Characteristics of gestational diabetes subtypes classified by oral glucose tolerance test values.

BACKGROUND: In clinical practice, gestational diabetes mellitus (GDM) is treated as a homogenous disease but emerging evidence suggests that the diagnosis of GDM possibly comprises different metabolic entities. In this study, we aimed to assess early pregnancy characteristics of gestational diabetes mellitus entities classified according to the presence of fasting and/or post-load hyperglycaemia in the diagnostic oral glucose tolerance test performed at mid-gestation. METHODS: In this prospective cohort study, 1087 pregnant women received a broad risk evaluation and laboratory examination at early gestation and were later classified as normal glucose tolerant (NGT), as having isolated fasting hyperglycaemia (GDM-IFH), isolated post-load hyperglycaemia (GDM-IPH) or combined hyperglycaemia (GDM-CH) according to oral glucose tolerance test results. Participants were followed up until delivery to assess data on pharmacotherapy and pregnancy outcomes. RESULTS: Women affected by elevated fasting and post-load glucose concentrations (GDM-CH) showed adverse metabolic profiles already at beginning of pregnancy including a higher degree of insulin resistance as compared to women with normal glucose tolerance and those with isolated defects (especially GDM-IPH). The GDM-IPH subgroup had lower body mass index at early gestation and required glucose-lowering medications less often (28.9%) as compared to GDM-IFH (47.8%, P = .019) and GDM-CH (54.5%, P = .005). No differences were observed in pregnancy outcome data. CONCLUSIONS: Women with fasting hyperglycaemia, especially those with combined hyperglycaemia, showed an unfavourable metabolic phenotype already at early gestation. Therefore, categorization based on abnormal oral glucose tolerance test values provides a practicable basis for clinical risk stratification.

Serum lipid levels in relation to clinical outcomes in pregnant women with gestational diabetes mellitus: an observational cohort study.

BACKGROUND: Research on dyslipidemia during pregnancy in women with gestational diabetes mellitus (GDM) has rarely been conducted in Asia. The present study aimed to evaluate maternal mid-trimester lipid profile in relation to GDM and clinical outcomes in these high-risk populations. METHODS: The medical records of 632 pregnant women in the second trimester were retrospectively analyzed. Maternal fasting serum lipids were assayed for total cholesterol (TC), triglycerides (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), apolipoprotein A1 (Apo A1) and Apo B concentrations during the second trimester. The atherogenic index of plasma (AIP) was calculated as log (TG/HDL). The clinical outcomes were collected by evaluating delivery mode, postpartum hemorrhage, prematurity, macrosomia, birth weight, body length and neonatal Apgar 5 min score. RESULTS: Levels of TG and AIP were elevated while decreased HDL-C was observed in women with GDM compared with that of the control group. Significant differences were observed in gestational weeks at birth, cesarean section, postpartum hemorrhage, birth weight, body length, prematurity and macrosomia between the two groups. Compared with women with hyperlipidemia, the incidence of GDM and cesarean section was lower in normal lipid group. Women in the hyperlipidemia group had smaller gestational weeks at birth than those in the control group. According to the logistic regression analysis, each unit elevation in AIP increased the risk of GDM by 18.48 times (OR = 18.48, CI: 2.38-143.22). Besides, age (OR = 1.11, CI: 1.06-1.16) and pre-pregnancy BMI (OR = 1.15, CI: 1.07-1.24) were the risk factors of GDM. CONCLUSIONS: These findings suggested that reasonable lipid control in the second trimester might reduce the incidence of GDM and be a potential strategy for improving clinical outcomes in these high-risk women.

Pregnancy Outcomes in Women with 1-Hour Glucose Challenge Test ≥ 200 mg/dL.

OBJECTIVE: Many protocols diagnose gestational diabetes mellitus (GDM) solely on a 1-hour glucose challenge test (GCT) ≥ 200 mg/dL. However, pregnancy outcomes in these women compared with women diagnosed with a 3-hour glucose tolerance test (GTT) has not been adequately evaluated. We hypothesize that a 1-hour GCT ≥ 200 mg/dL is associated with worse pregnancy outcomes as compared with a GCT 135 to 199 mg/dL with positive GTT. STUDY DESIGN: A retrospective cohort of singleton pregnancies complicated by GDM. Maternal outcomes included A2DM, preeclampsia, primary cesarean, and failed trial of labor after cesarean. Perinatal outcomes were large/small for gestational age, shoulder dystocia, and birth injury. Groups were compared with t-test and chi-square test, and logistic regression to adjust for confounders. RESULTS: A total of 602 women diagnosed with GDM by 1-hour GCT 135 to 199 mg/dL and confirmatory 3-hour GTT (< 200 group) and 225 women diagnosed with 1-hour GCT ≥ 200 alone (≥ 200) were included. The ≥ 200 group had a higher incidence of preeclampsia (16.4 vs. 10.6%) and shoulder dystocia (3.1 vs. 1.0%). Adjusted odds ratio and 95% confidence interval were 1.80 (1.10-2.94) and 5.10 (1.25-20.76), respectively. CONCLUSION: Preeclampsia and shoulder dystocia are more frequent in women with GCT ≥ 200 mg/dL than those with a positive GTT following a GCT of 135 to 199 mg/dL.

Transcriptome meta-analysis of peripheral lymphomononuclear cells indicates that gestational diabetes is closer to type 1 diabetes than to type 2 diabetes mellitus.

We performed a meta-analysis of the transcription profiles of type 1, type 2 and gestational diabetes to evaluate similarities and dissimilarities among these diabetes types. cRNA samples obtained from peripheral blood lymphomononuclear cells (PBMC) of 56 diabetes mellitus patients (type 1 = 19; type 2 = 20; gestational = 17) were hybridized to the same whole human genome oligomicroarray platform, encompassing 44,000 transcripts. The GeneSpring software was used to perform analysis and hierarchical clustering, and the DAVID database was used for gene ontology. The gene expression profiles showed more similarity between gestational and type 1 diabetes rather than between type 2 and gestational diabetes, a finding that was not influenced by patient gender and age. The meta-analysis of the three types of diabetes disclosed 3,747 differentially and significantly expressed genes. A total of 486 genes were characteristic of gestational diabetes, 202 genes of type 1, and 651 genes of type 2 diabetes. 19 known genes were shared by type 1, type 2 and gestational diabetes, highlighting EGF, FAM46C, HBEGF, ID1, SH3BGRL2, VEPH1, and TMEM158 genes. The meta-analysis of PBMC transcription profiles characterized each type of diabetes revealing that gestational and type 1 diabetes were transcriptionally related.

New International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosing gestational diabetes compared with former criteria: a retrospective study on pregnancy outcome.

AIMS: The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) Consensus Panel recommends new criteria for diagnosing gestational diabetes. We evaluated the clinical and metabolic characteristics, and pregnancy outcome, in women previously classifiable as 'normal' according to the 4th International Workshop Conference on gestational diabetes criteria, but reclassified as 'abnormal' according to the new recommendations. METHODS: Using the new IADPSG criteria, 3953 pregnancies were retrospectively reclassified as 1815 women with normal glucose tolerance and 2138 with gestational diabetes, 112 (2.8%) of whom would have been classified as normal according to the older criteria. RESULTS: Of the 2138 women classified as abnormal by the new criteria, the 112 women now reclassified as abnormal were younger and had a lower pre-pregnancy BMI than the 2026 women who had also been classified as abnormal by the previous criteria. The 100-g oral glucose tolerance test showed significantly higher glucose levels in these 112 women than in the 1815 women reclassified as normal (P < 0.0001). Caesarean section was significantly more frequent (P < 0.01) and the ponderal index for the newborn significantly higher in these reclassified women than in those classified as normal (P < 0.0001), and their basal glucose levels correlated significantly with the ponderal index (P < 0.05). CONCLUSION: The new criteria for diagnosing gestational diabetes identified a group of women previously classifiable as normal according to the 4th International Workshop Conference criteria, but revealing metabolic characteristics and pregnancy outcomes resembling those of women who would have been considered to have gestational diabetes by the previous criteria.

Screening and diagnosing gestational diabetes mellitus revisited: implications from HAPO.

Screening and diagnosis of gestational diabetes has lacked uniform criteria both nationally and internationally. In addition, the relationship between the degree of hyperglycemia or glucose intolerance and the risk of maternal, fetal, and neonatal adverse outcomes has not been clearly established. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently published their recommendation for diagnosing and classifying gestational hyperglycemia in pregnancy after evaluation of the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) observational study. Their recommendations have recently been accepted by the American Diabetes Association and are currently under review by the American College of Obstetricians and Gynecologist (ACOG) in the United States. If accepted in the United States and internationally, the world would have consistent thresholds for evaluating hyperglycemia in pregnancy, which would not only include the diagnosis of gestational diabetes mellitus but also overt diabetes, which has not been encompassed by previously accepted definitions.

Gestational prediabetes: a new term for early prevention?

Women with gestational diabetes mellitus (GDM) have higher rates of foetal macrosomia, shoulder dystocia and pregnancy-induced hypertension, and are at higher risk of developing type 2 diabetes. Herein, we introduce a new conceptual term, "gestational prediabetes", which requires the absence of diabetes before pregnancy, and the presence of blood glucose levels (or a related marker) in early pregnancy that are higher than normal, but not yet high enough to meet the diagnostic criteria for GDM. Identifying women with gestational prediabetes might be done in early pregnancy (e.g., 12 weeks' gestation) using conventional glycaemic testing, assessment of visceral abdominal adiposity or hepatic fat by ultrasonography, or measuring serum sex hormone-binding globulin or adiponectin. However, none of these approaches has been systematically compared to conventional predictors, such as maternal body mass index or waist circumference. Any early-pregnancy predictor of gestational prediabetes risk needs to have low cost, ease of administration, and a short turnaround time. The theoretical advantage of identifying women with gestational prediabetes would be to "prevent" the onset of GDM (and its inherent risks to the pregnancy) in a timelier manner. One sensible starting point would be an intervention to prevent early excessive weight gain in pregnancy, which is currently being evaluated by two randomized clinical trials. In addition, early intervention could offset the need for resource-intense GDM management or insulin therapy.

Gestational diabetes insipidus: a review of an underdiagnosed condition.

OBJECTIVE: To review the etiology, diagnosis, and management of diabetes insipidus during pregnancy. DATA SOURCES: A search of the literature was performed in PubMed using key word searching and citation snowballing to identify articles published in English between January 1, 1980, and December 31, 2008, on the subject of diabetes insipidus during pregnancy. Once the articles were identified, a thorough review of all results was conducted. Results and conclusions were compiled and summarized. STUDY SELECTION: We reviewed 50 studies selected using the following key words: diabetes insipidus, pregnancy, arginine vasopressin, vasopressinase. CONCLUSION: Gestational diabetes insipidus is underdiagnosed because polyuria is often considered normal during pregnancy. Clinicians caring for pregnant women should consider screening for gestational diabetes insipidus, because it could be associated with serious underlying pathology.

White's classification of diabetes in pregnancy in the 21st century: is it still valid?

White's classification system (WCS) was created 60 years ago to identify diabetic (DM) pregnancies at increased risk for perinatal morbidity and mortality. Our objective was to assess the association between WCS and adverse pregnancy outcome (APO) in contemporary DM pregnancies. We studied diabetic women with singleton pregnancies who delivered at >20 weeks at a single institution over a 1-year period (2007 to 2008). Perinatal outcomes were compared between WCS groups. APO was defined as any of the following: preterm birth <34 weeks, severe preeclampsia, shoulder dystocia, and neonatal respiratory disease. Presence of vascular disease was defined as presence of chronic hypertension, chronic renal insufficiency, retinopathy, coronary artery disease, or prior cerebrovascular event. One hundred ninety-six DM pregnancies met the criteria. No significant differences in APO existed between White's class groups among women with pregestational DM (32.7% class B versus 26.9% class C versus 57.1% class D to F; p = 0.46). Logistic regression revealed that vascular disease was associated with APO (odds ratio = 2.7, 95% confidence interval = 1.2 to 6.2). In our population, presence of vascular disease, rather than WCS, was a better predictor of APO in DM women.

Effects of Changing Diagnostic Criteria for Gestational Diabetes Mellitus in Queensland, Australia.

OBJECTIVE: To evaluate the effects of updated gestational diabetes mellitus (GDM) screening and diagnostic criteria on selected perinatal outcomes in Queensland, Australia. METHODS: This was a pre-post comparison study using perinatal data the year before (2014) and after (2016) the screening and diagnostic criteria for GDM was changed in Queensland, Australia. In 2015, Queensland adopted the one-step screening and diagnostic criteria based on the International Association of the Diabetes and Pregnancy Study Groups' recommendations. The data from 62,517 women in 2014 and 61,600 women in 2016 who gave birth from 24 weeks of gestation were analyzed in three groups in each year: women with GDM; women without diagnosed GDM; and total population. The outcome measures were gestational hypertension, cesarean birth, gestational age at delivery, birth weight, preterm delivery, large-for-gestational age (LGA) neonates, small-for-gestational-age (SGA) neonates, neonatal hypoglycemia, and respiratory distress. RESULTS: The diagnosis of GDM increased from 8.7% (n=5,462) to 11.9% (n=7,317). After changing the diagnostic criteria, the changes to outcomes, odds ratios (OR), and adjusted odds ratios (aOR) (95% CI) for outcomes with statistically significant differences for the total population were: gestational hypertension 4.6% vs 5.0%, OR 1.09 (1.03-1.15), aOR 1.07 (1.02-1.13); preterm birth 7.6% vs 8.0%, OR 1.05 (1.01-1.09), aOR 1.06 (1.02-1.10); neonatal hypoglycemia 5.3% vs 6.8%, OR 1.31 (1.25-1.37), aOR 1.32 (1.25-1.38); and respiratory distress 6.2% vs 6.0%, OR 0.96 (0.91-1.00), aOR 0.94 (0.89-0.99). There was no change to cesarean births or LGA or SGA neonates for women with or without diagnosed GDM or the total population. CONCLUSION: Except for a very small decrease in respiratory distress, changing the diagnostic criteria has resulted in more GDM diagnoses with no observed changes to measured perinatal outcomes for women with and without diagnosed GDM.

Gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of various degrees that is first detected during pregnancy. GDM is detected through the screening of pregnant women for clinical risk factors and, among at-risk women, testing for abnormal glucose tolerance that is usually, but not invariably, mild and asymptomatic. GDM appears to result from the same broad spectrum of physiological and genetic abnormalities that characterize diabetes outside of pregnancy. Indeed, women with GDM are at high risk for having or developing diabetes when they are not pregnant. Thus, GDM provides a unique opportunity to study the early pathogenesis of diabetes and to develop interventions to prevent the disease.

Gestational Diabetes: Diagnosis, Classification, and Clinical Care.

Gestational diabetes mellitus (GDM) affects approximately 6% of pregnant women, and prevalence is increasing in parallel with the obesity epidemic. Protocols for screening/diagnosing GDM are controversial with several guidelines available. Treatment of GDM results in a reduction in the incidence of preeclampsia, shoulder dystocia, and macrosomia. If diet and lifestyle changes do not result in target glucose levels, then treatment with metformin, glyburide, or insulin should begin. It is generally recommended that pregnancies complicated by GDM do not go beyond term. For women identified to have prediabetes, intensive lifestyle intervention and metformin have been shown to prevent or delay progression to type 2 diabetes.

What is appropriate fetal surveillance for women with diet-controlled gestational diabetes?

No evidence clearly supports the practice of increased fetal surveillance in the pregnancies of women with well-controlled (ie, fasting blood sugar <105 mg/dL) class A1 gestational diabetes (strength of recommendation [SOR]: B, consistent retrospective cohort studies). However, a number of guidelines recommend beginning surveillance of some kind between 32 and 40 weeks based on cumulative risk factors, including gestational diabetes (SOR: C, expert opinion).

[Diabetes mellitus--differential diagnosis]. / Typ 1 bei Alteren, Typ 2 bei Kindern!

Differentiation of the various forms of diabetes is necessary for therapeutic reasons. Typical signs of type 2 diabetes are age over 40, obesity, and other markers for metabolic syndrome, a positive famitory, gradual development of the classical symptoms, and no evidence of ketosis. It is important to distinguish this from LADA (latent autoimmune diabetes of adulthood), a form of type 1 diabetes mellitus. To establish this differential diagnosis antibody testing is employed. Antibody tests in patients with newly manifest diabetes make good sense when the clinical diagnosis is not unequivocal, that is, to distinguish it from type 2 diabetes, MODY diabetes, hereditary and secondary forms. At present, immunodiagnosis is used too often in unambiguous cases of type 1 diabetes, but too rarely in supposed type 2 diabetes. As a rule, LADA patients are GADA-positive. If MODY diabetes is suspected, a genetic examination is indicated. In patients with GDM, antibody testing with GADA makes sense, in particular in slim patients receiving insulin treatment, since these patients have a high risk for developing a postpartum diabetes already in the first years.

Fulminant Type 1 Diabetes Mellitus Presenting 11 Days after Delivery in a Patient of Mixed Genetic Background.

The patient was a 25-year-old woman whose paternal family was Japanese, maternal grandfather was Filipino, and maternal grandmother was Chinese. Eleven days after delivery, she presented with excessive thirst and disturbed consciousness due to diabetic ketoacidosis. She was diagnosed as having fulminant type 1 diabetes associated with pregnancy (PF). The antibody concentration against glutamic acid decarboxylase was 1.2 (<1.5) U/mL, and human leukocyte antigen (HLA) class II haplotypes were DRB1*04:10-DQB1*03:02 and DRB1*15:02-DQB1*05:01. The present case had unique HLA class II haplotypes that have not been previously reported in association with PF.

Variability in diagnostic evaluation and criteria for gestational diabetes.

OBJECTIVE: To determine the frequency of screening for gestational diabetes mellitus (GDM) among a population receiving regular prenatal care and to assess the extent to which National Diabetes Data Group (NDDG) criteria for the diagnosis of GDM are used by practicing obstetricians. RESEARCH DESIGN AND METHODS: We studied participants in the Nurses' Health Study II, a large prospective cohort study of 116,678 nurses aged 25-42 years in 1989. A total of 422 women who reported a first diagnosis of GDM between 1989 and 1991 were sent supplementary questionnaires regarding diagnosis and treatment, and medical records were requested for a subset of 120 to validate self-reported GDM and assess criteria used for diagnosis. A sample of 100 women who reported a pregnancy not complicated by GDM were sent questionnaires addressing GDM screening and prenatal care. RESULTS: Among a sample of 93 women who reported a pregnancy not complicated by GDM and responded to the supplementary questionnaire, 16 (17%) reported no glucose loading test; 69% of unscreened women had one or more risk factors for GDM. Among a sample of 114 women who self-reported GDM in a singleton pregnancy and whose medical records were available for review, a physician diagnosis of GDM was confirmed in 107 (94%). Records and supplementary questionnaires indicated that oral glucose tolerance tests (OGTTs) were performed in 96 (86%) of these women. Of women with a physician diagnosis of GDM whose OGTT results were available, 25% failed to meet NDDG criteria for this diagnosis, although all had evidence of abnormal glucose homeostasis. CONCLUSIONS: Screening for GDM is not universal, even among a group of health professionals in whom screening prevalence is likely to be higher than in the general population. Diagnostic criteria for GDM among obstetricians in practice remain nonstandard despite NDDG recommendations. Better understanding of the implications of differing degrees of glucose intolerance and of varying GDM screening and management strategies is required to make policy recommendations for appropriate and cost-effective care.

Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes.

OBJECTIVE: To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS: This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded. RESULTS: Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria. CONCLUSIONS: GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.