Effects of a Province-wide Change in Gestational Diabetes Mellitus Screening Policy on Treatment and Newborn Birth Weight

ObjectiveBoth of the above studies aimed to evaluate whether or not low levels of 25-hydroxyvitamin D in pregnancy were associated with an increased risk of developing GDM.The Parlea study measured vitamin D levels in the first trimester between weeks 15 and 18, while the Burris study tested for vitamin D levels during the second trimester between weeks 26 and 28.

The optimal approach for gestational diabetes mellitus (GDM) screening remains controversial. Since 2003, all Canadian guidelines have recommended universal GDM screening. Some countries, such as Sweden, use selective GDM screening among those with pre-existing risk factors. In Canada, antenatal care model (midwife, general practitioner or obstetrician) is partially self-selected; thus, patient populations may differ between care models. Despite the Canadian policy of universal GDM screening, screening nonadherence is more frequent in midwife-led care. We examined perinatal outcomes according to GDM screening adherence vs. nonadherence in this population. We conducted a population-based cohort study of singleton pregnancies and infants using linked administrative data from the province of British Columbia, Canada. We restricted the study to pregnancies with midwife-led antenatal care where GDM screening nonadherence occurred more frequently and was more likely by choice. We estimated adjusted risk ratios (aRR) according to GDM screening, comparing no glucose tests during pregnancy (21.4%), early glucose testing <20 weeks (5.5%), and glucose testing with alternate methods ≥20 weeks (4.0%) vs. normoglycemic pregnancies (69%) using multivariable log binomial regression. We stratified by known GDM risk factors. Our primary outcome was large for gestational age (LGA) infants. Secondary outcomes were small for gestational age infants (SGA), stillbirth, 5-min Apgar <7, birth trauma, preterm birth, cesarean birth, and obstetric anal sphincter injury (OASI). In this cohort of 83 522 pregnancies, having no glucose tests in pregnancy was associated with lower risks of LGA and cesarean birth (LGA aRR 0.82; 95% CI 0.79-0.86; cesarean birth aRR 0.75; 95% CI 0.72-0.78) and higher risks of stillbirth and SGA (stillbirth aRR 1.6; 95% CI 1.0-2.2; SGA aRR 1.2; 95% CI 1.1-1.3) compared with normoglycemic pregnancies. Stillbirth risks were further elevated (aRR 2.5; 95% CI 1.2-5.0) in strata with GDM risk factors, but not in strata without risk factors, while higher SGA risks persisted across strata. Nonadherence to GDM screening guidelines was associated with lower risks for excess fetal growth-related outcomes (LGA, cesarean birth), but higher risks of stillbirth and SGA.

Neonatal hypoglycemia in small for gestational age (SGA) and large for gestational age (LGA) infants can lead to neurological complications. Predictive factors including umbilical cord blood analysis, remain largely unexplored. We retrospectively investigated umbilical cord blood parameters as potential predictors of hypoglycemia in full-term SGA (n = 90) and LGA (n = 105) infants. Blood glucose was measured at 11 timepoints over 72 h. Hypoglycemia was defined as blood glucose <40 mg/dL. Hypoglycemia occurred in 13.3% of SGA and 14.3% of LGA infants, with all episodes occurring within the first 2 h of life. In SGA infants, cord blood glucose <69 mg/dL predicted hypoglycemia with 83% sensitivity, 59% specificity, and 96% negative predictive value (NPV); area under the curve (AUC) 0.78, 95% confidence interval (CI): 0.66-0.89. In LGA infants, cord blood bicarbonate >23.1 mmol/L showed 73% sensitivity, 54% specificity, 92% NPV; AUC 0.67, 95% CI: 0.52-0.82, though with marginal statistical significance after multiple comparison correction. Distinct cord blood markers reflect different pathophysiological mechanisms in SGA and LGA infants. While the glucose threshold <69 mg/dL provides a clinically applicable prediction for SGA infants, bicarbonate findings in LGA infants require prospective validation before clinical implementation. This study identifies distinct umbilical cord blood parameters as predictors of hypoglycemia in SGA and LGA infants. The findings reveal different pathophysiological mechanisms of hypoglycemia between SGA and LGA infants. Lower cord blood glucose levels predict hypoglycemia in SGA infants with good accuracy (AUC 0.78), while higher bicarbonate levels show potential association with hypoglycemia risk in LGA infants requiring validation. These group-specific markers could contribute to optimizing the frequency and timing of glucose monitoring strategies tailored to individual risk profiles.

To investigate the pregnancy outcomes of in vitro fertilization (IVF) and embryo transfer (ET) in infertile women with polycystic ovarian syndrome (PCOS). From August 2005 to June 2011, 200 IVF-ET cycles performed in women with polycystic ovarian syndrome in Shengjing Hospital and Shenyang 204 Hospital were enrolled in this retrospective study, matched with 400 IVF-ET cycles in infertile women with fallopian tube factors as control group. The incidence of abortion, gestational diabetes mellitus (GDM), hypertensive disorders in pregnancy, preterm birth, small for gestational age infant (SGA), large for gestational age infant (LGA), neonatal asphyxia, neonatal death and deformity was compared between two groups. The incidence of spontaneous abortion was 26.0% (52/200) in PCOS group, which was significantly higher than 10.2% (41/400) in control group (P < 0.05). The incidence of GDM, hypertensive disorders in pregnancy, preterm birth, cesarean section in PCOS group was 23.6% (35/148), 16.2% (24/148), 17.6% (26/148), 83.1% (123/148), which were significantly higher than 4.2% (15/359), 6.1% (22/359), 7.8% (28/359), 73.8% (265/359) in control group (P < 0.05). The incidence of SGA, LGA, neonatal asphyxia, neonatal death and deformity did not show remarkable difference between two groups, which were 2.7% (4/148), 4.7% (7/148), 5.4% (8/148), 0 in PCOS group and 1.4% (5/359), 2.2% (8/359), 2.8% (10/359), 0 in control group (P > 0.05). IVF-ET is an effective treatment for infertile women with PCOS, however, the incidence of spontaneous abortion, GDM, hypertensive disorders in pregnancy, preterm birth, cesarean section in PCOS patients was increased.

Objective To follow up the changes of postnatal cardiac sizes and function in infants of mothers with gestational diabetes mellitus （GDM）. Methods Eighteen GDM mothers with euglycemia （GDM group） and 24 gestational age matched normal pregnant women （control group）, having prenatal examination and delivered in Women＇s Hospital of Fudan University from January to August in 2007, received fetal echocardiographic examination in late pregnancy. Infants of these GDM mothers and 24 age-matched healthy infants of normal pregnancy （control group） received sonographic follow up. Cardiac sizes and function were evaluated and compared. Results At birth, there were six （33.3%） infants of large for gestational age （LGA） and 12（66.7%） appropriate for gestational age（AGA） in GDM group, while in the control group, there were two LGA （8.3%） and 22（91.7%） AGA infants （Х^2 =3. 840, P=0.05）. Both the interventricular septum and left ventricular walls in GDM fetuses were thicker than in control fetuses （P 〈 0.05）. No increase in the thickness of ventricular walls was observed till infantile period. However, the end-systolic thickness of left ventricular walls in LGA infants was still larger than in control infants [（4.55 ± 0. 37） mm vs （4.13±0.39） mm, P〈0.05], and end-diastolic left ventricular long-diameters were also larger [（37. 3±2. 3） mmvs （34.6±2.6） mm] （P〈0.05）. In GDM fetuses, the peak velocities of aorta and pulmonary artery and left cardiac output were higher than in the controls （P〈 0.01）, and right/left cardiac outputs ratios were lower （1.198±0.206 vs 1.430±0.321, t= 2.668,P=0.011）. Till infantile period, only right/left cardiac outputs ratios in AGA infants of GDM group were larger than in controls （P〈0.05）. GDM fetuses＇ left atrial shortening fraction and tricuspid E/A ratios were smaller （P〈0. 05）. In infantile period, only left atrial shortening fraction in GDM infants was still smaller than in controls （0.356±0.040 vs 0.386±0.041, t=-2.332, P=0.025）. Left and right ventricular Tel index in GDM fetuses were 0. 482±0. 129 and 0. 414±0. 094, both larger than those of control fetuses （0.309±0.074 and 0.283±0.072）（t=5.075 and 5. 129, P=0.000）. Till infantile period they both became significantly lower and no differences were found among LGA, AGA and control infants. Conclusions The cardiac sizes and function at 2-3 months of age, in infants of GDM mothers with good glucose control, became better than that in uterus. Key words: Diabetes, gestational; Infant; Ventricular function, left; Stroke volume; Follow up studies

39: One-step vs two-step screening for gestational diabetes: a randomized controlled trial

Pre‐Pregnancy Obesity and Weight Gain During Pregnancy: Relationship to the Development of Gestational Diabetes Mellitus and the Birth of a Large for Gestational Age Neonate

Background: Two changes to gestational diabetes mellitus (GDM) testing were implemented in the Australian Capital Territory in 2015 and 2017. Aims: We aimed to determine the associations between testing regimes and the prevalence of GDM and large-for-gestational-age (LGA) and small-for-gestational-age (SGA) infants and to compare the prevalence of LGA and SGA infants between women with and without GDM in each testing period. Methods: A total of 23,790 singleton live births with estimated GDM testing and birth dates between June 2012 and December 2019 were stratified into groups: pre-testing changes (June 2012–December 2014, group 1, n = 8069), revised diagnostic criteria (January 2015–May 2017, group 2, n = 8035) and changed pathology centrifugation protocol (June 2017-December 2019, group 3, n = 7686). Women were allocated to groups based on their estimated GDM testing date and stratified by their GDM status. A chi-square test, pairwise z-tests and logistic regression tested the associations. Results: The GDM prevalence significantly increased from 9.5% (group 1) to 19.4% (group 2) to 26.3% (group 3) (all: p &lt; 0.001). The LGA infant prevalence significantly decreased in non-GDM women following revised diagnostic criteria implementation (11.6% vs. 9.7%, p = 0.001). Compared to group 1, women with GDM in groups 2 and 3 had significantly reduced odds of having LGA infants (aOR = 0.73, 95% CI of 0.56–0.95 and p = 0.021 and aOR = 0.75, 95% CI of 0.59–0.97 and p = 0.029, respectively). Compared to group 1, non-GDM women in groups 2 and 3 had significantly reduced odds of having LGA infants (aOR = 0.83, 95% CI of 0.74–0.92 and p &lt; 0.001 and aOR = 0.88, 95% CI of 0.79–0.99 and p = 0.026, respectively). There were no significant associations for group 3 compared to group 2 nor for SGA infants. Conclusions: While significantly increasing the GDM prevalence, implementing the testing changes was associated with a reduced whole-population LGA infant prevalence without a change in the SGA infant prevalence.

It has been shown that leptin is present in breast milk and human mammary epithelial cells are able to synthesize leptin. It has been suggested that leptin in human milk might be involved in the regulation of postnatal nutrition and growth. To investigate whether there is a relationship between leptin levels in human milk and weight gain in the postnatal period and to compare variations of milk-borne maternal leptin concentrations for small for gestational age (SGA), large for gestational age (LGA) and appropriate for gestational age (AGA) infants. Forty-seven healthy lactating women aged from 17-38 years and their infants were included in the study. The infants were separated into three groups according to birth weight as SGA (n = 11), LGA (n = 14) and AGA (n = 22). All infants were fed with breast milk during the study period. Anthropometric measurements were performed on the 15th day of life and at 1, 2, and 3 months of age, and the body mass index (BMI) of the infants' mothers was calculated. Breast milk leptin levels were analyzed by radioimmunoassay. Breast milk leptin levels were found reduced in the SGA group and increased in the LGA group compared to the AGA group at 15 days of life (13.4 +/- 2.2, 28.5 +/- 4.4 and 18.4 +/- 2 ng/ml, respectively; p <0.05). At 1 month of age, leptin levels in breast milk were significantly lower in the LGA group than in the AGA group (15.5 +/- 4.9, 19.4 +/- 1.7 ng/ml, respectively; p<0.05). There was no difference among the three groups at 2 and 3 months of age (p>0.05). There was a positive correlation between birth Weight and breast milk leptin levels on the 15th day (r = 0.47, p = 0.001). A negative correlation was found between weight gain during the first 15 days and 1 month of life and breast milk leptin levels on the 15th day (r = -0.44, p = 0.002; r = -0.40, p = 0.005, respectively). No relationship could be determined between breast milk leptin levels and BMI of the mothers. Maternal milk of SGA, LGA and AGA infants had different leptin levels, especially during the first month of life. More rapid growth was shown in the SGA infants during the first postnatal 15 days compared to AGA and LGA infants, and human milk leptin levels were significantly reduced in the SGA group. However, LGA infants gained more weight during the second 15 days of life and breast milk leptin levels were dramatically decreased in LGA and increased in SGA infants at the end of first month of life. These findings suggest that the presence of leptin in breast milk might have a significant role in growth, appetite and regulation of nutrition in infancy, especially during the early lactation period, and the production of leptin in breast tissue by human mammary epithelial cells might be regulated physiologically according to necessity and state of the infant.

To explore the influence of glucose level of 75 g oral glucose tolerance test(OGTT)druing pregnancy on delivery of large for gestational age infants. This research selected 790 cases of patients diagnosed as gestational diabetes mellitus(GDM), 478 cases of pregnant women diagnosed as normal glucose tolerance(NGT)from Affiliated Hospital of Jining Medical University in 2014 and followed up until they delivered. Single live births were selected, risk factors which had influence on offsprings, birth weight were analysed. GDM group had significantly higher rate of delivering large for gestational age(LGA)infants than that of NGT group(47.30% vs 31.30%, P<0.05). Adjusting for confounding factors, it suggested that 2 h plasma glucose level of 75 g OGTT was an independent risk factor for the delivery of LGA infants, and 1 mmol/L glucose increment in 75 g OGTT 2 h plasma glucose level, may increase the risk of LGA by 29%(OR=1.29, 95%CI 1.05-1.58, P=0.02). The 2 h plasma glucose level of 75 g OGTT is an independent risk factor for delivery of LGA infants. (Chin J Endocrinol Metab, 2016, 32: 480-482) Key words: Gestational diabetes mellitus; Oral glucose tolerance test; Large for gestational age

Born Large for Gestational Age: Bigger Is Not Always Better

Introduction: Globally, Large for Gestational Age (LGA) infants constitute a significant proportion of live births, with Gestational Diabetes Mellitus (GDM) being a primary contributor. Infants born to GDM mothers are more prone for morbidity and mortality and if born large, the incidence of morbidities could increase. The clinico-demographical profile of LGA infants has not been well analysed, especially in Lower Middle Income Countries (LMIC) like India, where gestational diabetes is very common. Aim: To analyse the incidence, demographic profile and short-term neonatal outcomes of LGA births, stratified for GDM. Materials and Methods: This was an analytical retrospective cohort study conducted in a tertiary care hospital in South India. Medical records of LGA infants ≥35 weeks born between December 2018 and May 2020 were reviewed (in December 2020 and January 2021), after Institutional Human Ethics committee approval (No:296/IHEC/JAN 2021). The LGA infants were grouped as GDM induced large infants born to gestational and pregestational diabetes mellitus mothers (LIDM) and large infants born to non-gestational diabetes mellitus mothers (LnIDM). Case records with incomplete data were excluded. Demographic profile of the two groups at birth and their clinical morbidities during hospitalisation were recorded. The primary outcome was requirement of respiratory support in the two groups. The categorical outcomes were compared using Chi-square test/Fisher's exact test, while numerical variables were compared using Mann-Whitney U test. Odds ratio and their 95% Confidence Intervals (CI) were obtained as appropriate. Multivariate logistic regression, controlling for potential confounders, was done to derive the adjusted odds ratio. The p-value &lt;0.05 was taken as significant. All analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 22.0. Results: Out of 2653 live births, 268 were LGA infants ≥35 weeks (9.72%). LIDM were 126 (48.8%) and LnIDM were 132 (51.2%). Ten case records were excluded due to incomplete data hence, 258 infants were included in the final analysis. The median (Interquartile range) birth weight was significantly higher in the LIDM’s {3.92(3.86, 4.08) kg} compared to LnIDM’s {3.89(3.75, 3.96) kg}. The primary outcome of need for respiratory support was not significantly different between the two groups (aOR 1.62; 95% CI 0.92 -2.83; p-value=0.08). Multivariate logistic regression, controlling for confounders, showed higher neonatal intensive care admission rates (aOR 2.15; 95% CI 1.17-4, p=0.01), neonatal hyperbilirubinemia (aOR 1.70; 95% CI: 1.01-2.84, p=0.04) and Persistent Pulmonary Hypertension (PPHN) (aOR 4.43; 95% CI: 1.41-13.82, p=0.004) in the LIDM infants. Conclusion: GDM contributes significantly to LGA births in India, and is associated with higher NICU admissions, neonatal hyperbilirubinemia and PPHN, compared to non-GDM causes.

Objective: We examined if prepregnancy body mass index (BMI) is a risk factor for gestational hypertension, gestational diabetes, preterm labor, and small-for-gestational-age (SGA) and large-for-gestational-age (LGA) infants with consideration of gestational weight gain, to document the importance of preconception versus prenatal stage.Methods: We used the data of 219 868 women from 2004 to 2011 Pregnancy Risk Assessment Monitoring System (PRAMS). Multivariate logistic regression analyses were performed to examine the effect of prepregnancy BMI for gestational hypertension, gestational diabetes, preterm labor, and SGA and LGA infants with consideration of gestational weight gain.Results: Regardless of gestational weight gain, women with obese prepregnancy BMI (≥30 kg/m2) had increased odds of gestational hypertension (adjusted odds ratios (AOR) = 2.91; 95% CI = 2.76–3.07), gestational diabetes (2.78; 2.60–2.96), and LGA (1.87; 1.76–1.99) compared to women with normal prepregnancy BMI (18.5–24.9 kg/m2). Women with underweight prepregnancy BMI (<18.5 kg/m2) had increased odds of preterm labor (1.25; 1.16–1.36) and SGA infants (1.36; 1.25–1.49), but decreased odds of LGA infants (0.72; 0.61–0.85) in reference to women with normal prepregnancy BMI (18.5–24.9 kg/m2).Conclusions: Regardless of adequacy of gestational weight gain, the risk of gestational hypertension, gestational diabetes, and LGA infants increases with obese prepregnancy BMI, whereas that of preterm labor and SGA infants increases with underweight prepregnancy BMI. Preconception care of reproductive aged women is as important as prenatal care to lower the risk of gestational hypertension, gestational diabetes, preterm labor, and SGA and LGA infants.

Objective: Worldwide controversy exists regarding the best approach and criteria for gestational diabetes mellitus (GDM) screening and diagnosis. The aim of this systematic review and meta-analysis of randomized trials was to assess the incidence of maternal and neonatal outcomes comparing the one step with the two step approach for the diagnosis of GDM.Methods: Electronic databases were searched from their inception until June 2018. We included all the randomized trials comparing the one step versus the two step method for screening and diagnosis of GDM. The primary outcome was the incidence of large for gestational age (LGA), defined as birth weight >90th percentile. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI).Results: Four randomized clinical trials (RCTs) (n = 2582 participants) were identified as relevant and included in the meta-analysis. Women screened with the one step approach had a significantly lower risk of adverse perinatal outcomes, including LGA (RR 0.46, 95% CI 0.25–0.83), admission to neonatal intensive care unit (NICU) (RR 0.49, 95% CI 0.29–0.84) and neonatal hypoglycemia (RR 0.52, 95% CI 0.28–0.95), compared to those randomized to the screening with the two step approach. The one step approach was also associated with lower mean birth weight (mean difference −112.91 grams, 95% CI −190.48 to −35.33). No significant difference in the incidence of GDM was found comparing the one step versus the two step approach (8.3 versus 4.4%; RR 1.60, 95% CI 0.93–2.75).Conclusions: This study provides high quality evidence that the diagnosis of GDM by the one step approach is associated with better perinatal outcomes, including lower incidences of LGA, NICU admission and neonatal hypoglycemia, compared to the two step approach. Based on these findings, we recommend screening of GDM using the one-step approach.

Objective To investigate the incidence of gestational diabetes mellitus (GDM) and perinatal outcome in Beijing in 2013. Methods Fifteen hospitals in Beijing were selected by systematic and cluster sampling method. Clinical data of 15 194 pregnant women who attended prenatal care and delivered in these hospitals between June 20 and November 30, 2013 were collected. And 2 987 pregnant women were diagnosed with GDM (GDM group), and 11 999 had no diabetes (non-GDM group). The incidence of GDM, perinatal outcome and complications in mother and infant were compared between the two groups. Two independent samples t-test and Chi-square test were used for statistical analysis. Results The incidence of GDM in Beijing was 19.7% (2 987/15 194). The average age was much higher in GDM group than in non-GDM group [(29.4±4.5) vs (28.0±4.2) years, t=285.705, P<0.05]. The pre-pregnancy weight was much higher in GDM group than in non-GDM group [(59.5±10.2) vs (56.1±8.6) kg, t=352.565, P<0.05]. The incidence of GDM in pre-pregnancy overweight and obese women [29.9% (664/2 230) and 38.8% (250/664)] was much higher than in normal pre-pregnancy weight and low pre-pregnancy weight women [18.0% (1 777/9 890) and 12.9% (273/2 118)] (χ2=296.843, P<0.05). The incidence of GDM in pluripara was higher than in primipara [21.2% (910/4 298) vs 19.4% (2 077/10 688), χ2=5.813, P<0.05]. The incidence of GDM in grade Ⅲ hospitals was higher than in grade Ⅱ hospitals [21.1% (1 654/7 849) vs 18.7% (1 333/7 173), χ2=13.440, P<0.05]; and the incidence in urban areas was higher than in rural areas [21.3% (2 028/9 521) vs 17.1% (896/5 249), χ2=39.137, P<0.05]. The rate of cesarean section was 47.1% (1 407/2 987) in GDM group, significantly higher than in non-GDM group [39.8% (4 782/11 999)] (χ2=72.204, P<0.05). The incidences of preterm labor [7.3%(217/2 987)], hypertensive disorders [6.3%(185/2 987)], large-for-gestational-age infants [9.2%(275/2 987)], macrosomia [9.5%(283/2 987)] and neonatal ward admission [8.6%(258/2 987)] were all significantly higher in GDM group than in non-GDM group [5.7% (686/11 999), 3.9%(454/11 999), 5.8%(694/11 999), 7.2% (861/11 999), and 6.5% (778/11 999), respectively] (χ2=10.117, 34.371, 79.378, 20.346 and 17.236, respectively, all P<0.05). Conclusions The incidence of GDM is still high in Beijing, and advanced maternal age and pre-pregnancy overweight or obesity are high risk factors for GDM. The rate of preterm labor, hypertensive disorders, and macrosomia in GDM group is higher than in normal fasting glucose group. Systematic obstetric care for GDM should be intensified in Beijing. Key words: Diabetes, gestational; Pregnancy outcome; Incidence; Retrospective studies; Beijing