Metabolic phenotypes of early gestational diabetes mellitus and their association with adverse pregnancy outcomes.

AIMS: To describe the metabolic phenotypes of early gestational diabetes mellitus and their association with adverse pregnancy outcomes. METHODS: We performed a post hoc analysis using data from the Vitamin D And Lifestyle Intervention for gestational diabetes prevention (DALI) trial conducted across nine European countries (2012-2014). In women with a BMI ≥29 kg/m2 , insulin resistance and secretion were estimated from the oral glucose tolerance test values performed before 20 weeks, using homeostatic model assessment of insulin resistance and Stumvoll first-phase indices, respectively. Women with early gestational diabetes, defined by the International Association of Diabetes and Pregnancy Study Groups criteria, were classified into three groups: GDM-R (above-median insulin resistance alone), GDM-S (below-median insulin secretion alone), and GDM-B (combination of both) and the few remaining women were excluded. RESULTS: Compared with women in the normal glucose tolerance group (n = 651), women in the GDM-R group (n = 143) had higher fasting and post-load glucose values and insulin levels, with a greater risk of having large-for-gestational age babies [adjusted odds ratio 3.30 (95% CI 1.50-7.50)] and caesarean section [adjusted odds ratio 2.30 (95% CI 1.20-4.40)]. Women in the GDM-S (n = 37) and GDM-B (n = 56) groups had comparable pregnancy outcomes with those in the normal glucose tolerance group. CONCLUSIONS: In overweight and obese women with early gestational diabetes, higher degree of insulin resistance alone was more likely to be associated with adverse pregnancy outcomes than lower insulin secretion alone or a combination of both.

Care of women with diabetes before, during and after pregnancy: time for a new approach?

AIMS: This study assesses the impact of pregnancy and pre-pregnancy care on longer-term treatment goals in women with diabetes. METHODS: This retrospective study included women with Type 1 (n = 247) and Type 2 diabetes (n = 137) who were evaluated before, during and after pregnancy. RESULTS: Among women with Type 1 diabetes, average HbA1c at 12 months post-partum was similar to the preconception level [63 vs. 64 mmol/mol (7.9% vs. 8.0%), P = 0.60]. This was also the case for women with Type 2 diabetes [52 vs. 52 mmol/mol (6.9% vs. 6.9%), P = 0.79]. At 12 months post-partum, there was no improvement in other measures of diabetes control and one in five women are lost to follow-up from clinical care. In total, 44.9% of women with Type 1 diabetes and 27.7% of those with Type 2 diabetes attended pre-pregnancy care. Attendees maintained superior glycaemic control throughout the study and were more likely to be receiving specialist care post-partum. CONCLUSIONS: These findings identify a need to change our approach to the reproductive care of women with diabetes. In particular, efforts should be made to ensure all women have access to and attend pre-pregnancy care, and barriers to engagement with post-partum care should be addressed.

The role of microstructure in the thermal fatigue of solder joints.

Thermal fatigue is a common failure mode in electronic solder joints, yet the role of microstructure is incompletely understood. Here, we quantify the evolution of microstructure and damage in Sn-3Ag-0.5Cu joints throughout a ball grid array (BGA) package using EBSD mapping of localised subgrains, recrystallisation and heavily coarsened Ag3Sn. We then interpret the results with a multi-scale modelling approach that links from a continuum model at the package/board scale through to a crystal plasticity finite element model at the microstructure scale. We measure and explain the dependence of damage evolution on (i) the ß-Sn crystal orientation(s) in single and multigrain joints, and (ii) the coefficient of thermal expansion (CTE) mismatch between tin grains in cyclic twinned multigrain joints. We further explore the relative importance of the solder microstructure versus the joint location in the array. The results provide a basis for designing optimum solder joint microstructures for thermal fatigue resistance.

Atlantic DIP: subject recruitment, data collection, missing data management and analysis procedures.

This paper describes the experiences related to the universal screening study for gestational diabetes mellitus (GDM) with reference to the subject recruitment process, data collection processes, (data entry, editing, quality assurance) and statistical analysis including the importance of missing data.

The impact of travel distance on the decision to attend for screening for gestational diabetes mellitus.

This paper estimates the impact of travel distance on the decision to attend for screening for gestational diabetes mellitus (GDM), controlling for a range of personal, clinical and lifestyle characteristics. The results suggest that women who live further away from a screening site are less likely to attend for screening. In particular, the probability of attending for screening is reduced by 1.8% [95% CI: 1.2% to 2.4%] for every additional 10 kms of travel. This is consistent wth previous research that shows geographic inequalities in access to GDM screening in Ireland. We also find that older women, those with a family history of diabetes, and those who are obese are more likely to accept the screening offer, suggesting that certain higher-risk groups may be either self-selecting into the screening programme or are being targeted by health care professionals through specific initiatives.

New estimates of the costs of universal screening for gestational diabetes mellitus in Ireland.

The new International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria have been predicted to increase the prevalence of gestational diabetes mellitus 2-to-3 fold and will have important resource implications for healthcare systems. A bottom-up, prevalence-based analysis was undertaken to estimate the costs of universal screening for gestational diabetes mellitus in Ireland using the new criteria. Healthcare activity was identified from the Atlantic Diabetes in Pregnancy database and grouped into five categories: (i) screening and testing, (ii) GDM treatment, (iii) prenatal care, (iv) delivery care, and (v) neonatal care. When individual resource components were valued using unit cost data and aggregated, the total healthcare cost was estimated at Euro 46,311,301 (95% CI: Euro 36,381,038, Euro 68,007,432). The average cost per case detected was Euro 351 (95% CI: (Euro 126, Euro 558) and the average total cost per case detected and treated was Euro 9,325 (95% CI: Euro 5,982, Euro 13,996). Further research is required to determine the cost effectiveness of screening in the region with a view to improving resource allocation in this area in the future.

Is there a socioeconomic gradient in the prevalence of gestational diabetes mellitus?

Previous studies have shown an association between Type 2 diabetes and lower socioeconomic status. This link is less clear in those with gestational diabetes mellitus (GDM). We test for a socioeconomic gradient in the prevalence of GDM by analysing data on 9,842 pregnant women who were offered testing for GDM in the Atlantic Diabetes in Pregnancy universal screening programme. A bivariate probit model relating GDM prevalence to socioeconomic status was estimated, controlling for variation in screening uptake rates across socioeconomic groups. The estimated increased prevalence of GDM is 8.6% [95% CI 2.7%-12.0%] for women in the lowest socioeconomic group when compared to the highest, suggesting a strong socioeconomic gradient in the prevalence of GDM. This gradient is found to be driven by differences in personal, clinical and lifestyle factors across socioeconomic groups.

Changing clinical practice can improve clinical outcomes for women with pre-gestational diabetes mellitus.

Prospective evaluation of pregnancy outcomes in women with pre-gestational diabetes over 6 years. The ATLANTIC Diabetes in Pregnancy group represents 5 antenatal centres along the Irish Atlantic seaboard, providing care for women with diabetes throughout pregnancy. In 2007 the group published a report that recognised that women were poorly prepared for pregnancy and that outcomes were sub-optimal. A change in practice occurred, offering women specialist-led, evidence-based care, both pre-pregnancy and combined antenatal/diabetes clinics during pregnancy. We now compare outcomes from 2005-2007 with 2008-2010. There was an increase in the numbers attending pre-conception care. Glycemic control before and throughout pregnancy improved. There was an overall increase in live births and decrease in perinata mortality rate. There was a decrease in large-for-gestational-age babies in mothers with Type 1 Diabetes. Elective Caesarean section rates increased while emergency section rates decreased. More women had Type 2 diabetes over time and these women were more likely to be obese. Changing the process of clinical care delivery can improve outcomes in for women with pre-gestational diabetes.

The impact of maternal obesity on gestational outcomes.

To investigate the effects of raised maternal BMI on pregnancy outcome in glucose tolerant women, using the IADPSG criteria. Prospective observational study of fetal and maternal outcome in a cohort of pregnant women recruited to a universal screening programme for gestational diabetes under the ATLANTIC-DIP partnership. Maternal outcomes included glucose, delivery mode, pregnancy induced hypertension (PIH), preeclampsia (PET), antepartum hemorrhage (APH) and postpartum hemorrhage (PPH). Fetal outcomes included birthweight, congenital malformation, fetal death, neonatal jaundice, hypoglycemia and respiratory distress. Increasing maternal BMI was associated with adverse pregnancy outcomes: higher cesarean section rates, pre-eclamptic toxemia, pregnancy induced hypertension, increased birth weight and congenital malformation. There was also an association between normal range glucose and emergency cesarean section, hypertension of pregnancy and birthweight. In spite of tightening criteria for hyperglycemia during pregnancy, raised BMI is associated with adverse pregnancy outcome.

Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes.

Gestational diabetes mellitus (GDM) is associated with adverse foetal and maternal outcomes, and identifies women at risk of future Type 2 Diabetes Mellitus (T2DM). Breast-feeding may improve postpartum maternal glucose tolerance. We prospectively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance. We compared postpartum 75g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT). Breast-feeding data was collected at time of OGTT. Postpartum OGTT results were classified as normal [fasting plasma glucose (FPG) < 5.6mmol/l, 2-h < 7.8 mmol/l] and abnormal [impaired fasting glucose (IFG), FPG 5.6-6.9 mmol/l; impaired glucose tolerance (IGT), 2-h glucose 7.8-11 mmol/l; IFG+IGT; T2DM, FPG > or = 7 mmol/l +/- 2h glucose > or = 11.1 mmol/l]. 6 (2.7%) with NGT in pregnancy had postpartum dysglycaemia compared to 57 (19%) with GDM in index pregnancy (p < 0.001). Non-European ethnicity (OR 3.40, 95% CI 1.45-8.02, p = 0.005), family history of T2DM (OR 2.14, 95% CI 1.06-4.32, p = 0.034) and gestational insulin use (OR 2.62, 95% CI 1.17-5.87 p = 0.019) were associated with persistent dysglycaemia. The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum (8.2% v 18.4%, p < 0.001). Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

A regional pre-pregnancy care (PPC) programme for women with type 1 and type 2 diabetes.

Unfortunately the risks associated with pregnancy in a woman with Diabetes (Type 1 and Type 2) continue to be high. However these risks can be reduced significantly with pregnancy planning and pre-pregnancy care. We report here the establishment of a regional pre pregnancy service and the interim results of its benefits. Pre pregnancy care is as vital as combined diabetes antenatal care for women with diabetes and must become the norm for this population.

ATLANTIC DIP: pregnancy outcomes for women with type 1 and type 2 diabetes.

ATLANTIC DIP prospectively evaluated the perinatal and maternal outcomes of pregnancies complicated by Type 1 and Type 2 diabetes during 2006/2007 in 5 antenatal centres. All women with established diabetes for at least 6 months prior to the index pregnancy and booking for antenatal care between 1/1/2006 and 31/12/2007 were included in the study. Results were collected electronically via the DIAMOND Diabetes Information System. Pregnancy outcome was compared with that of the background population receiving antenatal care in the region during the same time. There were 104 singleton pregnancies during the period of study. The stillbirth rate (SBR) of 25/1000 was 5 times greater than that reported in the background population at 5/1000 and the perinatal mortality rate (PMR) of 25/1000 was 3.5 times greater than background 7/1000. The congenital malformation rate (CMR) of 24/1000 was twice that observed in the background population. Women were not well prepared for pregnancy with 28% receiving pre pregnancy care (PPC), 43% receiving pre pregnancy folic acid and 51% achieving a HbA1C < = 7% at first antenatal visit. Pregnancy induced hypertension (PIH) and/or pre eclampsia toxaemia (PET) were three times more common than in women in the background population. In conclusion women are not well prepared for pregnancy. Maternal and infant morbidity and infant mortality are greater in women with diabetes. A regional pre pregnancy care (PPC) programme and centralised glucose management are urgently needed.

Atlantic DIP: the prevalence and consequences of gestational diabetes in Ireland.

ATLANTIC DIP carried out a universal screening programme for gestational diabetes mellitus (GDM) along the Irish Atlantic seaboard. Using a 75g OGTT and new International Association of Diabetes in Pregnancy Study Groups (IADPSG) cut off points for diagnosis we found the prevalence of GDM to be 12.4%. Pregnancies complicated by GDM displayed increased morbidities for mother and infant when compared to women who had normal glucose tolerance. With rising obesity levels and older age of mothers, both risk factors for GDM, these results would support a national universal screening programme.

Psychological stress associated with diabetes during pregnancy: a pilot study.

Gestational Diabetes Mellitus (GDM) affects approximately 12% of women. The impact of a diagnosis of GDM may lead to increased stress in pregnancy due to the demands of adherence to a treatment regimen and maternal concern about adverse outcomes for the mother and baby. We examined the psychosocial profile of 25 women with gestational diabetes mellitus (GDM) and compared them to 25 non-diabetic pregnant women. Measures administered included the Pregnancy Experiences Scale (PES), the Depression, Anxiety Stress Scale (DASS), the Problem Areas in Diabetes Scale (PAID-5) and the Perceived Social Support Scale (PSSS). The GDM group reported a significantly greater ratio of pregnancy 'hassles' to pregnancy 'uplifts'. The GDM group also had a significantly higher Depression score and were twice as likely to score above the cut-off for possible depression. Elevated levels of diabetes-related distress were found in 40% of women with GDM. In addition, the GDM group reported less social support from outside the family. Our preliminary study indicates that the experience of GDM appears to be associated with increased psychological distress in comparison to the experience of non-diabetic pregnant women. This may indicate the need for psychological screening in GDM and the provision of psychological support in some cases.

Trimester-specific reference intervals for IFCC standardised haemoglobin A(1c): new criterion to diagnose gestational diabetes mellitus (GDM)?

We established trimester-specific reference intervals for IFCC standardised HbA(1c) in 311 non-diabetic Caucasian pregnant women (n = 246) and non-pregnant women (n = 65). A selective screening strategy based on risk factors for gestational diabetes was employed. Pregnancy trimester was defined as trimester 1 (T1, n = 40) up to 12 weeks + 6 days, trimester 2 (T2, n = 106) 13 to 27 weeks + 6 days, trimester 3 (T3, n = 100) > 28 weeks to delivery. The normal HbA(1c) reference interval for Caucasian non-pregnant women was 29-37 mmol/mol (DCCT: 4.8-5.5%), T1: 24-36 mmol/mol (DCCT: 4.3-5.4%), T2: 25-35 mmol/mol (DCCT: 4.4-5.4%), and T3: 28-39 mmol/mol (DCCT: 4.7-5.7%). HbA(1c) was significantly decreased in trimesters 1 (P < 0.01) and 2 (P < 0.001) compared to non-pregnant women. Retrospective application of selective screening to Caucasian women of the Atlantic DIP cohort determined that 5,208 met the criteria. 945 of those women (18.1%) were diagnosed with Gestational Diabetes Mellitus (GDM) using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) glucose concentration thresholds. HbA(1c) measurement within 2 weeks of the diagnostic Oral Glucose Tolerance Test (OGTT) was available in 622 of 945 (66%). Applying the decision threshold for T2: HbA(1c) > 35 mmol/mol (DCCT > 5.4%) identified 287 of 622 (46%) of those with GDM. HbA(1c) measurement in T2 (13 to 27 weeks) should be included in the diagnostic armamentarium for GDM. This would reduce the need for diagnostic OGTT in a significant number of women.

Quality of patient-reported outcome reporting in trials of diabetes in pregnancy: A systematic review.

AIMS: Patient-reported outcomes (PROs) are reports of the patient's health status that come directly from the patient without interpretation by the clinician or anyone else. They are increasingly used in randomised controlled trials (RCTs). In this systematic review we identified RCTs conducted in women with diabetes in pregnancy which included PROs in their primary or secondary outcomes. We then evaluated the quality of PRO reporting against an internationally accepted reporting framework (Consolidated Standards of Reporting Trials (CONSORT-PRO) guidelines). METHODS: We searched online databases for studies published 2013-2021 using a combination of keywords. Two authors reviewed all abstracts independently. Data on study characteristics and the quality of PRO reporting were extracted from relevant studies. We conducted a multiple regression analysis to identify factors associated with high quality reporting. RESULTS: We identified 7122 citations. Thirty-five articles were included for review. Only 17% of RCTs included a PRO as a primary or secondary outcome. Out of a maximum score of 100 the median score was 46, indicating sub-optimal reporting. A multiple regression analysis did not reveal any factors associated with high quality reporting. CONCLUSIONS: Researchers should be mindful of the importance of PRO inclusion and reporting and include reliable PROs in trials.

Diabetes care and pregnancy outcomes for women with pregestational diabetes in Ireland.

AIMS: Pre-gestational diabetes mellitus (PGDM) is associated with adverse outcomes. We aimed to examine pregnancies affected by PGDM; report on these pregnancy outcomes and compare outcomes for patients with type 1 versus type 2 diabetes mellitus; compare our findings to published Irish and United Kingdom (UK) data and identify potential areas for improvement. METHODS: Between 2016 and 2018 information on 679 pregnancies from 415 women with type 1 Diabetes Mellitus and 244 women with type 2 diabetes was analysed. Data was collected on maternal characteristics; pregnancy preparation; glycaemic control; pregnancy related complications; foetal and maternal outcomes; unscheduled hospitalisations; congenital anomalies and perinatal deaths. RESULTS: Only 15.9% of women were adequately prepared for pregnancy. Significant deficits were identified in availability and attendance at pre-pregnancy clinic, use of folic acid, attaining appropriate glycaemic targets and appropriate retinal screening. The majority of pregnancies (n = 567, 83.5%) resulted in a live birth but the large number of infants born large for gestational age (LGA) (n = 280, 49.4%), born prematurely <37 weeks and requiring neonatal intensive care unit (NICU) admission continue to be significant issues. CONCLUSIONS: This retrospective cohort study identifies multiple targets for improvements in the provision of care to women with pre-gestational DM which are likely to translate into better pregnancy outcomes.

Diabetes in pregnancy: worse medical outcomes in type 1 diabetes but worse psychological outcomes in gestational diabetes.

BACKGROUND: Women with diabetes experience an increased risk of adverse pregnancy outcomes. AIM: We aim to describe and quantify the psychological impact of the diagnosis of diabetes in pregnant women with type 1 diabetes and gestational diabetes mellitus (GDM) compared to each other and to their counterparts without diabetes. DESIGN: This is a survey-based study with prospective collection of pregnancy outcome data. METHODS: A total of 218 pregnant women (50% with diabetes) were administered questionnaires relating to psychological health. Maternal and neonatal characteristics and pregnancy outcomes were collected. Associations between key psychometric and health outcome variables were examined. RESULTS: At least 25% of women in all three pregnancy groups had scores indicating affective distress in at least one domain. Compared to those with type 1 diabetes, women with GDM evidenced a greater number of uplifts in pregnancy (U = 94, P = 0.041), but also higher levels of overall anxiety (U = 92, P = 0.03) and stress (U = 82, P < 0.01). Women with GDM also had significantly elevated overall depression scores, compared with the control group (U = 34, P = 0.02). Both groups of women with diabetes had clinically elevated levels of diabetes-related distress. There were no associations between maternal psychological variables and pregnancy outcomes. CONCLUSIONS: This work highlights a potential role for targeted psychological interventions to address and relieve symptoms of anxiety and depression among pregnant women with diabetes.

Abnormal glucose tolerance post-gestational diabetes mellitus as defined by the International Association of Diabetes and Pregnancy Study Groups criteria.

OBJECTIVE: An increase in gestational diabetes mellitus (GDM) prevalence has been demonstrated across many countries with adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. Here, we determine the cumulative incidence of abnormal glucose tolerance among women with previous GDM, and identify clinical risk factors predicting this. DESIGN: Two hundred and seventy women with previous IADPSG-defined GDM were prospectively followed up for 5years (mean 2.6) post-index pregnancy, and compared with 388 women with normal glucose tolerance (NGT) in pregnancy. METHODS: Cumulative incidence of abnormal glucose tolerance (using American Diabetes Association criteria for impaired fasting glucose, impaired glucose tolerance and diabetes) was determined using the Kaplan-Meier method of survival analysis. Cox regression models were constructed to test for factors predicting abnormal glucose tolerance. RESULTS: Twenty-six percent of women with previous GDM had abnormal glucose tolerance vs 4% with NGT, with the log-rank test demonstrating significantly different survival curves (P<0.001). Women meeting IADPSG, but not the World Health Organization (WHO) 1999 criteria, had a lower cumulative incidence than women meeting both sets of criteria, both in the early post-partum period (4.2% vs 21.7%, P<0.001) and at longer-term follow-up (13.7% vs 32.6%, P<0.001). Predictive factors were glucose levels on the pregnancy oral glucose tolerance test, family history of diabetes, gestational week at testing, and BMI at follow-up. CONCLUSIONS: The proportion of women developing abnormal glucose tolerance remains high among those with IADPSG-defined GDM. This demonstrates the need for continued close follow-up, although the optimal frequency and method needs further study.