Does weight management after gestational diabetes mellitus diagnosis improve pregnancy outcomes? A multi-ethnic cohort study.

AIMS: To assess the impact of achieving an Institute of Medicine based personalised weight target in addition to conventional glycaemic management after gestational diabetes mellitus diagnosis on maternal and neonatal outcomes. METHODS: A retrospective audit of clinical data (2016-2019) for singleton gestational diabetes pregnancies was conducted in a multi-ethnic cohort. Logistic regression analyses assessed relationships between achieving, exceeding and gaining less than a personalised weight target provided after gestational diabetes diagnosis and rates of large for gestational age, small for gestational age infants, insulin therapy initiation and neonatal outcomes. Adjusted odds ratios (aOR) were adjusted for glucose 2-h post-glucose load value, family history of type 2 diabetes, previous gestational diabetes, macrosomia in a previous pregnancy, and East and South-East Asian ethnicity. RESULTS: Of 1034 women, 44% (n = 449) achieved their personalised weight target. Women who exceeded their personalised weight target had significantly and higher mean insulin doses (28.8 ± 21.5 units vs. 22.7 ± 18.7, p = 0.006) and higher rates of large for gestational age infants (19% vs. 9.8%, p < 0.001), with aOR of 1.99 [95% CI 1.25-3.15] p = 0.004, but no difference in rates of small for gestational age infants (5.3% vs. 8.0%) (aOR 0.77 [0.41-1.44] p = 0.41). Lower rates of large for gestational age infants occurred in those who gained below their personalised weight target (aOR 0.48 [0.25-0.95] p = 0.034), but rates of small for gestational age infants concurrently increased (aOR 1.9 [1.19-3.12] p = 0.008). CONCLUSIONS: Weight management after gestational diabetes diagnosis does not appear to be too late to confer additional benefits to glucose-lowering treatment, resulting in lower mean insulin doses, and lower rates of large for gestational age infants without increasing the risk of small for gestational age infants.

Management of type 2 diabetes in young adults aged 18-30 years: ADS/ADEA/APEG consensus statement.

INTRODUCTION: Type 2 diabetes in young adults (nominally, 18-30 years of age) is a more aggressive condition than that seen in older age, with a greater risk of major morbidity and early mortality. This first Australian consensus statement on the management of type 2 diabetes in young adults considers areas where existing type 2 diabetes guidance, directed mainly towards older adults, may not be appropriate or relevant for the young adult population. Where applicable, recommendations are harmonised with current national guidance for type 2 diabetes in children and adolescents (aged < 18 years). The full statement is available at https://www.diabetessociety.com.au, https://www.adea.com.au and https://www.apeg.org.au. MAIN RECOMMENDATIONS: Advice is provided on important aspects of care including screening, diabetes type, psychological care, lifestyle, glycaemic targets, pharmacological agents, cardiovascular disease risk management, comorbidity assessment, contraception and pregnancy planning, and patient-centred education. Special considerations for Aboriginal and Torres Strait Islander Australians are highlighted separately. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Management recommendations for young adults, which differ from those for adults, include: ▪screening for diabetes in young adults with overweight or obesity and additional risk factors, including in utero exposure to type 2 diabetes or gestational diabetes mellitus; ▪more stringent glucose targets (glycated haemoglobin ≤ 6.5% [≤ 48 mmol/mol]); ▪in the context of obesity or higher cardio-renal risk, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors are preferred second line agents; ▪ß-cell decline is more rapid, so frequent review, early treatment intensification and avoidance of therapeutic inertia are indicated; ▪a blood pressure target of < 130/80 mmHg, as the adult target of ≤ 140/90 mmHg is too high; ▪absolute cardiovascular disease risk calculators are not likely to be accurate in this age group; early statin use should therefore be considered; and ▪a multidisciplinary model of care including an endocrinologist and a certified diabetes educator.

Medical nutrition therapy for gestational diabetes mellitus in Australia: What has changed in 10 years and how does current practice compare with best practice?

BACKGROUND: The present study aimed to report Australian dietetic practice regarding management of gestational diabetes mellitus (GDM) and to make comparisons with the findings from a 2009 survey of dietitians and with the Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines (NPG). METHODS: Cross-sectional surveys were conducted in 2019 and 2009 of dietitians providing medical nutrition therapy (MNT) to women with GDM in Australia. The present study compares responses on demographics, dietetic assessment and interventions, and guideline use in 2019 vs. 2009. RESULTS: In total, 149 dietitians (2019) and 220 (2009) met survey inclusion criteria. In both surveys >60% of respondents reported dietary interventions aiming for >45% energy from carbohydrate, 15%-25% energy from protein and 15%-30% energy from fat. Many variations in MNT found in 2009 continued to be evident in 2019, including the percentage of energy from carbohydrate aimed for (30%-65% in 2019 vs. 20%-75% in 2009) and the wide range in the recommended minimum daily carbohydrate intake (40-220 and 60-300 g). Few dietitians reported aiming for the NPG minimum of 175 g of carbohydrate daily in both surveys (32% in 2019 vs. 26% in 2009). There were, however, some significant increases in MNT consistent with NPG recommendations in 2019 vs. 2009, including the minimum frequency of visits provided (49%, n = 61 vs. 33%, n = 69; p < 0.001) and provision of gestational weight gain advice (59%, n = 95 vs. 40%, n = 195; p < 0.05). CONCLUSIONS: Although many dietitians continue to provide MNT consistent with existing NPG, there is a need to support greater uptake, especially for recommendations regarding carbohydrate intake.

Maternal and neonatal outcomes of women with gestational diabetes and without specific medical conditions: an Australian population-based study comparing induction of labor with expectant management.

BACKGROUND/AIMS: To evaluate maternal birth and neonatal outcomes among women with gestational diabetes mellitus (GDM), but without specific medical conditions and eligible for vaginal birth who underwent induction of labour (IOL) at term compared with those who were expectantly managed. MATERIALS AND METHODS: Population-based cohort study of women with GDM, but without medical conditions, who had a singleton, cephalic birth at 38-41 completed weeks gestation, in New South Wales, Australia between January 2010 and December 2016. Women who underwent IOL at 38, 39, 40 weeks gestation (38-, 39-, 40-induction groups) were compared with those who were managed expectantly and gave birth at and/or beyond the respective gestational age group (38-, 39-, 40-expectant groups). Multivariable logistic regression analysis was used to assess the association between IOL and adverse maternal birth and neonatal outcomes taking into account potential confounding by maternal age, country of birth, smoking, residential location, residential area of socioeconomic disadvantage and birth year. RESULTS: Of 676 762 women who gave birth during the study period, 66 606 (10%) had GDM; of these, 34799 met the inclusion criteria. Compared with expectant management, those in 38- (adjusted odds ratio (aOR) 1.11; 95% CI, 1.04-1.18), 39- (aOR 1.21; 95% CI, 1.14-1.28) and 40- (aOR 1.50; 95% CI, 1.40-1.60) induction groups had increased risk of caesarean section. Women in the 38-induction group also had an increased risk of composite neonatal morbidity (aOR 1.10; 95% CI, 1.01-1.21), which was not observed at 39- and 40-induction groups. We found no difference between groups in perinatal death or neonatal intensive care unit admission for births at any gestational age. CONCLUSION: In women with GDM but without specific medical conditions and eligible for vaginal birth, IOL at 38, 39, 40 weeks gestation is associated with an increased risk of caesarean section.

Women with type 1 diabetes and women with type 2 diabetes differ in knowledge and beliefs about contraception and pregnancy.

AIMS: To assess differences in knowledge and beliefs about pregnancy in women with diabetes. METHODS: Questions were from the Australian 'Contraception, Pregnancy & Women's Health' survey. Women (18-50 years) were eligible if pregnant or planning pregnancy. Knowledge and beliefs items were adapted from the Reproductive Health and Behaviours Questionnaire. RESULTS: Compared to women with type 2 diabetes (n = 103), women with type 1 diabetes (n = 526) had higher scores for knowledge about pregnancy in diabetes (type 1 diabetes 9.8 ± 2.4 vs. type 2 diabetes 7.7 ± 3.1), beliefs about benefits (type 1 diabetes 18.4 ± 2.2 vs. type 2 diabetes 17.2 ± 3.3), cues-to-action (type 1 diabetes 2.7 ± 1.4 vs. type 2 diabetes 1.5 ± 1.3) and self-efficacy (type 1 diabetes 22.6 ± 5.5 vs. type 2 diabetes 20.2 ± 6.1 (all p < 0.001) regarding preparing for pregnancy. Major knowledge gaps were the need for higher dose folate compared to women without diabetes and uncertainty about breastfeeding recommendations. Women with type 1 diabetes believed more strongly in the benefits of 'close to target' glucose levels prior to pregnancy and using contraception to prevent unplanned pregnancy; they also felt more confident to access pre-pregnancy care and to wait for optimal glycaemia before pregnancy. Women with type 2 diabetes were less aware of contraceptive choices, and risks associated with hyperglycaemia before or early in pregnancy. CONCLUSIONS: The findings highlighted main gaps in knowledge and beliefs about planning for pregnancy. Especially in type 2 diabetes, there is a need for evidence-based messaging and strategies addressing these gaps, to raise understanding to prepare for future pregnancies.

Utilisation, access and recommendations regarding technologies for people living with type 1 diabetes: consensus statement of the ADS/ADEA/APEG/ADIPS Working Group.

INTRODUCTION: Type 1 diabetes presents significant challenges for optimal management. Despite intensive glycaemic control being the standard of care for several decades, glycaemic targets are infrequently achieved and the burden of complications remains high. Therefore, the advancement of diabetes management technologies has a major role in reducing the clinical and economic impact of the disease on people living with type 1 diabetes and on health care systems. However, a national framework is needed to ensure equitable and sustainable implementation of these technologies as part of holistic care. MAIN RECOMMENDATIONS: This consensus statement considers technologies for insulin delivery, glucose sensing and insulin dose advice that are commercially available in Australia. While international position statements have provided recommendations for technology implementation, the ADS/ADEA/APEG/ADIPS Working Group believes that focus needs to shift from strict trial-based glycaemic criteria towards engagement and individualised management goals that consider the broad spectrum of benefits offered by technologies. CHANGES IN MANAGEMENT AS RESULT OF THIS STATEMENT: This Australian consensus statement from peak national bodies for the management of diabetes across the lifespan outlines a national framework for the optimal implementation of technologies for people with type 1 diabetes. The Working Group highlights issues regarding equity of access to technologies and services, scope of clinical practice, credentialling and accreditation requirements, regulatory issues with "do-it-yourself" technology, national benchmarking, safety reporting, and ongoing patient advocacy.

Options for screening for gestational diabetes mellitus during the SARS-CoV-2 pandemic.

The balance between avoiding severe acute respiratory syndrome coronavirus-2 contagion and reducing wider clinical risk is unclear for gestational diabetes mellitus (GDM) testing. Recent recommendations promote diagnostic approaches that limit collection but increase undiagnosed GDM, which potentially increases adverse pregnancy outcome risks. The most sensitive approach to detecting GDM at 24-28 weeks beyond the two-hour oral glucose tolerance test (OGTT) is a one-hour OGTT (88% sensitivity). Less sensitive approaches use fasting glucose alone (≥5.1 mmol/L: misses 44-54% GDM) or asking ~20% of women for a second visit (fasting glucose 4.7-5.0 mmol/L (62-72% sensitive)). Choices should emphasise local and patient decision-making.

Fetal biometry for guiding the medical management of women with gestational diabetes mellitus for improving maternal and perinatal health.

BACKGROUND: Gestational diabetes mellitus (GDM) is a common medical condition that complicates pregnancy and causes adverse maternal and fetal outcomes. At present, most treatment strategies focus on normalisation of maternal blood glucose values with use of diet, lifestyle modification, exercise, oral anti-hyperglycaemics and insulin. This has been shown to reduce the incidence of adverse outcomes, such as birth trauma and macrosomia. However, this involves intensive monitoring and treatment of all women with GDM. We propose that using medical imaging to identify pregnancies displaying signs of being affected by GDM could help to target management, allowing low-risk women to be spared excessive intervention, and facilitating better resource allocation. OBJECTIVES: We wanted to address the following question: in women with gestational diabetes, does the use of fetal imaging plus maternal blood glucose concentration to indicate the need for medical management compared with glucose concentration alone reduce the risk of adverse perinatal outcomes? SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (29 January 2019), ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (both on 29 January 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials, including those published in abstract form only. Studies using a cluster-randomised design and quasi-randomised controlled trials were both eligible for inclusion, but we didn't identify any. Cross-over trials were not eligible for inclusion in our review.We included women carrying singleton pregnancies who were diagnosed with GDM, as defined by the trials' authors. The intervention of interest was the use of fetal biometry on imaging methods in addition to maternal glycaemic values for indicating the use of medical therapy for GDM. The control group was the use of maternal glycaemic values alone for indicating the use of such therapy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors extracted data and checked them for accuracy. MAIN RESULTS: Three randomised controlled trials met the inclusion criteria for our systematic review - the studies randomised a total of 524 women.We assessed the three included studies as being at a low to moderate risk of bias; the nature of the intervention made it difficult to achieve blinding of participants and personnel and none of the trial reports contained information about methods of allocation concealment (and were therefore assessed as being at an unclear risk of selection bias).In all studies, the intervention was the use of fetal biometry on ultrasound to identify fetuses displaying signs of fetal macrosomia, and the use of this information to indicate the use of medical anti-hyperglycaemic treatments. Those pregnancies were subject to more stringent blood glucose targets than those without signs of fetal macrosomia.Maternal outcomesThe use of fetal biometry in addition to maternal blood glucose concentration (compared with maternal blood glucose concentration alone) may make little or no difference to the incidence of caesarean delivery (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.10; 2 trials, 428 women; low-certainty evidence). We are unclear about the results for hypertensive disorders of pregnancy (RR 0.80, 95% CI 0.34 to 1.89; 2 trials, 325 women) due to very low-certainty evidence. The included trials did not report on development of type 2 diabetes in the mother or maternal hypoglycaemia.Fetal and neonatal outcomesThe use of fetal biometry may make little or no difference to the incidence of neonatal hypoglycaemia (RR 0.90, 95% CI 0.57 to 1.42; 3 trials, 524 women; low-certainty evidence). Very low-certainty evidence means that we are unclear about the results for large-for-gestational age (RR 0.81, 95% CI 0.38 to 1.74; 3 trials, 524 women); shoulder dystocia (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women); a composite measure of perinatal morbidity or mortality (RR 1.00, 95% CI 0.21 to 4.71; 1 study, 96 women); or perinatal mortality (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women). AUTHORS' CONCLUSIONS: This review is based on evidence from three trials involving 524 women. The trials did not report some important outcomes of interest to this review, and the majority of our secondary outcomes were also unreported. The available evidence ranged from low- to very low-certainty, with downgrading decisions based on limitations in study design, imprecision and inconsistency.There is insufficient evidence to evaluate the use of fetal biometry (in addition to maternal blood glucose concentration values) to assist in guiding the medical management of GDM, on either maternal or perinatal health outcomes, or the associated costs.More research is required, ideally larger randomised studies which report the maternal and infant short- and long-term outcomes listed in this review, as well as those outcomes relating to financial and resource implications.

A Novel Early Pregnancy Risk Prediction Model for Gestational Diabetes Mellitus.

INTRODUCTION: Accurate early risk prediction for gestational diabetes mellitus (GDM) would target intervention and prevention in women at the highest risk. We evaluated novel biomarker predictors to develop a first-trimester risk prediction model in a large multiethnic cohort. METHODS: Maternal clinical, aneuploidy and pre-eclampsia screening markers (PAPP-A, free hCGß, mean arterial pressure, uterine artery pulsatility index) were measured prospectively at 11-13+6 weeks' gestation in 980 women (248 with GDM; 732 controls). Nonfasting glucose, lipids, adiponectin, leptin, lipocalin-2, and plasminogen activator inhibitor-2 were measured on banked serum. The relationship between marker multiples-of-the-median and GDM was examined with multivariate regression. Model predictive performance for early (< 24 weeks' gestation) and overall GDM diagnosis was evaluated by receiver operating characteristic curves. RESULTS: Glucose, triglycerides, leptin, and lipocalin-2 were higher, while adiponectin was lower, in GDM (p < 0.05). Lipocalin-2 performed best in Caucasians, and triglycerides in South Asians with GDM. Family history of diabetes, previous GDM, South/East Asian ethnicity, parity, BMI, PAPP-A, triglycerides, and lipocalin-2 were significant independent GDM predictors (all p < 0.01), achieving an area under the curve of 0.91 (95% confidence interval [CI] 0.89-0.94) overall, and 0.93 (95% CI 0.89-0.96) for early GDM, in a combined multivariate prediction model. CONCLUSIONS: A first-trimester risk prediction model, which incorporates novel maternal lipid markers, accurately identifies women at high risk of GDM, including early GDM.

Are the Institute of Medicine weight gain targets applicable in women with gestational diabetes mellitus?

AIMS/HYPOTHESIS: Our aim was to study the relationship between excessive gestational weight gain (GWG) according to Institute of Medicine (IOM) targets and perinatal outcomes, and examine whether modifying targets may improve outcomes in women with gestational diabetes mellitus (GDM). METHODS: This was a retrospective cohort study of all GDM pregnancies from 1992 to 2013. ORs were calculated for associations between excessive GWG (EGWG) using IOM targets and adverse pregnancy outcomes. ORs were then adjusted for maternal age, gestational age at diagnosis, prepregnancy BMI, gravidity, parity, ethnicity, antenatal fasting blood glucose level (BGL), 2 h BGL and HbA1c. BMI was categorised into underweight (<18.5 kg/m2), healthy weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2) and obese (≥30 kg/m2). Large for gestational age (LGA) was defined as birthweight above the 90th percentile, small for gestational age (SGA) was birthweight below the 10th percentile, macrosomia was birthweight >4000 g, and preterm delivery was delivery prior to 37 weeks' gestation. Modified GWG targets were derived by: (1) subtracting 2 kg from the upper IOM target only; (2) subtracting 2 kg from both upper and lower targets; (3) using the interquartile range of maternal GWG of women with infants who were appropriate for gestational age per BMI category; and (4) restricting GWG to 0-4 kg in women with BMI ≥35 kg/m2. RESULTS: Among 3095 GDM pregnancies, only 31.7% had GWG within IOM guidelines. Adjusted ORs for women who exceeded GWG were Caesarean section (1.5; 95% CI 1.2, 1.9), LGA (1.8; 95% CI 1.4, 2.4) and macrosomia (2.3; 95% CI 1.6, 3.3); there was a lower risk of SGA (adjusted OR 0.5; 95% CI 0.3, 0.7). CONCLUSIONS/INTERPRETATION: EGWG according to IOM targets was associated with Caesarean section, LGA and macrosomia. Modification of IOM criteria, including more restrictive targets, did not improve perinatal outcomes.

A novel validated model for the prediction of insulin therapy initiation and adverse perinatal outcomes in women with gestational diabetes mellitus.

AIMS/HYPOTHESIS: Identifying women with gestational diabetes mellitus who are more likely to require insulin therapy vs medical nutrition therapy (MNT) alone would allow risk stratification and early triage to be incorporated into risk-based models of care. The aim of this study was to develop and validate a model to predict therapy type (MNT or MNT plus insulin [MNT+I]) for women with gestational diabetes mellitus (GDM). METHODS: Analysis was performed of de-identified prospectively collected data (1992-2015) from women diagnosed with GDM by criteria in place since 1991 and formally adopted and promulgated as part of the more detailed 1998 Australasian Diabetes in Pregnancy Society management guidelines. Clinically relevant variables predictive of insulin therapy by univariate analysis were dichotomised and included in a multivariable regression model. The model was tested in a separate clinic population. RESULTS: In 3317 women, seven dichotomised significant independent predictors of insulin therapy were maternal age >30 years, family history of diabetes, pre-pregnancy obesity (BMI ≥30 kg/m(2)), prior GDM, early diagnosis of GDM (<24 weeks gestation), fasting venous blood glucose level (≥5.3 mmol/l) and HbA1c at GDM diagnosis ≥5.5% (≥37 mmol/mol). The requirement for MNT+I could be estimated according to the number of predictors present: 85.7-93.1% of women with 6-7 predictors required MNT+I compared with 9.3-14.7% of women with 0-1 predictors. This model predicted the likelihood of several adverse outcomes, including Caesarean delivery, early delivery, large for gestational age and an abnormal postpartum OGTT. The model was validated in a separate clinic population. CONCLUSIONS/INTERPRETATION: This validated model has been shown to predict therapy type and the likelihood of several adverse perinatal outcomes in women with GDM.

Survey on testing for gestational diabetes mellitus in Australia.

We surveyed members of National Association of Diabetes Centres (NADC) assessing use of new Australasian Diabetes In Pregnancy Society (ADIPS) and Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Gestational Diabetes Mellitus (GDM) diagnostic guidelines in Australia. We found piecemeal adoption of recommended changes, with cessation of the 50 g glucose challenge test (GCT) universal, early screening implementation common, but by varied methodologies, and new diagnostic criteria acceptance far from complete with significant workload increases almost universal.

Effect of a low glycaemic index diet in gestational diabetes mellitus on post-natal outcomes after 3 months of birth: a pilot follow-up study.

A low glycaemic index (LGI) diet during pregnancy complicated by gestational diabetes mellitus (GDM) may offer benefits to the mother and infant pair beyond those during pregnancy. We aimed to investigate the effect of an LGI diet during pregnancy complicated with GDM on early post-natal outcomes. Fifty-eight women (age: 23-41 years; mean ± SD pre-pregnancy body mass index: 24.5 ± 5.6 kg m(-2) ) who had GDM and followed either an LGI diet (n = 33) or a conventional high-fibre diet (HF; n = 25) during pregnancy had a 75-g oral glucose tolerance test and blood lipid tests at 3 months post-partum. Anthropometric assessments were conducted for 55 mother-infant pairs. The glycaemic index of the antenatal diets differed modestly (mean ± SD: 46.8 ± 5.4 vs. 52.4 ± 4.4; P < 0.001), but there were no significant differences in any of the post-natal outcomes. In conclusion, an LGI diet during pregnancy complicated by GDM has outcomes similar to those of a conventional healthy diet. Adequately powered studies should explore the potential beneficial effects of LGI diet on risk factors for chronic disease.

The relationship between body mass index and sleep in women with risk factors for gestational diabetes mellitus.

Background: Both obesity and sleep disorders are common among women during pregnancy. Although prior research has identified a relationship between obesity and sleep disorders, those findings are from women later in pregnancy. Objective: To explore the relationships between self-reported sleep duration, insufficient sleep and snoring with body mass index (BMI) among multiethnic women at risk of gestational diabetes mellitus (GDM)in early pregnancy. Methods: Cross-sectional study of baseline data from women at risk of GDM enrolled in the Treatment of BOoking Gestational diabetes Mellitus (TOBOGM) multicentre trial across 12 Australian/Austrian sites. Participants completed a questionnaire before 20 weeks' gestation to evaluate sleep. BMI <25 kg/m2 served as the reference group in multivariable logistic regression. Results: Among the 2865 women included, the prevalence of overweight and obesity classes I-III was 28%, 19%, 11% and 12%, respectively. There was no relationship between sleep duration and BMI. The risk of insufficient sleep >5 days/month was higher in class II and class III obesity (1.38 (1.03-1.85) and 1.34 (1.01-1.80), respectively), and the risk of snoring increased as BMI increased (1.59 (1.25-2.02), 2.68 (2.07-3.48), 4.35 (3.21-5.88) to 4.96 (3.65-6.74), respectively)). Conclusions: Obesity is associated with insufficient sleep among pregnant women at risk of GDM. Snoring is more prevalent with increasing BMI.

A Clinical Update on Gestational Diabetes Mellitus.

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Comparison of a subcutaneous versus intravenous insulin protocol for managing hyperglycemia following antenatal betamethasone in women with diabetes: a pilot randomized controlled trial.

INTRODUCTION: Evaluate the safety and efficacy of a subcutaneous insulin (SC-I) versus intravenous insulin (IV-I) protocol for optimizing maternal blood glucose levels (BGLs) post-betamethasone administration. METHODS: Randomized controlled in-patient pilot study in pregnant women with diabetes, excluding type 1 diabetes, receiving betamethasone ≥24 weeks' gestation. Interventions were stratified SC-I and IV-I protocols, titrated to hourly BGLs (IV-I) or predicted maternal hyperglycemia and 2-4 hourly BGLs (SC-I). Primary outcome was percentage at-target BGL 4.0-8.0 mmol/L over 48 h post-betamethasone. Secondary outcomes were rates of maternal hyperglycemia (>8.0 mmol/L), hypoglycemia (<4.0 mmol/L) and neonatal hypoglycemia (≤2.5 mmol/L). RESULTS: 19 women (3 with type 2 diabetes [T2DM], 4 with gestational diabetes [GDM]-diet, 12 GDM-insulin) were randomized to a SC-I (n = 13) or IV-I (n = 6) protocol in a 9-month period. There was a non-significant trend for higher mean percentage at-target BGLs with SC-I vs IV-I (87% vs 81%; p = .055); this was significant when the cohort was restricted to women with GDM (89% vs 81%; p = .04). Maternal hyperglycemia (85% vs 100%; p = .31) and hypoglycemia (54% vs 33%; p = .41) were not significantly different, but there were no BGLs <3.8 mmol/L with IV-I (vs 4 women with SC-I; p = .13). The rate of neonatal hypoglycemia was not different between groups. CONCLUSION: A SC-I or IV-I protocol controls maternal BGLs following betamethasone, but SC-I appears safe and minimizes labor intensive IV-I in GDM. An adequately powered RCT to assess superiority of SC-I is planned.

Estimating the impact of change in pre-pregnancy body mass index on development of Gestational Diabetes Mellitus: An Australian population-based cohort.

BACKGROUND: International studies examining maternal overweight and obesity have found GDM risk increases with increasing weight gain between pregnancies. AIM: The study aimed to estimate the association between pre-pregnancy maternal body mass index (BMI), change in BMI between pregnancies and Gestational Diabetes Mellitus (GDM) amongst women with consecutive births in an Australian cohort. METHODS: We used a population cohort of women who had at least two consecutive singleton births between 2010 and 2017 in one NSW health district to investigate the risk of GDM in the pregnancy after the index pregnancy, BMI change between pregnancies and the impact of BMI change on risk of GDM. FINDINGS: Of 10,074 women 1987 (16.7%) had no GDM in the index pregnancy but GDM in the subsequent one while 823 (8.2%) had GDM in both pregnancies. No change in BMI between pregnancies occurred in 47% of women, while 12% had a decrease and 41% an increase. After adjusting for socio-demographic characteristics and selected maternal and perinatal confounders, a reduction in BMI between births in women without GDM in the index pregnancy was associated with a 36% lower risk in GDM (aRR: 0.64; 95% CI: 0.49-0.85), while an increase in BMI was associated with increased risk of GDM with the greatest risk amongst those who gained 4+ kg/m² (aRR 2.27; 95%CI: 1.88-2.75). CONCLUSION: Interpregnancy weight change is an important modifiable risk factor for the risk of GDM in a subsequent pregnancy. Clinical guidelines and health messages about interpregnancy weight change are important for all women.

Ramadan and gestational diabetes: maternal and neonatal outcomes.

AIMS: The impact of Ramadan exposure to Gestational Diabetes Mellitus (GDM) pregnancies is not known. We therefore aimed to assess the association of Ramadan with maternal and neonatal outcomes among pregnant women with GDM. METHODS: Retrospective cohort study of 345 Muslim women with singleton pregnancies who attended a major Sydney teaching hospital during the period 1989-2010, was undertaken. Exposure to Ramadan was stratified by the: (1) total pregnancy days exposed to Ramadan, (2) duration (hours) of daily fasting and (3) trimester of exposure. Maternal and neonatal outcomes were examined by exposure status, and never exposed pregnancies were comparator in all three analyses. Fasting status was not recorded. RESULTS: We found no significant effect of Ramadan exposure on mean birthweight, macrosomia and maternal outcomes. However, we found a significant trend for increased neonatal hyperbilirubinemia with increasing Ramadan days exposure and later trimester exposure (ptrend ≤ 0.02 for both), with adjusted OR 3.9 (p=0.03) for those with ≥ 21 days exposure to Ramadan and adjusted OR 4.3 (p=0.04) for third trimester exposure. Conversely longer Ramadan exposure and late trimester exposure were independently associated with a lower prevalence of neonatal hypoglycaemia (adjusted OR 0.4 and 0.3 for ≥ 21 days and third trimester exposure, respectively). Furthermore, neonatal hypoglycaemia decreased for the fasting period of > 15 h group (adjusted OR 0.2, p = 0.01). CONCLUSIONS: Ramadan exposure is associated with reduced neonatal hypoglycaemia, with no effect on birthweight, implying more favourable glycaemic control. However, the fourfold excess of neonatal hyperbilirubinemia indicates a need for further study of Ramadan and GDM.

The Carbohydrate Threshold in Pregnancy and Gestational Diabetes: How Low Can We Go?

The original nutrition approach for the treatment of gestational diabetes mellitus (GDM) was to reduce total carbohydrate intake to 33-40% of total energy (EI) to decrease fetal overgrowth. Conversely, accumulating evidence suggests that higher carbohydrate intakes (60-70% EI, higher quality carbohydrates with low glycemic index/low added sugars) can control maternal glycemia. The Institute of Medicine (IOM) recommends ≥175 g/d of carbohydrate intake during pregnancy; however, many women are consuming lower carbohydrate (LC) diets (<175 g/d of carbohydrate or <40% of EI) within pregnancy and the periconceptual period aiming to improve glycemic control and pregnancy outcomes. This report systematically evaluates recent data (2018-2020) to identify the LC threshold in pregnancy in relation to safety considerations. Evidence from 11 reports suggests an optimal carbohydrate range of 47-70% EI supports normal fetal growth; higher than the conventionally recognized LC threshold. However, inadequate total maternal EI, which independently slows fetal growth was a frequent confounder across studies. Effects of a carbohydrate intake <175 g/d on maternal ketonemia and plasma triglyceride/free fatty acid concentrations remain unclear. A recent randomized controlled trial (RCT) suggests a higher risk for micronutrient deficiency with carbohydrate intake ≤165 g/d in GDM. Well-controlled prospective RCTs comparing LC (<165 g/d) and higher carbohydrate energy-balanced diets in pregnant women are clearly overdue.