Effects of GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation on offspring outcomes: a systematic review of the evidence

Breastfeeding in metabolic and bariatric patients: a comprehensive guide for surgeons, patients, and the multidisciplinary team

Since nearly 40% of metabolic and bariatric surgery (MBS) patients are individuals with the ability to bear children, many may seek to become pregnant or may be currently lactating when seeking surgery. While many patients plan to breastfeed, MBS patients are at high risk for premature cessation of breastfeeding. Limited literature exists on the impact of MBS on lactation and there are no established guidelines to help clinicians support and educate MBS patients about breastfeeding. Herein, we aim to fill that gap by providing a comprehensive guide for bariatric surgeons, obstetricians, women's health providers, lactation consultants, registered dietitians, bariatric nurse coordinators, and advanced practice providers to support breastfeeding in patients with a history of MBS or who are considering MBS. We review physician-patient discussion points on how MBS impacts lactation, the micronutrient and caloric needs for this unique population, and data to support successful breastfeeding in post-MBS patients who are lactating regarding practical, anesthetic, and imaging considerations.

GLP-1 Receptor Agonists in Pediatric and Adolescent Obesity

Obesity remains highly prevalent among children in the United States and is associated with an ever-increasing burden of obesity-related diseases. Effective pediatric obesity prevention and treatment will require both societal interventions and health care system innovation. One recent advancement is the approval of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for use in adolescents. GLP-1RAs are notable for their effectiveness in weight management and in their ability to ameliorate obesity-related diseases. GLP-1RAs can be an important part of a comprehensive treatment plan for pediatric patients seeking obesity care, and we will review the pediatric clinician's considerations for their effective use. We discuss the history of obesity pharmacology and development of GLP-1RAs. We review the indications for use and common adverse reactions. We highlight the importance of mental health care for obesity treatment, with a focus on disordered eating behaviors and their intersection with obesity and pharmacologic treatment of obesity. Nutrition remains an important issue for obesity prevention and management, and we highlight nutritional concerns during GLP-1RA therapy. Finally, we discuss health inequities in obesity, the dangers of perpetuating these inequities if GLP-1RA access remains biased, and the opportunities for improvement.

A Guide to the Management of Hidradenitis Suppurativa in Pregnancy and Lactation

Hidradenitis suppurativa is a chronic inflammatory condition characterized by recurrent abscesses, nodules, tunnels, and scarring. Fluctuations in disease activity are common during pregnancy, and more than half of women with hidradenitis suppurativa report experiencing post-partum flares. Both treatment efficacy and safety of the woman and fetus or infant must be considered when developing a treatment plan for pregnant and lactating women with hidradenitis suppurativa. Although certain commonly used hidradenitis suppurativa medications, such as tetracyclines and spironolactone, are contraindicated during pregnancy, there are still various medical therapies, including topicals, systemic antibiotics, metabolic modulators, and biologics, as well as procedural therapies that may be utilized during pregnancy. This paper aims to provide an updated evidence-based review of the management of hidradenitis suppurativa in pregnancy with an emphasis on safety data.

Efficacy and Safety of Glucagon-like Peptide-1 Receptor Agonist Use During the First Trimester in Pregnant Women With Type 2 Diabetes

BACKGROUND

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a newer class of antidiabetic drugs that have proven beneficial in reducing weight loss and improving cardiometabolic profile. Literature has shown worsened glycemic control and increased risk of cardiovascular outcomes after stopping GLP-1 RAs in the adult type 2 diabetes (T2D) population; however, the effect of exposure to GLP-1 RAs in first-trimester pregnancy, followed by discontinuation, is still unclear.

OBJECTIVE

To evaluate the maternal and fetal clinical outcomes after exposure of GLP-1 RAs in a T2D first-trimester pregnant population.

METHODS

This retrospective cohort was based on a global database of electronic health records (EHRs) of more than 140 million patients. After propensity score matching (PSM), the study population included 3,652 women with T2D, divided into 2 cohorts based on their exposure to GLP-1 RAs within 1 year before and 1 month after diagnosis of first-trimester pregnancy. Exposure to GLP-1 RAs within 1 year before and 1 month after diagnosis of first-trimester pregnancy in T2D women.

RESULTS

In this study of a 3,652 first-trimester T2D population, the average age of the GLP-1 RAs exposed cohort was 36.2 years. The primary outcome of the maternal all-cause mortality rate was comparable in the GLP-1 RAs-exposed first-trimester pregnant cohort compared to the control cohort after 42 weeks of follow-up. Secondary maternal outcomes, i.e., gestational hypertension, preeclampsia, and eclampsia, were also comparable after 42 weeks of follow-up in the women with T2D exposed to GLP-1 RAs during their pregnancy as compared to the control. Similarly, the relative risk of fetal cardiac and kidney anomalies was comparable between the cohorts.

CONCLUSION

In this study, exposure to GLP-1 RAs during the first trimester of pregnancy in T2D.

Semaglutide as a GLP-1 Agonist: A Breakthrough in Obesity Treatment

This review addresses the role of semaglutide (SMG), a GLP-1 receptor agonist, in the treatment of obesity and its related comorbidities. Originally developed for type 2 diabetes (DM2), SMG has shown significant efficacy in weight reduction, with superior results compared to other treatments in the same class. Its effects include appetite suppression, increased satiety, and improvements in cardiovascular, renal, and metabolic parameters. Studies such as SUSTAIN, PIONEER, and STEP highlight its superiority compared to other GLP-1 receptor agonists and anti-obesity drugs. The oral formulation showed promising initial results, with higher doses (50 mg) showing weight losses comparable to those of subcutaneous administration. Despite its benefits, there are challenges, such as weight regain after cessation of treatment, gastrointestinal adverse effects, and variability of response. Future studies should explore strategies to mitigate these effects, identify predictive factors of efficacy, and expand therapeutic indications to other conditions related to obesity and insulin resistance. The constant innovation in this class of drugs reinforces the potential of SMG to transform treatment protocols for chronic weight-related diseases.

What is the evidence regarding the safety of new obesity pharmacotherapies

The use of gut-hormone receptors agonists as new therapeutic options for obesity and some of its related comorbidities, such as type 2 diabetes, has resulted in an unprecedented efficacy in the medical management of people living with obesity (PLWO). Appraisal of the safety of these drugs is of utmost importance considering the large number of PLWO, and the potentially long exposure to these pharmacotherapies. In this narrative review we summarize the evidence on the safety of liraglutide, semaglutide, and tirzepatide as derived from randomized clinical trials conducted in adults living with obesity. Additionally, the safety of these drugs is put into perspective with that of other drugs currently approved for the treatment of PLWO. Overall, the available data support a favorable efficacy versus safety balance for gut-hormone hormone receptor analogues in the treatment of these subjects. Nonetheless, it should be acknowledged that in the context of a chronic disease that has reached epidemic proportions, data from randomized clinical trials aimed primarily at proving the efficacy of these drugs may have been insufficient to unveil all the safety issues. Thus, continuous surveillance on the adverse effects of liraglutide, semaglutide, and tirzepatide is required as we use these drugs in a broader population than that represented in currently available clinical trials.

Insulin Allergy: The Allergist's Updated Approach to Evaluation and Management

The transformative discovery of insulin in the early 20th century followed by its rapid clinical implementation was initially complicated by high rates of hypersensitivity reactions. Improvements in purification methods and the transition from animal-derived sources to human insulin products has significantly lowered, although not eliminated, hypersensitivity reactions to insulin. Although considered rare adverse reactions to insulin, hypersensitivity reactions and immune-mediated manifestations continue to occur in patients requiring insulin treatment. This has broad implications given that approximately 11.6% of the US population has a diagnosis of diabetes and 8.4 million Americans rely on insulin for survival. Because of the scope and impact of insulin as a life-saving treatment for patients with diabetes, it is important for allergists to evaluate, provide a diagnose for, and manage patients with hypersensitivity reactions to insulin appropriately. Recognizing early manifestations of insulin hypersensitivity is the first step in providing prompt and targeted management in these complex cases. The following article aims to summarize the allergist's recommended approach to insulin hypersensitivity reactions, including type I IgE-mediated and type III immune-complex mediated reactions, type IV T-cell mediated hypersensitivity reactions, as well as additional immune-mediated manifestations of insulin therapy such as lipoatrophy and insulin autoantibodies. Furthermore, the authors emphasize approaching insulin hypersensitivity cases with a broad differential diagnosis, which includes hypoglycemia, anaphylaxis mimics, hypersensitivity to excipients and medical devices, and cutaneous manifestations of diabetes.

GLP-1 receptor agonist therapy and pregnancy: Evolving and emerging evidence

The prevalence of type 2 diabetes mellitus (T2DM) and obesity is increasing in young adults, posing significant risks around pregnancy. Obesity also impacts on fertility and the co-existence of polycystic ovarian syndrome increases the prevalence of cardiovascular metabolic risk factors. There has been a renewed interest in glucagon-like peptide-1 receptor agonists (GLP-1RA) in this context, due to their multi-dimensional impact on the reproductive axis, as well as their ability to simultaneously target weight loss and glycaemic control. There is, however, limited availability of safety data with respect to these newer non-insulin-based diabetes medications from the perspective of fetal development. As GLP-1RA are not licensed for use in pregnancy, with the increasing chances of incidental exposure from pre-conception use for obesity and T2DM, it is imperative that pre-conception counselling should be an integral part of consultation prior to the initiation of these drugs.

Role of Glucagon-Like Peptide-1 Receptor Agonists in People With Infertility and Pregnancy

Obesity is a chronic condition that causes significant morbidity and mortality in people in the United States and around the world. Traditional means of weight loss include diet, exercise, behavioral modifications, and surgery. New weight loss medications, glucagon-like peptide-1 receptor agonists, are revolutionizing the management of weight loss but have implications for fertility and pregnancy. Obesity is associated with infertility and may affect response to ovulation induction medications. In pregnancy, obesity increases the risks of spontaneous abortion, birth defects, gestational diabetes, hypertensive disorders of pregnancy, cesarean delivery, and stillbirth. Lifestyle changes alone for weight loss have not improved outcomes. Glucagon-like peptide-1 receptor agonists and new medications targeting gut hormones can help people achieve their weight loss goals but are contraindicated in pregnancy. Obstetrician-gynecologists should work with patients to manage these medications before they become pregnant, between pregnancies, and after delivery.

Metformin in gestational diabetes: physiological actions and clinical applications

Metformin is an effective oral hypoglycaemic agent used in the treatment of type 2 diabetes mellitus; however, its use in pregnancy for the treatment of gestational diabetes mellitus (GDM) remains controversial owing to concerns around safety and efficacy. This comprehensive review outlines the physiological metabolic functions of metformin and synthesizes existing literature and key knowledge gaps pertaining to the use of metformin in pregnancy across various end points in women with GDM. On the basis of current evidence, metformin reduces gestational weight gain, neonatal hypoglycaemia and macrosomia and increases insulin sensitivity. However, considerable heterogeneity between existing studies and the grouping of aggregate and often inharmonious data within meta-analyses has led to disparate findings regarding the efficacy of metformin in treating hyperglycaemia in GDM. Innovative analytical approaches with stratification by individual-level characteristics (for example, obesity, ethnicity, GDM severity and so on) and treatment regimens (diagnostic criteria, treatment timing and follow-up duration) are needed to establish efficacy across a range of end points and to identify which, if any, subgroups might benefit from metformin treatment during pregnancy.

Kidney disease and reproductive health

Understanding the relationship between reproductive health and kidney function is important to provide holistic care for people living with kidney disease. Chronic kidney disease (CKD) has negative impacts on both male and female fertility owing to factors including inflammation, hormonal dysregulation, reduced ovarian reserve, reduced sperm quality and sexual dysfunction. However, pregnancy is achievable for most cisgender women with kidney disease, including kidney transplant recipients and patients on dialysis. CKD in pregnancy is associated with health risks to the mother and child, including increased risk of progression of kidney disease, hypertensive complications of pregnancy, and neonatal complications including fetal growth restriction, preterm birth and stillbirth. However, with appropriate pre-pregnancy counselling, fertility assessment and support, health optimization, and evidence-based antenatal care, the majority of patients will achieve a good outcome. Medication safety should be reviewed before and during pregnancy and lactation, weighing the risk of disease flare against potential adverse effects on the offspring. Important areas for further research include the optimal timing of delivery and the short- and long-term cardiovascular and renal impacts of pregnancy in patients with CKD, as well as long-term kidney and cardiovascular outcomes in their offspring.

Maternal lipids in overweight and obesity: implications for pregnancy outcomes and offspring's body composition

Overweight and obesity (OWO) are linked to dyslipidemia and low-grade chronic inflammation, which is fueled by lipotoxicity and oxidative stress. In the context of pregnancy, maternal OWO has long been known to negatively impact on pregnancy outcomes and maternal health, as well as to imprint a higher risk for diseases in offspring later in life. Emerging research suggests that individual lipid metabolites, which collectively form the lipidome, may play a causal role in the pathogenesis of OWO-related diseases. This can be applied to the onset of pregnancy complications such as gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), which in fact occur more frequently in women affected by OWO. In this review, we summarize current knowledge on maternal lipid metabolites in pregnancy and highlight associations between the maternal lipidome and the risk to develop GDM, HDP and childhood OWO. Emerging data underpin that dysregulations in maternal triglyceride, phospholipid and polyunsaturated fatty acid (PUFA) metabolism may play a role in modulating the risk for adverse pregnancy outcomes and childhood OWO, but it is yet premature to convert currently available insights into clinical guidelines. Well-designed large-scale lipidomic studies, combined with translational approaches including animal models of obesity, will likely facilitate the recognition of underling pathways of OWO-related pregnancy complications and child's health outcomes, based on which clinical guidelines and recommendations can be updated.

Semaglutide: Double-edged Sword with Risks and Benefits

Type 2 Diabetes Mellitus therapy has evolved over the years to now include a new class of therapeutics, semaglutide. This article reviews the mechanism of action and formulation of semaglutide therapy, potential benefits, contraindications, adverse effects, and drug interactions. Oral and subcutaneous semaglutide therapies have shown effectiveness in improving glycemic control, weight loss, and reducing cardiovascular risks associated with diabetes mellitus. Semaglutide has also shown potential in being used as a therapeutic strategy in Alzheimer's disease due to its anti-neuroinflammatory effects and being used to treat polycystic ovary syndrome. However, semaglutide therapy is also associated with concerning adverse effects like acute pancreatitis, anesthetic risks like pulmonary aspiration or residual gastric content, acute kidney injury, acute gallbladder injury, nonarteritic anterior ischemic optic neuropathy and diabetic retinopathy. Contraindications of semaglutide include history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2, and pregnancy. Drug interactions to consider with semaglutide therapy include those also used in diabetes treatment, like metformin, as well as anti-psychotics, due to anti-psychotics associated weight gain. The findings of this article emphasize the need for a cross-disciplinary approach to understand the molecular mechanisms and clinical implications of semaglutide on patients with complex medical histories and treatment regimens. The potential anesthetic risks of semaglutide therapy warrant careful consideratiion with ethical concerns. Further studies can assess if there is a need to modify pre-operative guidelines to account for patient using semaglutide and how delayed gastric emptying and constitpation will affect surgical outcomes and complications. While semaglutide therapy for diabetes mellitus has been established, there is a need for extensive research on repurposing semaglutide in neurodegenerative disease treatment.

Medical therapy to treat obesity and optimize fertility in women of reproductive age: a narrative review

BACKGROUND

Overweight and obesity-chronic illnesses in which an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass resulting in adverse metabolic, biomechanical, and psychosocial health consequences-negatively impact female fertility. Adverse conception outcomes are multifactorial, ranging from poor oocyte quality and implantation issues to miscarriages and fetal health issues. However, with the advent of novel pharmacologic agents, significant weight loss can be achieved, improving the chances of healthy pregnancies, and their use should be considered during periconceptual counseling. There are currently 6 FDA-approved medications for weight loss: 2 GLP1-receptor agonists (GLP1-RAs) liraglutide and semaglutide, 1 dual GLP-1 and gastric inhibitory peptide agonist (GLP1-GIP) tirzepatide, Contrave (naltrexone/bupropion), Qsymia (phentermine/Topamax), and Xenical (orlistat). GLP1-RAs reduce food cravings, appetite, and "food noise" and improve insulin sensitivity and satiety, all of which lead to significant weight loss, ranging from 6 to 30% of starting total body weight or greater, depending on the specific agent used. Their efficacy and relative safety should make them first-line options for women seeking to lose weight in the year before trying to conceive. Contrave, the combination of naltrexone and bupropion, seems to work most significantly for weight loss by inhibiting the rewarding and reinforcing effects of food consumption. Clinical trials report ~ 6% loss of starting total body weight with use of Contrave, as well as improvement in metabolic health factors. It may also improve a woman's ability to conceive by mitigating the effects of PCOS and endometriosis and reducing the drive for alcohol and smoking. Qsymia, the combination of phentermine and topiramate, results in more weight loss than Contrave but cannot be used in the acute preconception period, as its topiramate component is a known teratogen. Orlistat is another FDA-approved medication for weight loss; however, it is currently used much less often than other anti-obesity drugs because of its relatively lower efficacy and significant side effects. Bariatric surgery, which can lead to significant weight loss (25-50%), was previously regarded as the most durable method for weight loss, before the advent of GLP1-RAs. Given the inherent risks of surgery, the development of vitamin (i.e. B12, folate, vitamin D) and mineral (i.e. iron, copper, zinc) deficiencies, that may impact the health of the mother and fetus, as well as the recommended delay of 1-2 years prior to attempting pregnancy, bariatric surgery should not be considered first-line therapy for obesity management in women of reproductive age, especially for women who are hoping to conceive quickly or are nearing advanced maternal age.

CONCLUSION

Clinically significant and meaningful weight loss is achievable with pharmacotherapy to help enhance fertility in women of reproductive age who are overweight or obese. Current research supports the use of weight loss medications for enhancing spontaneous conception and response to ovulation induction. Further research on the effects upon live birth rates are warranted. For meaningful weight loss, GLP1-RAs can be considered for use in the preconception period, as long as they are stopped at least 2 months before conception. Contrave can be considered as well, though resulting in less weight loss. Phentermine and Qsymia are teratogenic but can be used with contraception for weight loss before trying to get pregnant.

GLP-1 and Its Analogs: Does Sex Matter?

While obesity and diabetes are prevalent in both men and women, some aspects of these diseases differ by sex. A new blockbuster class of therapeutics, glucagon-like peptide 1 (GLP-1) analogs (eg, semaglutide), shows promise at curbing both diseases. This review addresses the topic of sex differences in the endogenous and therapeutic actions of GLP-1 and its analogs. Work on sex differences in human studies and animal research is reviewed. Preclinical data on the mechanisms of potential sex differences in the endogenous GLP-1 system as well as the therapeutic effect of GLP-1 analogs, focusing on the effects of the drugs on the brain and behavior relating to appetite and metabolism, are highlighted. Moreover, recent clinical evidence of sex differences in the therapeutic effects of GLP-1 analogs in obesity, diabetes, and cardiovascular disease are discussed. Lastly, we review evidence for the role of GLP-1 analogs in mood and reproductive function, with particular attention to sex differences. Overall, while we did not find evidence for many qualitative sex differences in the therapeutic effect of clinically approved GLP-1 analogs, a growing body of literature highlights quantitative sex differences in the response to GLP-1 and its analogs as well as an interaction of these therapeutics with estrogens. What also clearly emerges is the paucity of data in female animal models or women in very basic aspects of the science of GLP-1-gaps that should be urgently mended, given the growing popularity of these medications, especially in women.

The Potential Role of Glucagon-Like Peptide-1 (GLP-1) Agonists for Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) poses a multifaceted challenge, affecting women through genetic susceptibility, obesity, and insulin resistance. This narrative review explores the potential therapeutic role of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in PCOS treatment, with a focus on weight loss and associated metabolic changes. The off-label use of GLP-1 RAs in this population helps to treat comorbid obesity. By thoroughly examining PCOS diagnostic criteria, current treatments, and clinical trial outcomes involving GLP-1 RAs, this research reveals encouraging results. However, concerns about the long-term safety of GLP-1 RAs, including serious adverse events, warrant further investigation. While GLP-1 RAs hold promise for treating obesity in PCOS, safety issues may limit their utility.

Glucagon-like peptide-1 receptor agonist use in pregnancy: a review

Glucagon-like peptide-1 receptor agonists are peptide analogues that are used to treat type 2 diabetes mellitus and obesity. The first medication in this class, exenatide, was approved in 2005, and these medications, specifically semaglutide, have become more popular in recent years due to their pronounced effects on glycemic control, weight reduction, and cardiovascular health. Due to successful weight loss from these medications, many women previously diagnosed with oligomenorrhea and unable to conceive have experienced unplanned pregnancies while taking the medications. However, there are currently little data for clinicians to use in counseling patients in cases of accidental periconceptional exposure. In some studies examining small animals exposed to glucagon-like peptide-1 receptor agonists in pregnancy, there has been evidence of adverse outcomes in the offspring, including decreased fetal growth, skeletal and visceral anomalies, and embryonic death. Although there are no prospective studies in humans, case reports, cohort studies, and population-based studies have not shown a pattern of congenital anomalies in infants. A recent large, observational, population-based cohort study examined 938 pregnancies affected by type 2 diabetes mellitus and compared outcomes from periconceptional exposure to glucagon-like peptide-1 receptor agonists and insulin. The authors concluded there was not a significantly increased risk of major congenital malformations in patients taking glucagon-like peptide-1 receptor agonists, although there was no information on maternal glycemic control or diabetic fetopathy. As diabetic embryopathy is directly related to the degree of maternal hyperglycemia and not the diagnosis of diabetes itself, it is not possible to make this conclusion without this information. Furthermore, there is little evidence available regarding fetal growth restriction, embryonic or fetal death, or other potential complications. At this time, patients should be counseled there is not enough evidence to predict any adverse effects, or the lack thereof, of periconceptional exposure of glucagon-like peptide-1 receptor agonists during pregnancy. We recommend that all patients use contraception to prevent unintended pregnancy while taking glucagon-like peptide-1 receptor agonists.

Exendin-4, a glucagon-like peptide-1 receptor agonist, regulates ductus arteriosus by vasodilation and anti-remodeling through the PKA pathway

The mechanisms of ductus arteriosus (DA) closure involve vasoconstriction and vascular remodeling. Previous findings indicate that the glucagon-like peptide-1 receptor agonist (GLP-1RA) exhibits antihypertensive and anti-remodeling effects in the pulmonary circulation. However, its role in the DA remains unknown. This study aimed to investigate whether exendin-4 (Ex-4), a GLP-1RA, can regulate DA patency and elucidate its mechanisms. After confirming the presence of GLP-1R in neonatal rat DA tissue in vivo, the effects of Ex-4 on DA patency in neonatal rats were sequentially examined. Two hours after birth, we observed spontaneous closure of the DA in control rats. In contrast, Ex-4 prevented the closure of DA, accompanied by reduced intimal thickening. Ex-4 attenuated oxygen-induced vasoconstriction in isolated DA rings ex vivo. This effect was diminished in the presence of H89, a PKA inhibitor. In vitro, Ex-4 inhibited platelet-derived growth factor (PDGF)-BB-induced proliferation and migration of DA smooth muscle cells. Additionally, Ex-4 inhibited PDGF-BB-induced reactive oxygen species (ROS) production, calcium mobilization, and signal transduction of MAPK and Akt pathways. Furthermore, Ex-4 preserved the nuclear expression of Nrf2 attenuated by PDGF-BB. Similarly, all these in vitro effects of Ex-4 were blunted by H89. In conclusion, Ex-4 maintains postnatal DA patency through vasodilatation and anti-remodeling via the PKA pathway. The GLP-1R/PKA pathway emerges as a promising target of DA patency in clinical management.

CKD in reproductive-aged women: a call for early nephrology referral and multidisciplinary care

Chronic Kidney Disease (CKD) affects millions globally, with a notable impact on biological females of reproductive age. This population faces specific issues such as fertility concerns, complex contraceptive decisions, and complications related to pregnancy that can exacerbate CKD. Given the increasing prevalence of CKD among young men and women owing to rising rates of hypertension, obesity, and diabetes, there is a need for early and tailored interventions among women of childbearing age. Current Kidney Disease Improving Global Outcomes (KDIGO) guidelines suggest nephrology referral primarily for advanced CKD stages or significant proteinuria. However, women at any CKD stage may face complex pregnancy-related decisions and increased risks that are not adequately addressed by these guidelines, warranting early specialty care. This review explores the distinct needs of women of reproductive age with CKD, identifies gaps in the existing management framework, and advocates for earlier and more comprehensive nephrology involvement. By focusing on preconception planning, risk factor management, adverse pregnancy outcomes, and existing disparities in care, this review seeks to improve understanding of the needs of women of reproductive age with CKD and calls for a shift towards more proactive, nephrology-driven care.

What is known about the use of weight loss medication in women with overweight/obesity on fertility and reproductive health outcomes? A scoping review

Pregnancy during or soon after treatment with weight loss medication, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs), is contraindicated due to potential teratogenicity. The aim of this scoping review is to investigate what is known about the use of weight loss medication in women of childbearing age in relation to reproductive health outcomes, focusing on the three medications licenced in the United Kingdom at the time of the search. A systematic search of studies that assessed reproductive health outcomes in women taking either orlistat, liraglutide or semaglutide was undertaken in July 2023 and updated in January 2024 across MEDLINE, Embase, CINAHL, Scopus, ClinicalTrials.gov, PROSPERO, Epistemonikos and OpenGrey. Studies focused on polycystic ovarian syndrome, diabetes or animals were excluded. Titles and abstracts were screened, and data from included articles were extracted. After removal of duplicates, 341 titles remained, of which 318 were excluded. Of the final 18 articles included, there were five interventional trials, one retrospective case-control study, six narrative reviews, two systematic reviews, three systematic review protocols and one registry protocol yet to start recruitment. All five interventional trials involved orlistat given preconceptionally, showing no improvement in live birth rate, despite improvement in reproductive hormone levels. There were no studies with primary data about GLP-1 RAs. There were no qualitative studies. There is an absence of primary data about the role of GLP-1 RAs on the reproductive health of women of childbearing age without polycystic ovarian syndrome. Future research should explore short- and long-term effects on reproductive health, pregnancy outcomes and experiences.

Approach to Glomerular Disease in Pregnancy

The presence of glomerular diseases in pregnancy presents challenges to both patients and nephrologists. The preconception planning in patients with kidney disease involves comprehensive stratification, treatment optimization, and comorbidity assessment, requiring nephrologists to engage in well-informed decision-making processes alongside their patients. There is a necessity for a multidisciplinary approach to meet their complex healthcare needs. Effective control of blood pressure, proteinuria, and disease activity are pivotal in mitigating adverse pregnancy events. This comprehensive review intends to equip nephrologists with the requisite knowledge and understanding to navigate the intricate landscape of glomerular diseases in pregnancy. It delves into the challenges associated with the diagnosis of glomerular diseases, the significance of preconception counseling, and the nuances of antenatal and postnatal care. Additionally, the article provides insights into the management and prognosis of glomerular diseases, shedding light on the judicious use of immunosuppression as a therapeutic tool.

How do BMI-restrictive policies impact women seeking NHS-funded IVF in the United Kingdom? A qualitative analysis of online forum discussions

BACKGROUND

Across the United Kingdom's National Health Service (NHS), women with a Body Mass Index (BMI) of > 30 face restrictions accessing In Vitro Fertilisation (IVF) treatment. This study asks: what are the (un)expected and (un)intended harms and consequences experienced by women restricted from accessing NHS-funded IVF due to BMI threshold criteria?

METHODS

Posts from a popular infertility online forum were collected and reflexively thematically analysed.

RESULTS

On the forum, users discussed how they struggled to lose weight, how they faced time pressures to meet BMI thresholds, and they shared knowledge on how to comply or appear compliant with BMI cut-offs. Our study found widespread moral discourses around body weight were reproduced in the forum, particularly commonplace narratives that body weight is under personal control, that people with a high BMI should 'work' to change their bodies, and that this work helps demonstrate deservingness for IVF treatment. Moralising discourses around weight were linked to the responsibilities of a hoped-for future of motherhood, as users performed deservingness through emphasising their commitment to meeting the BMI threshold.

CONCLUSION

We conclude that NHS-IVF policies in the United Kingdom do not consider the burdensome emotional and moral work placed on people seeking treatment due to inflexible upper-limit BMI criteria.

Assessing the therapeutic and toxicological profile of novel GLP-1 receptor agonists for type 2 diabetes

INTRODUCTION

GLP-1 receptor agonists provide multiple benefits for patients with type 2 diabetes. Nonetheless, there are also several significant adverse effects associated with these agents. A thorough understanding of both therapeutic and toxicological profiles of GLP-1 receptor agonists is crucial for appropriate utilization of this medication class. A literature search of PubMed and ClinicalTrials.gov was carried out to inform discussion on the topic.

AREAS COVERED

This review article discusses the key advantages and disadvantages derived from the use of GLP-1 receptor agonists in the treatment of type 2 diabetes. Landmark trials which helped characterize the cardiovascular and renal benefits of GLP-1 receptor agonists are highlighted. We also discuss key studies still in progress and new formulations under investigation.

EXPERT OPINION

GLP-1 receptor agonists provide glycemic and complication-risk reduction benefits for individuals with type 2 diabetes. Current data suggests there is a lot of potential for further applications, even outside of type 2 diabetes management. It would be of particular interest to see the range of benefits conferred from GLP-1 receptor agonists in individuals without type 2 diabetes. Broader application of these medications could be expected given the ongoing development of new oral formulations and combination agents.

Key results from observational studies and real-world evidence of sodium-glucose cotransporter-2 inhibitor effectiveness and safety in reducing cardio-renal risk

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, originally designed to manage blood sugar levels in individuals with type 2 diabetes (T2D), have emerged as a crucial class of drugs for managing cardio-renal diseases. These drugs work by targeting the SGLT2 protein in the kidneys, promoting the excretion of glucose and influencing metabolic pathways beyond glucose control. The relationship between cardio-renal diseases and SGLT2 inhibitors has been explored through landmark trials and real-world evidence (RWE) studies, demonstrating significant reductions in cardio-renal complications. This review discusses the importance of RWE studies alongside randomized controlled trials in understanding the real-world effectiveness and safety of SGLT2 inhibitors. It outlines the advantages and disadvantages of RWE compared to RCTs, highlighting their complementary roles in providing comprehensive insights into treatment outcomes. By examining a range of RWE studies, the review underscores the cardio-renal benefits of SGLT2 inhibitors across various patient populations. Safety assessments indicate that SGLT2 inhibitors are generally well tolerated, with severe adverse events being rare. Common issues, such as genital mycotic infections and urinary tract infections, are acknowledged, alongside less frequent but significant adverse events including diabetic ketoacidosis, lower-limb amputations, and bone fractures. In summary, SGLT2 inhibitors show promising cardio-renal protective effects in real-world scenarios across diverse populations in T2D, indicating their potential as early intervention measures. Continued research is essential for gaining a thorough understanding of their long-term effects and safety profiles.

Cardiac physiology and pathophysiology in pregnancy

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

What Do We Know about Peripartum Cardiomyopathy? Yesterday, Today, Tomorrow

Peripartum cardiomyopathy is a disease that occurs during or after pregnancy and leads to a significant decline in cardiac function in previously healthy women. Peripartum cardiomyopathy has a varying prevalence among women depending on the part of the world where they live, but it is associated with a significant mortality and morbidity in this population. Therefore, timely diagnosis, treatment, and monitoring of this disease from its onset are of utmost importance. Although many risk factors are associated with the occurrence of peripartum cardiomyopathy, such as conditions of life, age of the woman, nutrient deficiencies, or multiple pregnancies, the exact cause of its onset remains unknown. Advances in research on the genetic associations with cardiomyopathies have provided a wealth of data indicating a possible association with peripartum cardiomyopathy, but due to numerous mutations and data inconsistencies, the exact connection remains unclear. Significant insights into the pathophysiological mechanisms underlying peripartum cardiomyopathy have been provided by the theory of an abnormal 16-kDa prolactin, which may be generated in an oxidative stress environment and lead to vascular and consequently myocardial damage. Recent studies supporting this disease mechanism also include research on the efficacy of bromocriptine (a prolactin synthesis inhibitor) in restoring cardiac function in affected patients. Despite significant progress in the research of this disease, there are still insufficient data on the safety of use of certain drugs treating heart failure during pregnancy and breastfeeding. Considering the metabolic changes that occur in different stages of pregnancy and the postpartum period, determining the correct dosing regimen of medications is of utmost importance not only for better treatment and survival of mothers but also for reducing the risk of toxic effects on the fetus.

Implications of pregnancy on cardiometabolic disease risk: preeclampsia and gestational diabetes

Cardiometabolic disorders, such as obesity, insulin resistance, and hypertension, prior to and within pregnancy are increasing in prevalence worldwide. Pregnancy-associated cardiometabolic disease poses a great risk to the short- and long-term well-being of the mother and offspring. Hypertensive pregnancy, notably preeclampsia, as well as gestational diabetes are the major diseases of pregnancy growing in prevalence as a result of growing cardiometabolic disease prevalence. The mechanisms whereby obesity, diabetes, and other comorbidities lead to preeclampsia and gestational diabetes are incompletely understood and continually evolving in the literature. In addition, novel therapeutic avenues are currently being explored in these patients to offset cardiometabolic-induced adverse pregnancy outcomes in preeclamptic and gestational diabetes pregnancies. In this review, we discuss the emerging pathophysiological mechanisms of preeclampsia and gestational diabetes in the context of cardiometabolic risk as well as the most recent preclinical and clinical updates in the pathogenesis and treatment of these conditions.

Dyslipidemia management in women of reproductive potential: An Expert Clinical Consensus from the National Lipid Association

Cardiovascular disease (CVD) is the leading cause of death among women and its incidence has been increasing recently, particularly among younger women. Across major professional society guidelines, dyslipidemia management remains a central tenet for atherosclerotic CVD prevention for both women and men. Despite this, women, particularly young women, who are candidates for statin therapy are less likely to be treated and less likely to achieve their recommended therapeutic objectives for low-density lipoprotein cholesterol (LDL-C) levels. Elevated LDL-C and triglycerides are the two most common dyslipidemias that should be addressed during pregnancy due to the increased risk for adverse pregnancy outcomes, such as preeclampsia, gestational diabetes mellitus, and pre-term delivery, as well as pancreatitis in the presence of severe hypertriglyceridemia. In this National Lipid Association Expert Clinical Consensus, we review the roles of nutrition, physical activity, and pharmacotherapy as strategies to address elevated levels of LDL-C and/or triglycerides among women of reproductive age. We include a special focus on points to consider during the shared decision-making discussion regarding pharmacotherapy for dyslipidemia during preconception planning, pregnancy, and lactation.

Treating obesity and fertility in the era of glucagon-like peptide 1 receptor agonists

The objective of this narrative review is to advocate for improved comprehensive care of patients with obesity and infertility. Persons with an increased body mass index have less successful reproductive outcomes, and recently, new medications to treat neuroendocrine hormone imbalances are producing meaningful weight loss akin to surgical interventions. For the first time, obesity is publicly being recognized as a disease. These medications contain the newest generation of glucagon-like peptide 1 receptor agonists and deserve our attention for several reasons: regardless of body mass index, many patients will be using them; it is necessary to understand the mode of action, side effects, and implications for anesthetic procedures and pregnancy; and it is important to evaluate when they could be used to improve health outcomes and/or access to fertility care.

Kidney outcomes are altered by preconception weight modulation in rodent mothers with obesity

Obesity increases the risk of chronic kidney disease. We have previously demonstrated the benefits of preconception maternal weight loss on fertility and pregnancy outcomes in a mouse model of maternal obesity. Here, we elucidate if preconception weight loss, either by diet modification or the glucose-like peptide 1 agonist liraglutide, used in the treatment of diabetes and obesity, improves maternal kidney outcomes in late gestation. C57BL/6 female mice were fed either a high-fat-diet (HFD) or a chow (control) diet for 8 weeks. To induce pre-pregnancy weight loss, HFD-fed dams were switched to chow diet (HFD-C) or administered liraglutide (0.3 mg/kg subcutaneous) whilst continuing on HFD (HFD-L). Liraglutide was discontinued one week prior to mating. HFD-V mice continued on HFD, with saline injections. A group of HFD-fed dams were 'diet switched' to chow after conception (post-conception, HFD-PC). Maternal body weight and glucose tolerance were measured: (1) preconception and (2) during late gestation followed by blood, urine and kidney collection. Serum creatinine, urinary creatinine and albumin, kidney tissue gene expression and protein were measured. In the preconception period, HFD-L and HFD-C mothers have lower urine albumin:creatinine ratios (UACR) and fatty acid synthase (FAS) protein expression (P < 0.005 vs. HFD-V). At late gestation, kidneys of HFD-V and HFD-PC dams have increased gene expression of insulin receptor and FAS (P < 0.05) and higher UACR compared to controls (P < 0.01). In the HFD-PC group, kidneys show increased mRNA and protein expression of metabolic and oxidative stress markers (FAS, 8-OHdG vs. control, P < 0.05, P < 0.0001 respectively). The preconception intervention groups with liraglutide, or diet change show reduced oxidative stress (protein expression of 8-OHdG, P < 0.05 vs. HFD), mRNA and protein expression of FAS (P < 0.05 vs. HFD), protein expression of fibrosis markers (collagen IV, fibronectin vs. HFD, P < 0.05), and UACR (P < 0.05 vs. HFD). This study suggests that preconception weight loss benefits maternal kidney health during pregnancy, superior to diet intervention once already pregnant.

Exploring the Potential Impact of GLP-1 Receptor Agonists on Substance Use, Compulsive Behavior, and Libido: Insights from Social Media Using a Mixed-Methods Approach

Glucagon-like peptide-1 (GLP-1) is involved in a range of central and peripheral pathways related to appetitive behavior. Hence, this study explored the effects of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on substance and behavioral addictions, including alcohol, caffeine, nicotine, cannabis, psychostimulants, compulsive shopping, and sex drive/libido. Data were collected from various social platforms. Keywords related to GLP-1 RAs and substance/behavioral addiction were used to extract relevant comments. The study employed a mixed-methods approach to analyze online discussions posted from December 2019 to June 2023 and collected using a specialized web application. Reddit entries were the focus here due to limited data from other platforms, such as TikTok and YouTube. A total of 5859 threads and related comments were extracted from six subreddits, which included threads about GLP-1 RAs drugs and associated brand names. To obtain relevant posts, keywords related to potential substance use and compulsive behavior were selected. Further analysis involved two main steps: (1) manually coding posts based on users' references to the potential impact of GLP-1 RAs on substance use and non-substance habits, excluding irrelevant or unclear comments; (2) performing a thematic analysis on the dataset of keywords, using AI-assisted techniques followed by the manual revision of the generated themes. Second, a thematic analysis was performed on the keyword-related dataset, using AI-assisted techniques followed by the manual revision of the generated themes. In total, 29.75% of alcohol-related; 22.22% of caffeine-related; and 23.08% of nicotine-related comments clearly stated a cessation of the intake of these substances following the start of GLP-1 RAs prescription. Conversely, mixed results were found for cannabis intake, and only limited, anecdotal data were made available for cocaine, entactogens, and dissociative drugs' misuse. Regarding behavioral addictions, 21.35% of comments reported a compulsive shopping interruption, whilst the sexual drive/libido elements reportedly increased in several users. The current mixed-methods approach appeared to be a useful tool in gaining insight into complex topics such as the effects of GLP-1 RAs on substance and non-substance addiction-related disorders; some GLP-1 RA-related mental health benefits could also be inferred from here. Overall, it appeared that GLP-1 RAs may show the potential to target both substance craving and maladaptive/addictive behaviors, although further empirical research is needed.

Maternal Cardiac Function in Pregnancies with Metabolic Disorders

The obesity epidemic is growing and poses significant risks to pregnancy. Metabolic impairment can be associated with short- and long-term maternal and perinatal morbidity and mortality. The cardiovascular implications are known in those with metabolic disorder outside of pregnancy; however, little is known of the cardiac function in pregnancies complicated by obesity. Maternal cardiac adaptation plays a vital role in normal pregnancy and is known to be involved in the pathophysiology of adverse pregnancy outcomes. Bariatric surgery is the most successful treatment for sustainable weight loss and pre-pregnancy bariatric surgery can drastically change the maternal metabolic profile and pregnancy outcomes. In this review, we discuss the available evidence on maternal cardiac function in pregnancies affected by obesity and its associated consequences of gestational diabetes and hypertension (chronic and hypertensive disorders in pregnancy), as well as pregnancies following bariatric surgery.

Dispensing of Glucagon-Like Peptide-1 Receptor Agonists to Adolescents and Young Adults, 2020-2023

This study uses data from US retail pharmacies to assess national GLP-1RA dispensing to adolescents and young adults from 2020-2023.

Lupus nephritis: management challenges during pregnancy

Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.

Empagliflozin for treating neutropenia and neutrophil dysfunction in 21 infants with glycogen storage disease 1b

Empagliflozin has been successfully repurposed for treating neutropenia and neutrophil dysfunction in patients with glycogen storage disease type 1b (GSD 1b), however, data in infants are missing. We report on efficacy and safety of empagliflozin in infants with GSD 1b. This is an international retrospective case series on 21 GSD 1b infants treated with empagliflozin (total treatment time 20.6 years). Before starting empagliflozin (at a median age of 8.1 months with a median dose of 0.3 mg/kg/day) 12 patients had clinical signs and symptoms of neutrophil dysfunction. Six of these previously symptomatic patients had no further neutropenia/neutrophil dysfunction-associated findings on empagliflozin. Eight patients had no signs and symptoms of neutropenia/neutrophil dysfunction before start and during empagliflozin treatment. One previously asymptomatic individual with a horseshoe kidney developed a central line infection with pyelonephritis and urosepsis during empagliflozin treatment. Of the 10 patients who were treated with G-CSF before starting empagliflozin, this was stopped in four and decreased in another four. Eleven individuals were never treated with G-CSF. While in 17 patients glucose homeostasis remained stable on empagliflozin, four showed glucose homeostasis instability in the introductory phase. In 17 patients, no other side effects were reported, while genital (n = 2) or oral (n = 1) candidiasis and skin infection (n = 1) were reported in the remaining four. Empagliflozin had a good effect on neutropenia/neutrophil dysfunction-related signs and symptoms and a favourable safety profile in infants with GSD 1b and therefore qualifies for further exploration as first line treatment.

Type 2 Diabetes

Type 2 diabetes (T2D) is a prevalent disease that increases risk for vascular, renal, and neurologic complications. Prevention and treatment of T2D and its complications are paramount. Many advancements in T2D care have emerged over the past 5 years, including increased understanding of the importance of early intensive glycemic control, mental health, social determinants of health, healthy eating patterns, continuous glucose monitoring, and the benefits of some drugs for preventing cardiorenal disease. This review summarizes the evidence supporting T2D prevention and treatment, focusing on aspects that are commonly in the purview of primary care physicians.

Use of GLP1 receptor agonists in early pregnancy and reproductive safety: a multicentre, observational, prospective cohort study based on the databases of six Teratology Information Services

OBJECTIVES

Glucagon-like peptide 1 receptor agonists (GLP1-RA) are indicated for the treatment of type 2 diabetes and more recently for weight loss. The aim of this study was to assess the risks associated with GLP1-RA exposure during early pregnancy.

DESIGN

This multicentre, observational prospective cohort study compared pregnancy outcomes in women exposed to GLP1-RA in early pregnancy either for diabetes or obesity treatment with those in two reference groups: (1) women with diabetes exposed to at least one non-GLP1-RA antidiabetic drug during the first trimester and (2) a reference group of overweight/obese women without diabetes, between 2009 and 2022.

SETTING

Data were collected from the databases of six Teratology Information Services.

PARTICIPANTS

This study included 168 pregnancies of women exposed to GLP1-RA during the first trimester, alongside a reference group of 156 pregnancies of women with diabetes and 163 pregnancies of overweight/obese women.

RESULTS

Exposure to GLP1-RA in the first trimester was not associated with a risk of major birth defects when compared with diabetes (2.6% vs 2.3%; adjusted OR, 0.98 (95% CI, 0.16 to 5.82)) or to overweight/obese (2.6% vs 3.9%; adjusted OR 0.54 (0.11 to 2.75)). For the GLP1-RA group, cumulative incidence for live births, pregnancy losses and pregnancy terminations was 59%, 23% and 18%, respectively. In the diabetes reference group, corresponding estimates were 69%, 26% and 6%, while in the overweight/obese reference group, they were 63%, 29% and 8%, respectively. Cox proportional cause-specific hazard models indicated no increased risk of pregnancy losses in the GLP1-RA versus the diabetes and the overweight/obese reference groups, in both crude and adjusted analyses.

CONCLUSIONS

This study offers reassurance in cases of inadvertent exposure to GLP1-RA during the first trimester of pregnancy. Due to the limited sample size, larger studies are required to validate these findings.

Practical guide: Glucagon-like peptide-1 and dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonists in diabetes mellitus

In 2005, exenatide became the first approved glucagon-like peptide-1 receptor agonist (GLP-1 RA) for type 2 diabetes mellitus (T2DM). Since then, numerous GLP-1 RAs have been approved, including tirzepatide, a novel dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA, which was approved in 2022. This class of drugs is considered safe with no hypoglycemia risk, making it a common second-line choice after metformin for treating T2DM. Various considerations can make selecting and switching between different GLP-1 RAs challenging. Our study aims to provide a comprehensive guide for the usage of GLP-1 RAs and dual GIP and GLP-1 RAs for the management of T2DM.

Treatment recommendations for glycogen storage disease type IB- associated neutropenia and neutrophil dysfunction with empagliflozin: Consensus from an international workshop

Glycogen storage disease type Ib (GSD Ib, biallelic variants in SLC37A4) is a rare disorder of glycogen metabolism complicated by neutropenia/neutrophil dysfunction. Since 2019, the SGLT2-inhibitor empagliflozin has provided a mechanism-based treatment option for the symptoms caused by neutropenia/neutrophil dysfunction (e.g. mucosal lesions, inflammatory bowel disease). Because of the rarity of GSD Ib, the published evidence on safety and efficacy of empagliflozin is still limited and does not allow to develop evidence-based guidelines. Here, an international group of experts provides 14 best practice consensus treatment recommendations based on expert practice and review of the published evidence. We recommend to start empagliflozin in all GSD Ib individuals with clinical or laboratory signs related to neutropenia/neutrophil dysfunction with a dose of 0.3-0.4 mg/kg/d given as a single dose in the morning. Treatment can be started in an outpatient setting. The dose should be adapted to the weight and in case of inadequate clinical treatment response or side effects. We strongly recommend to pause empagliflozin immediately in case of threatening dehydration and before planned longer surgeries. Discontinuation of G-CSF therapy should be attempted in all individuals. If available, 1,5-AG should be monitored. Individuals who have previously not tolerated starches should be encouraged to make a new attempt to introduce starch in their diet after initiation of empagliflozin treatment. We advise to monitor certain safety and efficacy parameters and recommend continuous, alternatively frequent glucose measurements during the introduction of empagliflozin. We provide specific recommendations for special circumstances like pregnancy and liver transplantation.

An overview of diabetes mellitus in pregnant women with obesity

Rates of obesity are increasing world-wide with an estimated 1billion people projected to be obese by 2030 if current trends remain unchanged. Obesity currently considered one of the most significant associated factors of non-communicable diseases poses the greatest threat to health. Diabetes mellitus is an important metabolic disorder closely associated with obesity. It is therefore expected that with the increasing rates of obesity, the rates of diabetes in pregnancy will also be rising. This disorder may pre-date pregnancy (diagnosed or undiagnosed and diagnosed for the first time in pregnancy) or may be of onset in pregnancy. Irrespective of the timing of onset, diabetes in pregnancy is associated with both fetal and maternal complications. Outcomes are much better if control is maximised. Early diagnosis, multidisciplinary care and tailored management with optimum glycaemic control is associated with a significant reduction in not only pregnancy complications but long-term consequences on both the mother and offspring. This review brings together the current understanding of the pathogenesis of the endocrine derangements that are associated with diabetes in pregnancy how screening should be offered and management including pre-pregnancy care and the role of newer agents in management.