Use of levothyroxine among pregnant women with subclinical hypothyroidism in the United Kingdom: A population-based assessment.

Our study aimed to describe levothyroxine prescription patterns and trends over time among pregnant women with subclinical hypothyroidism (SCH) in the United Kingdom. We used data from the Clinical Practice Research Datalink linked to its Pregnancy Register and the Hospital Episode Statistics database from 1998 to 2017. The study population included women with a diagnosis of SCH or an abnormal thyroid-simulated hormone (TSH) level one year prior to or during pregnancy. We compared characteristics between women who received a prescription for levothyroxine during pregnancy and those who did not. We further described the timing, dose, duration, and temporal trends of levothyroxine prescriptions. Our cohort included 6,757 pregnancies from 6,287 women with SCH, of whom 10% received levothyroxine during pregnancy. Among women who received levothyroxine, most received their first prescription during the first trimester (median gestational age: 7 weeks; interquartile range [IQR]: 0, 16) with a median daily dosage of 50 mcg (IQR: 50, 73). Levothyroxine prescription varied over time, decreasing from 23% of pregnant women in 1998 to 7.5% in 2003, remaining stable until 2014, and increasing to 12.5% in 2016. Smoking, diabetes, polycystic ovary syndrome, infertility, timing of SCH diagnosis, age, TSH level at diagnosis, and general practice regions were associated with prescription. Few women with SCH received levothyroxine during pregnancy, and treatment varied by patient characteristics and geographical regions. These results highlight the need to increase awareness among healthcare providers and will guide future studies that explore barriers to initiating levothyroxine treatment for women with SCH during pregnancy.

Health service use and health system costs associated with diabetes during pregnancy in Australia.

BACKGROUND AND AIMS: In the context of the rising rate of diabetes in pregnancy in Australia, this study aims to examine the health service and resource use associated with diabetes during pregnancy. METHODS AND RESULTS: This project utilised a linked administrative dataset containing health and cost data for all mothers who gave birth in Queensland, Australia between 2012 and 2015 (n = 186,789, plus their babies, n = 189,909). The association between maternal characteristics and diabetes status were compared with chi-square analyses. Multiple logistic regression produced the odds ratio of having different outcomes for women who had diabetes compared to women who did not. A two-sample t-test compared the mean number of health services accessed. Generalised linear regression produced the mean costs associated with health service use. Mothers who had diabetes during pregnancy were more likely to have their labour induced at <38 weeks gestation (OR:1.39, 95% CI:1.29-1.50); have a cesarean section (OR: 1.26, 95% CI:1.22-1.31); have a preterm birth (OR:1.24, 95%: 1.18-1.32); have their baby admitted to a Special Care Nursery (OR: 2.34, 95% CI:2.26-2.43) and a Neonatal Intensive Care Unit (OR:1.25, 95%CI: 1.14-1.37). On average, mothers with diabetes access health services on more occasions during pregnancy (54.4) compared to mothers without (50.5). Total government expenditure on mothers with diabetes over the first 1000 days of the perinatal journey was significantly higher than in mothers without diabetes ($12,757 and $11,332). CONCLUSION: Overall, mothers that have diabetes in pregnancy require greater health care and resource use than mothers without diabetes in pregnancy.

Assessment of the effect of pregnancy planning in women with type 1 diabetes treated by insulin pump.

BACKGROUND: Pregnant women with type 1 diabetes (T1D) have high risk of complications despite improved care based on technology advancements. OBJECTIVE: To assess the effects of pregnancy planning on fetal and maternal outcomes in T1D women treated with continuous subcutaneous insulin infusion (CSII). STUDY DESIGN: We retrospectively assessed maternal and neonatal outcomes in T1D women using CSII who had planned or unplanned pregnancies between 2002 and 2018. The study was done in two European countries with similar sustained programs for pregnancy planning over the study period. RESULTS: Data from 107 pregnancies and newborn babies were collected. Seventy-nine pregnancies (73.8%) had been planned. HbA1c was lower in planned versus unplanned pregnancy before and during all three trimesters of pregnancy (p < 0.0001). Pregnancy planning was associated with a reduction in the occurrence of iatrogenic preterm delivery (RR 0.44, 95% CI 0.23-0.95; p = 0.01). Risk reduction persisted after adjustments for mother's age above 40 years and preeclampsia. High HbA1c before or during pregnancy was associated with an increased risk of iatrogenic preterm delivery (RR 3.05, 95% CI 1.78-5.22, p < 0.0001). Premature newborns needed intensive care more often than those at term (RR 3.10, 95% CI 1.53-4.31; p = 0.002). CONCLUSIONS: Pregnancy planning in T1D women using CSII was associated with better glucose control and decreased risk of iatrogenic preterm delivery. Hence preconception care also improves pregnancy outcome in patients using an advanced mode of insulin delivery. Planned pregnancies could further benefit from the use of new metrics of glucose control.

Socioeconomic and racial disparities in the risk of congenital anomalies in infants of diabetic mothers: A national population-based study.

We used a national population-based database to study socioeconomic and racial disparities associated with congenital anomalies in 293,498 infants of diabetic mothers. Risk of anomalies in infants of diabetic mothers was highest in poor families (13.3%) compared to the rich families (10.9%), and black families had the highest risk of anomalies (14.0%) compared to white families (11.8%).

Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention.

BACKGROUND: Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes. METHODS: A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines. DISCUSSION: This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Social and economic factors, maternal behaviours in pregnancy and neonatal adiposity in the PANDORA cohort.

BACKGROUND: Australian Indigenous women experience high rates of social disadvantage and type 2 diabetes (T2D) in pregnancy, but it is not known how social factors and maternal behaviours impact neonatal adiposity in offspring of women with hyperglycaemia in pregnancy. METHODS: Participants were Indigenous (n = 404) and Europid (n = 240) women with gestational diabetes mellitus (GDM) or T2D in pregnancy and their offspring in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) study. Social, economic factors, and maternal behaviours were measured in pregnancy and six neonatal anthropometric outcomes were examined after birth. RESULTS: On univariate analysis, maternal education < 12 years (p = 0.03), unemployment (p = 0.001), welfare income vs no welfare income (p = 0.001), lower area based socio-economic score (p < 0.001), and fast food intake > 2 times/week (p = 0.002) were associated with increased sum of skinfolds (SSF) in offspring. Smoking was significantly associated with a reduction in anthropometric measures, except SSF. In multivariable models adjusted for ethnicity, BMI and hyperglycaemia, social and economic factors were no longer significant predictors of neonatal outcomes. Smoking was independently associated with a reduction in length, head circumference and fat free mass. Frequent fast food intake remained independently associated with SSF (ß-coefficient 1.08 mm, p = 0.02). CONCLUSION: In women with hyperglycaemia in pregnancy, social factors were associated with neonatal adiposity, particularly skinfold measures. Promoting smoking cessation and limited intake of energy-dense, nutrient-poor foods in pregnancy are important to improve neonatal adiposity and lean mass outcomes. Addressing inequities in social and economic factors are likely to be important, particularly for Indigenous women or women experiencing social disadvantage.

Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period.

BACKGROUND: Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care. METHODS: Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62). RESULTS: Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58). CONCLUSION: These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

Outcomes, care utilization, and expenditures in adolescent pregnancy complicated by diabetes.

BACKGROUND AND OBJECTIVE: Adolescence and pregestational diabetes separately increase risks of adverse pregnancy outcomes, but little is known about their combined effect. To analyze pregnancy outcomes, healthcare utilization, and expenditures in adolescent pregnancies with and without pregestational diabetes using a national claims database. METHODS: Retrospective study using Truven Health MarketScan Commercial Claims and Encounters Database, 2011 to 2015. Females 12 to 19 years old, continuously enrolled for at least 12 months before a livebirth until 2 months after, were included. Pregestational diabetes, diabetes complications (ketoacidosis, retinopathy, neuropathy, nephropathy), comorbidities, and pregnancy outcomes (preeclampsia, preterm delivery, high birthweight, cesarean delivery) were identified using claims data algorithms. Healthcare utilization and payer expenditure were tabulated per enrollee. Multivariate logistic regressions assessed pregnancy outcomes; multivariate OLS regression assessed payer expenditures. RESULTS: About 33 502 adolescents were included. Adolescents without diabetes had pregnancy outcomes consistent with national estimates. Adolescents with uncomplicated diabetes had increased odds of preeclampsia adjusted odds ratios 2.41 (95% confidence interval 1.93-3.02), preterm delivery 1.50 (1.21-1.87), high birthweight 1.84 (1.50-2.27), and cesarean delivery 1.81 (1.52-2.15). Diabetes with ketoacidosis and/or end-organ damage had higher odds of preeclampsia 5.62 (2.77-11.41), preterm delivery 5.81 (3.00-11.25), high birthweight 2.38 (1.08-5.24), and cesarean delivery 3.43 (1.78-6.64). Adolescents with diabetes utilized significantly more outpatient and inpatient care during pregnancy. Payer expenditures increased by 45.3% (34.8-55.9%) among adolescents with diabetes and by 82.6% (49.1-116.0%) among adolescents with diabetes complicated by ketoacidosis and/or end-organ damage. CONCLUSION: Compared with normal adolescent pregnancies, pregestational diabetes significantly increases risks of adverse pregnancy outcomes and significantly escalates healthcare utilization and cost.

Comorbid hypertension and diabetes among U.S. women of reproductive age: Prevalence and disparities.

AIMS: Diabetes is associated with significant pregnancy complications, which can be further exacerbated by comorbid hypertension. Racial/ethnic differentials in the burden of comorbid hypertension and diabetes among women of reproductive age have not been described. METHODS: Using Wave IV of the nationally representative National Longitudinal Study of Adolescent to Adult Health (Add Health), we analyzed survey and biological data from 6576 non-pregnant women who were aged 24-32 in 2007-2008. Hypertension and diabetes were identified by self-report of diagnosis and biological measurements taken during in-home interviews. We used logistic regression models to predict the presence of comorbid hypertension and diabetes and whether each was diagnosed. RESULTS: Over a third (36.0%) of women with diabetes had comorbid hypertension. Compared to non-Hispanic white women, more non-Hispanic black women had comorbid hypertension and diabetes (adjusted odds ratio (aOR) 5.93, 95% CI 3.84-9.16), and, if comorbid, were less likely to have a diabetes diagnosis (aOR 0.03, 95% CI 0.007-0.1) or hypertension diagnosis (aOR 0.22, 95% CI 0.08-0.65). CONCLUSION: Comorbid hypertension and diabetes are more common among non-Hispanic black women and less likely to be diagnosed, signaling disparities threatening maternal and child health among women with diabetes.

The need for appropriate registration of pregnancy outcomes under newer oral glucose-lowering therapies.

Because of the increase in type 2 diabetes (T2DM) in young adults, women of childbearing age are frequently treated with newer glucose-lowering therapies, and an increase in unintentional exposure to therapies unapproved for use during pregnancy is expected. The clinician is left with the dilemma of deciding between discontinuation of a novel agent that is providing excellent glycaemic control, while switching to other agents may cause deterioration of glycaemia, and continued use of novel agents that may have uncertain effects on the unborn child. For T2DM, pregnancy data are collected only via spontaneous reporting systems. Therefore, we evaluated the available data on pregnancy outcomes under newer glucose-lowering agents in pharmaceutical safety databases. We found that data on pregnancy outcomes with new glucose-lowering agents in T2DM are scarce, with a high risk of bias towards negative outcomes, limiting their usefulness in robustly assessing safety. Because of the lack of information at present, these agents are not recommended for use during pregnancy or when planning pregnancy. To better guide clinical practice, structured systems of assessing pregnancy outcomes in women receiving these novel agents are urgently needed.

Epidemiology of maternal morbidity and mortality.

Maternal morbidity and mortality remains a significant health care concern in the United States, as the rates continue to rise despite efforts to improve maternal health. In 2013, the United States ranked 60th in maternal mortality worldwide. We review the definitions, rates, trends, and top causes of severe maternal morbidity and mortality, as well as risk factors for adverse maternal outcomes. We describe current local and national initiatives in place to reduce maternal morbidity and mortality and offer suggestions for future research.

Cervicovaginal bacteria and fungi in pregnant diabetic and non-diabetic women: a multicenter observational cohort study.

OBJECTIVE: We evaluated the prevalence of cervicovaginal Bacteria, group B Streptococcus (GBS), Gardnerella vaginalis (GV), Candida spp., Chlamydia trachomatis (CT), Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) in pregnant women with and without diabetes mellitus (DM). PATIENTS AND METHODS: Cervicovaginal swabs were gathered from 473 pregnant patients divided into 127 diabetic and 346 non-diabetic. The results were correlated to gestational age, parity and glycemic control. RESULTS: A higher prevalence of MH/UU (p=0.012) was found in the diabetic patients. After the 28th week of pregnancy, the prevalence for all investigated microorganisms appeared similar except for MH/UU (p=0.014). In multigravida, there were statistical differences between two groups in testing for Bacteria (p=0.015) and for MH/UU (p=0.037). The diabetic condition correlated to the state of multigravida in cases positive for Candida spp. (p=0.049) and in those testing positive for at least one microorganism (p=0.043). Pregnant with a blood glucose > 92 have twice the risk of being positive to a single microbiological test than those with better glycemic control. CONCLUSIONS: The higher prevalence of MH/UU after the 28th weeks can be explained with the physiologically reduced insulin tolerance characteristic of this gestational period. Among the diabetic testing positive to Candida spp. the statistically significant association was observed only in multigravida condition. These data suggest that diabetic multigravida women are at increased risk for Candida spp. infection in relation to the improper glycemic control.

Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: 1996-2014.

BACKGROUND: Despite concern for adverse perinatal outcomes in women with diabetes mellitus before pregnancy, recent data on the prevalence of pregestational type 1 and type 2 diabetes mellitus in the United States are lacking. OBJECTIVE: The purpose of this study was to estimate changes in the prevalence of overall pregestational diabetes mellitus (all types) and pregestational type 1 and type 2 diabetes mellitus and to estimate whether changes varied by race-ethnicity from 1996-2014. STUDY DESIGN: We conducted a cohort study among 655,428 pregnancies at a Northern California integrated health delivery system from 1996-2014. Logistic regression analyses provided estimates of prevalence and trends. RESULTS: The age-adjusted prevalence (per 100 deliveries) of overall pregestational diabetes mellitus increased from 1996-1999 to 2012-2014 (from 0.58 [95% confidence interval, 0.54-0.63] to 1.06 [95% confidence interval, 1.00-1.12]; Ptrend <.0001). Significant increases occurred in all racial-ethnic groups; the largest relative increase was among Hispanic women (121.8% [95% confidence interval, 84.4-166.7]); the smallest relative increase was among non-Hispanic white women (49.6% [95% confidence interval, 27.5-75.4]). The age-adjusted prevalence of pregestational type 1 and type 2 diabetes mellitus increased from 0.14 (95% confidence interval, 0.12-0.16) to 0.23 (95% confidence interval, 0.21-0.27; Ptrend <.0001) and from 0.42 (95% confidence interval, 0.38-0.46) to 0.78 (95% confidence interval, 0.73-0.83; Ptrend <.0001), respectively. The greatest relative increase in the prevalence of type 1 diabetes mellitus was in non-Hispanic white women (118.4% [95% confidence interval, 70.0-180.5]), who had the lowest increases in the prevalence of type 2 diabetes mellitus (13.6% [95% confidence interval, -8.0 to 40.1]). The greatest relative increase in the prevalence of type 2 diabetes mellitus was in Hispanic women (125.2% [95% confidence interval, 84.8-174.4]), followed by African American women (102.0% [95% confidence interval, 38.3-194.3]) and Asian women (93.3% [95% confidence interval, 48.9-150.9]). CONCLUSIONS: The prevalence of overall pregestational diabetes mellitus and pregestational type 1 and type 2 diabetes mellitus increased from 1996-1999 to 2012-2014 and racial-ethnic disparities were observed, possibly because of differing prevalence of maternal obesity. Targeted prevention efforts, preconception care, and disease management strategies are needed to reduce the burden of diabetes mellitus and its sequelae.

The interaction between maternal race/ethnicity and chronic hypertension on preterm birth.

BACKGROUND: In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well-documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature. OBJECTIVE: The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth. STUDY DESIGN: This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hypertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are reported as odds ratios, with 95% confidence intervals and significance set at P = .05. RESULTS: In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P < .001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their nonhypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P = .4). CONCLUSION: The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes.

Trends in the incidence of diabetes, its clinical sequelae, and associated costs in pregnancy.

BACKGROUND: Increasing diabetes prevalence affects a substantial number of pregnant women in the United States. Our aims were to evaluate health outcomes, medical costs, risks and types of complications associated with diabetes in pregnancy for mothers and newborns. METHODS: In this retrospective claims analysis, patients were identified from the Truven Health MarketScan(®) database (2004-2011 inclusive). Participants were aged 18-45 years, with ascertainable diabetes status [Yes/No], date of birth event >2005 and continuous health plan enrolment ≥21 months before and 3 months after the birth. RESULTS: In total, 839 792 pregnancies were identified, and 66 041 (7.86%) were associated with diabetes mellitus [type 1 (T1DM), 0.13%; type 2 (T2DM), 1.21%; gestational (GDM), 6.29%; and GDM progressing to T2DM (patients without prior diabetes who had a T2DM diagnosis after the birth event), 0.23%]. Relative risk (RR) of stillbirth (2.51), miscarriage (1.28) and Caesarean section (C-section) (1.77) was significantly greater with T2DM versus non-diabetes. Risk of C-section was also significantly greater for other diabetes types [RR 1.92 (T1DM); 1.37 (GDM); 1.63 (GDM progressing to T2DM)]. Risk of overall major congenital (RR ≥ 1.17), major congenital circulatory (RR ≥ 1.19) or major congenital heart (RR ≥ 1.18) complications was greater in newborns of mothers with diabetes versus without. Mothers with T2DM had significantly higher risk (RR ≥ 1.36) of anaemia, depression, hypertension, infection, migraine, or cardiac, obstetrical or respiratory complications than non-diabetes patients. Mean medical costs were higher with all diabetes types, particularly T1DM ($27 531), than non-diabetes ($14 355). CONCLUSIONS: Complications and costs of healthcare were greater with diabetes, highlighting the need to optimize diabetes management in pregnancy.

Trends in pre-pregnancy diabetes among deliveries in 19 U.S. states, 2000-2010.

BACKGROUND: Trends in state-level prevalence of pre-pregnancy diabetes mellitus (PDM; i.e., type 1 or type 2 diabetes diagnosed before pregnancy) among delivery hospitalizations are needed to inform healthcare delivery planning and prevention programs. PURPOSE: To examine PDM trends overall, by age group, race/ethnicity, primary payer, and with comorbidities such as pre-eclampsia and pre-pregnancy hypertension, and to report changes in prevalence over 11 years. METHODS: In 2014, State Inpatient Databases from the Agency for Healthcare Research and Quality were analyzed to identify deliveries with PDM and comorbidities using diagnosis-related group codes and ICD-9-CM codes. General linear regression with a log-link and binomial distribution was used to assess the annual change. RESULTS: Between 2000 and 2010, PDM deliveries increased significantly in all age groups, all race/ethnicity groups, and in all states examined (p<0.01). The age-standardized prevalence of PDM increased from 0.65 per 100 deliveries in 2000 to 0.89 per 100 deliveries in 2010, with a relative change of 37% (p<0.01). Although PDM rates were highest in the South, some of the largest relative increases occurred in five Western states (≥69%). Non-Hispanic blacks had the highest PDM rates and the highest absolute increase (0.26 per 100 deliveries). From 2000 to 2010, the proportion of PDM deliveries with pre-pregnancy hypertension increased significantly (p<0.01) from 7.4% to 14.1%. CONCLUSIONS: PDM deliveries are increasing overall and particularly among those with PDM who have hypertension. Effective diabetes prevention and control strategies for women of childbearing age may help protect their health and that of their newborns.

Trends in prevalence of diabetes among delivery hospitalizations, United States, 1993-2009.

To describe recent trends in prevalence of pre-existing diabetes mellitus (PDM) (i.e., type 1 or type 2 diabetes) and gestational diabetes mellitus (GDM) among delivery hospitalizations in the United States. Data on delivery hospitalizations from 1993 through 2009 were obtained from the Health Care Cost and Utilization Project (HCUP) Nationwide Inpatient Sample. Diagnosis-Related Group codes were used to identify deliveries and diagnosis codes on presence of diabetes. Rates of hospitalizations with diabetes were calculated per 100 deliveries by type of diabetes, hospital geographic region, patient's age, degree of urbanicity of patient's residence, categorized median household income for patient's ZIP Code, expected primary payer, and type of delivery. From 1993 to 2009, age-standardized prevalence of diabetes per 100 deliveries increased from 0.62 to 0.90 for PDM (trend p < 0.001) and from 3.09 to 5.57 for GDM (trend p < 0.001). In 2009, correlates of PDM at delivery included older age [40-44 vs. 15-24: odds ratio 6.45 (95 % CI 5.27-7.88)], Medicaid/Medicare versus private payment sources [1.77 (95 % CI 1.59-1.98)], patient's ZIP Code with a median household income in bottom quartile versus other quartiles [1.54 (95 % CI 1.41, 1.69)], and C-section versus vaginal delivery [3.36 (95 % CI 3.10-3.64)]. Correlates of GDM at delivery were similar. Among U.S. delivery hospitalizations, the prevalence of diabetes is increasing. In 2009, the prevalence of diabetes was higher among women in older age groups, living in ZIP codes with lower household incomes, or with public insurance.

Application of customized birth weight curves in the assessment of perinatal outcomes in infants of diabetic mothers.

OBJECTIVE: To determine whether the use of customized curves (CC) allows better detection of large- (LGA) or small-for-gestational age (SGA) infants at risk of adverse perinatal morbidity than non-CC in women with diabetes mellitus (DM). MATERIAL AND METHODS: A model of CC was applied to all infants of diabetic mothers (IDM) who attended the Hospital Universitario Materno Infantil de Canarias between 2008 and 2011. We compared perinatal outcomes of IDM classified as LGA or SGA by non-CC versus CC. RESULTS: One of 4 LGA was appropriate for gestational age (AGA) by CC (false-positive rate: 25%) and 30% of SGA by CC were not identified by non-CC (false-negative rate). False-positive LGA and SGA showed similar perinatal outcomes to AGA infants. The rates of cesarean section, cephalopelvic disproportion, total fetal distress and shoulder dystocia were significantly higher in false-negative LGA than in AGA by CC (p < 0.004, p < 0.02, p < 0.04 and p < 0.04, respectively). Fetal distress was higher in false-negative SGA than in AGA by CC (p < 0.03). DISCUSSION: In pregnancies complicated by DM, the use of CC allowed more accurate identification of LGA and SGA infants at high risk of perinatal morbidity than non-CC.

Diabetes and pregnancy: perspectives from Asia.

There has been a marked increase in the prevalence of diabetes in Asia over recent years. Diabetes complicating pregnancy, in particular gestational diabetes, has also increased markedly in the region. Multi-ethnic studies have highlighted the increased risk of gestational diabetes mellitus among the different Asian populations. Prevalence of gestational diabetes in Asian countries varies substantially according to the screening strategy and diagnostic criteria applied, and ranges from 1% to 20%, with evidence of an increasing trend over recent years. The International Association for Diabetes in Pregnancy Study group criteria have been adopted by some Asian countries, although they present significant challenges in implementation, especially in low-resource settings. Studies on offspring of mothers with gestational diabetes have reported adverse cardiometabolic profiles and increased risk of diabetes and obesity. Gestational diabetes is likely to be a significant factor contributing to the epidemic of diabetes and other non-communicable diseases in the Asian region. In recognition of this, several large-scale prevention and intervention programmes are currently being implemented in different Asian countries in order to improve glucose control during pregnancy, as well as overall maternal health. Lessons emerging from gestational diabetes studies in Asia may help inform and provide insights on the overall burden and treatment strategies to target gestational diabetes, with the ultimate aim to reduce its adverse short- and long-term consequences.