Perinatal Outcomes According to Treatment Targets for Gestational Diabetes: A Multi-Centre Retrospective Cohort Study.

Technology and Pregnancy

Born Large for Gestational Age: Bigger Is Not Always Better

Background: The prevalence of hyperglycemia first detected during pregnancy is showing an escalating increase in recent years contributed by the increasing obesity prevalence, advanced maternal age at delivery, and the universal screening protocol during the first antenatal visit. There exists a very little data on the role of HbA1c in pregnancy and the results remain inconsistent. There is a need to define diagnostic criteria to predict the adverse perinatal outcomes in gestational diabetes mellitus (GDM). Aims and Objectives: This study was aimed to assess the role of HbA1c as a prognostic indicator of third trimester mean blood glucose in GDM pregnancies and in predicting the birth of large for gestational age (LGA) babies. Materials and Methods: 200 pregnant women with GDM and 200 pregnant women without GDM and their neonates participated in this analytical cross-sectional study. Maternal age, height, weight, BMI, and neonatal birth weight were recorded. Third trimester maternal HbA1c level was analyzed by high-performance liquid chromatography. The association between HbA1c and LGA births was analyzed. Results: The mean HbA1c levels and percentage of LGA births were high in GDM group. Multiple logistic regression analysis showed association between high HbA1c values and LGA births in GDM. A Receiver operating characteristic curve was drawn to derive the optimal cut-off value, sensitivity, and specificity of HbA1c in predicting birth of LGA neonates in GDM. Conclusion: This study shows that high third trimester HbA1c levels in GDM increase the risk of LGA births. Further studies are needed to define standard cut-off values of glycated Hb in each trimester of pregnancy.

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 <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.

499: Depression is associated with increased rates of adverse perinatal outcomes in women with gestational diabetes

Background: To determine the perinatal outcome in patients attending Joint obstetric and diabetic clinic who had diabetes and one previous caesarean section.Methods: A prospective service evaluation was conducted in a secondary care hospital having approximately 5100 deliveries per year. The combined cesarean section rate during the study period for all pregnant women and for all diabetic patients were 31% and 60%, respectively. Patients attending joint obstetric diabetic clinic from July 2015 to July 2016 were considered for the study. Fifty five (55) patients with both pregestational diabetes and gestational diabetes requiring pharmacotherapy and one previous caesarean, out of 358 patients who attended the clinic, were identified. The perinatal care, including timing, mode of delivery and indication for Cesarean section, maternal and neonatal outcomes were studied.Results: Out of 55 women, 8 (15%) had type 2 diabetes mellitus and 47 (85%) had gestational diabetes mellitus requiring pharmacotherapy. Initially, during antenatal follow up, 23 women (41%) were planned for vaginal birth after caesarean and 32(59%) were planned for elective cesarean section. Seven (7) women (13%) had a successful vaginal birth after cesarean section. These women had no additional risk factors and delivery was uneventful. Forty eight (48) women (87%) had cesarean section (elective, 60% and emergency, 27%). Eleven (75%) out of these 15 emergency cesarean section patients had additional risk factors that contributed to the decision for cesarean section. Most of the maternal complications 13/55 (23%) were in the cesarean section group and the majority were from emergency cesarean section group. Fifteen out of the fifty five cases (27%) were due to intra-uterine growth restriction, preeclampsia, eclampsia, abruption and postpartum hemorrhage. Similarly in all neonatal complications 14/55 (25%) were from the Cesarean section group (2 cases of small for gestational age, 6 cases of respiratory distress syndrome, 6 cases of Large for date). Among the 8 type 2 diabetes mellitus patients, 7 delivered by Cesarean section (4 emergencies and 3 elective) and only one had a successful vaginal birth after cesarean section. All 4 of the emergency Cesarean cases had additional risk factors.Conclusion: We found an exceptionally high caesarean section rate of 87% in our study which is almost twice as high as was found in the general diabetic pregnant population from other studies. Our study is the first of its kind to determine the cesarean section rate and perinatal outcome in combined pregestational and gestational diabetic patients requiring medical treatment and with one prior cesarean section. This study highlights the need for multi-centered studies to determine the optimal cesarean section rate that affords the lowest perinatal and maternal morbidity and mortality and also on how to modify these confounding factors so as to decrease the high caesarean section rate amongst this high risk group of patients.

Elevated serum alanine aminotransferase (ALT) levels in early pregnancy and gestational diabetes mellitus (GDM) are linked to an increased rate of large for gestational age (LGA) births. Additionally, elevated ALT levels raise the risk of developing GDM, but it remains unclear whether GDM mediates the effect of ALT on neonatal birth weight. This study examines whether GDM mediates this relationship. We conducted a retrospective cohort study with participants from Jinxin Women's and Children's Hospital who delivered single live births between 2020 and 2023. A multifactorial logistic regression model assessed the relationship between early pregnancy ALT levels, GDM incidence, and LGA births. A mediation model evaluated GDM's role in the impact of elevated ALT on neonatal birth weight. Our study included 12,057 patients. After adjusting for confounders, the difference in LGA rates between elevated and normal ALT groups was significant (OR: 1.248, 95% CI: 1.001-1.556, P = 0.049). The GDM incidence difference between these groups was also significant (OR: 1.564, 95% CI: 1.306-1.873, P < 0.01), as was the LGA incidence difference between GDM and non-GDM groups (OR: 1.306, 95% CI: 1.129-1.511, P < 0.01). After adjusting for confounders, we found that elevated ALT levels in early pregnancy and GDM both affected neonatal birth weight. Specifically, elevated ALT levels had a direct impact on neonatal birth weight (β = 0.0291, 95% CI: 0.0100-0.0635), while GDM had an indirect effect (β = 0.0025, 95% CI: 0.0012-0.0056), with GDM accounting for 8.1% of the mediation effect. Our study shows that GDM partly mediates the effect of elevated ALT on neonatal birth weight, highlighting the importance of early ALT and glucose screening in routine prenatal care. Healthcare providers should consider including ALT testing in pregnancy protocols and focus on blood glucose control in patients with elevated ALT to reduce the risk of LGA births.

BackgroundWe assessed the incidence of infants born small-for-gestational-age (SGA) and large-for-gestational-age (LGA) in an Italian cohort over 20 years (1993–2013). Furthermore, we investigated maternal factors associated with SGA and LGA births.MethodsA retrospective review of obstetric records was performed on infants born in Chieti (Italy) covering every 5th year over a 20-year period, specifically examining data for 1993, 1998, 2003, 2008, and 2013. Infants with birthweight <10th percentile were defined as SGA, and those with birthweight >90th percentile as LGA. Data collected included newborn anthropometry, birth (multiple vs singleton), maternal anthropometry, previous miscarriage, gestational diabetes, hypertension, and smoking during pregnancy.ResultsThere were a pooled total of 5896 live births recorded across the 5 selected years. The number of SGA (+60.6 %) and LGA (+90.2 %) births increased considerably between 1993 and 2013. However, there were no marked changes in the incidence of SGA or LGA births (8.3 % and 10.8 % in 1993 versus 7.6 % and 11.7 % in 2013, respectively). Maternal factors associated with increased risk of SGA infants included hypertension, smoking, and previous miscarriage (all p < 0.05), while greater pre-pregnancy BMI and gestational diabetes were risk factors for LGA births (all p < 0.05).ConclusionsThere was an increase in the number of SGA and LGA births in Chieti over the last two decades, but there was little change in incidence over time. Most maternal factors associated with increased odds of SGA and LGA births were modifiable, thus incidence could be reduced by targeted interventions.

This study aimed to examine the risk of macrosomia and large for gestational age (LGA) births in relation to maternal pre-pregnancy body mass index (BMI) status mediated through gestational diabetes mellitus (GDM). This prospective study included 34,104 singleton pregnancies at 8–14 weeks of gestation. The interesting outcomes were macrosomia (≥4000 g) and LGA (≥90th percentile). Mediation analyses were conducted using log-binomial regression adjusted for age, education, parity, fetal sex, and gestational weight gain. The proportion mediated was estimated based on the risk difference scale, and the E-value was utilized to assess potential confounders. Overall, 15.9% of women had GDM, and there were 4.0% macrosomia and 9.9% LGA births. The proportion mediated by GDM on macrosomia was up to 40% among obese women, and the estimate of the total effect was 6.18 (95% CI: 5.26–7.26), of the natural direct effect was 4.10 (95% CI: 3.35–4.99), and of the natural indirect effect was 1.51 (95% CI: 1.31–1.76). Likewise, among overweight women, the proportion mediated by GDM on macrosomia was up to 40%. Furthermore, consistent findings were evident for the outcome of LGA births. Pre-pregnancy overweight/obesity increased the risk of macrosomia and LGA births independently and partly mediated by GDM.

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.

Diabetes and Pregnancy

Maternal obesity, pregestational type 1 diabetes, and gestational diabetes have been reported to increase the risks for large birth weight and preterm birth in offspring. However, the associations for insulin-treated diabetes and non-insulin-treated type 2 diabetes, as well as the associations for joint diabetes disorders and maternal body mass index, with these outcomes are less well documented. To examine associations of maternal diabetes disorders, separately and together with maternal underweight or obesity, with the offspring being large for gestational age and/or preterm at birth. This population-based cohort study used nationwide registries to examine all live births (n = 649 043) between January 1, 2004, and December 31, 2014, in Finland. The study and data analysis were conducted from April 1, 2018, to October 10, 2018. Maternal prepregnancy body mass index, pregestational diabetes with insulin treatment, pregestational type 2 diabetes without insulin treatment, and gestational diabetes. Offspring large for gestational age (LGA) at birth and preterm delivery. Logistic regression models were adjusted for offspring birth year; parity; and maternal age, country of birth, and smoking status. Of the 649 043 births, 4000 (0.62%) were delivered by mothers who had insulin-treated diabetes, 3740 (0.57%) by mothers who had type 2 diabetes, and 98 568 (15.2%) by mothers who had gestational diabetes. The mean (SD) age of mothers was 30.15 (5.37) years, and 588 100 mothers (90.6%) were born in Finland. Statistically significant interactions existed between maternal body mass index and diabetes on offspring LGA and prematurity (insulin-treated diabetes: LGA F = 3489.0 and prematurity F = 1316.4 [P < .001]; type 2 diabetes: LGA F = 147.3 and prematurity F = 21.9 [P < .001]; gestational diabetes: LGA F = 1374.6 and prematurity F = 434.3 [P < .001]). Maternal moderate obesity, compared with normal-weight mothers with no diabetes, was associated with a mildly increased risk of having an offspring LGA (1069 [3.5%] vs 5151 [1.5%]; adjusted odds ratio [aOR], 2.45; 95% CI, 2.29-2.62), and mothers with insulin-treated diabetes had markedly elevated risks of having an offspring LGA (1585 [39.6%] vs 5151 [1.5%]; aOR, 43.80; 95% CI, 40.88-46.93) and a preterm birth (1483 [37.1%] vs 17 481 [5.0%]; aOR, 11.17; 95% CI, 10.46-11.93). Mothers who were moderately obese with type 2 diabetes were at increased risks of LGA (132 [16.4%] vs 5151 [1.5%]; aOR, 12.44; 95% CI, 10.29-15.03) and prematurity (83 [10.3%] vs 17 481 [5.0%]; aOR, 2.14; 95% CI, 1.70-2.69). Mothers who were moderately obese with gestational diabetes had a milder risk of LGA (1195 [6.7%] vs 5151 [1.5%]; aOR, 4.72; 95% CI, 4.42-5.04). Among spontaneous deliveries, the risks were strongest for moderately preterm births, but insulin-treated diabetes was associated with an increased risk also for very and extremely preterm births. Maternal insulin-treated diabetes appeared to be associated with markedly increased risks for LGA and preterm births, whereas obesity in mothers with type 2 diabetes had mild to moderately increased risks; these findings may have implications for counseling and managing pregnancies.

Gestational diabetes mellitus (GDM) or hyperglycemia in pregnancy is associated with adverse perinatal outcomes such as large for gestational age (LGA), excess fetal adiposity and cesarean delivery. This study addressed the prevalence of diabetes in pregnancy and to compare the perinatal outcomes between GDM and non-GDM in a rural pregnancy cohort of Bangladesh. Ten villages were purposively selected in a rural area about 100 km off Dhaka City. A population census was conducted. A randomized sample of married women of age 15-45y was drawn from the census data. These women having either regular menstruation (non-regnant) or cessation of menstruation for ?24weeks (pregnant) were considered eligible. Both the pregnant and non-pregnant women were invited to volunteer the study. Weight, height, waist- and hip-girth and blood pressure were taken. Fasting blood sample was collected for the estimation of plasma glucose (FPG), triglycerides (TG), cholesterol (chol), high-density lipoprotein (HDL). FPG &gt;5.1 mmol/L was taken as cut-off for hyperglycemia in non-pregnant and gestational diabetes mellitus (GDM) for the pregnant women. The biophysical characteristics were compared between pregnant and non-pregnant; and then GDM and non-GDM. Only the pregnant women were taken as a pregnancy cohort. The cohort had followup from 24wks of pregnancy through 28 post-natal days. Results The census yielded 23545 (m / f=11896 / 11649) people of all ages. The married women of age 15-45y were 4526. Of them, 2100 were randomly selected for investigation and 1585 (75.5%) volunteered. The overall prevalence (95% CI) of hyperglycemia (FPG &gt;5.1 mmol/L) was 18.5% (16.7 – 20.3). The prevalence of GDM was 8.9% (7.0 – 10.8) and non-GDM was 19.8% (18.8 – 20.8). The BMI and WHR were significantly higher in the pregnant than non-pregnant women; whereas, there was no significant difference between GDM and non-GDM group. The prevalence rates of abortions, stillbirths, hospital delivery, cesarean delivery, hospital stay ?7days, puerperal sepsis and neonatal death did not differ between GDM and non-GDM subjects significantly. The prevalence of GDM in rural Bangladesh is comparable with any other population with higher prevalence of GDM. The prevalence of hyperglycemia was found significantly higher in the non-pregnant than the pregnant women. The anthropometric measures did not differ significantly between GDM and non-GDM though FPG was found significantly higher in the former. Compared with the non-GDM the GDM subjects had no significantly higher fetomaternal morbidity and mortality possibly due to non-sedentary habit, non-obesity, non-dyslipidemia or may be due to inherent genetic makeup. A well designed study in a larger sample may explain our findings. DOI: http://dx.doi.org/10.3329/imcj.v7i2.20101 Ibrahim Med. Coll. J. 2013; 7(2): 21-27

In Brief Objective To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM). Methods Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 43%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups. Results The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < 0.35; RR 0.22; 95% CI 0.05. 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94). Conclusion Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproporftion and macrosomia. Carbohydrate restriction in patients with diet-controlled gestational diabetes improves glycemic control and perinatal outcome.

Previous studies have demonstrated that abnormal body mass index (BMI) is associated with adverse pregnancy outcomes in frozen-thawed embryo transfer cycles. However, the relationship between BMI and pregnancy and perinatal outcomes in patients with polycystic ovary syndrome (PCOS) remains unclear. Furthermore, whether a diagnosis of PCOS could result in adverse pregnancy and perinatal outcomes in women with different BMIs remains unknown. A historical cohort study included 1667 women with PCOS and 12 256 women without PCOS after a freeze-all policy between January 2016 and December 2020. The outcomes encompassed both pregnancy and perinatal outcomes. Multivariate logistic regression analysis and restricted cubic spline models were performed to eliminate confounding factors when investigating the relationship between BMI and different outcomes. After controlling for covariates, pregnancy outcomes were comparable between underweight women with PCOS and normal weight women with PCOS. However, overweight patients had a lower clinical pregnancy rate and an overall live birth rate. Furthermore, patients with obesity had a lower rate of multiple pregnancies but a higher rate of biochemical pregnancy than in the normal BMI group. Additionally, the restricted cubic spline models showed that as maternal BMI increased to 32 kg/m2, the clinical pregnancy rate and live birth rate after blastocyst transfer decreased, but the risks of preterm birth, gestational diabetes mellitus, macrosomia, large-for-gestational age (LGA) and very LGA increased in patients with PCOS after a freeze-all strategy. Moreover, a diagnosis of PCOS resulted in a higher clinical pregnancy rate and live birth rate and a higher risk of small-for-gestational age in the normal weight group. However, women with PCOS in the overweight group exhibited higher risks of very preterm birth and gestational diabetes mellitus compared with women without PCOS. This study showed that a higher BMI had a detrimental impact on the pregnancy and perinatal outcomes of PCOS patients undergoing a freeze-all strategy. However, it was only statistically significant in the overweight group. A diagnosis of PCOS had a higher clinical pregnancy rate and live birth rate in normal weight women but higher risks of perinatal complications in normal weight and overweight women.