Maternal HbA1c Research Articles

Correlation of glycemic control in newborn at birth to maternal glycemic control

Background: Gestational diabetes mellitus (GDM) is a common endocrine disorder of pregnancy with an incidence of approximately 1 in 1000. Perinatal outcomes and long-term sequelae in infants of diabetic mothers (IDM) are related to onset and duration of glucose intolerance and severity of disease in mother. Objective: The objective of the study was to study the correlation of glycemic control in newborn to maternal glycemic control (glycosylated hemoglobin [HbA1c] levels). The occurrence of congenital malformations and other neonatal complications was also studied. Materials and Methods: A longitudinal study was carried out at a tertiary hospital of Central India from November 2018 to October 2019 and a total of 47 cases which were admitted during the study periodwere included in the study. All babies born either gestational or type 1 or type 2 diabetic mothers were included in the study. The sample size was calculated to be 38. Statistical analysis was done using Epi Info 7.1. Poor maternal glycemic control during the 3rd trimester has been shown to be strongly and independently correlate with neonatal hypoglycemia. Neonatal HbA1c correlates well with maternal HbA1c level after birth. Results: Poor maternal glycemic control during the 3rd trimester has been shown to be strongly and independently correlate with neonatal hypoglycemia. Neonatal HbA1c correlates well with maternal HbA1c level after birth. There was no statistically significant difference found between mean birth weight and gender (p>0.05) in IDM. Conclusion: It was concluded that IDM babies are at risk of hypoglycemia if the mother’s HbA1c level goes beyond 6.5%. There was no significant correlation between the duration of diabetes and hypoglycemia and other congenital anomalies associated with maternal diabetes.

Association Between Maternal Normal Range HbA1c Values and Adverse Birth Outcomes.

Higher blood glucose level during gestational periods has been consistently associated with increased risk of adverse birth outcomes. Evidence regarding the association between higher glycated hemoglobin A1c (HbA1c) within the normal range and adverse birth outcomes is limited. We aimed to examine the association between HbA1c within the normal range and the risk of adverse birth outcomes. The data were abstracted from the Information System of Guangdong Women and Children Hospital, China, from September 2014 to March 2018. A total of 5658 pregnant women with normal gestational HbA1c were included in this analysis. The adverse birth outcomes include preterm birth, macrosomia, and large for gestational age (LGA). Among 5658 subjects, the rates of preterm birth, macrosomia, and LGA were 4.6% (261/5658), 3.5% (200/5658), and 5.7% (325/5658), respectively. The results of multivariate logistic regression model showed that each 1% increase in maternal HbA1c was positively associated with increased risks of preterm birth (OR 1.58; 95% CI, 1.08-2.31), macrosomia (OR 1.70; 95% CI, 1.10-2.64), and LGA (OR 1.38; 95% CI, 0.98-1.96). The association between gestational HbA1c and preterm birth was more evident among women with prepregnancy body mass index (BMI) ≤ 24 kg/m2. Gestational higher HbA1c level within the normal range is an independent risk factor for preterm birth, macrosomia, and LGA. Intervention for reducing HbAc1 may help to prevent adverse birth outcomes.

Predictors of emergency cesarean section in women with preexisting diabetes

ObjectivePreexisting diabetes in pregnancy is associated with a high risk of emergency cesarean section (CS), which is associated with increased risk of maternal and neonatal complications. Thus, the aim of this study was to identify possible predictors of emergency CS in women with preexisting diabetes. Study designThis is a secondary analysis of a prospective observational study of 204 women with preexisting diabetes (118 with type 1 diabetes and 86 with type 2) with singleton pregnancies recruited at Rigshospitalet, Copenhagen, Denmark from August 2015 to February 2018. Mode of delivery (trial of labor or planned CS) was individually planned in late pregnancy based on clinical variables reflecting maternal and fetal health including glycemic control and ultrasonically estimated fetal weight. Univariate and multivariable analyses were performed to identify possible predictors of in labor emergency CS. ResultsTrial of labor was planned in 79 % (n = 162) of the women of whom 65 % (n = 105) were delivered vaginally and 35 % (n = 57) by an emergency CS, while the remaining 21 % (n = 42) were offered a planned CS. Nulliparity (adjusted odds ratio (aOR) 5.6 95 % CI 1.7–18.8), presence of a hypertensive disorder (aOR 2.8, 95 % CI 1.2–6.7) and previous CS (aOR 6.7, 95 % CI 1.5–28.9) were independently associated with an emergency CS. Maternal height was inversely associated with emergency CS (aOR 0.6 95 %, CI 0.5-0.9 per 5 cm decrease). Neither maternal HbA1c nor ultrasonically estimated fetal size in late pregnancy were associated with emergency CS. Women scheduled for a planned CS were characterized by poorer glycemic control and higher estimated fetal size than those offered a trial of labor. ConclusionNulliparity, presence of a hypertensive disorder, previous CS and shorter maternal height were predictors of emergency CS in women with a planned trial of labor, whereas this not was the case for late pregnancy maternal Hba1c or fetal size estimated by ultrasound.

Both glycaemic control and insulin dose during pregnancy in women with type 1 diabetes are associated with neonatal anthropometric measures and placental weight.

To investigate longitudinal associations of maternal glucose/HbA1c and insulin dose with birthweight-related outcomes in women with type 1 diabetes. We performed a cohort study including 473 pregnant women with type 1 diabetes with singleton pregnancies. We investigated maternal self-monitored blood glucose (SMBG, mmol/L), HbA1c (%, mmol/mol) and insulin dose (IU/kg/day) in the three trimesters as potential independent variables, while adjusting for potential confounders. Outcomes of interest were birthweight, birthweight SD score, neonatal length, weight/length index, ponderal index and placental weight. Multiple linear regression analysis was performed with separate analyses for SMBG and HbA1c . Maternal glucose and insulin dose were independently associated with birthweight-related outcomes. In the main analysis, in the first trimester most associations were positive for insulin dose, in the second the associations were positive for glucose and inverse for insulin while in the third there were no associations. Most sensitivity analyses produced consistent results. In a sensitivity analysis splitting the first trimester in two periods, positive associations of maternal insulin with birthweight-related outcomes were observed in weeks 0+ to 6+. Early in pregnancy in women with type 1 diabetes, maternal insulin dose is positively associated with birthweight-related outcomes, whereas in the second trimester, a positive association with SMBG emerges and the association with maternal insulin becomes inverse. If confirmed in other cohorts, these results would have implications in the management of women with type 1 diabetes.

No association between early maternal HbA1c and offspring birthweight among women without pre-existing diabetes in Greenland

ABSTRACT Studies of the association between maternal blood glucose measured by glycated haemoglobin (HbA1c) during pregnancy and the offspring’s birthweight have been heterogeneous. The aim of this study was to examine the association between maternal HbA1c level before gestational week 20 and the offspring’s birthweight among predominantly indigenous women in Greenland. A retrospective cohort study including all women (n = 503) and their offspring delivered from September 2015 to September 2016 at Queen Ingrid’s Hospital in Nuuk was conducted. Data were obtained from the electronic medical record. Linear regression models were used to analyse the effect of maternal HbA1c on the offspring’s birthweight with adjustment and stratification for relevant confounders and effect modifiers. Birthweight increased with 3.3 g per mmol/mol increase in HbA1c. Yet, no significant association between maternal HbA1c and the offspring’s birthweight was found after adjustment for maternal age, ethnicity, residence, smoking, and parity (β = 0.058, p = 0.711). Among obese women, a borderline significant positive association (β = 0.657, p = 0.059) was found. For term newborns, this corresponded to an increase in birthweight of 31 g per mmol/mol increase in HbA1c. Based on the current study, the use of HbA1c during pregnancy to detect the risk of delivering a newborn with macrosomia is not recommended in Greenland. Abbreviation: HbA1c: glycosylated haemoglobin; GA: gestational age; SD: standard deviation; CI: confidence interval.

Potentially modifiable predictors of adverse neonatal and maternal outcomes in pregnancies with gestational diabetes\xa0mellitus: can they help for future risk stratification and risk-adapted patient care?

BackgroundGestational diabetes mellitus (GDM) exposes mothers and their offspring to short and long-term complications. The objective of this study was to identify the importance of potentially modifiable predictors of adverse outcomes in pregnancies with GDM. We also aimed to assess the relationship between maternal predictors and pregnancy outcomes depending on HbA1c values and to provide a risk stratification for adverse pregnancy outcomes according to the prepregnancy BMI (Body mass index) and HbA1c at the 1st booking.MethodsThis prospective study included 576 patients with GDM. Predictors were prepregnancy BMI, gestational weight gain (GWG), excessive weight gain, fasting, 1 and 2-h glucose values after the 75 g oral glucose challenge test (oGTT), HbA1c at the 1st GDM booking and at the end of pregnancy and maternal treatment requirement. Maternal and neonatal outcomes such as cesarean section, macrosomia, large and small for gestational age (LGA, SGA), neonatal hypoglycemia, prematurity, hospitalization in the neonatal unit and Apgar score at 5 min < 7 were evaluated. Univariate and multivariate regression analyses and probability analyses were performed.ResultsOne-hour glucose after oGTT and prepregnancy BMI were correlated with cesarean section. GWG and HbA1c at the end pregnancy were associated with macrosomia and LGA, while prepregnancy BMI was inversely associated with SGA. The requirement for maternal treatment was correlated with neonatal hypoglycemia, and HbA1c at the end of pregnancy with prematurity (all p < 0.05). The correlations between predictors and pregnancy complications were exclusively observed when HbA1c was ≥5.5% (37 mmol/mol). In women with prepregnancy BMI ≥ 25 kg/m2 and HbA1c ≥ 5.5% (37 mmol/mol) at the 1st booking, the risk for cesarean section and LGA was nearly doubled compared to women with BMI with < 25 kg/m2 and HbA1c < 5.5% (37 mmol/mol).ConclusionsPrepregnancy BMI, GWG, maternal treatment requirement and HbA1c at the end of pregnancy can predict adverse pregnancy outcomes in women with GDM, particularly when HbA1c is ≥5.5% (37 mmol/mol). Stratification based on prepregnancy BMI and HbA1c at the 1st booking may allow for future risk-adapted care in these patients.

Factors associated with stillbirth in women with diabetes

Aims/hypothesisStillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors.MethodsA retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA1c data and delivery timing were compared between stillborn and liveborn groups.ResultsStillbirth rates were 16.1 (95% CI 12.4, 20.8) and 22.9 (95% CI 16.4, 31.8) per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA1c before pregnancy (OR 1.03 [95% CI 1.01, 1.04]; p = 0.0003) and in later pregnancy (OR 1.06 [95% CI 1.04, 1.08]; p < 0.0001) were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI (OR 1.07 [95% CI 1.01, 1.14]; p = 0.02) and pre-pregnancy HbA1c (OR 1.02 [95% CI 1.00, 1.04]; p = 0.016) were associated with stillbirth. Risk was highest in infants with birthweights <10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th–90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights >95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week (7.0 [95% CI 3.7, 12.9] per 1000 ongoing pregnancies) among mothers with type 1 diabetes and in the 39th week (9.3 [95% CI 2.4, 29.2]) for type 2 diabetes.Conclusions/interpretationMaternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies.

Importance of early elevated maternal HbA1c levels in identifying adverse fetal and neonatal events

AimsThe aims of this study were to explore factors that associated with gestational diabetes mellitus (GDM), and to determine the relationship between early maternal HbA1c levels and adverse fetal or neonatal events, and to determine an optimal maternal glucose testing method in order to decrease the potential health risk for their offspring. MethodsFrom December 2015 to May 2016, a total of 6744 pregnant women were enrolled from Shanghai First Maternal and Infant Hospital affiliated to Tongji University prospectively in the nested case-control study. Each GDM case was matched with a healthy pregnant woman and followed up. Outcome analyses were conducted between GDM case and control groups, as well as elevated and normal maternal HbA1c levels, respectively. ResultsA total of 1836 women were included in the adverse fetal and neonatal events examination. For pregnant women with early HbA1c ≥ 5.2%, the adjusted risk ratios (RR) of respiratory distress syndrome (RDS), pneumonia and jaundice were 4.37 (95%CI 1.54–12.35), 2.03 (95%CI 1.24–3.33) and 1.49 (95%CI 1.01–2.20), respectively. After treatments, the frequency for the majority of events in GDM group was similar to that of healthy pregnant women. Moreover, the area under the curve (AUC) of early maternal HbA1c in predicting potential RDS is 0.734. HbA1c ≤ 4.9% excluded for RDS. ConclusionsCompared with women with normal HbA1c, those with an early elevated HbA1c level were more likely to develop adverse events, including RDS, pneumonia and jaundice. Early HbA1c testing can be used as an auxiliary method identifying potential RDS.

1411-P: Glycated Hemoglobin A1c Levels during Pregnancy and Risk of Autism in Offspring

Children exposed in utero to pre-existing type 1, type 2 diabetes or gestational diabetes diagnosed by second trimesters are at increased risk of developing autism spectrum disorders (ASD). Here we assessed the role of maternal glycemic levels using hemoglobin A1c. Data were from 35,819 singleton children born in 2012 and 2013 with maternal HbA1c measured during the first two trimesters of pregnancy (median=9.0 weeks, interquartile range (IQR) 6.7-11.4 weeks). All children were from an integrated healthcare system and enrolled in the health plan by age one. Children were tracked from age one until December 31, 2017. Risk of ASD associated with maternal HbA1c levels were estimated by hazard ratio (HR) using Cox regression. Potential confounding by maternal age, maternal obesity, parity, education, race/ethnicity, history of comorbidity, and sex of the child were assessed. During a median of 4.5 (IQR of 4.0-5.0) years after birth, 707 (2.0%) children were diagnosed with ASD. Univariately, the HR of ASD associated with each 1% increase of HbA1c was 1.23 (95% CI 1.08-1.41; p=0.002). When analyzed categorically, compared to exposure to HbA1c &amp;lt;5.7% (n=30,419), the HR (95% CI) associated with exposure to HbA1c 5.7% to 5.9% (n=4,172), 6.0% to 6.5% (n=871) and &amp;gt;6.5% (n=357) were 1.24 (1.01-1.54; p=0.04), 0.98 (0.61-1.59; p=0.94) and 2.17 (1.30-3.62; p=0.003) respectively. None of the potential confounders changed the model estimates by more than 10% except for maternal pre-pregnancy BMI and race/ethnicity. Adjusting for both reduced the corresponding HRs to 1.08 (0.87-1.35; p=0.46), 0.79 (0.48-1.28; p=0.33) and 1.79 (1.06-3.00; p=0.03) respectively. Thus, exposure to hyperglycemia defined by HbA1c &amp;gt;6.5% in the first two trimesters was associated with an increased ASD risk in offspring. Improving glycemic control during pregnancy may reduce the risk of ASD in children, and monitoring HbA1c may assist in identifying at-risk children for early intervention to reduce ASD disabilities. Disclosure A. Xiang: None. T. Chow: None. M.P. Martinez: None. D. Getahun: Research Support; Self; Bayer AG. K.A. Page: None. T.A. Buchanan: Research Support; Self; Allergan, Apollo EndoSurgery. R. Feldman: None.

Maternal glucose levels during pregnancy and childhood adiposity in the Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study.

Maternal type 2 diabetes during pregnancy and gestational diabetes are associated with childhood adiposity; however, associations of lower maternal glucose levels during pregnancy with childhood adiposity, independent of maternal BMI, remain less clear. The objective was to examine associations of maternal glucose levels during pregnancy with childhood adiposity in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) cohort. The HAPO Study was an observational epidemiological international multi-ethnic investigation that established strong associations of glucose levels during pregnancy with multiple adverse perinatal outcomes. The HAPO Follow-up Study (HAPO FUS) included 4832 children from ten HAPO centres whose mothers had a 75g OGTT at ~28weeks gestation 10-14years earlier, with glucose values blinded to participants and clinical caregivers. The primary outcome was child adiposity, including: (1) being overweight/obese according to sex- and age-specific cut-offs based on the International Obesity Task Force (IOTF) criteria; (2) IOTF-defined obesity only; and (3) measurements >85th percentile for sum of skinfolds, waist circumference and per cent body fat. Primary predictors were maternal OGTT and HbA1c values during pregnancy. Fully adjusted models that included maternal BMI at pregnancy OGTT indicated positive associations between maternal glucose predictors and child adiposity outcomes. For one SD difference in pregnancy glucose and HbA1c measures, ORs for each child adiposity outcome were in the range of 1.05-1.16 for maternal fasting glucose, 1.11-1.19 for 1h glucose, 1.09-1.21 for 2h glucose and 1.12-1.21 for HbA1c. Associations were significant, except for associations of maternal fasting glucose with offspring being overweight/obese or having waist circumference >85th percentile. Linearity was confirmed in all adjusted models. Exploratory sex-specific analyses indicated generally consistent associations for boys and girls. Exposure to higher levels of glucose in utero is independently associated with childhood adiposity, including being overweight/obese, obesity, skinfold thickness, per cent body fat and waist circumference. Glucose levels less than those diagnostic of diabetes are associated with greater childhood adiposity; this may have implications for long-term metabolic health.

Assessment of Ventricular Outflow Tract in Macrosomic Neonates

Introduction: Fetal macrosomia is encountered in up to 10% of all deliveries. It occurs in 15-45% of diabetic pregnancies. Factors associated with fetal macrosomia include genetics; duration of gestation; presence of gestational diabetes; high pre-pregnancy body mass index (BMI); excessive gestational weight gain and diabetes mellitus. Macrosomia is reportedly associated with neonatal morbidity, neonatal injury, maternal injury, and cesarean delivery. Moreover, shoulder dystocia, brachial plexus injury, skeletal injuries, meconium aspiration, prenatal asphyxia, hypoglycemia, and fetal death. All types of maternal diabetes are risk factors for macrosomia and can affect the foetal cardiac development in the form of Hypertrophic cardiomyopathy and congenital cardiac malformation. Aim of work: To evaluate the cardiac changes and ventricular outflow tracts in macrosomic neonates clinically and by 2D transthoracic echocardiography. Patients and Methods: This prospective study was carried out in NICU of Sayed Galal University Hospital on fifty macrosomic neonates’ thorough detailed history, clinical examination, Chest X-ray, important laboratory investigation, two dimensional M-mode and Doppler echocardiographic examination. Results: The fifty macrosomic neonates consisted of 29 males (58%) and 21 females (42%) with mean age ± SD of 2.16±0.84 days (range, 1-5 days). Statistically, significant relation between inter ventricular septum diastole (IVSD) (mm) according to HbA1c level, increase IVSD with increase HbA1c level, and show statistically significant relation between inter ventricular septum diastole (mm) and LTVOTO. When IVSD increase the incidence of LVOTO increase While TABSE decrease with the increase in IVSD. It also showed significant negative correlation between IVSD and MPI and PAP. Conclusion: Elevated maternal HbA1c level can lead hypertrophic cardiomyopathy mainly septal hypertrophy, which increased incidence of ventricular outflow tract obstruction. These echocardiographic findings (TAPSE and MPI) seem to be a better index of the cardiac outcome of macrosomic neonates than other clinical, laboratory or radiological parameters. Recommendations: Early echocardiographic examination for early detection of myocardial dysfunction or cardiac defect is essential in all macrosomic neonates andIDM even those without audible murmur, especially so if not improving with proper intervention. Echocardiographic indices especially TAPSE and Tei index for all macrosomic neonates to detect early cardiac changes in particular left ventricular dysfunction.

Assessment of Ventricular Outflow Tract in Macrosomic Neonates

Introduction: Fetal macrosomia is encountered in up to 10% of all deliveries. It occurs in 15-45% of diabetic pregnancies. Factors associated with fetal macrosomia include genetics; duration of gestation; presence of gestational diabetes; high pre-pregnancy body mass index (BMI); excessive gestational weight gain and diabetes mellitus. Macrosomia is reportedly associated with neonatal morbidity, neonatal injury, maternal injury, and cesarean delivery. Moreover, shoulder dystocia, brachial plexus injury, skeletal injuries, meconium aspiration, prenatal asphyxia, hypoglycemia, and fetal death. All types of maternal diabetes are risk factors for macrosomia and can affect the foetal cardiac development in the form of Hypertrophic cardiomyopathy and congenital cardiac malformation. Aim of work: To evaluate the cardiac changes and ventricular outflow tracts in macrosomic neonates clinically and by 2D transthoracic echocardiography. Patients and Methods: This prospective study was carried out in NICU of Sayed Galal University Hospital on fifty macrosomic neonates’ thorough detailed history, clinical examination, Chest X-ray, important laboratory investigation, two dimensional M-mode and Doppler echocardiographic examination. Results: The fifty macrosomic neonates consisted of 29 males (58%) and 21 females (42%) with mean age ± SD of 2.16±0.84 days (range, 1-5 days). Statistically, significant relation between inter ventricular septum diastole (IVSD) (mm) according to HbA1c level, increase IVSD with increase HbA1c level, and show statistically significant relation between inter ventricular septum diastole (mm) and LTVOTO. When IVSD increase the incidence of LVOTO increase While TABSE decrease with the increase in IVSD. It also showed significant negative correlation between IVSD and MPI and PAP. Conclusion: Elevated maternal HbA1c level can lead hypertrophic cardiomyopathy mainly septal hypertrophy, which increased incidence of ventricular outflow tract obstruction. These echocardiographic findings (TAPSE and MPI) seem to be a better index of the cardiac outcome of macrosomic neonates than other clinical, laboratory or radiological parameters. Recommendations: Early echocardiographic examination for early detection of myocardial dysfunction or cardiac defect is essential in all macrosomic neonates andIDM even those without audible murmur, especially so if not improving with proper intervention. Echocardiographic indices especially TAPSE and Tei index for all macrosomic neonates to detect early cardiac changes in particular left ventricular dysfunction.

406: The association between one abnormal value on oral glucose tolerance test and neonatal diabetic markers

Infants who are large for gestational age (LGA) are more likely than other infants to be obese in childhood, adolescence and early adulthood, and are inherently at a higher risk of cardiovascular and metabolic complications in adulthood. We aimed to investigate the association between pregnancies with one abnormal value (OAV) in the oral glucose tolerance test (OGTT) to neonatal skinfold thickness and umbilical cord C-peptide. This was a prospective controlled trial performed from January 2016 - May 2018. Included were women with OAV in the OGTT performed between 24-28 weeks of gestation, who delivered at the Edith Wolfson Medical Center. The control group included normoglycemic women, who delivered during the same time period. The following 'diabetic' variables were measured: maternal HbA1C and blood glucose level (on admission), umbilical cord (UC) C-peptide concentration, and neonatal skinfold thickness at 3 sites. Maternal and obstetric characteristics, and the 'diabetic variables, were compared between the OAV group and the control group. LGA was defined as birthweight (BW) >90th % and macrosomia was defined as BW>4000 gram. As compared to the control group (n=56), the OAV group (n=84) was older, 33.4±5 years vs. 32.5±7 years p=0.002, had lower GA at delivery (p=0.01), increased rate of macrosomia (<0.001) and LGA (p=0.003). Regarding the diabetic variables, as compared to the controls, the OAV group had increased concentration of UC C-peptide (1.7±1.6 vs. 1.3±1.1 units, p=0.007) and increased maternal HbA1C (5.3±0.4 vs. 5.1±0.3 units, p=0.01). Neonatal skinfold thickness measurements did not differ between the groups. By logistic regression analysis after controlling for confounders (birthweight, GA at delivery, and maternal body mass index), LGA was independently associated with the presence of OAV group: aOR 4.7, 95%CI 1.48-14.8, p=0.008. One pathological value on OGTT is associated with increased level of UC C-peptide and increased maternal HbA1C. LGA is independently associated with OAV. These findings indicate the continuum of risk for fetal adiposity that is associated with increasing maternal glucose intolerance in pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Maternal obesity and gestational diabetes mellitus affect body composition through infancy: the PONCH study.

To determine how maternal obesity or gestational diabetes mellitus (GDM) affect infant body size and body composition during the first year of life. Eighty three normal-weight (NW) women, 26 obese (OB) women, and 26 women with GDM were recruited during pregnancy. Infant body composition was determined by air-displacement plethysmography at 1 and 12 weeks, and anthropometric measurements made until 1 year of age. Girl infants born to OB women and women with GDM had a higher body-fat percentage (BF%) at 1 and 12 weeks of age than girls born to NW women. Girls had higher BF% than boys in OB and GDM groups only. Maternal HbA1c and fasting plasma glucose correlated with girl infant BF% at 1 week of age. Maternal weight at start of pregnancy correlated with birthweight in NW and OB groups, but not the GDM group. OB group infants showed greater BMI increases from 1 week to 1 year than both NW and GDM group infants. Results show that both maternal glycaemia and obesity are determinants of increased early life adiposity, especially in girls, with glycaemic levels being more influential than maternal weight for infants born to women with GDM.

Five-year follow up of a low glycaemic index dietary randomised controlled trial in pregnancy-no long-term maternal effects of a dietary intervention.

To determine whether a dietary intervention in pregnancy had a lasting effect on maternal outcomes of diet, HbA1c and weight retention 5 years post-intervention; and to establish whether modifiable maternal behaviours were associated with these outcomes. Randomised control trial of low glycaemic index (GI) diet in pregnancy with longitudinal follow up to 5 years post-intervention. Dublin, Ireland (2007-2016). In all, 403 women of 759 (53.1%) were followed up at 5 years. A total of 370 (intervention n = 188; control n = 182) were included in this analysis. Fasting glucose was measured at 13 and 28 weeks' gestation and HbA1c (mmol/mol) at 5-year follow up. Weight retention (kg) from early pregnancy to 5 years post-intervention was calculated. Dietary intakes, anthropometry, and lifestyle factors were measured in pregnancy and 5 years post-intervention. Multiple linear regression models, controlling for confounders, were used for analysis. Maternal diet, HbA1c, and weight retention at 5 years post-intervention. There was no difference between the intervention and control at 5 years post-intervention for any long-term maternal outcomes measured. HbA1c at 5 years post-intervention was associated with early-pregnancy fasting glucose (B 1.70, 95% CI 0.36-3.04) and parity ≥3 (B 1.04, 95% CI 0.09-1.99). Weight retention was associated with change in well-being from pregnancy to 5 years (B -0.06, 95% CI -0.11 to -0.02), gestational weight gain (B 0.19, 95% CI 0.00-0.38), and GI (B 0.26, 95% CI 0.06-0.46) at 5 years. The ROLO low-GI dietary intervention in pregnancy had no impact on maternal dietary intakes, HbA1c or body composition 5 years post-intervention. Maternal factors and lifestyle behaviours in pregnancy have long-term effects on glucose metabolism and weight retention up to 5 years later. Pregnancy factors are associated with maternal glucose metabolism and weight retention 5 years later-findings from the ROLO Study.

Maternal diabetes alters the development of ductus venosus shunting in the fetus.

Despite adequate glycemic control, the risks of fetal macrosomia and perinatal complications are increased in diabetic pregnancies. Adjustments of the umbilical venous distribution, including increased ductus venosus shunting, can be important fetal compensatory mechanisms, but the impact of pregestational diabetes on umbilical venous and ductus venosus flow is not known. In this prospective study, 49 women with pregestational diabetes mellitus underwent monthly ultrasound examinations from gestational week 20 to 36. The blood velocity and the mean diameters of the umbilical vein and ductus venosus were used for calculating blood flow volumes. The development of the umbilical venous flow, ductus venosus flow and ductus venosus shunt fraction (% of umbilical venous blood shunted through the ductus venosus) was compared with a reference population, and the effect of HbA1c on the ductus venosus flow was assessed. The umbilical venous flow was larger in pregnancies with pregestational diabetes mellitus than in low-risk pregnancies (p<0.001) but smaller when normalized for fetal weight (p=0.036). The distributional pattern of the ductus venosus flow developed differently in diabetic pregnancies, particularly during the third trimester, being smaller (p=0.007), also when normalized for fetal weight (p<0.001). Correspondingly, the ductus venosus shunt fraction was reduced (p<0.0001), most prominently at 36weeks. There were negative relations between the maternal HbA1c and the ductus venosus flow velocity, flow volume and shunt fraction. In pregnancies with pregestational diabetes mellitus, prioritized umbilical venous distribution to the fetal liver and lower ductus venosus shunt capacity reduce the compensatory capability of the fetus and may represent an augmented risk during hypoxic challenges during late pregnancy and birth.

Community-based pre-pregnancy care programme improves pregnancy preparation in women with pregestational diabetes

Aims/hypothesisWomen with diabetes remain at increased risk of adverse pregnancy outcomes associated with poor pregnancy preparation. However, women with type 2 diabetes are less aware of and less likely to access pre-pregnancy care (PPC) compared with women with type 1 diabetes. We developed and evaluated a community-based PPC programme with the aim of improving pregnancy preparation in all women with pregestational diabetes.MethodsThis was a prospective cohort study comparing pregnancy preparation measures before and during/after the PPC intervention in women with pre-existing diabetes from 1 June 2013 to 28 February 2017. The setting was 422 primary care practices and ten National Health Service specialist antenatal diabetes clinics. A multifaceted approach was taken to engage women with diabetes and community healthcare teams. This included identifying and sending PPC information leaflets to all eligible women, electronic preconception care templates, online education modules and resources, and regional meetings and educational events. Key outcomes were preconception folic acid supplementation, maternal HbA1c level, use of potentially harmful medications at conception and gestational age at first presentation, before and during/after the PPC programme.ResultsA total of 306 (73%) primary care practices actively participated in the PPC programme. Primary care databases were used to identify 5075 women with diabetes aged 18–45 years. PPC leaflets were provided to 4558 (89.8%) eligible women. There were 842 consecutive pregnancies in women with diabetes: 502 before and 340 during/after the PPC intervention. During/after the PPC intervention, pregnant women with type 2 diabetes were more likely to achieve target HbA1c levels ≤48 mmol/mol (6.5%) (44.4% of women before vs 58.5% of women during/after PPC intervention; p = 0.016) and to take 5 mg folic acid daily (23.5% and 41.8%; p = 0.001). There was an almost threefold improvement in ‘optimal’ pregnancy preparation in women with type 2 diabetes (5.8% and 15.1%; p = 0.021). Women with type 1 diabetes presented for earlier antenatal care during/after PPC (54.0% vs 67.3% before 8 weeks’ gestation; p = 0.003) with no other changes.Conclusions/interpretationA pragmatic community-based PPC programme was associated with clinically relevant improvements in pregnancy preparation in women with type 2 diabetes. To our knowledge, this is the first community-based PPC intervention to improve pregnancy preparation for women with type 2 diabetes.Data availabilityFurther details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-pregnancy-in-diabetes-audit.

Determinants of a good perinatal outcome in 588 pregnancies in women with type 1 diabetes

AimThis study assessed pregnancy outcomes in women with type 1 diabetes (T1D) over the last 15 years and identified modifiable factors associated with good perinatal outcomes. MethodsPregnancy outcomes were prospectively assessed in this cohort study of 588 singleton pregnancies (441 women) managed by standardized care from 2000 to 2014. A good perinatal outcome was defined as the uncomplicated delivery of a normally formed, non-macrosomic, full-term infant with no neonatal morbidity. Factors associated with good perinatal outcomes were identified by logistic regression. ResultsThe rate of severe congenital malformations was 1.5%, and 0.7% for perinatal mortality. The most frequent perinatal complications were macrosomia (41%), preterm delivery (16%) and neonatal hypoglycaemia (11%). Shoulder dystocia occurred in 2.6% of cases, but without sequelae. Perinatal outcomes were good in 254 (44%) pregnancies, and were associated with lower maternal HbA1c values at delivery [adjusted odds ratio (aOR): 2.78, 95% CI: 2.04–3.70, for each 1% (11mmol/mol) absolute decrease], lower gestational weight gains (aOR: 1.06, 95% CI: 1.02–1.10) and absence of preeclampsia (aOR: 2.63, 95% CI: 1.09–6.25). The relationship between HbA1c at delivery and a good perinatal outcome was continuous, with no discrimination threshold. ConclusionIn our study, rates of severe congenital malformations and perinatal mortality were similar to those of the general population. Less severe complications, mainly macrosomia and late preterm delivery, persisted. Also, our study identified modifiable risk factors that could be targeted to further improve the prognosis of pregnancy in T1D.

Umbilical Cord Blood Acidosis in Term Pregnancies With Gestational Diabetes Mellitus and Its Relations to Maternal Factors and Neonatal Outcomes

Background: Umbilical cord blood (UCB) gas analysis is recommended in high-risk pregnancies. However, in chronic medical conditions, cord blood acidosis might not indicate acute fetal stress, rather it might be due to fetal adaptation to the chronic stress. Objectives: Evaluating the association between UCB acidosis with maternal factors and adverse neonatal outcomes in term pregnancies with gestational diabetes mellitus. Methods: This prospective cohort evaluated 673 pregnant women who had term pregnancies and were admitted for elective cesarean delivery. A total of 80 women had gestational diabetes. After delivery, a blood sample was obtained from the umbilical artery for arterial blood gas analysis. The neonates were then followed. Results: Term pregnancies with gestational diabetes had significantly higher UCB acidosis rates compared to the healthy controls (26.2% vs. 6%, P < 0.001). In mothers with gestational diabetes, UCB acidosis was independently associated with higher maternal body mass index (P = 0.04) and HbA1C levels (P = 0.01). In the term neonates born to gestational diabetes mothers, after adjustment for gestational age, birth weight and pre-delivery blood glucose, UCB acidosis remained significantly associated with macrosomia (47.6% vs. 23.7%, P = 0.04), neonatal hypoglycemia (76.1% vs. 25.4%, P = 0.002), and moderate-severe jaundice (71.4% vs. 27.1%, p0.01). Conclusions: In our study term, pregnancies with gestational diabetes had a higher rate of UCB acidosis, which was associated with poor maternal glycemic and weight control during the last gestational trimester. UCB acidosis in these pregnancies seems to be independently associated with adverse neonatal outcomes.

Elevated glycated hemoglobin during pregnancy in diabetic women as a predictor of large-for-gestational age infants in an Asian cohort

Introduction: Diabetes mellitus in pregnancy is often associated with large-for-gestational-age (LGA) infants. However, there is substantial variation in the reported relationship between LGA infants and glycated hemoglobin (HbA1c) values in pregnancies complicated by diabetes mellitus. Our study aims to investigate whether elevated HbA1c values (≥6.5%) during pregnancy are associated with a higher risk of an LGA infant (birth weight ≥90th percentile for gestational age). Methods: A retrospective study was done on a study population of 202 women with diabetes in pregnancy, whose babies were born healthy and at term (37 + 0—41 + 6 weeks) at KK Women's and Children's Hospital, Singapore, between January 1, 2012, and December 31, 2013. Relevant maternal and neonatal data including maternal HbA1c values were extracted from the electronic medical records system. Results: Mothers who had LGA infants had significantly higher HbA1c values as compared against those without (6.8 ± 1.2 vs. 5.8 ± 0.9, P