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Ahmed MA, Bailey HD, Pereira G, White SW, Wong K, McNamara BJ, Rheeder P, Marriott R, Shepherd CCJ. The impact of diabetes during pregnancy on neonatal outcomes among the Aboriginal population in Western Australia: a whole-population study. Int J Epidemiol 2023; 52:1400-1413. [PMID: 37263617 DOI: 10.1093/ije/dyad072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 05/13/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have a high prevalence of diabetes in pregnancy (DIP), which includes pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). We aimed to characterize the impact of DIP in babies born to Aboriginal mothers. METHODS A retrospective cohort study, using routinely collected linked health data that included all singleton births (N = 510 761) in Western Australia between 1998 and 2015. Stratified by Aboriginal status, generalized linear mixed models quantified the impact of DIP on neonatal outcomes, estimating relative risks (RRs) with 95% CIs. Ratio of RRs (RRRs) examined whether RRs differed between Aboriginal and non-Aboriginal populations. RESULTS Exposure to DIP increased the risk of adverse outcomes to a greater extent in Aboriginal babies. PGDM heightened the risk of large for gestational age (LGA) (RR: 4.10, 95% CI: 3.56-4.72; RRR: 1.25, 95% CI: 1.09-1.43), macrosomia (RR: 2.03, 95% CI: 1.67-2.48; RRR: 1.39, 95% CI: 1.14-1.69), shoulder dystocia (RR: 4.51, 95% CI: 3.14-6.49; RRR: 2.19, 95% CI: 1.44-3.33) and major congenital anomalies (RR: 2.14, 95% CI: 1.68-2.74; RRR: 1.62, 95% CI: 1.24-2.10). GDM increased the risk of LGA (RR: 2.63, 95% CI: 2.36-2.94; RRR: 2.00, 95% CI: 1.80-2.22), macrosomia (RR: 1.95, 95% CI: 1.72-2.21; RRR: 2.27, 95% CI: 2.01-2.56) and shoulder dystocia (RR: 2.78, 95% CI: 2.12-3.63; RRR: 2.11, 95% CI: 1.61-2.77). Birthweight mediated about half of the DIP effect on shoulder dystocia only in the Aboriginal babies. CONCLUSIONS DIP differentially increased the risks of fetal overgrowth, shoulder dystocia and congenital anomalies in Aboriginal babies. Improving care for Aboriginal women with diabetes and further research on preventing shoulder dystocia among these women can reduce the disparities.
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Affiliation(s)
- Marwan Awad Ahmed
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen D Bailey
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Gavin Pereira
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Centre for Fertility and Health (CeFH), Norwegian Institute of Public Health, Oslo, Norway
- enAble Institute, Curtin University, Perth, Western Australia, Australia
| | - Scott W White
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
- Maternal Fetal Medicine Service, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Bridgette J McNamara
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Paul Rheeder
- Department of Internal Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Rhonda Marriott
- Ngangk Yira Research Centre, Murdoch University, Perth, Western Australia, Australia
| | - Carrington C J Shepherd
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Ngangk Yira Research Centre, Murdoch University, Perth, Western Australia, Australia
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Tol AJC, Hribar K, Kruit J, Bongiovanni L, Vieira-Lara MA, Koster MH, Kloosterhuis NJ, Havinga R, Koehorst M, de Bruin A, Bakker BM, Oosterveer MH, van der Beek EM. Hyperglycaemia, pregnancy outcomes and maternal metabolic disease risk during pregnancy and lactation in a lean gestational diabetes mouse model. J Physiol 2023; 601:1761-1780. [PMID: 37010236 DOI: 10.1113/jp284061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/10/2023] [Indexed: 04/04/2023] Open
Abstract
Hyperglycaemia in pregnancy (HIP) is a pregnancy complication characterized by mild to moderate hyperglycaemia that negatively impacts short- and long-term health of mother and child. However, relationships between severity and timing of pregnancy hyperglycaemia and postpartum outcomes have not been systemically investigated. We investigated the impact of hyperglycaemia developing during pregnancy (gestational diabetes mellitus, GDM) or already present pre-mating (pre-gestational diabetes mellitus, PDM) on maternal health and pregnancy outcomes. GDM and PDM were induced in C57BL/6NTac mice by combined 60% high fat diet (HF) and low dose streptozotocin (STZ). Animals were screened for PDM prior to mating, and all underwent an oral glucose tolerance test on gestational day (GD)15. Tissues were collected at GD18 or at postnatal day (PN)15. Among HFSTZ-treated dams, 34% developed PDM and 66% developed GDM, characterized by impaired glucose-induced insulin release and inadequate suppression of endogenous glucose production. No increased adiposity or overt insulin resistance was observed. Furthermore, markers of non-alcoholic fatty liver disease (NAFLD) were significantly increased in PDM at GD18 and were positively correlated with basal glucose levels at GD18 in GDM dams. By PN15, NAFLD markers were also increased in GDM dams. Only PDM affected pregnancy outcomes such as litter size. Our findings indicate that GDM and PDM, resulting in disturbances of maternal glucose homeostasis, increase the risk of postpartum NAFLD development, related to the onset and severity of pregnancy hyperglycaemia. These findings signal a need for earlier monitoring of maternal glycaemia and more rigorous follow-up of maternal health after GDM and PDM pregnancy in humans. KEY POINTS: We studied the impact of high-fat diet/streptozotocin induced hyperglycaemia in pregnancy in mice and found that this impaired glucose tolerance and insulin release. Litter size and embryo survival were compromised by pre-gestational, but not by gestational, diabetes. Despite postpartum recovery from hyperglycaemia in a majority of dams, liver disease markers were further elevated by postnatal day 15. Maternal liver disease markers were associated with the severity of hyperglycaemia at gestational day 18. The association between hyperglycaemic exposure and non-alcoholic fatty liver disease signals a need for more rigorous monitoring and follow-up of maternal glycaemia and health in diabetic pregnancy in humans.
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Affiliation(s)
- Angela J C Tol
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kaja Hribar
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Janine Kruit
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Laura Bongiovanni
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
- Faculty of Veterinary Medicine, University of Teramo, Teramo, Italy
| | - Marcel A Vieira-Lara
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mirjam H Koster
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Niels J Kloosterhuis
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Rick Havinga
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Martijn Koehorst
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Alain de Bruin
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands
| | - Barbara M Bakker
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maaike H Oosterveer
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Eline M van der Beek
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Benítez-Guerrero T, Vélez-Ixta JM, Juárez-Castelán CJ, Corona-Cervantes K, Piña-Escobedo A, Martínez-Corona H, De Sales-Millán A, Cruz-Narváez Y, Gómez-Cruz CY, Ramírez-Lozada T, Acosta-Altamirano G, Sierra-Martínez M, Zárate-Segura PB, García-Mena J. Gut Microbiota Associated with Gestational Health Conditions in a Sample of Mexican Women. Nutrients 2022; 14. [PMID: 36432504 DOI: 10.3390/nu14224818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Gestational diabetes (GD), pre-gestational diabetes (PD), and pre-eclampsia (PE) are morbidities affecting gestational health which have been associated with dysbiosis of the mother's gut microbiota. This study aimed to assess the extent of change in the gut microbiota diversity, short-chain fatty acids (SCFA) production, and fecal metabolites profile in a sample of Mexican women affected by these disorders. Fecal samples were collected from women with GD, PD, or PE in the third trimester of pregnancy, along with clinical and biochemical data. Gut microbiota was characterized by high-throughput DNA sequencing of V3-16S rRNA gene libraries; SCFA and metabolites were measured by High-Pressure Liquid Chromatography (HPLC) and (Fourier Transform Ion Cyclotron Mass Spectrometry (FT-ICR MS), respectively, in extracts prepared from feces. Although the results for fecal microbiota did not show statistically significant differences in alfa diversity for GD, PD, and PE concerning controls, there was a difference in beta diversity for GD versus CO, and a high abundance of Proteobacteria, followed by Firmicutes and Bacteroidota among gestational health conditions. DESeq2 analysis revealed bacterial genera associated with each health condition; the Spearman's correlation analyses showed selected anthropometric, biochemical, dietary, and SCFA metadata associated with specific bacterial abundances, and although the HPLC did not show relevant differences in SCFA content among the studied groups, FT-ICR MS disclosed the presence of interesting metabolites of complex phenolic, valeric, arachidic, and caprylic acid nature. The major conclusion of our work is that GD, PD, and PE are associated with fecal bacterial microbiota profiles, with distinct predictive metagenomes.
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Dugalic S, Petronijevic M, Vasiljevic B, Todorovic J, Stanisavljevic D, Jotic A, Lukic L, Milicic T, Lalić N, Lalic K, Stoiljkovic M, Terzic-Supic Z, Stanisavljevic T, Stefanovic A, Stefanovic K, Vrzic-Petronijevic S, Macura M, Pantic I, Piperac P, Jovanovic M, Cerovic R, Djurasevic S, Babic S, Perkovic-Kepeci S, Gojnic M. Trends of the Prevalence of Pre-gestational Diabetes in 2030 and 2050 in Belgrade Cohort. Int J Environ Res Public Health 2022; 19:ijerph19116517. [PMID: 35682099 PMCID: PMC9180675 DOI: 10.3390/ijerph19116517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/17/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022]
Abstract
The aim of this study was to analyze the trends in diabetes in pregnancy in Belgrade, Serbia for the period of the past decade and forecast the number of women with pre-gestational diabetes for the years 2030 and 2050. The study included the data on all pregnant women with diabetes from the registry of the deliveries in Belgrade, by the City Institute of Public Health of Belgrade, Serbia for the period between 2010 and 2020 and the published data on the deliveries on the territory of Belgrade. During the examined period the total number of live births in Belgrade was 196,987, and the prevalence of diabetes in pregnancy was 3.4%, with the total prevalence of pre-gestational diabetes of 0.7% and overall prevalence of GDM of 2.7%. The average age of women in our study was significantly lower in 2010 compared to 2020. The forecasted prevalence of pre-gestational diabetes among all pregnant women for 2030 is 2% and 4% for 2050 in our cohort. Our study showed that the prevalence of pre-gestational diabetes has increased both among all pregnant women and among women with diabetes in pregnancy in the past decade in Belgrade, Serbia and that it is expected to increase further in the next decades and to further double by 2050.
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Affiliation(s)
- Stefan Dugalic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | - Milos Petronijevic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | - Brankica Vasiljevic
- Maternity and Child Health Service, NMC Royal Hospital DIP, Dubai Hospital, Dubai P.O. Box 7832, United Arab Emirates;
| | - Jovana Todorovic
- Faculty of Medicine, Institute of Social Medicine, University of Belgrade, 11000 Belgrade, Serbia; (J.T.); (Z.T.-S.)
| | - Dejana Stanisavljevic
- Faculty of Medicine, Institute for Medical Statistics and Informatics, University of Belgrade, 11000 Belgrade, Serbia;
| | - Aleksandra Jotic
- Faculty of Medicine, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (A.J.); (L.L.); (T.M.); (N.L.); (K.L.); (M.S.)
| | - Ljiljana Lukic
- Faculty of Medicine, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (A.J.); (L.L.); (T.M.); (N.L.); (K.L.); (M.S.)
| | - Tanja Milicic
- Faculty of Medicine, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (A.J.); (L.L.); (T.M.); (N.L.); (K.L.); (M.S.)
| | - Nebojsa Lalić
- Faculty of Medicine, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (A.J.); (L.L.); (T.M.); (N.L.); (K.L.); (M.S.)
| | - Katarina Lalic
- Faculty of Medicine, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (A.J.); (L.L.); (T.M.); (N.L.); (K.L.); (M.S.)
| | - Milica Stoiljkovic
- Faculty of Medicine, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (A.J.); (L.L.); (T.M.); (N.L.); (K.L.); (M.S.)
| | - Zorica Terzic-Supic
- Faculty of Medicine, Institute of Social Medicine, University of Belgrade, 11000 Belgrade, Serbia; (J.T.); (Z.T.-S.)
| | | | - Aleksandar Stefanovic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | - Katarina Stefanovic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | - Svetlana Vrzic-Petronijevic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | - Maja Macura
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | - Igor Pantic
- Faculty of Medicine, Institute for Medical Physiology, University of Belgrade, 11000 Belgrade, Serbia;
| | - Pavle Piperac
- Department for Humanities, University of Belgrade, Faculty of Medicine, 11000 Belgrade, Serbia;
| | | | - Radmila Cerovic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | | | - Sandra Babic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
| | | | - Miroslava Gojnic
- Faculty of Medicine, Clinic for Obstetrics and Gynecology, University Clinical Centre of Serbia, University of Belgrade, 11000 Belgrade, Serbia; (S.D.); (M.P.); (A.S.); (K.S.); (S.V.-P.); (M.M.); (R.C.); (S.B.)
- Correspondence:
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Shah K, Shah H. A systematic review of maternal diabetes and congenital skeletal malformation. Congenit Anom (Kyoto) 2022; 62:113-122. [PMID: 35319786 DOI: 10.1111/cga.12463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/11/2022] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
Abstract
The magnitude of association of skeletal anomalies with maternal diabetes is not known. The systemic review was done to detect the frequency of congenital skeletal malformations with diabetes mellitus in pregnancy in the literature evidence of the past 50 years. Literature on maternal diabetes and skeletal malformation was searched by two independent authors by following PRISMA guidelines. Strict inclusion and exclusion criteria were followed. After quality assessment, 21 original articles were included. The frequency of congenital malformation, skeletal malformation was extracted from the included studies. 11,574 congenital anomalies were detected diabetic mothers. 1182 skeletal anomalies were noted in 20,11 552 diabetic mothers. The skeletal malformation was noted in 20.4% of total anomalies. The most common skeletal malformation was the defect of the spine (39.9%). The limb deficiency was found in 32.8% of the infants of diabetic mothers. The skeletal malformations were higher, that is, 24.6% in pre-gestational diabetes. The incidence of skeletal malformation from the evidence was 1.5% (range: 0.03-4.27%) in maternal diabetes. Pre-gestation diabetes is more frequently associated with skeletal malformations, which is 1.9% (range: 0.07-5.89%). The association of congenital malformations and skeletal malformations in diabetic pregnancy is significant and hence, effective management of diabetes in childbearing age is essential to reduce this incidence and related long-term morbidity.
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Affiliation(s)
- Krupa Shah
- Department of Obstetrics & Gynaecology, Melaka Manipal Medical College, Manipal, India.,Manipal Academy of Higher Education, Manipal, India
| | - Hitesh Shah
- Manipal Academy of Higher Education, Manipal, India.,Pediatric Orthopedics Department, Kasturba Medical College, Manipal, Madhav nagar, Manipal, Manipal, India, 576104, India
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Rao C, Ping F. Comparison of insulin requirements across gestation in women with hyperglycemia in pregnancy: A prospective cohort study. Front Endocrinol (Lausanne) 2022; 13:1013663. [PMID: 36339424 PMCID: PMC9633005 DOI: 10.3389/fendo.2022.1013663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/05/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study is to explore the daily insulin dose and the percentage change in preprandial and basal insulin dosage of women with different types of hyperglycemia in pregnancy (HIP) during the whole gestation and postpartum period. METHODS A total of 121 subjects with HIP requiring insulin therapy were enrolled from a prospective cohort consisted of 436 pregnant women with hyperglycemia. The subjects were divided into three groups: Group 1 [type 1 diabetes mellitus (T1DM) and maturity onset diabetes of the young (MODY)], Group 2 [type 1 diabetes mellitus (T2DM)], and Group 3 [gestation diabetes mellitus (GDM)]. The primary study measurements included daily dose and percentage of different types of exogenous insulin requirements across gestation in different groups. RESULTS Insulin total daily dosage of Group 1 was highest among the three groups and increased significantly from the first to the second/third trimester. Percentage of preprandial insulin increased from 53.8% (46.7, 60.0) and 54.5% (42.3, 62.9) in the first trimester to 63.6% (54.9, 75.0) and 67.2% (51.8, 73.7) in the second/third trimester in Group 1 and Group 2. All subjects with T1DM and 18.6% of subjects with T2DM still required insulin administration after delivery, with a 26.9% (19.0, 46.0) and 36.7% (26.9, 52.6) decrease in total insulin dose, respectively, whereas subjects with GDM and MODY weaned off insulin completely. CONCLUSION The insulin requirements for pregnancy complicated with T1DM and MODY were higher than those for T2DM and GDM. In the subjects with PGDM, the insulin requirement and percentage of preprandial insulin increased gradually from early to mid- and late pregnancy.
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Affiliation(s)
- Chong Rao
- Department of Endocrinology, Beijing ChuiYangLiu Hospital, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Key Laboratory of Endocrinology Assigned by Ministry of Health, Beijing, China
- *Correspondence: Fan Ping,
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Dori-Dayan N, Cukierman-Yaffe T, Kedar N, Zemet R, Cohen O, Mazaki-Tovi S, Yoeli-Ullman R. Maternal glucose variability during pregnancy & birthweight percentile in women with pre-gestational diabetes. Gynecol Endocrinol 2021; 37:1116-1120. [PMID: 34672842 DOI: 10.1080/09513590.2021.1993814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Pre-gestational diabetes mellitus (PGDM) is a major risk factor for fetal overgrowth. Interestingly, even in relatively well controlled PGDM women, as determined by average glucose indices such HbA1c, there is an increased rate of LGA (large for gestational age). Glucose variability (GV) has emerged as an important independent risk factor for several diabetes complications. The aim of this study was to determine the relationship between maternal GV indices and neonatal birth percentile. METHODS This was a historical cohort study that included all consecutive PGDM women monitored in a single tertiary care center. Clinical and demographic variables, as well as data regarding glucose control, were prospectively recorded. Mean, standard deviation (SD) and coefficient of variance (CV) of glucose values were calculated. Pearson correlations coefficient was used to determine the correlation between glucose indices and birth percentile. The analysis was repeated after adjustment for several confounders. RESULTS Mean birthweight and birthweight percentile were 3212 ± 532 g and 66.9%, respectively. There was a statistically significant correlation between birthweight percentile and maternal glucose SD (β = 0.28, p = .002) and maternal glucose CV (β = 0.21, p = .019). There was no significant correlation between birthweight percentile and mean glucose values. The association between the maternal glucose SD and birthweight percentile remained statistically significant after adjustment for maternal age, pre-pregnancy BMI and duration of diabetes. CONCLUSION There is an association between maternal glucose variability indices (SD and CV) during pregnancy and neonatal birth percentile. Larger studies are needed to confirm these results.
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Affiliation(s)
- Nimrod Dori-Dayan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Tali Cukierman-Yaffe
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Endocrinology Department, Sheba Medical Center, Tel Hashomer, Israel
| | - Neomi Kedar
- Endocrinology Department, Sheba Medical Center, Tel Hashomer, Israel
| | - Roni Zemet
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ohad Cohen
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Endocrinology Department, Sheba Medical Center, Tel Hashomer, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rakefet Yoeli-Ullman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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Xodo S, Londero AP, D’Agostin M, Novak A, Galasso S, Pittini C, Baccarini G, Grimaldi F, Driul L. Is Glycated Hemoglobin A1c Level Associated with Adverse Pregnancy Outcomes of Women Affected by Pre-Gestational Diabetes? Medicina (Kaunas) 2021; 57:medicina57050461. [PMID: 34065046 PMCID: PMC8151463 DOI: 10.3390/medicina57050461] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 01/24/2023]
Abstract
Background and Objectives: This observational study aims to determine the correlation between glycemic control with the HbA1c value and adverse obstetric outcome in women affected by pre-gestational diabetes. Materials and Methods: A retrospective analysis has been performed at the University Hospital of Udine. Only patients with a singleton pregnancy, pre-gestational diabetes, and known level of Hb A1c throughout pregnancy were included in the study. Results: According to the HbA1c level, at the beginning of pregnancy, 49 patients with HbA1c ≤ 7.0% were compared with 45 patients with HbA1c > 7.0%. Maternal age at diagnosis of the disease was significantly higher in the group with HbA1c ≤ 7% than in the group with HbA1c > 7%, 26.00 (18.00–32.00) vs. 20.00 (12.50–27.00). Women with HbA1c ≤ 7.0% reached, at term of pregnancy, significantly lower levels of HbA1c, 5.8% (5.7–6.0) vs. 6.7% (6.3–7.3). Daily insulin units were statistically different between the two groups at the end of pregnancy (47.92 (39.00–67.30) vs. 64.00 (48.00–82.00)). Proteinuria was significantly higher in the group with HbA1c > 7.0%, who delivered at earlier gestational age (37.57 (35.57–38.00) vs. 38.14 (38.00–38.43). Moreover, women with HbA1c > 7.0% had a significantly higher prevalence of an adverse composite outcome. Of note, in multivariate logistic regression analysis, pregnancy complications were significantly correlated to pre-pregnancy HbA1c > 7.0% (OR 2.95 CI.95 1.16–7.48, p < 0.05) independently of age, insulin treatment, and type of diabetes. Conclusions: Our data, obtained from a single-center cohort study, suggest that starting pregnancy with poor glycemic control might predict more complex management of diabetes in the following trimesters.
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Affiliation(s)
- Serena Xodo
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
- Correspondence: ; Tel.: +39-0432-559635
| | - Ambrogio Pietro Londero
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
| | - Martina D’Agostin
- Department Medical Area, School of Medicine, University of Udine, 33100 Udine, Italy;
| | - Alice Novak
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
| | - Silvia Galasso
- Endocrinology and Metabolism Unit, University Hospital of Udine, 33100 Udine, Italy; (S.G.); (F.G.)
| | - Carla Pittini
- Unit of Neonatology, University Hospital of Udine, 33100 Udine, Italy;
| | - Giovanni Baccarini
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
| | - Franco Grimaldi
- Endocrinology and Metabolism Unit, University Hospital of Udine, 33100 Udine, Italy; (S.G.); (F.G.)
| | - Lorenza Driul
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
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Yoeli-Ullman R, Maayan-Metzger A, Zemet R, Dori Dayan N, Mazaki-Tovi S, Cohen O, Weiss L, Cukierman-Yaffe T. The association between novel glucose indices in parturients with type 1 diabetes mellitus and clinically significant neonatal hypoglycemia. Gynecol Endocrinol 2020; 36:615-619. [PMID: 31825267 DOI: 10.1080/09513590.2019.1698027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The aim of this study was to determine the association between glucose control indices of parturient with type 1 diabetes (T1DM), treated with an insulin pump and utilizing continuous glucose monitoring (CGM), and clinically significant neonatal hypoglycemia. This was a retrospective cohort study which included 37 pregnant women with T1DM. All women were followed at a single tertiary center and had available CGM data. The association between maternal glucose indices before delivery and the risk for neonatal hypoglycemia requiring IV glucose (clinically significant hypoglycemia) was assessed using logistic regression. Mothers to neonates that experienced clinically significant hypoglycemia had a higher glucose standard deviation (SD) before delivery than did mothers to neonates who did not (25.5 ± 13 mg/dL vs. 14.7 ± 6.7 mg/dl respectively; p = .008). This association persisted after adjustment for maternal age, maternal pregestational body mass index (BMI), gestational age at delivery, neonatal birth weight, large for gestational age (LGA) and gender. This study demonstrates an association between high maternal glucose standard deviation before delivery and the risk for clinically significant neonatal hypoglycemia. Larger studies are needed to confirm these results and further explore the role of intrapartum glucose variability in the prediction and prevention of significant neonatal hypoglycemia.
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Affiliation(s)
- Rakefet Yoeli-Ullman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayala Maayan-Metzger
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neonatology, The Edmond and Lili Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Roni Zemet
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Dori Dayan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Cohen
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Sheba Medical Center, Tel Hashomer, Israel
| | - Lotem Weiss
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics, Ruth Rapport Children Hospital, Rambam Medical Center, Haifa, Israel
| | - Tali Cukierman-Yaffe
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Sheba Medical Center, Tel Hashomer, Israel
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10
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Saiyin T, Engineer A, Greco ER, Kim MY, Lu X, Jones DL, Feng Q. Maternal voluntary exercise mitigates oxidative stress and incidence of congenital heart defects in pre-gestational diabetes. J Cell Mol Med 2019; 23:5553-5565. [PMID: 31211496 PMCID: PMC6653048 DOI: 10.1111/jcmm.14439] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/01/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
Women with pre‐gestational diabetes have a higher risk of producing children with congenital heart defects (CHDs), caused predominantly by hyperglycemia‐induced oxidative stress. In this study, we evaluated if exercise during pregnancy could mitigate oxidative stress and reduce the incidence of CHDs in the offspring of diabetic mice. Female mice were treated with streptozotocin to induce pre‐gestational diabetes, then mated with healthy males to produce offspring. They were also given access to running wheels 1 week before mating and allowed to exercise voluntarily until E18.5. Heart morphology, gene expression, and oxidative stress were assessed in foetal hearts. Maternal voluntary exercise results in a significantly lower incidence of CHDs from 59.5% to 25%. Additionally, diabetes‐induced defects in coronary artery and capillary morphogenesis were also lower with exercise. Myocardial cell proliferation and epithelial‐mesenchymal transition at E12.5 was significantly lower with pre‐gestational diabetes which was mitigated with maternal exercise. Cardiac gene expression of Notch1, Snail1, Gata4 and CyclinD1 was significantly higher in the embryos of diabetic mice that exercised compared to the non‐exercised group. Furthermore, maternal exercise produced lower reactive oxygen species (ROS) and oxidative stress in the foetal heart. In conclusion, maternal exercise mitigates ROS and oxidative damage in the foetal heart, and results in a lower incidence of CHDs in the offspring of pre‐gestational diabetes. Exercise may be an effective intervention to compliment clinical management and further minimize CHD risk in mothers with diabetes.
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Affiliation(s)
- Tana Saiyin
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
| | - Anish Engineer
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
| | - Elizabeth R Greco
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
| | - Mella Y Kim
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
| | - Xiangru Lu
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
| | - Douglas L Jones
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
| | - Qingping Feng
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Health Research Institute, London, ON, Canada
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11
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Chen L, Wang WJ, Auger N, Xiao L, Torrie J, McHugh NGL, Luo ZC. Diabetes in pregnancy in associations with perinatal and postneonatal mortality in First Nations and non-Indigenous populations in Quebec, Canada: population-based linked birth cohort study. BMJ Open 2019; 9:e025084. [PMID: 30992290 PMCID: PMC6500205 DOI: 10.1136/bmjopen-2018-025084] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Both pregestational and gestational diabetes mellitus (PGDM, GDM) occur more frequently in First Nations (North American Indians) pregnant women than their non-Indigenous counterparts in Canada. We assessed whether the impacts of PGDM and GDM on perinatal and postneonatal mortality may differ in First Nations versus non-Indigenous populations. DESIGN A population-based linked birth cohort study. SETTING AND PARTICIPANTS 17 090 First Nations and 217 760 non-Indigenous singleton births in 1996-2010, Quebec, Canada. MAIN OUTCOME MEASURES Relative risks (RR) of perinatal and postneonatal death. Perinatal deaths included stillbirths and neonatal (0-27 days of postnatal life) deaths; postneonatal deaths included infant deaths during 28-364 days of life. RESULTS PGDM and GDM occurred much more frequently in First Nations (3.9% and 10.7%, respectively) versus non-Indigenous (1.1% and 4.8%, respectively) pregnant women. PGDM was associated with an increased risk of perinatal death to a much greater extent in First Nations (RR=5.08[95% CI 2.99 to 8.62], p<0.001; absolute risk (AR)=21.6 [8.6-34.6] per 1000) than in non-Indigenous populations (RR=1.76[1.17, 2.66], p=0.003; AR=4.2[0.2, 8.1] per 1000). PGDM was associated with an increased risk of postneonatal death in non-Indigenous (RR=3.46[1.71, 6.99], p<0.001; AR=2.4[0.1, 4.8] per 1000) but not First Nations (RR=1.16[0.28, 4.77], p=0.35) infants. Adjusting for maternal and pregnancy characteristics, the associations were similar. GDM was not associated with perinatal or postneonatal death in both groups. CONCLUSIONS The study is the first to reveal that PGDM may increase the risk of perinatal death to a much greater extent in First Nations versus non-Indigenous populations, but may substantially increase the risk of postneonatal death in non-Indigenous infants only. The underlying causes are unclear and deserve further studies. We speculate that population differences in the quality of glycaemic control in diabetic pregnancies and/or genetic vulnerability to hyperglycaemia's fetal toxicity may be contributing factors.
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Affiliation(s)
- Lu Chen
- Obstetrics and Gynecology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Obstetrics and Gynecology, Sainte-Justine Hospital Research Center, University of Montreal, Montreal, Québec, Canada
- Ministry of Education-Shanghai Key Laboratory of Children’s Environmental Health, Shanghai Jiaotong University School of Medicine, Xinhua Hospital, Shanghai, China
| | - Wen-Juan Wang
- Ministry of Education-Shanghai Key Laboratory of Children’s Environmental Health, Shanghai Jiaotong University School of Medicine, Xinhua Hospital, Shanghai, China
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
| | - Nathalie Auger
- Epidemiology, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Lin Xiao
- Obstetrics and Gynecology, Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada
| | - Jill Torrie
- Public Health Department, Cree Board of Health and Social Services of James Bay, Mistissini, Quebec, Canada
| | - Nancy Gros-Louis McHugh
- Research Sector, First Nations of Quebec and Labrador Health and Social Service Commission, Wendake, Quebec, Canada
| | - Zhong-Cheng Luo
- Obstetrics and Gynecology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sainte-Justine Hospital Research Center, University of Montreal, Montreal, Québec, Canada
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Ibarra A, Vega-Guedes B, Brito-Casillas Y, Wägner AM. Diabetes in Pregnancy and MicroRNAs: Promises and Limitations in Their Clinical Application. Noncoding RNA 2018; 4:E32. [PMID: 30424584 DOI: 10.3390/ncrna4040032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 12/12/2022] Open
Abstract
Maternal diabetes is associated with an increased risk of complications for the mother and her offspring. The latter have an increased risk of foetal macrosomia, hypoglycaemia, respiratory distress syndrome, preterm delivery, malformations and mortality but also of life-long development of obesity and diabetes. Epigenetics have been proposed as an explanation for this long-term risk, and microRNAs (miRNAs) may play a role, both in short- and long-term outcomes. Gestation is associated with increasing maternal insulin resistance, as well as β-cell expansion, to account for the increased insulin needs and studies performed in pregnant rats support a role of miRNAs in this expansion. Furthermore, several miRNAs are involved in pancreatic embryonic development. On the other hand, maternal diabetes is associated with changes in miRNA both in maternal and in foetal tissues. This review aims to summarise the existing knowledge on miRNAs in gestational and pre-gestational diabetes, both as diagnostic biomarkers and as mechanistic players, in the development of gestational diabetes itself and also of short- and long-term complications for the mother and her offspring.
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Keely E, Berger H, Feig DS. New Diabetes Canada Clinical Practice Guidelines for Diabetes and Pregnancy - What's Changed? J Obstet Gynaecol Can 2018; 40:1484-1489. [PMID: 30274918 DOI: 10.1016/j.jogc.2018.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/23/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON; The Ottawa Hospital, Ottawa, ON.
| | - Howard Berger
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Maternal Fetal Medicine, St. Michael's Hospital, Toronto, ON
| | - Denice S Feig
- Department of Medicine, University of Toronto, Toronto, On, Canada; Mount Sinai Hospital, Toronto, ON
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Yu L, Zeng XL, Cheng ML, Yang GZ, Wang B, Xiao ZW, Luo X, Zhang BF, Xiao DW, Zhang S, Liu HJ, Hu YX, Lei HK, Li QF, Wang ZR. Quantitative assessment of the effect of pre-gestational diabetes and risk of adverse maternal, perinatal and neonatal outcomes. Oncotarget 2017; 8:61048-56. [PMID: 28977845 DOI: 10.18632/oncotarget.17824] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/05/2017] [Indexed: 01/11/2023] Open
Abstract
Pregnancies complicated by pre-gestational diabetes (PGD) are associated with a higher rate of adverse outcomes, including an increased rage of preterm delivery, pregnancy-induced hypertension, pre-eclampsia, caesarean section, perinatal mortality, stillbirth, shoulder dystocia, macrosomia, small for gestational age, large for gestational age, low birth weight, neonatal hypoglycemia, neonatal death, low Apgar score, NICU admission, jaundice and respiratory distress. In the past two decades, numerous reports have been published regarding associations between PGD and risk of adverse outcomes. However, study results are inconsistent. To provide a synopsis of the current understanding of PGD for risk of adverse pregnancy outcomes, a random-effects meta-analysis over 40 million subjects from 100 studies was performed to calculate the pooled ORs. Potential sources of heterogeneity were systematically explored by multiple strata analyses and meta-regression. Overall, PGD were significantly associated with increased risk of preterm delivery (OR=3.48), LGA (OR=3.90), perinatal mortality (OR=3.39), stillbirth (OR=3.52), pre-eclampsia (OR=3.48), caesarean section (OR=3.52), NICU admission (OR=3.92), and neonatal hypoglycemia (OR=26.62). Significant results were also observed for 7 adverse outcomes with OR range from 1.54 to 2.82, while no association was found for SGA and respiratory distress after Bonferroni correction. We found that women with T1DM had higher risks for most of adverse pregnancy outcomes compared with women with T2DM. When stratified by study design, sample size, type of diabetes, geographic region, and study quality, significant associations remains. Our findings demonstrated that PGD is a strong risk-conferring factor for adverse maternal, perinatal and neonatal outcomes.
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