGROUND

Complement factor H (CFH) has been found to be associated with insulin resistance. This study assessed the correlation between CFH and other clinical parameters, and determined whether CFH played a role in gestational diabetes mellitus (GDM) and adverse pregnancy outcomes.

METHODS

A total of 397 pregnant women were included for analysis in this nested case-control study. Clinical parameters and serum were collected within the 11-17th gestational age at the first prenatal visit. At 24-28 weeks of gestation, a 75 g oral glucose tolerance test was performed and subjects were divided into a GDM (n = 80) and a non-GDM control group (n = 317). The delivery data were also followed. The serum CFH level was assayed by ELISA.

RESULTS

CFH was higher in GDM than in non-GDM controls (280.02 [58.60] vs. 264.20 [68.77]; P = 0.014). CFH level was moderately associated with pre-pregnancy body mass index (BMI), BMI and total triglycerides (TG), and slightly associated with gestational age, low density lipoprotein cholesterol (LDL-C), total cholesterol (TC) in GDM and non-GDM (all P <  0.05). Moreover, CFH level was moderately correlated with alkaline phosphatase (ALP) and slightly correlated with age, uric acid (UA) and total bilirubin (TB) in non-GDM (all P <  0.05). After adjustment for clinical confounding factors, BMI, TG, gestational age, ALP, TB, age and UA were independent risk factors for log₁₀ CFH levels (all P <  0.05) in all subjects. In addition, overweight or obese pregnant women, women with hypertriglyceridemia and women in the second trimester had significantly higher CFH levels than normal weight and underweight group (P <  0.001), the non-hypertriglyceridemia group (P <  0.001) and women in the first trimester group (P < 0.05) in all pregnant women respectively. Following binary logistic regression, CFH was not independently associated with GDM and related pregnant outcomes.

CONCLUSIONS

The CFH in 11-17th weeks of gestation might be affected by many factors, including BMI, TG, gestational age, ALP, TB, age and UA. CFH was not an independent risk factor for GDM and avderse pregnancy outcomes.

Research Progress on Gestational Diabetes Mellitus and Endothelial Dysfunction Markers

Gestational diabetes mellitus (GDM) is the onset or first recognition of diabetes during pregnancy in women with normal glucose metabolism or potentially impaired glucose tolerance before pregnancy. Studies have shown that vascular endothelial cells (VECs) are an important target organ of insulin, which is injured by multiple factors in the case of GDM, thereby leading to worsened insulin resistance (IR) and the further development of GDM. When VECs are abnormal, there will be changes in the content of a variety of cell markers, which may be helpful for the clinical prediction and diagnosis of GDM. This study attempted to investigate the mechanism and markers of VECs injury in GDM patients.

Prognostic models versus single risk factor approach in first-trimester selective screening for gestational diabetes mellitus: a prospective population-based multicentre cohort study

Objectives

To evaluate whether (1) first‐trimester prognostic models for gestational diabetes mellitus (GDM) outperform the currently used single risk factor approach, and (2) a first‐trimester random venous glucose measurement improves model performance.

Design

Prospective population‐based multicentre cohort.

Setting

Thirty‐one independent midwifery practices and six hospitals in the Netherlands.

Population

Women recruited before 14 weeks of gestation without pre‐existing diabetes.

Methods

The single risk factor approach (presence of at least one risk factor: BMI ≥30 kg/m², previous macrosomia, history of GDM, positive first‐degree family history of diabetes, non‐western ethnicity) was compared with the four best performing models in our previously published external validation study (Gabbay‐Benziv 2014, Nanda 2011, Teede 2011, van Leeuwen 2010) with and without the addition of glucose.

Main outcome measures

Discrimination was assessed by c‐statistics, calibration by calibration plots, added value of glucose by the likelihood ratio chi‐square test, net benefit by decision curve analysis and reclassification by reclassification plots.

Results

Of the 3723 women included, a total of 181 (4.9%) developed GDM. The c‐statistics of the prognostic models were higher, ranging from 0.74 to 0.78 without glucose and from 0.78 to 0.80 with glucose, compared with the single risk factor approach (0.72). Models showed adequate calibration, and yielded a higher net benefit than the single risk factor approach for most threshold probabilities. Teede 2011 performed best in the reclassification analysis.

Conclusions

First‐trimester prognostic models seem to outperform the currently used single risk factor approach in screening for GDM, particularly when glucose was added as a predictor.

Tweetable abstract

Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes.

Prognostic models seem to outperform the currently used single risk factor approach in screening for gestational diabetes.

Early triglyceride and glucose index as a risk marker for gestational diabetes mellitus

OBJECTIVE

To assess the risk of gestational diabetes mellitus (GDM) according to the triglyceride and glucose (TyG) index values during the first trimester of pregnancy in Latin American women.

METHODS

Pregnant women were enrolled at their first prenatal visit at the Obstetric Division in the University Hospital "Dr. José E. González". Triglycerides and fasting plasma glucose (FPG) were collected to determine the TyG index. GDM diagnosis was performed by a single-step 2-hour 75-g oral glucose tolerance test. Generalized linear models were used to determine risk ratios; pregnancy outcomes at delivery were collected from the hospital medical records.

RESULTS

A total of 164 pregnant women were included. GDM was present in 29 (17.7%) women. No significant differences in age, first-trimester body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), family history of diabetes, and TyG index were observed between GDM cases and the reference group without GDM. The adjusted analysis showed no association between TyG and GDM (risk ratio [RR] 1.03, 95% confidence interval [CI] 0.57-1.88]). Higher TyG index values between women with and without a diagnosis of GDM in the second trimester were observed. No significant differences were identified in pregnancy outcomes, although a trend was observed for hyperbilirubinemia in women with first-trimester TyG index values greater than 8.7.

CONCLUSIONS

Our findings do not support the use of the TyG index for GDM prediction in Latin American women.

Role of C-reactive Protein(CRP) or high-sensitivity CRP in predicting gestational diabetes Mellitus:Systematic review

BACKGROUND AND AIMS

Gestational Diabetes Mellitus (GDM) is the most common disorder during pregnancy in 8-18% of pregnancies. Due to maternal and neonatal morbidity and mortality, early diagnosis and appropriate treatment have always been of interest to researchers. One of the recent cases for early diagnosis of GDM is the size of the C-reactive protein (CRP). The purpose of this review study was to investigate the role of CRP or its high sensitivity type in predicting GDM.

METHODS

Systematic searching of MEDLINE, ISI Web of Science, PubMed, Scopus, Google Scholar, and ProQuest databases between 2009 and 2019 using keywords 'Gestational Diabetes Mellitus','Screening', 'C-reactive protein',' High sensitivity CRP'was performed. The quality of articles was also assessed using the STROBE checklist.

RESULTS

After a thorough search of the mentioned databases, 31 articles with the desired quality were finally selected. Most of studies showed significant relationship between CRP or high-sensitivity CRP(hs-CRP) level with GDMbutthe relationship was not significant in fewstudies.

CONCLUSIONS

Blood levels of CRP or hs-CRP could be used as a potential indicator for GDM, but more studies are needed.

Metabolic flexibility is impaired in women who are pregnant and overweight/obese and related to insulin resistance and inflammation

CONTEXT

Maternal obesity is a significant public health concern that contributes to unfavorable outcomes such as inflammation and insulin resistance. Women with obesity may have impaired metabolic flexibility (i.e. an inability to adjust substrate metabolism according to fuel availability). Impaired metabolic flexibility during pregnancy may mediate poor pregnancy outcomes in women with obesity.

PURPOSE

The purposes of this study were to: 1) compare metabolic flexibility between overweight/obese and lean women; and 2) determine the relationships between metabolic flexibility, inflammation following a high-fat meal, and maternal metabolic health outcomes (i.e. gestational weight gain and insulin resistance).

PROCEDURES

This interventional physiology study assessed lipid oxidation rates via indirect calorimetry before and after consumption of a high-fat meal. The percent change in lipid metabolism was calculated to determine 'metabolic flexibility.' Maternal inflammatory profiles (CRP, IL-6, IL-8, IL-10, IL-12, TNF-α) and insulin resistance (HOMA-IR) were determined via plasma analyses.

MAIN FINDINGS

64 women who were pregnant (lean = 35, overweight/obese = 29) participated between 32 and 38 weeks gestation. Lean women had significantly higher metabolic flexibility compared to overweight/obese women (lean 48.0 ± 34.1% vs overweight/obese 29.3 ± 34.3%, p = .035). Even when controlling for pre-pregnancy BMI, there was a negative relationship between metabolic flexibility and percent change in CRP among the overweight/obese group (r = -0.526, p = .017). Metabolic flexibility (per kg fat free mass) was negatively correlated with postprandial HOMA-IR (2 h: r = -0.325, p = .016; 4 h: r = -0.319, p = .019).

CONCLUSIONS

Overweight and obese women who are pregnant are less 'metabolically flexible' than lean women, and this is related to postprandial inflammation and insulin resistance.

Gestational Diabetes Mellitus Screening and Diagnosis

An ideal screening test for gestational diabetes should be capable of identifying not only women with the disease but also the women with a high risk of developing gestational diabetes mellitus (GDM). Screening and diagnosis are the main steps leading to the way of management. There is a lack of consensus among healthcare professionals regarding the screening methods worldwide. Different study groups advocate a variety of screening methods with the support of evidence-based comprehensive data. Some of the organizations suggest screening for high risk or all pregnant women, while others prefer to offer definitive testing without screening. Glycemic thresholds are also not standardized to decide GDM among different guidelines. Prevalence rates of GDM vary between populations and with the choice of glucose thresholds for both screening and definitive tests. One-step or two-step methods have been used for GDM diagnosis. However, screening includes selecting patients with historical risk factors, 50 g 1-h glucose challenge test, fasting plasma glucose, random plasma glucose, and hemoglobin A1c with different cutoffs. In this chapter, screening and diagnosis methods of GDM accepted by different study groups will be discussed which will be followed by the evaluation of different glycemic thresholds. Then the advantages and disadvantages of used methods will be explained and the chapter will finish with an evaluation of the current international guidelines.

Changes of serum pentraxin-3 and hypersensitive CRP levels during pregnancy and their relationship with gestational diabetes mellitus

OBJECTIVE

To investigate the changes of inflammatory factors pentraxin 3 (PTX3) and hypersensitive C-reactive protein (hs-CRP) during pregnancy and their relationship with gestational diabetes mellitus (GDM).

METHODS

The nested case-control study method was used. Eighty non-obese single-pregnant women diagnosed with GDM were included into the case group (GDM, n = 80), together with another eighty pregnant women with normal glucose tolerance were matched in the same period and divided into the control group (CON, n = 80), for detecting multiple biochemical indicators in different pregnancy stages by ELISA.

RESULTS

The serum levels of PTX3 and hs-CRP in pregnant women increased with the increase of gestational age (p < 0.001, p < 0.001). The levels of PTX3 and hs-CRP in group GDM were significantly higher in the middle and late pregnancy stages than group CON (p < 0.01, p < 0.05; p < 0.05, p < 0.05). PTX3 was positively correlated with hs-CRP, body mass index (BMI), fasting plasma glucose (FPG), and homeostasis model assessment of insulin resistance (HOMAIR).

CONCLUSIONS

PTX3 and hs-CRP may be related to the pathogenesis of GDM, and they are significantly increased in the second trimester, which provides a new idea for early prevention and treatment of GDM and risk prediction of long-term cardiovascular diseases.

Serum magnesium and high-sensitivity C-reactive protein as a predictor for gestational diabetes mellitus in Sudanese pregnant women

Background

Gestational diabetes mellitus (GDM) is a big health problem that adversely affects both the maternal and perinatal outcomes. We aimed to predict the development of GDM in the first trimester using high sensitivity C-reactive protein (hs-CRP) and serum magnesium.

Methods

The study conducted in the antenatal care clinic of Saad Abualila Hospital (Khartoum, Sudan). Pregnant women were enrolled in this longitudinal cohort study during first trimester ≤14 weeks of gestation. Serum hs-CRP and magnesium concentrations were measured between weeks 11 and 14 of gestation. Glucose tolerance test and fasting plasma insulin (FPI) measurement were performed between 24 and 28 weeks gestational age. To assess insulin sensitivity and β-cell function, Homeostatic Model Assessment Insulin Resistance (HOMA-IR), HOMA-β indices and Quantitative Insulin Sensitivity Check Index (QUICKI) were calculated and used.

Results

Out of the 126 who completed the study 19 (15%) were diagnosed as GDM. The median (interquartile) of FBG was significantly higher in women with GDM [81 (70–95) vs. 67(60–75) mg/dl; P = < 0.001] compared to women without GDM. There was no significant difference in hs-CRP, serum magnesium, HOMA-IR, QUICKI and HOMA- β between women with GDM and women without GDM. No correlation was observed between body mass index (BMI), serum magnesium, hs-CRP, FBG and insulin levels.

Conclusions

First trimester hs-CRP and serum magnesium levels were not correlated with the later development of gestational diabetes in this setting.

Maternal serum glycosylated hemoglobin and fasting plasma glucose predicts gestational diabetes at the first trimester in Turkish women with a low-risk pregnancy and its relationship with fetal birth weight; a retrospective cohort study

OBJECTIVE

To examine the accuracy of maternal serum glycosylated hemoglobin (HbA1c) and fasting plasma glucose (FPG) levels in predicting gestational diabetes at the first trimester in Turkish women with a low-risk pregnancy and its relationship with fetal birth weight.

METHODS

This cohort study was conducted retrospectively in a tertiary referral hospital from January 2010 to January 2017. HbA1c and FPG serum concentrations were measured in 670 pregnant women at the first-trimester screening. HbA1c and FPG concentrations of women who subsequently developed gestational diabetes mellitus (GDM) were compared to those who did not, and its relationship with fetal weight was investigated.

RESULTS

First-trimester screening was performed on 608 pregnant women, of whom 69 (11.3%) women had developed GDM. Median HbA1c and FPG concentrations were significantly higher in women developing GDM (n = 69) in comparison to those with uncomplicated pregnancies (n = 539) (5.31 ± 0.58% versus 5.01 ± 0.45%, p < .001 and 89.74 ± 8.71% versus 84.09 ± 9.16%, p < .001, respectively). The cut-off value calculated with the highest Youden index was HbA1c levels above 5.6% with a sensitivity of 34.78%, specificity of 89.8%, with a diagnostic accuracy of 83.55%, and FPG levels above 86.85 mg/dl with a sensitivity of 69.57%, specificity of 61.78%, with a diagnostic accuracy of 62.66%. The calculated odds ratio (OR) for HbA1c > 5.6% and FPG > 86 mg/dl were 4.69 (95% CI: 2.66-8.29), and 3.7 (95% CI: 2.15-6.35), respectively. HbA1c and FPG combined had improved the predictive capability for GDM (OR: 7.26, 95% CI: 3.71-14.19). According to correlation analyses, a noteworthy positive correlation was found between HbA1c and, FPG, 50 g GCT, age, BMI, parity, and birth weight. However, there was no correlation between FPG and birth weight.

CONCLUSION

Diagnostic accuracy of HbA1c for GDM prediction in Turkish women with a low-risk pregnancy is 83.55% with a very good negative predictive value of 91.49%. HbA1c and FPG combined enhanced the predictive capability for GDM. In addition, there is a positive relationship between HbA1c and 50 g GCT, and birth weight. However, to suggest HbA1c as a potential screening test for gestational diabetes mellitus, further research is warranted.

Value of fasting plasma glucose to screen gestational diabetes mellitus before the 24th gestational week in women with different pre-pregnancy body mass index

BACKGROUND

Gestational diabetes mellitus (GDM) is usually diagnosed between 24th and 28th gestational week using the 75-g oral glucose tolerance test (OGTT). It is difficult to predict GDM before 24th gestational week because fast plasma glucose (FPG) decreases as the gestational age increases. It is controversial that if FPG ≥5.1 mmol/L before 24th gestational week should be intervened or not. The aim of this study was to evaluate the value of FPG to screen GDM before 24th gestational week in women with different pre-pregnancy body mass index (BMI).

METHODS

This was a multi-region retrospective cohort study in China. Women who had a singleton live birth between June 20, 2013 and November 30, 2014, resided in Beijing, Guangzhou and Chengdu, and received prenatal care in 21 selected hospitals, were included in this study. Pre-pregnancy BMI, FPG before the 24th gestational week, and one-step GDM screening with 75 g-OGTT at the 24th to 28th gestational weeks were extracted from medical charts and analyzed. The pregnant women were classified into four groups based on pre-pregnancy BMI: Group A (underweight, BMI < 18.5 kg/m), Group B (normal, BMI 18.5-23.9 kg/m), Group C (overweight, BMI 24.0-27.9 kg/m) and Group D (obesity, BMI ≥28.0 kg/m). The trend of FPG before 24th week of gestation was described, and the sensitivity and specificity of using FPG before the 24th gestational week to diagnose GDM among different pre-pregnancy BMI groups were reported. Differences in the means between groups were evaluated using independent sample t-test and analysis of variance. Pearson Chi-square test was used for categorical variables.

RESULTS

The prevalence of GDM was 20.0% (6806/34,087) in the study population. FPG decreased gradually as the gestational age increased in all pre-pregnancy BMI groups until the 19th gestational week. FPG was higher in women with higher pre-pregnancy BMI. FPG before the 24th gestational week and pre-pregnancy BMI could be used to predict GDM. The incidence of GDM in women with FPG ≥5.10 mmol/L in the 19th to 24th gestational weeks and pre-pregnancy overweight or obesity was significantly higher than that in women with FPG ≥5.10 mmol/L and pre-pregnancy BMI <24.0 kg/m (78.5% [62/79] vs. 52.9% [64/121], χ = 13.425, P < 0.001).

CONCLUSIONS

FPG decreased gradually as the gestational age increased in all pre-pregnancy BMI groups until the 19th gestational week. Pre-pregnancy overweight or obesity was associated with an increased FPG value before the 24th gestational week. FPG ≥5.10 mmol/L between 19 and 24 gestational weeks should be treated as GDM in women with pre-pregnancy overweight and obesity.

Prediction of gestational diabetes mellitus in the first trimester: comparison of maternal fetuin-A, N-terminal proatrial natriuretic peptide, high-sensitivity C-reactive protein, and fasting glucose levels

OBJECTIVE

We investigated the utility of maternal fetuin-A, N-terminal proatrial natriuretic peptide (pro-ANP), high-sensitivity C-reactive protein (hs-CRP), and fasting glucose levels at 11-14 gestation weeks for predicting pregnancies complicated by gestational diabetes mellitus (GDM).

SUBJECTS AND METHODS

This prospective cohort study included 327 low-risk pregnant women who completed antenatal follow-up at a tertiary research hospital between January and April 2014. Maternal blood samples were collected between 11-14 gestational weeks in the first trimester of pregnancy and then stored at -80 °C until further analyses. During follow-up, 29 (8.8%) women developed GDM. The study population was compared 1:2 with age- and body mass index-matched pregnant women who did not develop GDM (n = 59). Fasting plasma glucose (FPG) levels and serum fetuin-A, pro-ANP, and hs-CRP levels were measured using automated immunoassay systems.

RESULTS

There was a significant negative correlation between fetuin-A and hs-CRP (CC = -0.21, p = 0.047) and a positive correlation between FPG and hs-CRP (CC = 0.251, p = 0.018). The areas under the receiver operating characteristic curve for diagnosing GDM were 0.337 (p = 0.013), 0.702 (p = 0.002), and 0.738 (p < 0.001) for fetuin-A, hs-CRP, and FPG, respectively. The optimal cut-off values were > 4.65, < 166, and > 88.5 mg/dL for maternal hs-CRP, fetuin-A, and FPG, respectively.

CONCLUSION

Reduced fetuin-A, elevated hs-CRP, and FPG levels in women in the first trimester can be used for the early detection of GDM. Further research is needed before accepting these biomarkers as valid screening tests for GDM.

Individual free fatty acids have unique associations with inflammatory biomarkers, insulin resistance and insulin secretion in healthy and gestational diabetic pregnant women

OBJECTIVE

We investigated the relationships of maternal circulating individual free fatty acids (FFA) with insulin resistance, insulin secretion and inflammatory biomarkers during mid-pregnancy.

RESEARCH DESIGN AND METHODS

The data were drawn from a prospective cohort of generally healthy pregnant women (n=1368, African-American 36%, Hispanic 48%, Caucasian 16%) in Camden, NJ. We quantitatively determined 11 FFAs, seven cytokine/adipokine, homeostatic model assessment of insulin resistance (HOMA-IR) and C-peptide levels from the fasting blood samples that were collected at 16 weeks of gestation. Multivariate analyses were performed along with separate analyses for each individual FFA.

RESULTS

High HOMA-IR (p<0.001) and C-peptide (p<0.0001) levels were positively associated with a twofold to fourfold increased risk for developing gestational diabetes mellitus (GDM). Negative relationships were found with specific FFAs (molecular percentage, palmitoleic, oleic, linolenic, myristic acids) and HOMA-IR and C-peptide levels (p<0.01 to p<0.0001). In contrast, palmitic, stearic, arachidonic, dihomo-γ-linolenic (DGLA) and docosahexaenoic acids were positively associated with HOMA-IR and C-peptide (p<0.01 to p<0.0001). The individual FFAs also predicted cytokine/adipokine levels. For example, women who had elevated DGLA (highest quartile) were twice as (adjusted OR 2.06, 95% CI 1.42 to 2.98) likely to have higher interleukin (IL)-8 (p<0.0001) levels. Conversely, women with high palmitoleic, oleic, and linolenic acid levels had reduced odds (≥2-fold, p<0.01 to p<0.001) for having higher IL-8, IL-6 or tumor necrosis factor-alpha levels.

CONCLUSION

Our results suggest that maternal individual FFAs uniquely affect insulin resistance and secretion. The effects are either direct or indirect via modulation of the inflammatory response. Modifying the composition of FFAs may help in reducing the risk of GDM.

The post-HAPO situation with gestational diabetes: the bright and dark sides

AIM

In 2010, in light of the data coming from the HAPO study, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed a new detection strategy and diagnostic criteria for gestational diabetes based on a one-step approach with a 75 g OGTT. This review analyzes and discusses the bright and dark sides of their application.

METHODS

The assessment of these recommendations by the international organizations involved in the care of gestational diabetes and a series of observational, retrospective and prospective studies that have been published since 2010 regarding the use of the IADPSG recommendations have been evaluated.

RESULTS

The different international associations involved in the care of pregnancy and of pregnancy complicated by diabetes have not taken an univocal position some of which have accepted them, while others have criticized them. Then, the actual application of the approach recommended by the IADPSG for detecting and diagnosing GDM varies, even at centers that reportedly accept the new diagnostic criteria.

CONCLUSION

So the challenge lies in making every effort to achieve a global standardization of the strategies for detecting, diagnosing and treating GDM.

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.

Reduced Cortical Excitability, Neuroplasticity, and Salivary Cortisol in 11-13-Year-Old Children Born to Women with Gestational Diabetes Mellitus

Background

Children exposed to gestational diabetes mellitus (GDM) in utero are at increased risk of neurodevelopmental difficulties, including autism and impaired motor control. However, the underlying neurophysiology is unknown.

Methods

Using transcranial magnetic stimulation, we assessed cortical excitability, long-term depression (LTD)-like neuroplasticity in 45 GDM-exposed and 12 control children aged 11–13 years. Data were analysed against salivary cortisol and maternal diabetes severity and treatment (insulin [N = 22] or metformin [N = 23]) during pregnancy.

Findings

GDM-exposed children had reduced cortical excitability (p = .003), LTD-like neuroplasticity (p = .005), and salivary cortisol (p < .001) when compared with control children. Higher maternal insulin resistance (IR) before and during GDM treatment was associated with a blunted neuroplastic response in children (p = .014) and this was not accounted for by maternal BMI. Additional maternal and neonatal measures, including fasting plasma glucose and inflammatory markers, predicted neurophysiological outcomes. The metformin and insulin treatment groups had similar outcomes.

Interpretation

These results suggest that GDM can contribute to subtle differences in child neurophysiology, and possibly cortisol secretion, persisting into early adolescence. Importantly, these effects appear to occur during second trimester, before pharmacologic treatment typically commences, and can be predicted by maternal insulin resistance. Therefore, earlier detection and treatment of GDM may be warranted. Metformin appears to be safe for these aspects of neurodevelopment.

•

Children exposed to gestational diabetes (GDM) had lower cortical excitability, measured as higher resting motor thresholds.

•

The GDM group also exhibited smaller LTD-like neuroplastic responses to repetitive brain stimulation.

•

These were associated with lower salivary cortisol and with maternal diabetes severity, especially insulin resistance.

Our results suggest that gestational diabetes, even when detected and treated as per clinical guidelines, has subtle effects on important neurophysiological processes persisting into early adolescence, including neuroplasticity and possibly cortisol secretion. The extent of these effects is related to the severity of maternal diabetes, particularly insulin resistance, during mid pregnancy. These results may aid in understanding how insulin resistance and hyperglycemia affect the developing brain. Further, our results indicate that earlier detection and pharmacologic treatment of gestational diabetes may attenuate or prevent these changes to neurodevelopment, and that maternal metformin treatment does not influence these aspects of development.

Relationship between advanced glycation end products and gestational diabetes mellitus

Objective: To investigate the levels of and dynamic changes of advanced glycation end products (AGEs) in maternal plasma during pregnancy and explore the association between these levels and gestational diabetes mellitus (GDM). Methods: This study recruited 90 GDM women and 90 healthy pregnant controls. The women received prenatal care and were hospitalized for delivery in Peking University First Hospital in China between October 2015 and April 2016. The patients were recruited and provided blood samples during gestational weeks 24-29. The levels of AGEs, TNF-α, hs-CRP, plasma glucose, and FINS and lipid profiles were measured, and HOMA-IR was calculated. New blood samples were collected and AGE was measured again in the two groups at 33-41 weeks of gestation to identify its dynamic changes. Results: The levels of AGEs were significantly higher in the GDM group than in the NGT group at both 24-29 weeks (473.65 ± 105.32 versus 324.36 ± 57.86 ng/L; p < .001) and 33-41 weeks (533.47 ± 146.95 versus 315.50 ± 77.79 ng/L; p < .001), and plasma levels of TNF-α and hs-CRP were significantly higher in the GDM group than in the NGT group (282.58 ± 45.85 versus 177.54 ± 35.14 pg/mL; 1.11 ± 0.25 versus 0.6 ± 0.19 µg/mL; p < .001), even after adjusting for other confounding factors, AGE levels were positively correlated with the levels of 2hPG (p = .003), TNF-α (p = .005), and hs-CRP (p < .001). A logistic regression analysis showed that AGE (OR = 1.037, 95%CI: 1.017 ∼ 1.058) and TNF-α (OR = 1.115, 95%CI: 1.048 ∼ 1.186) levels were independent risk factors for GDM. In the GDM group, the concentration of AGEs was significantly higher at 33-41 weeks than at 24-29 weeks (p = .001). In the NGT group, there was no significant change in the concentration of AGEs between the two gestational periods (p = .388). Conclusions: Plasma levels of AGEs are associated with GDM. During pregnancy, the changes observed in the levels of AGEs were different between GDM and normal pregnancies.

First trimester serum biomarkers to predict gestational diabetes in a high-risk cohort: Striving for clinically useful thresholds

OBJECTIVES

Screening and diagnosis of gestational diabetes (GDM) has been a source of controversy. The prevalence has increased in line with an obesity epidemic and a trend towards delayed child-bearing. Treatment of even modest glycaemic impairment in pregnancy has been shown to be beneficial in preventing its clinical sequalae. However the cumbersome nature and timing of the oral glucose tolerance test coupled with debate around universal versus risk factor based screening have been problematic. This group aimed to investigate a panel of biomarkers which have shown promise in the literature to predict GDM from the first trimester in a group of high risk women.

METHODS

Serum samples were drawn on 248 women deemed at risk of GDM before 15 weeks' gestation to measure C-reactive protein, sex hormone binding globulin, adiponectin and 1,5 anhydroglucitol. Patients underwent an oral glucose tolerance test as per IADPSG criteria at 28 weeks' gestation. Multiple logistic regression was used to examine the link between incidence of GDM and early pregnancy serum biomarkers.

RESULTS

Adiponectin levels in the first trimester are independently linked to the risk of GDM. Serum adiponectin <8.9 μg/ml gives an odds ratio of 3.3 for GDM.Mean 1,5 AG levels are significantly lower in those that go on to develop GDM. SHBG levels measured in the first trimester were linked to the risk of GDM. However, this was no longer statistically significant once BMI, ethnicity and family history were taken into consideration. First trimester measurement of CRP is not a useful indicator of GDM risk.

CONCLUSIONS

First trimester measurement of Adiponectin and 1,5 Anhydroglucitol are potential early biomarkers for the later onset of GDM. Risk stratification using these biomarkers may facilitate early diagnosis and management of GDM to mitigate against its complications.

Roles of Inflammation and Depression in the Development of Gestational Diabetes

Inflammation, the body's response to harmful external agents, has long been found to be associated with depressive symptoms. The relationship between inflammation and depression is well established in the general population of people with depression, but is less so among perinatal women. Depression in the perinatal period is a common disorder, however available data do not indicate that there is a specific inflammatory picture associated with perinatal depression. We suggest that perinatal depression may be a heterogeneous construct, and that inflammation may be relevant to it in the context of other inflammatory morbidities of pregnancy. In this review we explore the available support for the hypothesis that inflammation associated with depression can represent a precipitating insult for the development of gestational diabetes, a known inflammatory morbidity of pregnancy.

Low-intensity Physical Activity is Associated with Lower Maternal Systemic Inflammation during Late Pregnancy

Excessive maternal inflammation during pregnancy increases the risk for maternal and neonatal metabolic complications. Fortunately, maternal physical activity during pregnancy appears to reduce maternal inflammation. The purpose of this study was to examine the relationship between maternal physical activity intensity and maternal inflammation during late pregnancy. Maternal physical activity levels (sedentary, light, lifestyle, and moderate), fitness levels, and systemic inflammation (plasma C-reactive protein (CRP) concentration) were measured between 32–37 weeks gestation. Relationships were examined by Spearman Rank Coefficient Correlation analyses. Maternal plasma CRP was negatively associated with time spent in light and lifestyle physical activities (Light: r=−0.40, p=0.01; Lifestyle: r=−0.31, p=0.03), but not with time spent in moderate physical activity (r=−0.18, p=0.21). Higher maternal plasma CRP tended to correlate with more time spent sedentary (r=0.27, p=0.06). In addition, increases in light and lifestyle activities may elicit a clinically meaningful change in inflammation. In conclusion, pregnant women should be encouraged to incorporate more low-intensity physical activities into their daily routines in order to decrease systemic inflammation and potentially improve maternal and neonatal pregnancy outcomes.

Fasting plasma glucose and body mass index during the first trimester of pregnancy as predictors of gestational diabetes mellitus in a Chinese population

This retrospective study assessed fasting plasma glucose (FPG) and body mass index (BMI) during the first trimester of pregnancy as potential screening indicators of later gestational diabetes mellitus (GDM). The study population included 820 pregnant women who delivered in our hospital between 17 September 2013 and 3 March 2014. Demographics and baseline characteristics were collected at the first antenatal visit; FPG levels were measured at 8 or 9 weeks. All participants underwent a 75-g oral glucose tolerance test at 24-28 weeks gestation. Multivariate logistic regression and receiver operating characteristic curve analysis were performed to determine the diagnostic power of risk factors. GDM was diagnosed in 20.3% of the women. There was an increased prevalence of GDM with advancing age, parity, high FPG, and obesity, but not in women with family predisposition. FPG (OR: 3.984; 95% CI: 2.397-6.62) and BMI (OR: 1.144; 95% CI: 1.083-1.208) were independent risk factors for later development of GDM (p<0.01). FPG level ≥4.6 mmol/L was the best threshold for predicting GDM with a sensitivity of 53.89 and specificity of 70.90%. BMI ≥23.5 kg/m² yielded a sensitivity of 48.5% and a specificity of 73.1% for predicting GDM. FPG and BMI combined markedly enhanced the predictive capability for GDM (OR, 3.861; 95% CI: 2.701-5.520). High FPG or BMI in the first trimester, especially in combination, may predict later GDM with limited accuracy and specificity in Chinese women.

Increased intestinal permeability, measured by serum zonulin, is associated with metabolic risk markers in overweight pregnant women

BACKGROUND

Increased intestinal permeability with subsequent metabolic endotoxemia, i.e., elevated circulating levels of bacterial lipopolysaccharide, LPS, has been introduced as a novel initiator of obesity related metabolic disturbances in non-pregnant individuals. The objective was to investigate the extent to which intestinal permeability, measured by serum zonulin concentration, is related to metabolic endotoxemia and metabolic risk markers in overweight pregnant women.

METHODS

This was a cross-sectional study including 100 pregnant overweight women in early pregnancy. Serum zonulin was analyzed using ELISA, and markers for metabolic endotoxemia (LPS), inflammation (high-sensitive C-reactive protein and glycoprotein acetylation GlyA), glucose metabolism (fasting glucose and insulin), and lipid metabolism were measured.

RESULTS

Higher serum zonulin concentration associated positively with LPS (P=0.02), inflammatory markers (P<0.001), insulin (P<0.001), insulin resistance (P<0.001), and triglycerides (P=0.001), and negatively with insulin sensitivity (P=0.001) (ANOVA with Tukey's corrections or Kruskal-Wallis nonparametric test with Bonferroni correction for zonulin quartiles). All the observed associations were confirmed (P<0.015) in a linear regression model adjusted with potential confounding factors. Both LPS and GlycA showed positive relationship with insulin resistance, serum insulin, triglycerides, total and LDL-cholesterol and negative relationship with insulin sensitivity (P≤0.03) in the univariate linear regression. Positive relationship was also found between LPS and HDL-cholesterol (P=0.03).

CONCLUSIONS

Our findings suggest that increased serum zonulin concentration, i.e., increased intestinal permeability, contributes to metabolic endotoxemia, systemic inflammation, and insulin resistance in overweight pregnant women. By reinforcing intestinal barrier, it may be possible to manipulate maternal metabolism during pregnancy with subsequent health benefits.

Evaluation of serum zonulin for use as an early predictor for gestational diabetes

Diet has an important role in regulating intestinal permeability and subsequently the risk for metabolic disorders. In this observational study, we examined whether serum intestinal permeability marker zonulin, could be used as a predictor for gestational diabetes mellitus (GDM). Serum zonulin concentration was measured in early pregnancy in overweight or obese pregnant women (n=88) at risk for developing GDM. Serum zonulin was associated with higher odds of GDM (adjusted OR for 1 ng ml⁻¹ increase in zonulin: 1.08, 95% CI: 1.02–1.15; P=0.009), diagnosed by a 2-h 75-g oral glucose tolerance test at late pregnancy. The optimal cutoff value was 43.3 ng ml⁻¹, with sensitivity of 88% (95% CI: 71–100%) and specificity of 47% (95% CI: 33–58%). The area under the ROC-curve was 0.67 (95% CI: 0.54–0.81). Our results show an association between increased early-pregnancy serum zonulin concentration and GDM, suggesting zonulin as a possible predictor for GDM.

Early Pregnancy Biochemical Predictors of Gestational Diabetes Mellitus

PURPOSE OF REVIEW

Universal oral glucose tolerance-based screening is employed to identify pregnant women with gestational diabetes mellitus (GDM), as treatment of this condition decreases the risk of associated complications. A simple and accurate blood test which identifies women at low or high risk for GDM in the first trimester would have the potential to decrease costs and improve outcomes through prevention or treatment. This review summarizes published data on early pregnancy biomarkers which have been tested as predictors of GDM.

RECENT FINDINGS

A large number of first-trimester biochemical predictors of GDM have been reported, mostly in small case-control studies. These include glycemic markers (fasting glucose, post-load glucose, hemoglobin A1C), inflammatory markers (C-reactive protein, tumor necrosis factor-alpha), insulin resistance markers (fasting insulin, sex hormone-binding globulin), adipocyte-derived markers (adiponectin, leptin), placenta-derived markers (follistatin-like-3, placental growth factor, placental exosomes), and others (e.g., glycosylated fibronectin, soluble (pro)renin receptor, alanine aminotransferase, ferritin). A few large studies suggest that first-trimester fasting glucose or hemoglobin A1C may be useful for identifying women who would benefit from early GDM treatment. To translate the findings from observational studies of first-trimester biomarkers for GDM to clinical practice, trials or cost-effectiveness analyses of screening and treatment strategies based on these novel biomarkers are needed.

Neopterin and hsCRP are not correlated in gestational diabetes mellitus

OBJECTIVE

To determine serum neopterin and high sensitive C-reactive protein (hsCRP) levels in patients with and without gestational diabetes mellitus (GDM).

METHODS

Neopterin and hsCRP levels were quantified in 28 women with GDM and 20 pregnant women with normal glucose tolerance (NGT). Postpartum neopterin and hsCRP levels were measured in a follow-up study.

RESULTS

Neopterin levels were significantly higher in women with GDM than in women with NGT (15.89 ± 8.19 nmol/L versus 10.4 ± 3.8 nmol/L, p < 0.008, respectively), however the levels significantly decreased after delivery in GDM group (15.89 ± 8.19 nmol/L versus 11.63 ± 5.96 nmol/L, p < 0.001). hsCRP levels were not different between women with and without GDM (5.74 ± 3.91 versus 5.73 ± 3.34, p = 0.9, respectively). In contrast, hsCRP levels decreased after delivery in patients with GDM (5.74 ± 3.91 versus 3.78 ± 2.78, p < 0.01). Neopterin levels were correlated with maternal age (r = 0.3, p = 0.02) and fasting glucose (r = 0.4, p = 0.004), postprandial glucose (r = 0.3, p = 0.01), HbA1c (r = 0.3, p = 0.02), whereas hsCRP levels were correlated with pre-pregnancy (r = 0.3, p = 0.04) and pregnancy body mass index (r = 0.4, p = 0.008). No correlation between serum neopterin and hsCRP levels was found (p = 0.9).

CONCLUSION

Neopterin levels increased in patients with GDM; hence, it may be related to inflammation. However, the lack of correlation between neopterin and hsCRP suggests the role of different attitudes of these two parameters in the course of pregnancy and GDM.

Gestational diabetes mellitus: Screening with fasting plasma glucose

Fasting plasma glucose (FPG) as a screening test for gestational diabetes mellitus (GDM) has had a checkered history. During the last three decades, a few initial anecdotal reports have given way to the recent well-conducted studies. This review: (1) traces the history; (2) weighs the advantages and disadvantages; (3) addresses the significance in early pregnancy; (4) underscores the benefits after delivery; and (5) emphasizes the cost savings of using the FPG in the screening of GDM. It also highlights the utility of fasting capillary glucose and stresses the value of the FPG in circumventing the cumbersome oral glucose tolerance test. An understanding of all the caveats is crucial to be able to use the FPG for investigating glucose intolerance in pregnancy. Thus, all health professionals can use the patient-friendly FPG to simplify the onerous algorithms available for the screening and diagnosis of GDM - thereby helping each and every pregnant woman.

Prediction and prevention of Gestational Diabetes: an update of recent literature

A diagnosis of Gestational Diabetes (GDM) confers adverse risk to the health of the mother and fetus both in pregnancy and later life. The background rate in pregnancy varies between 2 and 14% with incidences reported to be as high as 40% in obese populations. GDM diagnoses are escalating because of rising numbers of overweight and obesity in the reproductive age group but also because of different screening and diagnostic criteria. Lifestyle modification in those diagnosed with GDM has been proven to be an effective treatment in attenuating the metabolic dysregulation associated with this and potentially avoiding the need for medical therapy with either metformin or insulin. Emerging evidence in previous years suggests lifestyle interventions (dietary±physical activity and behavior modification) either pre-pregnancy or antenatally may reduce the incidence of GDM. The first trimester is also becoming an important interrogation period for the prediction of many adverse obstetric outcomes including abnormal glucose metabolism. This review outlines the most contemporary evidence on the prediction and non-pharmacological antenatal prevention strategies used for Gestational Diabetes.

Impact of Systemic Inflammation on the Progression of Gestational Diabetes Mellitus

With increasing rates of obesity and new diagnostic criteria for gestational diabetes mellitus (GDM), the overall prevalence of GDM is increasing worldwide. Women with GDM have an increased risk of maternal and fetal complications during pregnancy as well as long-term risks including higher prevalence of type 2 diabetes mellitus and cardiovascular disease. In recent years, the role of immune activation and inflammation in the pathogenesis of GDM has gained increasing attention. This monograph explores the current state of the literature as regards the expression of markers of inflammation in the maternal circulation, placenta, and adipose tissue of women with GDM.

Residual β-Cell Function Predicts Clinical Response After Autologous Hematopoietic Stem Cell Transplantation

New strategies of autologous hematopoietic stem cell transplantation (auto-HSCT) have gained much interest for the treatment of type 1 diabetes mellitus. However, assessing the clinical response and residual β-cell function still has limitations. The aim of the study was to select the optimal quantitative index to assess pre-existing β-cell function and to explore its predictive function for clinical response after auto-HSCT therapy. In this study, all of the patients who had undergone auto-HSCT were clustered into a responder group (Δβ-score > 0) and a nonresponder group (Δβ-score ≤ 0). We compared their quantitative metabolic indexes at baseline and performed receiver-operating characteristic (ROC) analysis to analyze the correlations between the indexes and clinical response. Kaplan-Meier analysis was conducted to compare the cumulative response durations in each quartile of the selected indexes. In an average of 15.13 ± 6.15 months of follow-up, 44 of 112 patients achieved a clinical response. The responder group had lower levels of fasting plasma glucose and quantitative insulin sensitivity check index (QUICKI) but higher levels of fasting C-peptide, fasting insulin, and homeostasis model assessments for insulin resistance (HOMA-IR). ROC analysis showed that HOMA-IR had the largest area under the curve (0.756), which was similar to that of QUICKI. Kaplan-Meier analysis further confirmed that the third quartile (1.3371-1.7018) of HOMA-IR or the second quartile (0.3523-0.3657) of QUICKI was preferential for a prolonged response. In conclusion, HOMA-IR and QUICKI could be optimal measurements for β-cell reserves, and they were predictive for the clinical response after auto-HSCT.

SIGNIFICANCE

The β-score was comprehensive and reliable in evaluating clinical response after autologous hematopoietic stem cell transplantation (HSCT). The homeostasis model assessments for insulin resistance and the quantitative insulin sensitivity check index could serve as precise assessments for residual β-cell function and good predictors of clinical response. They might be used to select optimal clinical trial participants or predict the clinical response after auto-HSCT.

Antenatal inflammation and gestational diabetes mellitus risk among pregnant African-American women

Although inflammation is associated with risk of gestational diabetes mellitus (GDM), little is known if there is an association between inflammation and GDM in African-American women, a group at higher risk for GDM complications. In the present study, we aimed to determine if selected inflammatory cytokines (i.e. TNF-α, hs-CRP, IL-6, IL-10, IL-6/IL-10 ratio, IL-1β) measured in the 2nd trimester, were associated with GDM risk in 185 pregnant African-American women. GDM was defined as a physician-documented GDM diagnosis, a fasting glucose between 92 and 125mg/dl, or evidence of glucose intolerance (defined using the 3-h glucose tolerance test). A total of 18 women (9.7%) had GDM. After covariate adjustment, C-reactive protein, measured at a mean 21.2±3.7 weeks gestation, was statistically significantly associated with GDM development (P=0.025); for every one-unit increase in log-transformed C-reactive protein, the odds of GDM increased by 5.3. Results were similar using a principal component analysis approach. This study provides evidence that higher levels of 2nd trimester C-reactive protein is associated with increased risk of GDM in African-American women. Further research is needed to examine whether C-reactive protein may be a useful early-pregnancy screen for evaluating potential GDM risk in African-American women.

Maternal inflammation during late pregnancy is lower in physically active compared with inactive obese women

The primary purpose of this study was to compare maternal plasma inflammation between physically active and inactive obese women during late pregnancy. The secondary purpose was to examine the relationships between maternal plasma inflammation and lipid metabolism and maternal and neonatal metabolic health in these women. A cross-sectional, observational study design was performed in 16 obese-inactive (OBI; means ± SD; age, 25.0 ± 4.8 years; prepregnancy body mass index (BMI), 36.3 ± 4.3 kg/m(2); body fat percentage in late gestation, 37.7% ± 3.5%) and 16 obese-active (OBA; age, 28.9 ± 4.8 years; prepregnancy BMI, 34.0 ± 3.7 kg/m(2); body fat in late gestation, 36.6% ± 3.8%) women during the third trimester of pregnancy. Maternal plasma inflammation (C -reactive protein (CRP)) and insulin resistance (Homeostatic Model Assessment-Insulin Resistance) were measured at rest. Plasma lipid concentration and metabolism (lipid oxidation and lipolysis) were measured at rest, during a 30-min bout of low-intensity (40% peak oxygen uptake) exercise, and during a resting recovery period using indirect calorimetry. Umbilical cord blood was collected for measurement of neonatal plasma insulin resistance, inflammation, and lipid concentration. Neonatal body composition was measured via air displacement plethysmography. Maternal plasma CRP concentration was significantly higher in OBI compared with OBA women (9.1 ± 4.0 mg/L vs. 6.3 ± 2.5 mg/L, p = 0.02). Maternal plasma CRP concentration was significantly associated with maternal lipolysis (r = 0.43, p = 0.02), baseline lipid oxidation rate (r = 0.39, p = 0.03), and baseline plasma free fatty acid concentration (r = 0.36, p = 0.04). In conclusion, maternal physical activity may reduce inflammation during pregnancy in obese women. Maternal lipid metabolism is related to systemic inflammation.

Hyperglycemia down-regulates cGMP-dependent protein kinase I expression in first trimester cytotrophoblast cells

Diabetes in pregnancy is associated with microvascular complications and a higher incidence of preeclampsia. The regulatory signaling pathways involving nitric oxide, cGMP, and cGMP-dependent protein kinase (PKG) have been shown to be down-regulated under diabetic conditions and contribute to the pathogenesis of vascular complications in diabetes. The present study was undertaken to investigate how high glucose concentrations regulate PKG expression in cytotrophoblast cells (CTBs). Human CTBs (Sw. 71) were treated with 45, 135, 225, 495, or 945 mg/dL glucose for 48 h. Some cells were pretreated with a p38 inhibitor (10 μM SB203580) or 10 μM rosiglitazone. After treatment, the cell lysates were subjected to measure the expression of protein kinase G1α (PKG1α), protein kinase G1β (PKG1β), soluble guanylate cyclase 1α (sGC1α), and soluble guanylate cyclase 1 β (sGC1β) by Western blot. Statistical comparisons were performed using analysis of variance with Duncan's post hoc test. The expressions of PKG1α, PKG1β, sGC1α, and sGC1β were significantly down-regulated (p < 0.05) in CTBs treated with >135 mg/dL glucose compared to basal (45 mg/dL). The hyperglycemia-induced down-regulation of cGMP and cGMP-dependent PKG were attenuated by the SB203580 or rosiglitazone pretreatment. Exposure of CTBs to excess glucose down-regulates cGMP and cGMP-dependent PKG, contributing to the development of vascular complications in diabetic mothers during pregnancy. The attenuation of hyperglycemia-induced down-regulation of PKG proteins by SB203580 or rosiglitazone pretreatment further suggests the involvement of stress signaling mechanisms in this process.