Neonatal Hypoglycemia Research Articles

Risk factors of neonatal hypoglycemia in neonates born to mothers with gestational diabetes.

Hypoglycemia is one of the most significant problems in neonates born to mothers with gestational diabetes (GDM). This study aimed to identify novel predictors of hypoglycemia in neonates born to mothers with GDM. A total of 443 term singleton infants from mothers diagnosed with GDM and cared for at Keio University Hospital between January 2013 and December 2019 were included in this study. Neonatal hypoglycemia was defined as hypoglycemia of less than 47 mg/dL at 1 or 2 or 4 h after birth, according to previous studies. Among 443 full-term singleton neonates born to mothers with GDM, 200 developed hypoglycemia (45%). Gestational weight gain (GWG), HbA1c at 1st trimester, HbA1c at GDM diagnosis, and the incidence of insulin therapy in the neonatal hypoglycemia group were significantly higher than those in the non-neonatal hypoglycemia group (p = 0.016, p = 0.032, p = 0.011, and p = 0.017, respectively). Regarding the multiple regression analysis adjusted for nulliparity, GWG, and gestational weeks at delivery, the odds ratio for maternal HbA1c ≥5.2% at 1st trimester was 1.63 (p = 0.034), and maternal insulin therapy during pregnancy was 1.72 (p = 0.015). In conclusion, HbA1c in the 1st trimester and insulin therapy during pregnancy were good predictors of hypoglycemia in neonates born to GDM mothers, especially when their HbA1c was 5.2% or more. Further research will be necessary to improve the perinatal management of hypoglycemia.

Prediction of neonatal hypoglycemia risk from maternal continuous glucose monitoring data using artificial intelligence

Neonatal hypoglycemia is a major complication in infants born to mothers with diabetes; delayed recognition can result in neurodevelopmental morbidities. We sought to use an artificial intelligence (AI) framework to develop a prediction model to identify neonates at risk of hypoglycemia using maternal continuous glucose monitoring (CGM) data. The study hypothesis was that the model for identifying neonates at risk of hypoglycemia using maternal CGM data would have good predictive accuracy (area under the receiver operating characteristic curve, AUC >0.70). Retrospective cohort study of mother-infant pairs monitored using CGM during prenatal care who delivered at our center from 9/1/2018 to 3/31/2022. The primary outcome was neonatal hypoglycemia, defined by serum/point of care glucose measurements of < 40 mg/dl in the first 24 hours after birth. AI-based Multiple Representations Sequence Miner (MrSQM) framework was used to build the prediction model. Outcome stratified data were randomly split into 80% train and 20% test datasets. The predictive accuracy of the model was assessed using the AUC and area under the precision-recall curve (AUCPR). A total of 90 mother-infant pairs were eligible and included in the study, of which 40 neonates (44%) had hypoglycemia. Baseline characteristics did not differ between neonates with hypoglycemia and those without (Table 1). The MrSQM saliency map (Figure 1), demonstrated low variance, indicating no single CGM reading was highly predictive; however, higher values were more important than lower values in the model’s prediction. The model had an AUC of 0.74 and AUCPR of 0.81. Given the 56%/44% negative/positive class balance, these metrics indicated good predictive accuracy of the model. We developed an AI-based model with good predictive accuracy for neonatal hypoglycemia using maternal CGM data. Adding clinical variables may enhance predictive ability. Further studies should prospectively assess its implementation as a clinical decision support tool.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Association between intrapartum glycemic control using continuous glucose monitoring and neonatal outcomes

ACOG recommends maintaining maternal euglycemia during labor to prevent neonatal hypoglycemia at birth; however, supporting data are limited. We evaluated the association between predelivery glycemic control using continuous glucose monitoring (CGM) and neonatal outcomes. Retrospective cohort study of patients with pregestational diabetes who used real-time CGM and delivered a live, singleton at a tertiary care center (9/2018-7/2022). Patients with major fetal anomalies were excluded. Glycemic control was measured by CGM, and time spent in target range (TIR) of 65-140mg/dL was calculated for 6hr before delivery. The primary outcome was neonatal hypoglycemia (initial glucose < 40mg/dL). Secondary outcomes included hypoglycemia requiring treatment, initial glucose, hyperbilirubinemia, NICU admission and length of stay. Baseline characteristics and outcomes were compared between patients with TIR >70% vs TIR ≤70%. Multivariable regression estimated the association between TIR >70% and outcomes. In sensitivity analyses, we varied the exposure definition to TIR 12hr and 2hr before delivery. Of 53 included patients, 42 (79%) had TIR >70% and 11 (21%) had TIR≤70%. Patients with TIR >70% were more likely to have type 2 diabetes and higher BMI (Table 1). Neonatal hypoglycemia was less common among patients with TIR >70% compared to TIR≤70%, but it was not statistically significant (24% vs 36%, aOR 0.52, 95% CI 0.11-2.50; Table 2). Other outcomes were also similar between groups. In sensitivity analyses, there was no association between TIR >70% during 12hr before delivery and hypoglycemia (aOR 0.28, 95% CI 0.07-1.07); however, TIR >70% during 2hr before delivery was associated with a lower odds of hypoglycemia (aOR 0.01, 95% CI 0.02-0.80). Maternal glycemic control immediately before delivery appears to be more important for prevention of neonatal hypoglycemia in patients with pregestational diabetes. Use of CGM data should be considered in future studies to better understand the optimal maternal glucose level and timing before delivery to minimize neonatal hypoglycemia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Does excess gestational weight gain increase the risk for neonatal hypoglycemia?

Neonatal hypoglycemia is a significant contributor to NICU admissions and prolonged hospitalization. Poorly controlled diabetes, preterm delivery, cesarean delivery, growth restriction, and maternal obesity, among other factors, have been shown to increase the risk. We hypothesized that excess gestational weight gain (GWG) is associated with increased rates of neonatal hypoglycemia.

Association of Antenatal Corticosteroid use with Hypoglycaemia and Hyperbilirubinemia in Preterm Neonates Admitted in a Tertiary Hospital of Kolkata: A Longitudinal Study

AbstractBackground: Timely use of antenatal corticosteroids in a mother of preterm labour decreases the rates ofperinatal death, respiratory distress syndrome, intra-ventricular hemorrhage, necrotizing enterocolitis inthe new borns. However it is reported to have a causative role in neonatal hypoglycemia and hyperbilirubinemia.So the present study attempts to determine the association between the use of antenatal corticosteroids withhypoglycaemiaand hyperbilirubinemia in newborns with less than 35 weeks of gestational age.Methods: A prospective observational study was conducted during a time period of 24 months from January 2020to December 2021 in a tertiary care hospital of Kolkata on 99 preterm neonates of less than 35 weeks of gestationalage. Antenatal history of corticosteroid use, neonatal glucose level and bilirubin level were measured amongothers. Data were analyzed using MS-EXCEL.Results: Majority of neonates’ mothers (71.7%) had received antenatal corticosteroids. Only 4.0% of the cases hadhypoglycaemia at birth. But there was no cases of hypoglycaemia at 12 hour and 24 hour after birth. In 58.6% ofthe cases bilirubin level was in the phototherapy range and double surface photo therapy was required. In 14.1%of the cases double volume exchange transfusion was required.Conclusion: Antenatal corticosteroid administration is not associated with neonatal hypoglycaemia but it issignificantly related to neonatal hyperbilirubinemia.

Role of Umbilical Cord C- Peptide Level in Early Detection of Hypoglycemia in Infant of Diabetic Mother

Until date, diabetes during pregnancy has been linked to an increased risk of maternal, fetal, and neonatal morbidity and mortality. Infants of diabetic mothers (IDM) frequently have difficulties related to fetal hyperglycemia and hyperinsulinemia caused by maternal hyperglycemia. Because insulin breakdown is accelerated in the presence of mild hemolysis, cord serum C-peptide levels are utilized as an indicator of fetal beta-cell function rather than insulin levels. Objective:

Evaluation of a cesarean surgical site infection (SSI) prevention protocol on SSI and neonatal hypoglycemia

Evaluation of a cesarean surgical site infection (SSI) prevention protocol on SSI and neonatal hypoglycemia

Fetomaternal outcome in patients with gestational diabetes mellitus

Background: Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy and associated with adverse outcomes of pregnancy for mother and baby. GDM exposes fetus to hyperglycemia and it leads to macrosomia, birth trauma, shoulder dystocia, neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia, and respiratory distress syndrome. Aim and Objectives: The objective of this study is to analyze maternal and neonatal outcomes of pregnancy in women with GDM. Materials and Methods: This study was carried out prospectively in the department of obstetrics and gynecology, tertiary care hospital, Gujarat, over a period of December 2020–December 2021. Total 104 patients were diagnosed with GDM and included in this study. Exclusion criteria include pregnant women with pre-existing diabetes, pregnancy with more than one fetus, other chronic disease, still birth, on medication that might affect glucose metabolism (steroids, anti-psychotic medications, etc.), not willing to participate. A detailed history of all patients was taken. Results: Out of 990 patients, 104 (10.5%) pregnant women were found to have GDM. Adverse maternal outcomes were polyhydramnios (38.4%), antepartum haemorrhage (1.9%), postpartum hemorrhage (4.8%), sepsis (1.9%), wound infection (1.9%), and urinary tract infection (10.6%). Most common neonatal complication was hypoglycemia (29.8%), prematurity (16.3%), and macrosomia (10.5%). Conclusion: The increasing prevalence of risk factors related to GDM; it is likely that GDM in pregnant women will give adverse outcomes. The antenatal screening for GDM is key for early diagnosis and treatment during antennal visit and that will improve maternal and fetal outcome. Management of GDM can prevent development of future diabetes mellitus in women.

СОСТОЯНИЕ ЗДОРОВЬЯ ДЕТЕЙ ОТ МАТЕРЕЙ С ГЕСТАЦИОННЫМ САХАРНЫМ ДИАБЕТОМ

Increasingly, in obstetric practice, a violation of carbohydrate metabolism began to occur, gestational diabetes mellitus. In response to maternal hyperglycemia, the fetus also develops hyperglycemia and hypertrophy of the endocrine part of the pancreas, leading to increased metabolism and the formation of macrosomia. Neonatal complications such as respiratory distress syndrome, neonatal hypoglycemia, and birth trauma are often found in a newborn [1]. Mentioning the long-term consequences, it is worth noting the trend towards adolescent obesity, diseases of the cardiovascular system, and type 2 diabetes mellitus in the future [2]. Our study aims to study the characteristics of the fetus and newborns in mothers with gestational diabetes. The following results were obtained: patients with GSD were more likely to have large fetuses and newborns were monitored in the neonatal pathology department.

The Study of Offspring and Mothers with Gestational Diabetes Treated with Metformin or Glibenclamide in a Randomized Controlled Trial after 9 Years

Introduction: Follow-up of the mothers and their offspring recruited to a randomized controlled trial comparing neonatal outcomes in women with gestational diabetes treated with metformin or glibenclamide was conducted 9 years ago. A significant decrease in neonatal hypoglycemia in the group treated with metformin was seen in the original study. Methodology: Results of clinical examination, blood sample collection, and dual-energy X-ray absorptiometry (DEXA) scan not published in a brief communication are described in this study. The nutritional status was assessed using a 3-day recall method using the Indian Food Composition Table 2017. The physical activity of offspring was assessed using the Global Physical Activity Questionnaire. Results: The overall follow-up rate of the cohort was 49% and similar in both the groups. The anthropometric details, blood tests, and DEXA in the women and their offspring were similar except that the offspring of the group on metformin had higher triglyceride values than the offspring of the women treated with glibenclamide. The average body mass index of the offspring was similar and was 18. Currently, women who were treated with glibenclamide 9 years ago had higher fasting plasma glucose levels (9.2 [7.3, 12.6]) than the metformin group (7.2 [6.1, 8.4] median [interquartile range]), P = 0.02. They also had significantly higher diastolic blood pressure readings 77.1mmHg (8.9) and 72.1mmHg (11.7) mean (SD), P = 0.035. (Information from the previously published brief communication). Conclusion: No significant adverse outcome was seen in women treated with metformin and the offspring 9 years later.

Systematic review of the use of metformin compared to insulin for the management of gestational diabetes: Implications for low-resource settings.

This systematic review examines the effectiveness of metformin treatment compared to insulin treatment for gestational diabetes within the context of a low-resource environment. Electronic data searches of Medline, EMBASE, Scopus and Google scholar databases from 1 January, 2005 to 30 June, 2021 were performed using medical subject headings: 'gestational diabetes or pregnancy diabetes mellitus' AND 'Pregnancy or pregnancy outcomes' AND 'Insulin' AND 'Metformin Hydrochloride Drug Combination/or Metformin/or Hypoglycemic Agents' AND 'Glycemic control or blood glucose'. Randomized controlled trials were included if: participants were pregnant women with gestational diabetes mellitus (GDM); the interventions were metformin and/or insulin. Studies among women with pre-gestational diabetes, non-randomised control trials or studies with a limited description of the methodology were excluded. Outcomes included adverse maternal outcomes: weight gain, C-section, pre-eclampsia and glycaemic control and adverse neonatal outcomes: birth weight, macrosomia, pre-term birth and neonatal hypoglycaemia. The revised Cochrane Risk of Bias Assessment for randomised trials was used for the evaluation of bias. We screened 164 abstracts and 36 full-text articles. Fourteen studies met the inclusion criteria. The studies provide moderate to high-quality evidence demonstrating the effectiveness of metformin as an alternative therapy to insulin. Risk of bias was low; multiple countries and robust sample sizes improved external validity. All studies were from urban centres with no rural data. These recent high quality studies comparing metformin to insulin for the treatment of GDM generally found either improved or equivalent pregnancy outcome and good glycaemic control for most patients, although many required insulin supplementation. Its ease of use, safety and efficacy suggest metformin may simplify the management of gestational diabetes, particularly in rural and other low-resource environments.

The association between continuous glucose metrics and adverse outcomes in individuals undergoing gestational diabetes screening

To ascertain the association between continuous glucose monitoring (CGM) metrics and adverse outcomes among individuals undergoing gestational diabetes (GDM) screening. A prospective study (06/2020 to 01/2022) of individuals who underwent 2-step GDM screening at ≤ 30 weeks. Participants had a blinded CGM placed (Dexcom G6PRO) for 10 days during their glucose challenge test. Primary outcome was a composite of adverse neonatal outcomes including large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, hypoglycemia, or fetal and neonatal death. Secondary neonatal outcomes included NICU admission, need for intravenous glucose, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. We also evaluated maternal outcomes related to glucose control. Time in target range (TIR) (70–140 mg/dL), time above target range (TAR) ( >140mg/dL) expressed as percentage of all CGM readings, and mean glucose were analyzed. Youden index was used to choose cut point of ≥10% for TAR and association with outcomes. Of the 136 participants recruited, 45 (33%) did not return the CGM. The study focuses on the 91 (67%) with CGM data and among them 2-step method diagnosed GDM in 2 individuals (2.2%) (Table 1). CGM indicated that 16 (17.6%) had TAR≥10%. Individuals with TAR ≥10% had increased risk of composite adverse neonatal outcome (80% vs. 26%, p< 0.001) compared to those with TAR< 10% (Table 2). Furthermore, neonates born to individuals with TAR≥10% were born at an earlier gestational age, had increased IV glucose treatment (43% vs. 9%, p=0.004) and longer length of stay (4 vs. 2 days, p=0.007). No difference in maternal outcomes was found between the groups. In this prospective study of individuals undergoing GDM screening a cutoff of TAR of ≥10% using CGM was associated with a higher rate of neonatal adverse outcomes. A randomized trial of CGM vs. 2-step screening for GDM to lower the rate of adverse outcomes is planned (NCT05430204).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Antenatalni kortikosteroidi - između leka i rizika za razvoj fetusa i programiranja odrastanja

Antenatal corticosteroid therapy (ACST) is very important in reducing the sequelae of prematurity, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). This therapy has short-term and long-term neonatal consequences that range from reduced neonatal body weight, brain growth, hypertension, hypoglycemia and obesity to delayed neurological development. In addition to undeniable importance this type of therapy has on fetal maturation, it may also impact programming of fetuses future development and health during childhood and adulthood. ACST must be personalized, as a single course, and determined by indications and assessment of the expected time of delivery, so that the exposure time of the fetus to the effects of endogenous and exogenous steroids is shortened.

Disproportionate fetal abdominal growth and risk of neonatal hypoglycemia in pregnancies with fetal growth restriction

Disproportionate fetal abdominal growth and risk of neonatal hypoglycemia in pregnancies with fetal growth restriction

ALGORITMO DE INDICAÇÃO DE ACESSO VENOSO PARA RECÉM-NASCIDOS EM UNIDADE DE TERAPIA INTENSIVA NEONATAL

ABSTRACT Objective: to present an algorithm for the indication of venous accesses for newborns in Neonatal Intensive Care Unit. Development: descriptive study conducted in a Neonatal Intensive Care Unit in southern Brazil, in the period from 2017 to 2020 in two stages of idealization: design of the algorithm; and the adequacy based on the application according to observations made by the nurses involved. The developed algorithm contemplated the prediction of venous access for patients with indication for abdominal and other surgeries, premature infants stratified in gestational age higher and lower than 30 weeks, heart diseases with dependence or not on arterial channel and persistent neonatal hypoglycemia. According to the venous network, number of prescribed therapies, fasting, antibiotic therapy and vasoactive drugs, there is an initial indication for one type of catheter that may be followed by another according to need. Conclusion: the participation of nurses in the indication of venous access integrates interprofessional practices and increases neonatal care.

Timing of delivery for “poorly controlled” diabetes and associated neonatal outcomes

ACOG recommends delivery in the 39th week of pregnancy for pre-gestational and medication-controlled gestational diabetes with consideration for earlier delivery in those with poor glucose control. Although delivery before 39 weeks aims to reduce the risk of stillbirth, it is associated with increased neonatal morbidity. We examined the impact of delivery < 39 weeks performed solely for suboptimal glucose control on neonatal outcomes. This is a retrospective cohort study of all singleton, non-anomalous pregnancies with diabetes within a multi-institution health system, as identified via query of a comprehensive obstetric outcome database. Patients delivering at a given week gestation exclusively due to diabetes-related indications were compared to ongoing pregnancies (OP) (Figure 1). The primary outcome was NICU admission and secondary outcomes included stillbirth, neonatal death, hypoglycemia, respiratory distress syndrome (RDS), and NICU length of stay (LOS). Continuous and categorical variables were statistically compared. 4750 patients with perinatal diabetes met inclusion criteria. Of those, 30.5% delivered for a diabetes-related indication with 19.8% delivering before 39 weeks. Those delivering at 36 and 37 weeks for diabetes-related indications compared to OP had higher NICU admission (63% vs 9%, p< 0.001, median LOS 11.0 vs 2.8 days, p< 0.001 and 25% vs 7%, p< 0.001, median LOS 4.4 vs 2.6, p=0.026). There was no difference in NICU admission for delivery at 38 or 39 weeks compared to OP (Figure 2). There were significantly increased rates of neonatal hypoglycemia and RDS in the diabetes-related deliveries at 36, 37, and 38 weeks compared to OP. There were no differences in stillbirth or neonatal death. In pregnancies complicated by diabetes with suboptimal glucose control, early delivery is associated with increased NICU admissions, LOS, and neonatal morbidity. Optimal timing of delivery to balance the risk of stillbirth with neonatal morbidity remains undetermined. Our data suggest delivery at 38 weeks may be optimal.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prelabor rupture of membranes in women with gestational diabetes and the risk of neonatal hypoglycemia

Prelabor rupture of membranes in women with gestational diabetes and the risk of neonatal hypoglycemia

Remote patient monitoring for diabetes management in pregnancy associated with improved maternal and neonatal outcomes

Remote Patient Monitoring (RPM) allows providers to monitor patients’ acute or chronic conditions, with near real-time data, in between clinic visits to make timely adjustments to care. Our objective was to determine if using RPM for outpatient management of diabetes in pregnancy leads to improvement in maternal and neonatal outcomes. This was a retrospective cohort study of pregnant patients with diabetes managed by the Maternal Fetal Medicine practice at one academic institution between October 2019 – April 2021. The practice transitioned from paper blood glucose logs to use of EHR-based RPM tools in January 2020. RPM options included: 1) Device integration with Bluetooth glucometers that automatically upload measured glucose values to the patient’s Epic MyChart app or 2) Manual entry where patients manually log glucose readings into their MyChart app. Values in the MyChart app directly transfer to the patient’s Electronic Health Record (Epic, Verona, WI) for review by providers. In total, 533 patients were studied. We compared 173 patients with paper logs to 360 patients managed with RPM (176 device integration and 184 manual entry). Data on maternal characteristics, measures of glycemic control, and maternal and neonatal outcomes were collected. Maternal baseline characteristics were not significantly different between the RPM and paper groups, including similar rates of gestational diabetes (94.7 vs 95.9%) and pre-gestational diabetes (5.3% vs 4.1%). RPM patients submitted more values, were more likely to achieve glycemic control in target range, and achieved target range sooner than patients managed with paper logs (Table 1). This was achieved without increasing in-person visits. RPM patients had lower rates of preeclampsia and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (Figure 1). Remote patient monitoring for management of diabetes in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and leads to improved maternal and neonatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A Case of Hyperinsulinemic Hypoglycemia in Premature Infant Treated with Oral Diazoxide

Neonatal hyperinsulinism, whether permanent or transient, results in prolonged hypoglycemia, which increases the risk of hypoglycemic brain injury. Therefore, prompt diagnosis and management of hyperinsulinemic hypoglycemia is important. Drawing a “critical sample” at the time of hypoglycemia is useful for diagnosis. Genetic testing for defective insulin-regulating genes in pancreatic beta-cells might also be helpful in cases of prolonged hypoglycemia. High-calorie feeding or glucose infusion is necessary to maintain normoglycemia. Diazoxide is the treatment of choice for hyperinsulinism and should be continued until the hypoglycemia resolves. We describe a case of transient neonatal hyperinsulinemia hypoglycemia in a small-for-gestational-age preterm infant who underwent diazoxide treatment and achieved a favorable outcome.

Early Gestational Diabetes Screening Based on ACOG Guidelines.

A recent randomized controlled trial suggested that early gestational diabetes mellitus (GDM) screening in patients with obesity (body mass index [BMI] ≥30 kg/m2) does not improve perinatal outcomes. The American College of Obstetrics and Gynecology currently recommends early screening for gestational diabetes in patients who are overweight with one or more additional risk factors. We evaluated the effect of screening based on the number of additional risk factors for development of gestational diabetes. This was a secondary analysis of a multicenter randomized controlled trial of obese patients with singleton nonanomalous fetuses comparing early (14-20 weeks' gestation) with routine (24-28 weeks' gestation) GDM screening. Exclusion criteria were pregestational diabetes, major medical illnesses, bariatric surgery, chronic steroid use, and prior cesarean. Early versus routine GDM screening groups were compared and stratified by the number of additional risk factors for GDM (0, 1, 2, and ≥3). The primary outcome was an adverse perinatal composite outcome composed of: macrosomia, primary cesarean delivery, hypertensive disorders of pregnancy, shoulder dystocia, neonatal hyperbilirubinemia, and neonatal hypoglycemia. Analyses examined effects of early versus routine screening by the number of additional risk factors and their possible interaction on the incidences of the primary outcome and GDM. Of 913 patients, 5% had 0, 52% had 1, 33% had 2, and 10% had ≥3 additional risk factors. Baseline characteristics, including the number and type of risk factors, were similar between early and routine screening groups. Breslow-Day test for interaction between early versus routine screening and the number of additional risk factors was not significant for either the primary outcome (p = 0.37) or the diagnosis of GDM (p = 0.28). The incidence of GDM and the adverse perinatal composite outcome increased as the number of risk factors increased (p < 0.001). In patients with BMI ≥30 kg/m2 and additional risk factors, early GDM screening does not prevent adverse outcomes. · The ACOG currently recommends early screening for gestational diabetes if patients have risk factors.. · Even in patients with multiple risk factors, early screening for GDM does not improve outcomes.. · Patients with three or more risk factors may have worse outcomes if they undergo early screening..