No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Association between gestational abnormal glucose tolerance and maternal‐fetal outcomes
Abstract
Aim:
To investigate the relationship between abnormal glucose tolerance during pregnancy and maternal-fetal outcomes, after categorizing women into groups with different levels of gestational abnormal glucose tolerance.
Methods:
A total of 1858 pregnant women who received two-step screening for gestational diabetes mellitus (GDM) at Fooyin University Hospital were categorized into four groups, according to their glucose abnormalities, and their maternal-fetal outcomes were investigated from October 2015 to June 2020.
Results:
Among the groups having different levels of abnormal glucose tolerance, there were significant differences and trends in mother's age, currently married status, and prepregnancy overweight or obesity, incidences of cesarean section, preterm, and gestational hypertension or preeclampsia; and with respect to neonatal incidence of large for gestational age (LGA), average weight, and average height (p < 0.05). After adjusting for potential factors, there were higher incidences of cesarean section (AOR = 1.71; 95% confidence interval [CI]: 1.12-2.61), preterm (AOR = 2.20; 95% CI: 1.23-3.91), neonatal LGA (AOR = 4.94; 95% CI: 2.87-8.51), and neonatal intensive care unit (NICU) admission (AOR = 2.66; 95% CI: 1.14-6.24) in the GDM group, relative to the control group. Furthermore, the women in the oral glucose tolerance test (OGTT)-1 group had a higher incidence of neonatal LGA when compared with the women in the normal group (AOR = 2.31; 95% CI: 1.02-5.33).
Conclusions:
We found higher incidences of cesarean section, preterm, and neonatal LGA and NICU admission in the GDM women, and a higher incidence of neonatal LGA in the OGTT-1 group, relative to control group.
... In this respect, a 2016 meta-analysis by Roeckner [8], including 23 studies and 4466 pregnant women with OAV, observed a higher risk of macrosomia, Cesarean delivery, higher birthweight, large for gestational age, neonatal hypoglycemia and 5 min' Apgar <7, compared with normal OGTT women. Further, other recent studies have also found higher obstetrical risk in OAV women [9,24,25]. The study of Kang et al. [9] included 2120 pregnant NGT women and 137 women with OAV in the first OGTT that did not receive a specific intervention. ...
Objective
To analyze pregnancy outcomes of women with one abnormal value (OAV) during oral glucose tolerance test (OGTT) or OGTT-intolerance, compared with gestational diabetes mellitus (GDM) and normal glucose tolerance (NGT) pregnant women, according to whether they received any health intervention or not.
Methods
An observational retrospective study was designed including pregnant women who gave birth at Hospital del Mar, Barcelona (Spain) during December/2014–July/2018. Baseline characteristics, pregnancy outcomes and health interventions were obtained from a database collected previously for other study. Inclusion criteria were singleton pregnancies with OAV or OGTT-intolerants who gave birth at the Hospital. GDM screening followed a two-step approach: 50 g O’Sullivan test and 100 g 3-hour OGTT if the former was abnormal.
Results
From a total of 2,662 pregnancies, 326 (12.2%) had GDM, 87 OAV (3.3%), 65 OGTT intolerance (2.4%) and 2,184 were NGT women. First trimester HbA1c in both OAV and OGTT-intolerant women was significantly higher than in NGT group, and significantly lower than in GDM pregnants. No differences in obstetric outcomes were found between OGTT-intolerants and NGT/GDM groups. Treated OGTT-intolerants had greater gestational age at delivery than non-treated ones (weeks, 39.6 ± 1.2 vs 38.0 ± 4.0, respectively). In OAV women, significant differences were observed in newborns’ birthweight (g, 3227.3 ± 500.8 vs 3351.1 ± 436.7, vs GDM) and gestational age at birth (weeks, 38.7 ± 1.8 vs 39.3 ± 1.9, vs NGT), but not in macrosomia/pre-eclampsia. No differences were found according to treatment in OAV.
Conclusions
OAV and OGTT-intolerants account for a third of pregnant women referred to Diabetes Unit. Their rates of preterm birth, pre-eclampsia and macrosomia were not different from NGT or GDM women.
... Indeed, independently of other known risk factors for GDM, ultrasound-estimated maternal visceral adipose tissue (VAT) thickness in pregnancy is strongly associated with insulin resistance and higher risks of developing GDM [2][3][4][5]. Along with increased adiposity, GDM can have detrimental health consequences for both the mother and the fetus [6][7][8][9]. Hence, glycemic control is particularly fundamental in all pregnant individuals (with or without GDM), as continuous associations between maternal glucose levels (below those of GDM diagnosis) and adverse pregnancy outcomes, such as primary cesarean delivery and neonatal hypoglycemia, have been observed [10]. ...
This study aimed to (1) characterize the variations in serum fructosamine across trimesters and according to pre-pregnancy BMI (ppBMI), and (2) examine associations between fructosamine and adiposity/metabolic markers (ppBMI, first-trimester adiposity, leptin, glucose homeostasis, and inflammation measurements) during pregnancy. Serum fructosamine, albumin, fasting glucose and insulin, leptin, adiponectin, interleukin-6 (IL-6), and C-reactive protein (CRP) concentrations were measured at each trimester. In the first trimester, subcutaneous (SAT) and visceral (VAT) adipose tissue thicknesses were estimated by ultrasound. In the 101 healthy pregnant individuals included (age: 32.2 ± 3.5 y.o.; ppBMI: 25.5 ± 5.5 kg/m2), fructosamine concentrations decreased during pregnancy whereas albumin-corrected fructosamine concentrations increased (p < 0.0001 for both). Notably, fructosamine concentrations were inversely associated with ppBMI, first-trimester SAT, VAT, and leptin (r = −0.55, r = −0.61, r = −0.48, r = −0.47, respectively; p < 0.0001 for all), first-trimester fasting insulin and HOMA-IR (r = −0.46, r = −0.46; p < 0.0001 for both), and first-trimester IL-6 (r = −0.38, p < 0.01). However, once corrected for albumin, most of the correlations lost strength. Once adjusted for ppBMI, fructosamine concentrations were positively associated with third-trimester fasting glucose and CRP (r = 0.24, r = 0.27; p < 0.05 for both). In conclusion, serum fructosamine is inversely associated with adiposity before and during pregnancy, with markers of glucose homeostasis and inflammation, but the latter associations are partially influenced by albumin concentrations and ppBMI.
Background
Concerns are prevalent about preterm infant long‐term growth regarding plotting low on growth charts at discharge, stunting, underweight, high body fat and subsequent cardiometabolic morbidities.
Objectives
To examine (a) longitudinal growth patterns of extremely and very preterm infants to 3 years corrected age (CA) (outcome), categorised by their birthweight for gestational age: small, appropriate and large for gestational age (SGA, AGA and LGA, respectively) (exposure); and (b) the ability of growth faltering (<−2 z‐scores) to predict suboptimal cognitive scores at 3 years CA.
Methods
Post‐discharge head, length, weight and weight‐4‐length growth patterns of the PreM Growth cohort study infants born <30 weeks and < 1500 g, who had dietitian and multi‐disciplinary support before and after discharge, were plotted against the World Health Organization growth standard. Infants with brain injuries, necrotising enterocolitis and bronchopulmonary dysplasia were excluded.
Results
Of the included 405 infants, the proportions of infants with anthropometric measures > − 2 z‐scores improved with age. The highest proportions <−2 z‐scores for length (24.2%) and weight (24.0%) were at 36 gestational weeks. The proportion with small heads was low by 0 months CA (1.8%). By 3 years CA, only a few children plotted lower than −2 z‐scores for length, weight‐4‐length and weight (<6%). After zero months CA, high weight‐4‐length and body mass index > + 2 z‐scores were rare (2.1% at 3 years CA). Those born SGA had higher proportions with shorter heights (16.7% vs. 5.2%) and lower weights (27.8% vs. 3.5%) at 3 years CA compared to those born AGA. The ability of growth faltering to predict cognitive scores was limited (AUROC 0.42, 95% CI 0.39, 0.45 to 0.52, 95% CI 0.41, 0.63).
Conclusions
Although children born <30 weeks gestation without major neonatal morbidities plot low on growth charts at 36 weeks CA most catch up to growth chart curves by 3 years CA.
Compared to Western populations, Chinese and Asians possess distinct genetics, lifestyles, and dietary habits. They tend to have shorter stature, lower Body Mass Index (BMI), and higher body fat percentages than Western populations. The aim of this study was to compare disparities in maternal–fetal outcomes by combining pre-pregnancy BMI and gestational weight gain (GWG) based on distinct US and Chinese guidelines. A total of 2,271 pregnant women who received perinatal care at Fooyin University Hospital from 2016 to 2021 were included. Logistic regression analysis categorized women into twelve groups based on the two criteria to explore the relationships between BMI and GWG, and maternal–fetal outcomes. Among the subjects, only 23.2% and 21.8% women had a normal weight BMI and adequate GWG, based on US and Chinese criteria, respectively. As BMI and GWG increase, the likelihood of developing complications such as gestational diabetes, gestational hypertension or preeclampsia, Cesarean section, and Large for Gestational Age also rises. Conversely, underweight women with excessive GWG exhibited lower risk of preterm birth either by US or Chinese guidelines. Two criteria exhibited similar odds for investigated outcomes, except for gestational hypertension or preeclampsia. Women had more than double the odds of developing gestational hypertension or preeclampsia when using US criteria compared to Chinese criteria. Therefore, it is essential for Asian, especially Chinese women, to be aware of the differences in adverse outcomes such as gestational hypertension or preeclampsia when using US criteria.
Diabetes mellitus (DM) is a chronic metabolic condition characterized predominantly by hyperglycemia. The most common causes contributing to the pathophysiology of diabetes are insufficient insulin secretion, resistance to insulin’s tissue-acting effects, or a combination of both. Over the last 30 years, the global prevalence of diabetes increased from 4% to 6.4%. If no better treatment or cure is found, this amount might climb to 430 million in the coming years. The major factors of the disease’s deterioration include age, obesity, and a sedentary lifestyle. Finding new therapies to manage diabetes safely and effectively without jeopardizing patient compliance has always been essential. Among the medications available to manage DM on this journey are glucagon-like peptide-1 agonists, thiazolidinediones, sulphonyl urease, glinides, biguanides, and insulin-targeting receptors discovered more than 10 years ago. Despite the extensive preliminary studies, a few clinical observations suggest this process is still in its early stages. The present review focuses on targets that contribute to insulin regulation and may be employed as targets in treating diabetes since they may be more efficient and secure than current and traditional treatments.
Objective:
To evaluate the risks of large-for-gestational-age birth weight (LGA) and birth weight-related complications in pregnant individuals with gestational glucose intolerance, an abnormal screening glucose loading test result without meeting gestational diabetes mellitus (GDM) criteria.
Methods:
In a retrospective cohort study of 46,989 individuals with singleton pregnancies who delivered after 28 weeks of gestation, those with glucose loading test results less than 140 mg/dL were classified as having normal glucose tolerance. Those with glucose loading test results of 140 mg/dL or higher and fewer than two abnormal values on a 3-hour 100-g oral glucose tolerance test (OGTT) were classified as having gestational glucose intolerance. Those with two or more abnormal OGTT values were classified as having GDM. We hypothesized that gestational glucose intolerance would be associated with higher odds of LGA (birth weight greater than the 90th percentile for gestational age and sex). We used generalized estimating equations to examine the odds of LGA in pregnant individuals with gestational glucose intolerance compared with those with normal glucose tolerance, after adjustment for age, body mass index, parity, health insurance, race and ethnicity, and marital status. In addition, we investigated differences in birth weight-related adverse pregnancy outcomes.
Results:
Large for gestational age was present in 7.8% of 39,685 pregnant individuals with normal glucose tolerance, 9.5% of 4,155 pregnant individuals with gestational glucose intolerance and normal OGTT, 14.5% of 1,438 pregnant individuals with gestational glucose intolerance and one abnormal OGTT value, and 16.0% of 1,711 pregnant individuals with GDM. The adjusted odds of LGA were higher in pregnant individuals with gestational glucose intolerance than in those with normal glucose tolerance overall (adjusted odds ratio [aOR] 1.35, 95% CI 1.23-1.49, P<.001). When compared separately with pregnant individuals with normal glucose tolerance, those with either gestational glucose intolerance subtype had higher adjusted LGA odds (gestational glucose intolerance with normal OGTT aOR 1.21, 95% CI 1.08-1.35, P<.001; gestational glucose intolerance with one abnormal OGTT value aOR 1.77, 95% CI 1.52-2.08, P<.001). The odds of birth weight-related adverse outcomes (including cesarean delivery, severe perineal lacerations, and shoulder dystocia or clavicular fracture) were higher in pregnant individuals with gestational glucose intolerance with one abnormal OGTT value than in those with normal glucose tolerance.
Conclusion:
Gestational glucose intolerance in pregnancy is associated with birth weight-related adverse pregnancy outcomes. Glucose lowering should be investigated as a strategy for lowering the risk of these outcomes in this group.
Macrosomia, usually defined as infant birth weight of ≥4000 g, does not consider gestational age, sex, or country/region‐specific differences in mean birth weight and maternal body weight. This issue is particularly relevant for Asia, where 60% of the world's population lives, due to variations in maternal size and birth weights across populations. Large for gestational age (LGA), defined as birth weight > 90th centile, is a more sensitive measure as it considers gestational age and sex, though it is dependent on the choice of growth charts. We aimed to review reporting of macrosomia and LGA in Asia. We reviewed the literature on prevalence and risk of macrosomia and LGA in Asia over the last 29 years. Prevalence of macrosomia ranged from 0.5% (India) to 13.9% (China) while prevalence of LGA ranged from 4.3% (Korea) to 22.1% (China), indicating substantial variation in prevalence within and between Asian countries. High pre‐pregnancy body mass index, excessive gestational weight gain, and impaired glucose tolerance conferred risk of macrosomia/LGA. Incidence of macrosomia and LGA varies substantially within and between Asian countries, as do the growth charts and definitions. The latter makes it impossible to make comparisons but suggests differences in intrauterine growth between populations. Reporting LGA, using standardized country/regional growth charts, would better capture the incidence of high birth weight and allow for comparison and identification of contributing factors. Better understanding of local drivers of excessive intrauterine growth could enable development of improved strategies for prevention and management of LGA.
Objectives
To assess the association between advanced maternal age and adverse perinatal outcomes in single pregnancies.
Materials and methods
A cohort study was conducted using data from 27,455 singleton births attended at our hospital between 2007 and 2018. Three maternal age groups were established, and perinatal outcomes were compared between-groups (<35 years (n = 19,429; 70.7%), 35–40 years (n = 7189; 26.2%), and >40 years (n = 846; 3.1%). The data were compared using chi-square analysis and the results were adjusted using a logistic regression model. Decision trees were designed to examine the fetal mortality and caesarean section variables. We used the SPSS 23 statistical software program for the statistical analysis.
Results
The mean age of the women was 31.21 years. No differences were found associated with age for neonatal acidosis, an Apgar score <7 at 5 min after birth, threatened preterm labour, preterm rupture of membranes, or high-grade perineal tear. The analyses found statistically significant increases in the rates of hypertensive disorders, diabetes mellitus, induction of labour, and caesarean section, after 35 years of age. The risks of fetal death, neonatal admission, small for gestational age, placenta previa, instrument delivery, maternal ICU admission, and postpartum haemorrhage were greater after 40 years of age.
Conclusions
The results of our study indicated that women >35 years of age had worse perinatal outcomes, compared with younger women. This finding was more evident in patients >40 years of age, which highlighted the greater risk of fetal death and serious maternal complications in this group.
Background: We investigated the treatment effects of tight glycaemic targets in a population universally screened according to the International Association of Diabetes and Pregnant Study Groups (IADPSG)/World Health Organisation (WHO) gestational diabetes mellitus (GDM) guidelines. As yet there, have been no randomized control trials evaluating the effectiveness of treatment of mild GDM diagnosed under the IADPSG/WHO diagnostic thresholds. We hypothesize that tight glycaemic control in pregnant women diagnosed with GDM will result in similar clinical outcomes to women just below the diagnostic thresholds. Methods: A multiple cutoff regression discontinuity study design in a retrospective observational cohort undergoing oral glucose tolerance tests (OGTT) (n = 1178). Treatment targets for women with GDM were: fasting capillary blood glucose (CBG) of ≤5.0 mmol/L and the 2-h post-prandial CBG of ≤6.7 mmol/L. Regression discontinuity study designs estimate treatment effects by comparing outcomes between a treated group to a counterfactual group just below the diagnostic thresholds with the assumption that covariates are similar. The counterfactual group was selected based on a composite score based on OGTT plasma glucose categories. Results: Women treated for GDM had lower rates of newborns large for gestational age (LGA), 4.6% versus those just below diagnostic thresholds 12.6%, relative risk 0.37 (95% CI, 0.16-0.85); and reduced caesarean section rates, 32.2% versus 43.0%, relative risk 0.75 (95% CI, 0.56-1.01). This was at the expense of increases in induced deliveries, 61.8% versus 39.3%, relative risk 1.57 (95% CI, 1.18-1.9); notations of neonatal hypoglycaemia, 15.8% versus 5.9%, relative risk 2.66 (95% CI, 1.23-5.73); and high insulin usage 61.1%. The subgroup analysis suggested that treatment of women with GDM with BMI ≥30 kg/m 2 drove the reduction in caesarean section rates: 32.9% versus 55.9%, relative risk 0.59 (95%CI, 0.4-0.87). Linear regression interaction term effects between non-GDM and treated GDM were significant for LGA newborns (p = 0.001) and caesarean sections (p = 0.015). Conclusions: Tight glycaemic targets reduced rates of LGA newborns and caesarean sections compared to a counterfactual group just below the diagnostic thresholds albeit at the expense of increased rates of neonatal hypoglycaemia, induced deliveries, and high insulin usage.
Background:
The rate of preterm birth has been increasing worldwide. Most preterm babies are at an increased risk of central nervous system impairments as well as respiratory and gastrointestinal complications. The aim of this study was to investigate the epidemiologic characteristics of and associated factors contributing to preterm birth in Taiwan.
Methods:
Information on obstetric antecedents and risk factors for preterm birth in pregnant women was obtained from the National Health Insurance Research (NHIR) database provided by the Taiwan National Health Research Institute. All live births from 2004 to 2013 in Taiwan were included in this study.
Results:
A total of 130,362 live births from 2004 to 2013 were included in this study. Overall, the average annual rate of preterm births increased by 5.3% (from 3.33% in 2004 to 5.11% in 2013). Multiple logistic regression analyses showed that nulliparous women, multifetal pregnancies, advanced mother age, history of preterm birth, history of maternal drug abuse/dependence, and maternal medical complications were positively associated with an increased risk of preterm birth (all p-values< 0.05).
Conclusion:
The overall proportion of preterm births increased from 2004 to 2013 in Taiwan. Babies born preterm had a higher risk of developing morbidities and mortalities. The development of a comprehensive program to identify the high-risk group is needed for effective interventions to prevent premature birth.
Objectives
There is no consensus regarding a possible relation between false positive glucose challenge test (GCT) results and large-for-gestational-age (LGA) infants. This study aimed to clarify the association between false positive GCT results and LGA, after adjusting for potential confounding factors, using a large clinical dataset.
Design
Retrospective cohort study.
Setting
National Hospital Organisation Kofu National Hospital, which is a community hospital, between January 2012 and August 2019.
Participants
Japanese women who underwent GCT between 24 and 28 weeks of gestation at the hospital were included. After excluding those with gestational diabetes mellitus, diabetes in pregnancy and multiple pregnancies, subjects were divided into a false positive GCT group (≥140 mg/dL) and a GCT negative group (<140 mg/dL).
Methods
Obstetric records of patients were examined. The χ ² -test and multivariable logistic regression analysis were used to investigate the association between false positive GCT results and LGA.
Primary and secondary outcome measures
Incidence of LGA and the association between false positive GCT results and LGA.
Results
The mean subject age was 31.4±5.5 years, with 43.3% nulliparity (n=974) and 2160 (96.1%) term deliveries. The incidence of LGA was 9.4% (211/2248) and 11.4% (257/2248) of the women had false positive GCT results. False positive GCT results were significantly associated with an increased risk of LGA (OR, 1.51; 95% CI, 1.02 to 2.23), after controlling for maternal age, prepregnancy maternal weight, maternal weight gain during pregnancy and parity.
Conclusions
It appears that there is a significant association between false positive GCT results and LGA. Additional research is required to confirm these results and to investigate appropriate interventions for women with abnormal screens for gestational diabetes mellitus.
While there is evidence that being born large-for-gestational-age (LGA) is associated with an increased risk of obesity later in life, the data are conflicting. Thus, we aimed to examine the associations between proportionality at birth and later obesity risk in adulthood. This was a retrospective study using data recorded in the Swedish Birth Register. Anthropometry in adulthood was assessed in 195,936 pregnant women at 10–12 weeks of gestation. All women were born at term (37–41 weeks of gestation). LGA was defined as birth weight and/or length ≥2.0 SDS. Women were separated into four groups: appropriate-for-gestational-age according to both weight and length (AGA – reference group; n = 183,662), LGA by weight only (n = 4,026), LGA by length only (n = 5,465), and LGA by both weight and length (n = 2,783). Women born LGA based on length, weight, or both had BMI 0.12, 1.16, and 1.08 kg/m² greater than women born AGA, respectively. The adjusted relative risk (aRR) of obesity was 1.50 times higher for those born LGA by weight and 1.51 times for LGA by both weight and height. Length at birth was not associated with obesity risk. Similarly, women born LGA by ponderal index had BMI 1.0 kg/m² greater and an aRR of obesity 1.39 times higher than those born AGA. Swedish women born LGA by weight or ponderal index had an increased risk of obesity in adulthood, irrespective of their birth length. Thus, increased risk of adult obesity seems to be identifiable from birth weight and ignoring proportionality.
Gestational diabetes mellitus (GDM) and large for gestational age (LGA) offspring are two common pregnancy complications. Connections also exist between the two conditions, including mutual maternal risk factors for the conditions and an increased prevalence of LGA offspring amongst pregnancies affected by GDM. Thus, it is important to elucidate potential shared underlying mechanisms of both LGA and GDM. One potential mechanistic link relates to macronutrient metabolism. Indeed, derangement of carbohydrate and lipid metabolism is present in GDM, and maternal biomarkers of glucose and lipid control are associated with LGA neonates in such pregnancies. The aim of this paper is therefore to reflect on the existing nutritional guidelines for GDM in light of our understanding of the pathophysiological mechanisms of GDM and LGA offspring. Lifestyle modification is first line treatment for GDM, and while there is some promise that nutritional interventions may favourably impact outcomes, there is a lack of definitive evidence that changing the macronutrient composition of the diet reduces the incidence of either GDM or LGA offspring. The quality of the available evidence is a major issue, and rigorous trials are needed to inform evidence-based treatment guidelines.
The study aimed to compare the incidence of large for gestational age (LGA) infants between women with a false positive and normal glucose challenge test (GCT), and to evaluate the factors associated with LGA. A total of 480 pregnant women at risk for gestational diabetes mellitus (GDM); 160 with a false positive GCT and 320 with normal GCT results were included. The incidence of LGA and other pregnancy outcomes were compared between the two groups. Possible associated factors for LGA were also evaluated. Women with a false positive GCT were significantly older and more likely to be multiparous. The incidence of LGA was comparable between the false positive and normal GCT groups (15.6% vs. 13.1%, p = .456). Other pregnancy outcomes were also comparable. Logistic regression analysis showed that pre-pregnancy underweight significantly reduced the risk of LGA (adjusted OR 0.25, 95% CI 0.07–0.87, p = .029) while a second trimester weight gain >7 kg significantly increased the risk of LGA (adjusted OR 3.13, 95% CI 1.67–5.89, p 7 kg significantly increased the risk of LGA. What the implications are of these findings for clinical practice and/or further research? As a gestational weight gain is modifiable, behavioural and a dietary intervention as well as a close monitoring of the weight gain could help in lowering the risk of LGA, even in the absence of GDM. Further studies which are more widely generalisable are needed to elucidate the relationship between 50 g GCT and the adverse outcomes and to investigate the benefits of a specific intervention among this specific group of women.
With the improvement of living standard, gestational diabetes mellitus (GDM) incidence is increasing every year. We observed the effects of abnormal 75 g oral glucose tolerance test (OGTT) at different time points on neonatal complications and neurobehavioral development in GDM.
A total of 144 newborns whose mothers were diagnosed with GDM and received prenatal examination and childbirth in our hospital from October 2015 to April 2016, were observed in this study. Pregnant women underwent 75 g OGTT and the blood glucose level was recorded on an empty stomach, as well as postprandial 1 and 2 hours, respectively. Based on the frequency of 75 g OGTT-abnormal time points, the pregnant women were divided into group 1 (OGTT abnormality at 1 time point), group 2 (OGTT abnormality at 2 time points), and group 3 (OGTT abnormality at 3 time points). Neonatal behavioral neurological assessment (NBNA) was performed on the 3 groups, respectively.
In the total score of NBNA, there was a significant difference among the 3 groups (F = 17.120, P = .000), and there were significant differences between the 3 groups (all P < .05). The incidence of neonatal hypoglycemia was significantly lower in groups 1 and 2 than in group 3, and the incidence of macrosomia was significantly lower in groups 1 than in groups 2 and 3 (all P < .05). In the 144 newborns, NBNA scoring was significantly lower in the newborns with hypoglycemia than in the newborns with normal blood glucose level, and in macrosomia than in the newborns with normal body weight (all P < .01).
With the increase of OGTT-abnormal time points in the pregnant women with GDM, the incidences of neonatal hypoglycemia and macrosomia rise and neonatal NBNA score decreases. Therefore, reasonable measures should be adopted as early as possible to prevent poor prognosis in the pregnant women with GDM.
In the epidemiologic context of maternal obesity and type 2 diabetes (T2D), the incidence of gestational diabetes has significantly increased in the last decades. Infants of diabetic mothers are prone to various neonatal adverse outcomes, including metabolic and hematologic disorders, respiratory distress, cardiac disorders and neurologic impairment due to perinatal asphyxia and birth traumas, among others. Macrosomia is the most constant consequence of diabetes and its severity is mainly influenced by maternal blood glucose level. Neonatal hypoglycemia is the main metabolic disorder that should be prevented as soon as possible after birth. The severity of macrosomia and the maternal health condition have a strong impact on the frequency and the severity of adverse neonatal outcomes. Pregestational T2D and maternal obesity significantly increase the risk of perinatal death and birth defects. The high incidence of maternal hyperglycemia in developing countries, associated with the scarcity of maternal and neonatal care, seriously increase the burden of neonatal complications in these countries.
The prevalence of gestational diabetes mellitus (GDM) is rising worldwide, along with overweight and obesity. In utero exposure to hyperglycemia increases perinatal complications including preterm birth, macrosomia, neonatal respiratory distress, hypoglycemia, and polycythemia. More significantly, GDM places the offspring at risk of insulin resistance and type 2 diabetes mellitus, obesity and cardiovascular disease. The relative contributory roles of the intrauterine environment, shared genes, and postnatal environment on long-term outcomes are not yet fully understood. Maternal obesity in particular remains a significant confounding factor. Opportunities for ameliorating both the perinatal effects and long-term and intergenera-tional effects of GDM exist at the level of prevention of GDM, screening for and treatment of GDM, and postnatal interventions in offspring.
The International Association of Diabetes in Pregnancy Study Groups (IADPSG) recommended a new protocol of 1-step testing with a 75 g oral glucose tolerance test for gestational diabetes in 2010. Since that time, these recommendations have been carefully scrutinized and accepted by a variety of organizations, but challenged or rejected by others. In the current review, we present more details regarding the background to the development of the IADPSG recommendations and seek to place them in context with the available epidemiologic and randomized controlled trial data. In this "counterpoint," we also provide specific rebuttal for errors of fact and disputed contentions provided by Long and Cundy in their 2013 article in Current Diabetes Reports.
To investigate the relationship between abnormal degrees of oral glucose tolerance test (OGTT) results and pregnancy outcomes.
A total of 7513 singleton pregnancies screened for gestational diabetes mellitus were enrolled in this retrospective observational study. The pregnancy outcomes of six different groups with different degrees of glucose intolerance using the OGTT were compared [both the National Diabetes Data Group (NDDG) and Carpenter and Coustan (C&C) criteria were used]. The pregnancies were classified into the following groups: the normal group, consisting of pregnancies with a negative 50-g glucose challenge test (GCT), and Grade 0, 1, 2, 3 and 4 groups, consisting of pregnancies with positive 50-g GCT, and abnormal values of 0, 1, 2, 3 and 4 from the 100-g OGTT, respectively.
The adjusted odds ratios (95% confidence interval) for preterm labor and admission to the neonatal intensive care unit (NICU) were shown to be increased in the Grade 4 groups [3.31 (1.47-7.43) and 6.31 (3.14-12.70) by the NDDG criteria; 4.13 (2.30-7.43) and 5.25 (3.00-9.19) by the C&C criteria] compared with the normal group.
The results indicated an increased risk for preterm labor and admission to the NICU as the abnormal value of the OGTT increased.
The rate of cesarean delivery was 35% in 2007 in Taiwan. It is unclear how many of the cesarean deliveries were without medical indications. Women's preference for cesarean delivery during their course of pregnancy has rarely been studied and therefore our objectives were to examine rate of cesarean deliveries without medical indications, to explore women's preference for cesarean delivery as their gestation advances, and to compare background and perinatal factors among women who underwent different modes of delivery in Taiwan.
This prospective study applied a longitudinal design. The study participants were 473 women who received prenatal care at four hospitals in Taipei and answered structured questionnaires at 20 to 24 weeks of pregnancy, 34 to 36 weeks of pregnancy, and 5 to 7 weeks after delivery.
Of the 151 women (31.9%) who had cesarean deliveries, 19.9% were without medical indication. Three indications: malpresentation, prior cesarean section, and dysfunctional labor together accounted for 82.6% of cesarean section with medical indications. The prevalence of maternal preference for cesarean delivery was found to be 12.5% and 17.5% during the second and third trimester, respectively. Of the women who preferred cesarean delivery during the second trimester, 93.2% eventually had a cesarean delivery. Women who were older, with older spouses, and who had health problems before or during pregnancy were more likely to have cesarean deliveries.
About 20% of cesarean deliveries were without medical indications. Women's preference for cesarean delivery during the second trimester predicts subsequent cesarean delivery. Counseling regarding mode of delivery should be offered early in pregnancy, especially for women who are older or with older spouses, have health problems, or had a prior cesarean section.
It is uncertain whether treatment of mild gestational diabetes mellitus improves pregnancy outcomes.
Women who were in the 24th to 31st week of gestation and who met the criteria for mild gestational diabetes mellitus (i.e., an abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg per deciliter [5.3 mmol per liter]) were randomly assigned to usual prenatal care (control group) or dietary intervention, self-monitoring of blood glucose, and insulin therapy, if necessary (treatment group). The primary outcome was a composite of stillbirth or perinatal death and neonatal complications, including hyperbilirubinemia, hypoglycemia, hyperinsulinemia, and birth trauma.
A total of 958 women were randomly assigned to a study group--485 to the treatment group and 473 to the control group. We observed no significant difference between groups in the frequency of the composite outcome (32.4% and 37.0% in the treatment and control groups, respectively; P=0.14). There were no perinatal deaths. However, there were significant reductions with treatment as compared with usual care in several prespecified secondary outcomes, including mean birth weight (3302 vs. 3408 g), neonatal fat mass (427 vs. 464 g), the frequency of large-for-gestational-age infants (7.1% vs. 14.5%), birth weight greater than 4000 g (5.9% vs. 14.3%), shoulder dystocia (1.5% vs. 4.0%), and cesarean delivery (26.9% vs. 33.8%). Treatment of gestational diabetes mellitus, as compared with usual care, was also associated with reduced rates of preeclampsia and gestational hypertension (combined rates for the two conditions, 8.6% vs. 13.6%; P=0.01).
Although treatment of mild gestational diabetes mellitus did not significantly reduce the frequency of a composite outcome that included stillbirth or perinatal death and several neonatal complications, it did reduce the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders. (ClinicalTrials.gov number, NCT00069576.)
There are limited nationwide population-based data about birth weight percentiles by gestational age in Taiwan. The purpose of this study was to develop updated intrauterine growth charts that are population based and contain the information of birth weight percentiles by gestational age for singleton newborns in Taiwan. We abstracted and analyzed the birth registration database from the Ministry of the Interior in Taiwan during the period of 1998-2002 that consisted of over one million singleton births. Percentiles of birth weight for each increment of gestational week from 21 to 44 weeks were estimated using smoothed means and standard deviations. The analyses revealed that birth weight rose with advancing gestational age, with greater slopes during the third trimester and then leveled off beyond 40 weeks of gestational age. The male to female ratio ranged from 1.088 to 1.096. The mean birth weights during the period of 1998-2002 were higher than those previously reported for the period of 1945-1967; while the birth weight distribution and percentile during the period of 1998-2002 were similar to those reported for the period of 1979-1989. The 10th, 50th, and 90th percentiles of birth weigh at 40th gestational age among the male newborns were 2914, 3374, and 3890 g respectively; and for the female newborns 2816, 3250, and 3747 g. At the gestational age of 37 weeks, the 10th, 50th, and 90th percentiles of birth weigh among the male newborns were 2499, 2941, and 3433 g respectively; and for the female newborns 2391, 2832, and 3334 g. From 1998 to 2002, there was a gradual increase in the prevalence of low birth weight and preterm birth together with the percentage of infants born to foreign-born mothers. This study provides the first nationwide singleton intrauterine growth charts in Taiwan that are population-based and gender-specific. The normative data are particularly useful for the investigation of predictors and outcomes of altered fetal growth.
of GDM that are based on perinatal out- comes. Thus, for the interim, the partic- ipants o f t he F ifth I nternational Workshop-Conference on GDM en- dorsed a motion to continue use of the definition, classification criteria, and strategies for detection and diagnosis of GDM that were recommended at the Fourth Workshop-Conference. Those guidelines are reproduced (with minor modifications) in this article in APPENDIX Tables 1 and 2.
To determine whether 1-h oral glucose challenge test (OGCT) or 3-h oral glucose tolerance test (OGTT) results below gestational diabetes mellitus (GDM) criteria are associated with developing diabetes.
A retrospective cohort study was performed among women without GDM who had a pregnancy OGCT (n = 24,780) or OGTT (n = 6,222). Subsequent diabetes was ascertained by ICD-9 codes or pharmacy or laboratory data over a median follow-up of 8.8 years.
Diabetes risk increased across OGCT quartiles: adjusted hazard ratio (HR) 1.67 (95% CI 1.07-2.61) for 5.4-6.2 mmol/l, 2.13 (1.39-3.25) for 6.3-7.3 mmol/l, and 3.60 (2.41-5.39) for >or=7.4 mmol/l compared with <or=5.3 mmol/l. Women with one abnormal OGTT result had a higher risk compared with those with normal values (HR 2.08 [95% CI 1.35-3.20]).
Women with modestly elevated glucose levels below the threshold for GDM had a higher risk for diabetes.
Background
It remains unclear if migrants have different odds for adverse outcomes associated with GDM. We investigated if the associations between GDM and adverse pregnancy outcomes are modified by country of origin; and examined the odds of these outcomes according to GDM status and country of origin.
Methods
Nationwide register-based study of singleton deliveries in Denmark, 2004-2015. We used logistic regression models and tested for interaction.
Results
Among the 710413 singleton deliveries, 2.6% had GDM and 14.4% were immigrants. Country of origin modified the association between GDM and pre-eclampsia, large for gestational age (LGA) and small for gestational age (SGA), but not between GDM and planned or emergency caesarean section and preterm delivery. GDM increased the risk of pre-eclampsia among women from Denmark (OR1.28, 95%CI 1.18-1.39), Lebanon (OR 3.34, 95%CI 1.35-8.26) and Morocco (OR 2.28, 95%CI 1.16-6.88). GDM was associated with increased odds of LGA among women from most countries, particularly women from Sri Lanka (OR 4.20 95%CI 2.67-6.61), and with reduced odds of SGA in some countries. Compared to Danish-born women with GDM, the odds of LGA were significantly lower and the odds of SGA higher among women with GDM from India, Lebanon, Pakistan, Iraq, and Somalia.
Conclusions
Our study documents that different immigrant groups have higher odds of different GDM associated adverse pregnancy outcomes – also among countries of origin often grouped together. This highlights the importance of increased awareness to both immigrant background and GDM status in the clinical assessment.
The association between birth size and cardiometabolic disease risk may be U-shaped. Being born small for gestational age (SGA) has a definitive association with later cardiovascular risk, but the impact of being born large for gestational age (LGA) on cardiometabolic health is more controversial. In addition to birth size, early postnatal growth pattern and later weight gain affect cardiometabolic risk in adulthood. Most SGA-born children have catch-up and LGA-born children have catch-down growth during the first years of life. The extent of this early compensatory growth may contribute to the adverse health outcomes. Both SGA- and LGA-born children are at an increased risk for overweight and obesity. This may have a long-term impact on cardiometabolic health as overweight tends to track to adulthood. Other cardiometabolic risk factors, including alterations in glucose metabolism, dyslipidemia, hypertension, and low-grade inflammation are associated with birth weight. Many of these risk factors are related to overweight or adverse fat distribution. Since later cardiometabolic risk is often mediated by early growth pattern and later overweight in SGA and LGA children, it is important to focus on staying normal weight throughout life. Hence, effective interventions to reduce cardiometabolic risk in LGA and SGA children should be developed.
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Gestational diabetes mellitus (GDM) is the commonest medical condition in pregnancy. It is associated with a range of maternal and infant complications including large-for-gestational-age, stillbirth, pre-term birth, shoulder dystocia, caesarean section, and neonatal hypoglycaemia. Increasingly, longer-term metabolic risks are also being recognized for women who have GDM and their children. Because the relationship between maternal glucose and complications is linear, the appropriate thresholds for diagnosis and treatment remain controversial. Because screening for and treating, GDM can improve outcomes for women and their children, optimizing management warrants widespread attention and implementation. Diet and lifestyle interventions offer sufficient treatment for the majority of women with GDM, however evidence to support specific dietary interventions, and to support either oral hypoglycaemic agents or insulin as the preferred pharmacotherapy is inconsistent. This review provides an up-to-date summary of evidence related to prevention, screening, diagnosis, management, and follow-up of GDM.
One in six live births occur in women with diabetes mellitus, of which the most common type, accounting for approximately 87.5% of all diabetes in pregnancy, is gestational diabetes mellitus (GDM). Maternal hyperglycaemia is one of the principle determinants of maternal–fetal complications in pregnancy in GDM. In particular, hyperglycaemia is most commonly associated with increased rates of instrumental and/or operative delivery, pre-eclampsia, increased adiposity, macrosomia and infant birthweight >90th percentile. Large for gestational age infants have an increased risk of birth complications, including shoulder dystocia and stillbirth. Maternal hyperglycaemia is also one of the factors most amenable to treatment during pregnancy. For most women with GDM, dietary and lifestyle modifications are sufficient to achieve glycaemic targets and optimal pregnancy outcomes. This chapter summarizes the latest evidence-based recommendations for the screening, diagnosis and treatment of pregnancies complicated by GDM. It considers the International Association of Diabetes and Pregnancy Study Groups and the National Institute for Health and Care Excellence guidelines. The evidence in support of dietary interventions for antenatal management and treatment options for postpartum care are reviewed.
Aims:
To evaluate the association between impaired fasting glucose (IFG) prior to pregnancy with maternal and neonatal outcome.
Methods:
A retrospective cohort study of singleton deliveries in a single, tertiary, university-affiliated medical center between August 2007 and December 2012. We included women who had a fasting glucose test done up to 26 weeks prior to pregnancy. We excluded women with diabetes mellitus and women carrying a fetus with structural or chromosomal anomalies. Maternal and neonatal outcome were compared between two groups: women with pre-pregnancy IFG (defined as fasting glucose ≥100 mg/dl and < 126 mg/dl) versus those with normoglycemia (fasting glucose < 100 mg/dl).
Results:
Overall, 1,945 women met inclusion criteria. Of whom, 1,790 had pre-pregnancy glucose < 100 mg/dl and 155 had IFG. There were no differences between groups in basic characteristics. As for maternal outcome, IFG was associated with higher rates of mild preeclampsia (5.16% vs. 0.67%), abnormal glucose challenge test (21.94% vs. 13.46%) and gestational diabetes (13.55 vs. 2.85%), p<0.05 for all. There were no significant differences in neonatal outcome. After adjusting for potential confounders, on multivariable logistic regression, pre-pregnancy IFG remained significantly and independently associated with mild preeclampsia (aOR 6.92, 95% CI 2.68-18.05, p<0.001).
Conclusions:
Pre-pregnancy IFG is associated with increased risk for abnormal glucose challenge test and gestational diabetes, and it is an independent risk factor for adverse pregnancy outcome including mild preeclampsia.
Background:
Gestational Diabetes Mellitus (GDM) is diagnosed using a two-step method, with a 3 hour, 100g oral glucose tolerance test (OGTT) reserved for women with an abnormal 1 hour, 50g glucose challenge test. While the increased maternal-fetal morbidity with GDM is well established, controversy remains about the risk associated with an isolated abnormal value during 3 hr, 100 g oral glucose tolerance test.
Objective:
To determine if women with one abnormal value on 3hr 100-g OGTT are at an increased risk for adverse pregnancy outcomes.
Study design:
Prospective and retrospective studies which evaluated the maternal and perinatal impact of one abnormal value (GTT-1) during a 3 hour, 100g OGTT were identified using computerized databases. Data were extracted and quantitative analyses were performed.
Results:
Twenty-five studies (7 prospective and 18 retrospective) met criteria for meta-analysis including 4466 women with one abnormal glucose value (GTT-1) on OGTT. Patients with GTT-1 had significantly worse pregnancy outcomes compared to women with zero abnormal values (GTT-0) with the following pooled odds ratios and 95% CI: macrosomia 1.59 (1.16-2.19), large for gestational age 1.38 (1.09-1.76), increased mean birth weight of 44.5g (8.10-80.80g), neonatal hypoglycemia 1.88 (1.05-3.38), total cesarean delivery 1.69 (1.40-2.05), pregnancy induced hypertension 1.55 (1.31-1.83), and Apgar <7 at 5min 6.10 (2.65-14.02). There was also an increase in NICU admission and respiratory distress syndrome. Similar results were seen comparing GTT-1 to a population with a normal 1hr 50 g glucose challenge test (Normal Glucose Screen). With the exception of birthweight, outcomes of patients with GTT-1 were similar to outcomes of patients with GDM.
Conclusion:
Women with one abnormal value on 3 hour, 100 g OGTT have significantly increased risk for poor outcomes comparable to women having GDM.
The updated guidelines by the Institute of Medicine regarding gestational weight gain provide clinicians with a basis for practice. Health care providers who care for pregnant women should determine a woman's body mass index at the initial prenatal visit and counsel her regarding the benefits of appropriate weight gain, nutrition and exercise, and, especially, the need to limit excessive weight gain to achieve best pregnancy outcomes. Individualized care and clinical judgment are necessary in the management of the overweight or obese woman who is gaining (or wishes to gain) less weight than recommended but has an appropriately growing fetus.
Objective:
The extent to which pregnant women are screened for gestational diabetes mellitus (GDM) at the population level is not known. We examined the rate, type, and timing of GDM screening and diagnostic testing in the province of Alberta, Canada. Geographic and temporal differences in screening rates, and maternal risk factors associated with lower likelihood of screening, were also determined.
Research design and methods:
Our retrospective linked-database cohort study included 86,842 primiparous women with deliveries between 1 October 2008 and 31 December 2012. Multivariable logistic regression analysis was used to examine maternal factors associated with lower likelihood of GDM screening.
Results:
Overall, 94% (n = 81,304) of women underwent some form of glycemic assessment in the 270 days prior to delivery. The majority (91%) received a 50-g glucose screen (GDS). Women not screened were younger and more likely to smoke and had lower maternal weight and median household income. When a diagnostic 75-g oral glucose tolerance test (OGTT) was indicated, it occurred a median of 10 (interquartile range 7, 15) days after the screen.
Conclusions:
GDS occurred widely in a system where it was universally recommended and paid for publicly. When indicated, a 75-g OGTT was completed within 15 days in 75% of cases. Our finding that this two-step approach was widely implemented in a timely fashion supports continued endorsement of a two-step approach to screening and diagnosis of GDM. Further research is merited to assess if the one-step GDM diagnostic approach results in different rates and timing of the 75-g OGTT and impacts pregnancy outcomes.
Screening and diagnostic criteria for gestational diabetes (GDM) are inconsistent across Europe, and the development of a uniform GDM screening strategy is necessary. Such a strategy would create opportunities for more women to receive timely treatment for GDM. Developing a consensus on screening for GDM in Europe is challenging, as populations are diverse and healthcare delivery systems also differ. The European Board & College of Obstetrics and Gynaecology (EBCOG) has responded to this challenge by appointing a steering committee, including members of the EBCOG and the Diabetic Pregnancy Study Group (DPSG) associated with the EASD, to develop a proposal for the use of uniform diagnostic criteria for GDM in Europe. A proposal has been developed and has now been approved by the Council of the EBCOG. The current proposal is to screen for overt diabetes at the first prenatal contact using cut-off values for diabetes outside pregnancy, with particular efforts made to screen high-risk groups. When screening for GDM is performed at 24 weeks' gestation or later, the proposal is now to use the 75 g OGTT with the new WHO diagnostic criteria for GDM. However, more research is necessary to evaluate the best GDM screening strategy for different populations in Europe. Therefore, no clear recommendation has been made on whether a universal one-step, two-step or a risk-factor-based screening approach should be used. The use of the same WHO diagnostic GDM criteria across Europe will be an important step towards uniformity.
Diet is the cornerstone treatment of patients with gestational diabetes mellitus (GDM), but its role in maternal and newborn outcomes has been scarcely studied. The purpose of this study was to analyze the efficacy of dietary interventions on maternal or newborn outcomes in patients with GDM.
A systematic review and meta-analysis of randomized clinical trials (RCTs) of dietary intervention in GDM or pregnancy with hyperglycemia was performed. MEDLINE, Embase, ClinicalTrials.gov, Cochrane, and Scopus were searched through to March 2014. The main evaluated maternal outcomes were proportion of patients using insulin and proportion of cesarean delivery; the newborn outcomes were proportion of macrosomia and hypoglycemia and newborn weight.
From 1,170 studies, nine RCTs, including 884 women aged 31.5 years (28.7-33.2) with 27.4 weeks (24.1-30.3) of gestation, were eligible. We divided the RCTs according to the type of dietary intervention: low glycemic index (GI) (n = 4; 257 patients), total energy restriction (n = 2; 425 patients), low carbohydrates (n = 2; 182 patients), and others (n = 1; 20 patients). Diet with low GI reduced the proportion of patients who used insulin (relative risk 0.767 [95% CI 0.597, 0.986]; P = 0.039) and the newborn birth weight (weight mean differences -161.9 g [95% CI -246.4, -77.4]; P = 0.000) as compared with control diet. Total restriction and low carbohydrate diets did not change either maternal or newborn outcomes.
A low GI diet was associated with less frequent insulin use and lower birth weight than control diets, suggesting that it is the most appropriate dietary intervention to be prescribed to patients with GDM.
© 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
Background
The association between low birth weight and adult disease is well known. Less is known on long-term effects of high birth weight.Objective
This study aims to investigate whether a high birth weight increases risk for adult metabolic disease.Methods
Swedish term single births, 1973-1982 (n = 759 999), were studied to age 27.5-37.5 years using Swedish national registers. Hazard ratios (HRs) were calculated in relation to birth weight for type 2 diabetes, obesity, hypertension and dyslipidaemia.ResultsMen with birth weights between 2 and 3 standard deviation score (SDS) had a 1.9-fold increased risk (HR 1.91, 95% confidence interval [CI] 1.25-2.90) of type 2 diabetes, whereas those with birth weights above 3 SDS had a 5.4-fold increased risk (HR 5.44, 95% CI 2.70-10.96) compared to men with birth weights between −2 and 2 SDS. The corresponding HRs for women were 0.60 (95% CI 0.40-0.91) and 1.71 (95% CI 0.85-3.43) for birth weights 2-3 SDS and >3 SDS, respectively. Men with birth weights between 2 and 3 SDS had a 1.5-fold increased risk (HR 1.47, 95% CI 1.22-1.77) of obesity. The corresponding risk for women was 1.3-fold increased (HR 1.32, 95% CI 1.19-1.46). For men and women with birth weights above 3 SDS, the risks of adult obesity were higher, HR 2.46 (95% CI 1.63-3.71) and HR 1.85 (95% CI 1.44-2.37), respectively.ConclusionsA high birth weight, particularly very high, increases the risk of type 2 diabetes in male young adults. The risk of obesity increases with increasing birth weight in both genders.
The occurrence of common pregnancy-related medical disorders identifies women at high-risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, while preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Both gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the two-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance of post-pregnancy surveillance of vascular risk factors in these women is underappreciated by both the women themselves and their physicians.
Although a prudent diet and physically-active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low; qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.
Background:
Outcomes of treating gestational diabetes mellitus (GDM) are not well-established.
Purpose:
To summarize evidence about the maternal and neonatal benefits and harms of treating GDM.
Data sources:
15 electronic databases from 1995 to May 2012, gray literature, Web sites of relevant organizations, trial registries, and reference lists.
Study selection:
English-language randomized, controlled trials (n = 5) and cohort studies (n = 6) of women without known preexisting diabetes.
Data extraction:
One reviewer extracted data, and a second reviewer verified them. Two reviewers independently assessed methodological quality and evaluated strength of evidence for primary outcomes by using a Grading of Recommendations Assessment, Development and Evaluation approach.
Data synthesis:
All studies compared diet modification, glucose monitoring, and insulin as needed with no treatment. Women who were treated had more prenatal visits than those in control groups. Moderate evidence showed fewer cases of preeclampsia, shoulder dystocia, and macrosomia in the treated group. Evidence was insufficient for maternal weight gain and birth injury. Low evidence showed no difference between groups for neonatal hypoglycemia. Evidence was insufficient for long-term metabolic outcomes among offspring. No difference was found for cesarean delivery (low evidence), induction of labor (insufficient evidence), small-for-gestational-age neonates (moderate evidence), or admission to a neonatal intensive care unit (low evidence).
Limitations:
Evidence is low or insufficient for many outcomes of greatest clinical importance. The strongest evidence supports reductions in intermediate outcomes; however, other factors (for example, maternal weight and gestational weight gain) may impart greater risk than GDM, particularly when glucose levels are modestly elevated.
Conclusion:
Treating GDM results in less preeclampsia, shoulder dystocia, and macrosomia; however, current evidence does not show an effect on neonatal hypoglycemia or future poor metabolic outcomes. There is little evidence of short-term harm of treating GDM other than an increased demand for services.
To evaluate the risks of perinatal complications in infants born to mothers with treated or untreated gestational diabetes mellitus (GDM).
A search of the PubMed database was performed and recommendations from NICE and the French National Authority for Health were consulted.
Untreated moderate or severe GDM increases the risk of foetal and neonatal complications (EL1). The risk of malformations slightly increases in newborns of mothers with GDM compared to the general population (EL2). This risk is probably associated with the presence of undiagnosed type 2 diabetes among patients with GDM (EL2). There is a linear relationship between maternal blood glucose levels and an increased birth weight (EL2). Treatment for GDM reduces the incidence of macrosomia (EL1). Although the risk of cardiomyopathy in cases of GDM cannot be accurately estimated based on the available data, severe clinical forms are rare. The risks of neonatal asphyxia and perinatal mortality are no higher in infants born to women with GDM (EL2). Birth injuries and brachial plexus injuries are rare, and no more likely to occur in cases of untreated GDM. It is difficult to assess the risk of respiratory distress, regardless of its cause. It is not possible to establish a link between GDM and neonatal respiratory problems due to insufficient data. Although the risk of neonatal hypoglycaemia is difficult to determine due to the variable definitions reported in the literature, the incidence of hypoglycaemia requiring intravenous therapy is low (EL1). The risks of hypocalcaemia (EL4) and hyperbilirubinemia (EL1) are similar to the general population.
Serious perinatal complications specifically associated with GDM are rare. Macrosomia has been demonstrated to be the predominant adverse outcome in cases of GDM. It is the main factor linked to reported cases of complications in GDM. Maternal obesity is an additional risk factor for complications, regardless of diabetes status.
In this study we sought to test the hypothesis that treatment of women with one abnormal oral glucose tolerance test value will result in reduction of adverse outcome. One hundred twenty-six women with one abnormal oral glucose tolerance test value and 146 women in the control group (normal oral glucose tolerance test values) participated in a prospective study during the third trimester of pregnancy. The subjects with one abnormal test result were randomized into treated (group 1) and untreated groups (group II). Group 1 subjects were treated with a strict diabetic protocol to maintain tight glycemic control by means of diet and insulin therapy. Group 2 subjects tested their capillary blood glucose for a baseline period. The study revealed that the level of glycemic control was similar before initiation of therapy (mean capillary blood glucose 118 +/- 14 vs. 119 +/- 15 mg/dl, p = NS) for groups 1 and 2, respectively. There was a significant difference in mean capillary blood glucose (95 +/- 10 vs. 119 +/- 15 mg/dl, p less than 0.0001), preprandial, and postprandial determinations between the treated and untreated groups. The overall incidence of neonatal metabolic complications (4% vs. 14%, p less than 0.05) and large infants (6% vs. 24%, p less than 0.03) was significantly lower in the treated group. Comparison between the control (normal oral glucose tolerance test) and the untreated groups showed a significantly higher incidence of large infants and metabolic complications. No difference was found between the normal and treated groups. Thus we conclude that treatment of individuals with one abnormal oral glucose tolerance test value will result in significant reduction in adverse outcome in pregnancy.
Infant macrosomia is a serious medical concern. Pregnant women who do not meet the specific diagnosis for gestational diabetes may still have glucose-mediated macrosomia. In Santa Barbara County all pregnant women are screened for gestational diabetes at 24-28 weeks with a 50-g, 1-hr glucose challenge test (GCT). All patients who fail this test are placed on a standard euglycemic diet (40% carbohydrate, 20% protein, 40% fat) and perform home glucose monitoring of fasting and postprandial glucose levels. The objective of this study was to examine the effectiveness of this treatment program in decreasing infant macrosomia, maternal and infant morbidity, maternal complications, and operative delivery. We studied 103 women who had a positive GCT, but a negative 100-g, 3-hr oral glucose tolerance test (OGTT). The women were randomly assigned to either experimental or control groups with experimental women receiving dietary counseling and home glucose monitoring instruction (HBGM). HBGM diaries were reviewed weekly by clinic nurses. All women had hemoglobin A1c (HbA1c) tests at 28 and 32 weeks. Maternal and fetal charts were reviewed to determine delivery type and complications, indications for cesarean section (C-section), and infant gestational age, gender, Apgar scores, birth weight, morbidities, and congenital anomalies. Of the 103 women, 5 women required insulin treatment, 1 woman had an abortion, and 14 women were indeterminate regarding compliance or were control women who received diet counseling and HBGM. The results are based on 83 women--48 control and 35 experimental. There were no significant differences between the groups for age, parity, or weight at 28-30 weeks or 37 weeks to delivery, or HbA1c at 28 weeks. HbA1c was significantly higher in control women at 32 weeks. Birth weight expressed in grams or as a percentile specific for gender, ethnicity, and gestational age was significantly higher in control infants. Birth weight was significantly correlated with maternal intake weight, weight at 28-30 weeks, and weight at delivery and with HbA1c at 32 weeks' gestation. There were no significant differences between groups for maternal complications. Groups were significantly different for mode of delivery with experimental women having more induced vaginal deliveries but fewer repeat C-sections than control women. Groups were not different for primary C-sections. Women who fail the GCT, but not the OGTT and thus do not receive the diagnosis of GDM are still at risk for delivering a macrosomic infant and operative delivery. Our program of treatment for all women who fail the GCT improves outcome by reducing infant birth weight and the number of cesarean sections.
The purpose of this study was to evaluate the characteristics and outcomes of patients who had abnormal glucose challenge test results and subsequent normal oral glucose tolerance test results and to assess whether such patients are at a greater risk than normal pregnant patients for adverse perinatal outcome.
In this retrospective cohort study that was conducted between June and December 2003, 101 pregnant women (group A) had an abnormal glucose challenge test result and a normal oral glucose tolerance test result. Data were also collected on 2 control groups: 100 pregnant women with normal glucose challenge test results (group B) and all 76 pregnant women who were diagnosed with gestational diabetes mellitus during this period of time (group C). Patients with multiple pregnancies, chronic hypertension, pregestational diabetes mellitus, or any other maternal or fetal problems that were diagnosed before 24 weeks (when the glucose challenge test was performed) were excluded from the study groups. The following data were collected and analyzed: maternal age, maternal weight and height, parity and gravidity, diabetes mellitus in first-degree relatives, medical and obstetric history, ethnicity, complications during the third trimester of pregnancy, birth weight, gestational age at delivery, mode of delivery, Apgar scores, cord blood gas results, maternal complications of labor and during the postpartum period, and infant admission to the neonatal intensive care unit. For comparison between groups, we used the Student t test, 1-way analysis of variance, the chi-square test, and stepwise logistic regression.
Patients in groups A and C were significantly older compared with group B (29.2 +/- 5.6 years and 30.4 +/- 5.5 years, respectively, vs 24.8 +/- 5.5 years; P < .01), had a lesser rate of primiparity (48% and 31%, respectively, vs 24%; P < .05), had greater body mass index (30.8 +/- 5 kg/m2 and 31.3 +/- 6 kg/m2, respectively, vs 29.2 +/- 4.4 kg/m2; P < .01), had a greater rate of previous gestational diabetes mellitus (6% and 20%, respectively, vs 0%; P < .05), and had a greater rate of first-degree family members with diabetes mellitus (21% and 21%, respectively, vs 3%; P < .01). None of the outcome parameters was statistically significant when group A was compared with group B.
Patients with an abnormal glucose challenge test result and a subsequent normal oral glucose tolerance test result have different maternal characteristics and backgrounds compared with patients in whom both test results are normal, yet both groups have normal outcomes. We should continue to consider patients who have an abnormal glucose challenge test result and subsequent normal oral glucose tolerance test result as low-risk; however, these findings may represent an indication of an increased likelihood for the development of overt diabetes mellitus later in life.
To evaluate the use of cesarean delivery in Taiwan by comparing local clinical indications with those in international cohorts.
In-patient claims from the National Health Insurance (NHI) in Taiwan were analyzed. Indications for cesarean delivery were evaluated with primary diagnosis codes and procedure codes from the NHI dataset. To produce a stable numerator for cesarean section, 3 years (1998-2000) of claims for cesarean delivery were abstracted and annualized.
Rates ranged between 27.3% and 28.7% for primary cesarean delivery and were below 5% for vaginal birth after a cesarean section (VBAC). Compared with rates in other countries, rates for overall and primary cesarean section as well as for VBAC were significantly higher in medical centers in Taiwan (P<0.001). However, the clinics contributed the most to the difference in both overall and primary cesarean rates. The most common indication for cesarean section was prior cesarean section (43.3%-45.5%), followed by malpresentation (19.6%-23.4%). The proportion of fetuses with malpresentation delivered by cesarean section in Taiwan was 7.9%, almost twice the upper limit expected for all pregnancies as indicated in international studies.
It is important to use appropriately documented data and to compare them with international data when monitoring local obstetric practices. The disproportionately high cesarean delivery rates in Taiwan may hold major lessons for the many countries contemplating or having universal health insurance coverage with a similar mix of providers.
The rising rate of cesarean section (CS) is a subject of concern, intensive discussion, and investigation. However, few, if any, systematic studies of this trend have been recorded among the oriental populations. This study examines factors that may contribute to the high incidence of CS in Taiwan, where the rate of CS is among the highest in the world. Multiple logistic regression and stratified analyses were used to determine the association between CS and various factors, including provider and patient parameters. Our study sample of 2,497 cases was drawn from a total of 10,654 in-patient deliveries in Chang Gung Memorial Hospital of Taiwan. A number of factors associated with the use of CS were explored, including maternal age, occupation, education and marital status of the mother, sex and body weight of the infant at birth, parity, insurance status, source of admission, and time of birth. Our study also shows that CS in Taiwan is affected by the folk belief of Pe-Ji, which influences the preference of some patients for delivery at a specific time. Such a preference reflects a unique right of choice by women in Taiwan.
Fetal glucose metabolism depends on additive effects of fetal plasma glucose and insulin. Glucose-stimulated insulin secretion increases over gestation, is down-regulated by constant hyperglycemia, but enhanced by pulsatile hyperglycemia. Insulin production is diminished in fetuses with intrauterine growth restriction (IUGR) by inhibition of pancreatic beta-cell replication, but not by mechanisms that regulate insulin production or secretion, while the opposite occurs with hypoglycemia alone, despite its common occurrence in IUGR. Chronic hyperglycemia down-regulates glucose tolerance and insulin sensitivity with decreased expression of skeletal muscle and hepatic Glut 1 and 4 glucose transporters, while chronic hypoglycemia up-regulates these transporters. The opposite occurs for signal transduction proteins that regulate amino acid synthesis into protein. These results demonstrate the mixed phenotype of the IUGR fetus with enhanced glucose utilization capacity, but diminished protein synthesis and growth. Such adaptations might underlie childhood and adult metabolic disorders of insulin resistance, obesity, and diabetes mellitus.
Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222
Gestational hypertension and preeclampsia: ACOG practice
bulletin, number 222. Obstet Gynecol. 2020;135(6):e237-60.
https://doi.org/10.1097/AOG.0000000000003891
American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical Care in Diabetes-2021
American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical Care in Diabetes-2021.
Diabetes Care. 2021;44:S15-33.
ACOG Committee opinion no. 548: weight gain during pregnancy
- American College of Obstetricians and Gynecologists
Standards of medical care in diabetes-2020
American Diabetes Association. Standards of medical care in
diabetes-2020. Diabetes Care. 2020;43:S183-92.
American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 548: weight gain during pregnancy
American College of Obstetricians and Gynecologists.
ACOG Committee opinion no. 548: weight gain during
pregnancy. Obstet Gynecol. 2013;121(1):210-2.