Profiles and Outcomes of Women with Gestational Diabetes Mellitus in the United States.

To estimate the incidence of gestational diabetes mellitus (GDM) according to The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and the pregnancy complications in women fulfilling these criteria but who are not considered diabetic according to the Canadian Diabetes Association criteria. We estimated the rate of GDM according to the IADPSG criteria from November 2008 to October 2010. Then, we conducted a chart review to compare maternal and neonatal outcomes between women classified as GDM according to the IADPSG criteria but not by the Canadian Diabetes Association criteria (group 1; n=186) and nondiabetic women according to both criteria (group 2; n=372). Results were expressed as crude (odds ratio [OR]) or adjusted OR and 95% confidence interval (CI). The study has a statistical power of 80% to detect a difference between 16% and 8% in large for gestational age newborns (α level of 0.05; two-tailed). The rate of GDM using the IADPSG criteria was 27.51% (95% CI 25.92-29.11). Group 1 presented similar rates of large-for-gestational-age newborns (9.1% compared with 5.9%, adjusted OR 1.58, 95% CI 0.79-3.13; P=.19), delivery complications (37.1% compared with 30.1%, OR 1.37, 95% CI 0.95-1.98; P=.10), preeclampsia (6.5% compared with 2.7%, adjusted OR 2.40, 95% CI 0.92-6.27; P=.07), prematurity (6.5% compared with 2.7%, OR 1.10, 95% CI 0.53-2.27; P=.85), neonatal complications at delivery (13.4% compared with 9.7%, OR 1.45, 95% CI 0.84-2.49; P=.20), and metabolic complications (10.8% compared with 14.2%, OR 0.73, 95% CI 0.42-1.26; P=.29) compared with group 2. Women classified as nondiabetic by the Canadian Diabetes Association Criteria but considered GDM according to the IADPSG criteria have similar pregnancy outcomes as women without GDM. More randomized studies with cost-effectiveness analyses are needed before implementation of these criteria. II.

Background: With the increasing need to explore the association between interpregnancy interval (IPI) and adverse maternal and neonatal outcome, numerous studies have been conducted worldwide. However, national reports of the IPI in China are lacking. Furthermore, except for age as a known factor for IPI and adverse maternal and neonatal outcomes, the effect of gestational age in previous pregnancy is unknown. The aim of this study was to determine the IPI distribution between 2010 and 2019 and identify the effect of IPI and gestational age in previous pregnancy on adverse maternal and neonatal outcomes in China. Methods: We used individual data from China's National Maternal Near Miss Surveillance System (NMNMSS) between 2010 and 2019. The surveillance system collected data prospectively on all pregnant and postpartum women admitted to the obstetric department. The analysis was restricted to women with records of at least two consecutive singleton births and without any complication that the NMNMSS collected during their previous pregnancy. Multivariable generalized linear models with the restricted cubic spline (RCS) were used to evaluate the effect of IPI on each adverse neonatal and maternal outcome on different categories of gestational age in previous pregnancy. Further analysis was performed in subgroups categorized by the gestational age of previous pregnancy. Results: Over the study period, 408,843 women with 420,810 pregnancies were enrolled in our study. The median and quartile range of IPI was 32 [22, 47] months. Few women (49,084, 11.67%) became pregnant again within an extremely short (≤6 months) or long (≥60 months) IPI, and over half (289,846, 68.88%) of the women became pregnant again after an IPI between 7 and 42 months. The risk of large for gestational age (LGA), Gestational Diabetes Mellitus (GDM) and gestational hypertension was increased with increased IPI, while the risk of spontaneous preterm and small for gestational age (SGA) was inversely decreased with increased IPI. The relationship between IPI and all the other adverse neonatal and maternal outcomes was in a “U” shape. The risk of adverse neonatal and maternal outcomes differs between subgroups stratified by gestational age in the previous pregnancy. The risk of spontaneous preterm and abortion at short IPI, iatrogenic preterm, GDM, preeclampsia or eclampsia and gestational hypertension at long IPI increased more when women were of a greater gestational age in the previous pregnancy. Conclusions: This was the first comprehensive exploration of the IPIs of Chinese women from a national database. In this research, both extreme short and long IPI were associated with a higher risk of adverse maternal and neonatal outcomes. The gestational age in the previous pregnancy was also a determinant factor for the adverse maternal and neonatal outcomes in subsequent pregnancies. Funding Statement: This study was supported by the National Key R&D Program of China (Grant No. 2019YFC1005100), the National Health Commission of the People’s Republic of China, the China Medical Board (Grant No. 11-065), the WHO (Grant No. CHN-12-MCN-004888), and UNICEF (Grant No. 2016EJH016). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study was approved by the ethics committee of the West China Second University Hospital.

Adverse maternal and neonatal outcomes among women with preeclampsia with severe features <34weeks gestation with versus without comorbidity.

Gestational diabetes mellitus and COVID-19: results from the COVID-19–Related Obstetric and Neonatal Outcome Study (CRONOS)

694 Impact of neonatal birth weight on adverse perinatal outcomes in cesarean deliveries in nulliparous women

BackgroundTo examine the association between maternal education and adverse maternal and neonatal outcomes in women who conceived using medically assisted reproduction, which included fertility medications, intrauterine insemination, or in vitro fertilization.MethodsWe conducted a retrospective cohort study utilizing the US Vital Statistics data set on national birth certificates from 2016 to 2020. Women with live, non-anomalous singletons who conceived using MAR and had education status of the birthing female partner recorded were included. Patients were stratified into two groups: bachelor’s degree or higher, or less than a bachelor’s degree. The primary outcome was a composite of maternal adverse outcomes: intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or blood transfusion. The secondary outcome was a composite of neonatal adverse outcomes: neonatal ICU admission, ventilator support, or seizure. Multivariable modified Poisson regression models with robust error variance adjusted for maternal age, race, marital status, prenatal care, smoking during pregnancy, neonatal sex, and birth year estimated the relative risk (RR) of outcomes with a 95% confidence interval (CI).Results190,444 patients met the inclusion criteria: 142,943 had a bachelor’s degree or higher and 47,501 were without a bachelor’s degree. Composite maternal adverse outcomes were similar among patients with a bachelor’s degree (10.1 per 1,000 live births) and those without a bachelor’s degree (9.4 per 1,000 live births); ARR 1.05, 95% CI (0.94–1.17). However, composite adverse neonatal outcomes were significantly lower in women with a bachelor’s degree or higher (94.1 per 1,000 live births) compared to women without a bachelor’s degree (105.9 per 1,000 live births); ARR 0.91, 95% CI (0.88–0.94).ConclusionsOur study demonstrated that lower maternal education level was not associated with maternal adverse outcomes in patients who conceived using MAR but was associated with increased rates of neonatal adverse outcomes. As access to infertility care increases, patients who conceive with MAR may be counseled that education level is not associated with maternal morbidity. Further research into the association between maternal education level and neonatal morbidity is indicated.

Pregnant women in Asia, the Middle East, Africa and Latin America are at risk of vitamin D deficiency (VDD) and prevalence throughout these regions are among the highest, globally. Maternal VDD has been associated with increased risk of a number of adverse maternal and neonatal health outcomes, yet research from developing countries is limited. We assessed the associations of maternal VDD during pregnancy with adverse health outcomes by synthesizing the literature from observational studies conducted in developing countries. Six electronic databases were searched for English-language studies published between 2000 and 2017. Thirteen studies from seven countries were included in the review. Prevalence of VDD ranged from 51.3% to 100%. Six studies assessed both maternal and neonatal outcomes, four studies assessed only maternal outcomes and three studies assessed only neonatal outcomes. Ten studies showed at least one significant association between VDD and adverse maternal and/or neonatal health outcomes including pre-eclampsia (n = 3), gestational diabetes mellitus (n = 1), postpartum depression (n = 1), emergency cesarean section delivery (n = 1), low birth weight babies (n = 4), small for gestational age (n = 2), stunting (n = 1). However most of these studies (n = 6) also showed no association with multiple health outcomes. Vitamin D assessment methods, criteria applied to define VDD, season and trimester in which studies were conducted varied considerably across studies. In conclusion, this study highlights the need to improve maternal vitamin D status in developing countries in an effort to support best maternal and child health outcomes across these regions. Future research should focus on more unified approaches to vitamin D assessment and preventative approaches that may be embedded into already existing antenatal care settings.

Objective To evaluate the association between a low 50-gram, 1-hour glucose challenge test (GCT) value and adverse maternal and neonatal outcomes among patients receiving care at a single center tertiary care academic hospital. Methods We performed a retrospective cohort study of pregnant patients with a documented result of a 50-gram, 1-hour GCT performed ≥24 weeks 0 days gestation at a single tertiary care academic hospital from 2013–2021. Patients with a low GCT value, defined as cohort specific ≤10th percentile (<82 mg/dL), were compared to patients with a GCT value ≥82 mg/dL who were not diagnosed with gestational diabetes (GDM) to examine adverse maternal and neonatal outcomes. Additionally, these comparisons were repeated across patients with low GCT (<82 mg/dL), those with a GCT ≥82 mg/dL without diagnosis of GDM (heretofore referred to as normal glycemic screening) and patients diagnosed with GDM. Our primary outcome was a composite neonatal morbidity variable, inclusive of stillbirth, neonatal death, neonatal hypoglycemia with neonatal intensive care unit (NICU) admission, neonatal hyperbilirubinemia with NICU admission, respiratory distress with NICU admission, and/or small for gestational age (SGA). Multivariable logistic regression modeling was used to examine the association of low GCT value and the composite neonatal morbidity outcome, compared to those with the normal glycemic screening. Results Of 36,342 eligible patients, 3,789 (10.4%) had a low GCT value of <82 mg/dL, 30,729 (84.6%) had a GCT value ≥82 mg/dL and were not diagnosed with GDM, and 1,824 (5.0%) had a diagnosis of GDM. Patients with a low GCT value were significantly less likely to be diagnosed with hypertensive disorder of pregnancy (HDP) (12.4% vs 16.3%, p < .01), undergo cesarean delivery (22.8% vs 29.9%, p < .01), or experience postpartum hemorrhage (7.8% vs 9.4%, p < .01) as compared to patients with normal glycemic screening. Compared to newborns whose mothers had normal glycemic screening, newborns of mothers with a low GCT value were significantly more likely to experience the composite morbidity outcome (OR 1.17; 95% CI 1.08–1.27); this persisted after adjusting for potential confounders (aOR 1.18; 95% CI 1.09–1.29). Conclusion A low maternal GCT value after 24 weeks gestation is significantly associated with an increased risk of morbidity in the newborn, driven by higher rates of SGA. Patients with a low GCT value may have underlying maternal hypoglycemia or other glycemic dysregulation affecting fetal development and may benefit from enhanced antenatal surveillance.

Objective To analyze the glycemic variability in patients with gestational diabetes mellitus (GDM) by using continuous glucose monitoring system (CGMS) and to explore the relationship between GDM glycemic variability and infant birth weight and maternal and neonatal adverse pregnancy outcomes. Methods From April 2011 to August 2012, 189 cases of patients with GDM who were ready to regularly receive prenatal examination in the Department of Obstetrics of Guangdong Women and Children Hospital were enrolled in this study. All the GDM patients in this research met the GDM diagnostic criteria recommended by American Diabetes Association. They were instructed to wear the CGMS for 72 consecutive hours in the first week of this study. After four weeks of individual glucose control following strictly with doctors' advice, all the patients wear the CGMS for 72 consecutive hours for the second time in the fifth week of this study The parameters of glycemic variability which included mean blood glucose (MBG), the standard deviation of blood glucose (SDBG), mean amplitude of glycemic excursions (MAGE), and the mean of daily differences (MODD) were measured in the first and fifth weeks of this study. The maternal and neonatal adverse pregnancy outcomes and infant birth weight were collected. The relationship between infant birth weight and GDM patients' age, height, pregnancy history, body weight before pregnancy, fasting blood glucose level, oral glucose tolerance test (OGTT) 1 h glucose (OGTT-GLU1h), OGTT 2 h glucose (OGTT-GLU2h) and level of glycosylated hemoglobin A1c (HbA1c) on OGTT day, and MBG, SDBG, MAGE, MODD in the first and fifth weeks of this study were analyzed by multiple linear regression analysis. The relationship between maternal and neonatal adverse pregnancy outcomes and those above indexes of GDM patients in the first and fifth weeks of this study were analyzed by multiple logistic regression analysis. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Guangdong Women and Children Hospital. Results ①The MBG, SDBG, MAGE, MODD, duration of hyperglycemia level (≥7.8 mmol/L) and duration of hypoglycemia level (≤3.3mmol/L) of GDM patients in the fifth week of this study were (5.7±0.7) mmol/L, (1.1±0.4) mmol/L, (2.4±0.9) mmol/L, (1.2±0.3) mmol/L, 60 min/d (0-380 min/d) and 0 min/d (0~270 min/d) respectively, which all were significantly lower than those (6.1±0.9) mmol/L, (1.3±0.4) mmol/L, (3.1±0.9) mmol/L, (1.5±0. 4) mmol/L, 100 min/d (0~760 min/d) and 0 min/d (0~470 min/d) in the first week of this study respectively, and all the differences were statistically significant (χ2=4.197, P<0.001; χ2=7.028, P<0.001; χ2=7.691, P<0.001; χ2=12.986, P<0.001; Z=-4.992, P<0.001; Z=-2.601, P=0.009). ②189 women with GDM delivered 186 living infants, as 1 woman miscarried and 2 women experienced intrauterine fetal death. The average birth weight of infants was (3 345±508) kg. The maternal adverse pregnancy outcomes included: 1(0.5%) miscarriage, 2 (1.1%) intrauterine fetal deaths, 19(10.1%) combined with preeclampsia, 88(46.6%) primary cesarean delivery, 36(19.0%) repeat cesarean delivery. The neonatal adverse pregnancy outcomes included: 1(0.5%) obstetric trauma, 20(10.8%) macrosomia, 48(25.8%) large for gestational age, 5(2.7%) small for gestational age, 26(14.0%) combined with hypoglycemia, 18(9.7%) combined with hyperbilirubinemia, 11(5.9%) combined with respiratory distress syndrome. In total, 92(49.5%) infants suffered adverse pregnancy outcomes. ③MBG in the first week and MAGE in the fifth week were strongly associated with infant birth weight (b=104.709, P=0.013; b=87.804, P=0.035). ④MBG in the first week of GDM patients and primipara were independent risk factors for primary cesarean delivery (OR=1.728, 95% CI: 1.160-2.573, P=0.007; OR=5.208, 95% CI: 2.677-10.133, P=0.000). MAGE and MBG in the first week of GDM patients were independent risk factors for large or small for gestational age (OR=1.632, 95% CI: 1.137-2.343, P=0.008; OR=1.992, 95% CI: 1.269-3.128, P=0.003). MAGE, MBG in the first week and MAGE in the fifth week of GDM patients were independent risk factors for macrosomia (OR=1.800, 95% CI: 1.107-2.925, P=0.018; OR=1.987, 95% CI: 1.038-3.803, P=0.038; OR=1.885, 95% CI: 1.063-3.341, P=0.030). MAGE in the first week of GDM patients was independent risk factor for neonatal adverse pregnancy outcome (OR=1.452, 95% CI: 1.050-2.008, P=0.024). Conclusions Abnormal glycemic variability in patients with GDM may lead to maternal and neonatal adverse pregnancy outcomes. Therefore, seven times of measurements for glucose levels per day may be not enough for GDM. Monitoring for glycemic variability is also recommended. Key words: Diabetes, gestational; Glycemic variability; Pregnancy outcome; Continuous glucose monitoring system

Continuous glucose monitoring (CGM) has become available for women with type 2 diabetes mellitus (T2DM) or gestational diabetes mellitus (GDM) during pregnancy. The recommended time in range (TIR, blood glucose 70-140 mg/dL) and its correlation with adverse pregnancy outcomes in this group is unknown. Our aim was to compare maternal and neonatal outcomes in pregnant people with T2DM or GDM with average CGM TIR values >70 versus ≤70%. We conducted a retrospective cohort study of all individuals using CGM during pregnancy from January 2017 to June 2022. Individuals with type 1 diabetes mellitus, or those missing CGM or delivery data were excluded. Primary composite neonatal outcome included any of the following: large for gestational age, NICU admission, need for intravenous glucose, respiratory support, or neonatal death. Secondary outcomes included other maternal and neonatal outcomes. Regression models were used to estimate adjusted odds ratio (aOR) and 95% confidence interval (CI). During the study period, 141 individuals with diabetes utilized CGM during pregnancy, with 65 (46%) meeting inclusion criteria. Of the study population, 28 (43%) had TIR ≤70% and 37 (57%) had TIR > 70%. Compared with those with TIR > 70%, the primary composite outcome occurred more frequently in neonates of individuals TIR ≤70% (71.4 vs. 37.8%, aOR: 4.8, 95% CI: 1.6, 15.7). Furthermore, individuals with TIR ≤70% were more likely to have hypertensive disorders (42.9 vs. 16.2%, OR: 3.9, 95% CI: 1.3, 13.0), preterm delivery (54 vs. 27%, OR: 3.1, 95% CI: 1.1, 9.1): , and cesarean delivery (96.4 vs. 51.4%, OR: 4.6, 95% CI: 2.2, 15.1) compared with those with TIR >70%. Among people with T2DM or GDM who utilized CGM during pregnancy, 4 out 10 individuals had TIR ≤70% and, compared with those with TIR > 70%, they had a higher likelihood of adverse neonatal and maternal outcomes. · Time in range can be utilized as a metric for pregnant patients using continuous glucose monitor.. · Time in range >70% is achievable by 6 out of 10 patients.. · Time in range below goal is associated with adverse neonatal and maternal outcomes..

How much worse, really, are neonatal and maternal outcomes of infertility treatment?

Excerpts from the World Medical Literature: Obstetrics

To assess clinical utility of the urine Congo red dot test (CRDT) in predicting composite adverse maternal and neonatal outcomes in women with suspected preeclampsia (PE). CRDT result and pregnancy outcomes were prospectively documented in women with new onset or pre-existing hypertension, new or pre-existing proteinuria, PE symptoms and suspected PE-related fetal growth restriction or abnormal Doppler presenting from 20weeks' gestation between January 2020 and December 2022. Participants and clinicians were blinded to the CRDT result and managed according to internally agreed protocols. Composite maternal outcome was defined as PE, postpartum hemorrhage, intensive care unit admission, and maternal death. Composite neonatal outcome was defined as small for gestational age, preterm birth, 5-min Apgar score < 7, neonatal intensive care unit admission, and neonatal death. Two hundred and forty-four women out of two hundred and fifty-one (97.2%) had a negative CRDT. All seven women with positive CRDT had both adverse maternal and neonatal outcomes, giving positive predictive values (PPV) of 100%. Rates of composite adverse maternal and neonatal outcomes in CDRT negative women were 103/244 [42.2%, 95% confidence interval (CI) 36.2%-48.5%] and 170/244 (69.7%, 95% CI 63.6%-75.1%), respectively. CRDT negative predictive values (NPV) for adverse maternal and neonatal outcomes were, respectively, 141/244 (57.8%, 95% CI 48.6%-68.2%) and 74/244 (30.3%, 95% CI 23.8%-38.1%). CRDT had low NPV but high PPV for adverse maternal and neonatal outcomes in women with suspected PE. Its role in clinical management and triage of women with suspected PE is limited as it cannot identify those at low risk of developing adverse outcomes.

Anaemia in pregnancy is a global health problem with associated maternal and neonatal morbidity and mortality. We aimed to investigate the association between maternal haemoglobin concentrations during pregnancy and the risk of adverse maternal and neonatal outcomes. In this prospective, observational, multinational, INTERBIO-21st fetal study conducted at maternity units in Brazil, Kenya, Pakistan, South Africa, and the UK, we enrolled pregnant women (aged ≥18 years, BMI <35 kg/m2, natural conception, and singleton pregnancy) who initiated antenatal care before 14 weeks' gestation. At each 5±1 weekly visit until delivery, information was collected about the pregnancy, as well as the results of blood tests taken as part of routine antenatal care, including haemoglobin values. The outcome measures were maternal (gestational diabetes, pregnancy-induced hypertension, and preterm premature rupture of membranes) and neonatal outcomes (small for gestational age, preterm birth, and acute respiratory distress syndrome). Between Feb 8, 2012, and Nov 30, 2019, 2069 women (mean age 30·7 years [SD 5·0]) had at least one routinely haemoglobin concentration measured at 14-40 weeks' gestation, contributing 4690 haemoglobin measurements for the analysis. Compared with a haemoglobin cutoff of 110 g/L, the risk was increased more than two-fold for pregnancy-induced hypertension at haemoglobin concentrations of 170 g/L (risk ratio [RR] 2·29 [95% CI 1·19-4·39]) and higher, for preterm birth at haemoglobin concentrations of 70 g/L (RR 2·04 [95% CI 1·20-3·48]) and 165 g/L (RR 2·06 [95% CI 1·41-3·02]), and for acute respiratory distress syndrome at haemoglobin concentrations of 165 g/L (RR 2·84 [95% CI 1·51-5·35]). Trimester-specific results are also presented. Our data suggests that the current WHO haemoglobin cutoffs are associated with reduced risk of adverse maternal and neonatal outcomes. The current haemoglobin concentration cutoffs during pregnancy should not only consider thresholds for low haemoglobin concentrations that are associated with adverse outcomes but also define a threshold for high haemoglobin concentrations given the U-shaped relationship between haemoglobin concentration and adverse neonatal and maternal outcomes. Bill & Melinda Gates Foundation.

993: Adverse pregnancy outcomes with glyburide vs insulin among patients with gestational diabetes established by the International Association of Diabetes and Pregnancy Study Group (IADPSG)