Abnormal Glucose Tolerance in Women Diagnosed With Gestational Diabetes (WHO 2013) 10 Years After Index Pregnancy.

Context: It is not clear if the risk of abnormal glucose tolerance (AGT) is attenuated in the long-term in women diagnosed with gestational diabetes (GDM) using the World Health Organization (WHO) 2013 criteria and who have received appropriate treatment during pregnancy. Objective: We aimed to assess the long-term prevalence of AGT and other cardiovascular disease (CVD) risk factors in this cohort. Methods: A retrospective cohort follow-up study was conducted of 37 and 107 women diagnosed with and without GDM respectively using the WHO 2013 criteria between June 2010 and December 2010. Women were invited to attend our center, where they underwent a 75-g oral glucose tolerance test, blood and urine collection, body measurements, and electrocardiography. Main outcome measure included the development of AGT using the American Diabetes Association criteria. Results: Sixteen (43.2%) women with GDM compared to 5 (4.7%) women with normal glucose tolerance (NGT) at index pregnancy had AGT (P < .001). In the GDM group, 10 (27.0%), 7 (18.9%), and 4 (10.8%) women had impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and type 2 diabetes mellitus (T2DM), respectively. In the NGT group, 2 (1.9%), 3 (2.8%), and 1 (0.9%) woman had IFG, IGT, and T2DM, respectively. Women with AGT also had an unfavorable metabolic profile including obesity, hypertension, insulin resistance, and dyslipidemia. Conclusion: Women treated for GDM (WHO 2013 criteria) remain at increased risk for developing AGT and adverse CVD risk factors as early as a decade after diagnosis. Continued efforts are needed to accurately follow this population to address modifiable risk factors.

Retrospective national cohort study of pregnancy outcomes for women with type 1 and type 2 diabetes mellitus in Republic of Ireland.

AIM: Report the outcomes of pregnant women with type 1 and type 2 diabetes and to identify modifiable and non-modifiable factors associated with poor outcomes. METHODS: Retrospective analysis of pregnancy preparedness, pregnancy care and outcomes in the Republic of Ireland from 2015 to 2020 and subsequent multivariate analysis. RESULTS: In total 1104 pregnancies were included. Less than one third attended pre-pregnancy care (PPC), mean first trimester haemoglobin A1c was 7.2 ± 3.6% (55.5 ± 15.7 mmol/mol) and 52% received pre-conceptual folic acid. Poor preparation translated into poorer pregnancy outcomes. Livebirth rates (80%) were comparable to the background population however stillbirth rates were 8.7/1000 (four times the national rate). Congenital anomalies occurred in 42.5/1000 births (1.5 times the background rate). More than half of infants were large for gestational age and 47% were admitted to critical care. Multivariate analyses showed strong associations between non-attendance at PPC, poor glycaemic control and critical care admission (adjusted odds ratio of 1.68 (1.48-1.96) and 1.61 (1.43-1.86), p < 0.05 respectively) for women with type 1 diabetes. Smoking and teratogenic medications were also associated with critical care admission and hypertensive disorders of pregnancy. CONCLUSION: Pregnancy outcomes in women with diabetes are suboptimal. Significant effort is needed to optimize the modifiable factors identified in this study.

ATLANTIC DIP: Despite insulin therapy in women with IADPSG diagnosed GDM, desired pregnancy outcomes are still not achieved. What are we missing?

AIMS: To assess if pregnancy outcomes for women with GDM treated with insulin (GDM-I) are comparable to outcomes for women with GDM treated with medical nutritional therapy (MNT) (GDM-M). MATERIALS AND METHODS: This retrospective cohort study included 752 women with GDM-I and 567 women with GDM-M. Maternal and foetal outcomes were examined. RESULTS: Women with GDM-I had a greater risk of polyhydramnios (aOR 2.33, 95%CI 1.31-4.14) and were more likely to deliver by caesarean section (CS) (aOR 1.67, 95%CI 1.25-2.23). Their offspring had higher rates of macrosomia (22.2% vs 12.7%; p < .01), large for gestational age (LGA) (19.7% vs 12.5%; p < .01) and were more likely to require neonatal intensive care unit (NICU) admission (aOR 4.88, 95%CI 3.54-6.73). There was no difference between the groups in rates of pre-eclampsia (PET), pregnancy-induced hypertension (PIH), infant mortality, congenital malformations, neonatal hypoglycaemia, prematurity and rates of small for gestational age (SGA). CONCLUSIONS: GDM-I and GDM-M mothers have similar rates of maternal medical morbidities. Despite this, the rate of delivery by CS remains greater, possibly driven by physician choice for elective intervention in the GDM-I group. Despite insulin therapy, offspring of GDM-I mothers experience higher rates of macrosomia, LGA and NICU admissions. This may be related to the higher baseline risk profile in GDM-I women, to sub-optimal glycaemic control, excessive gestational weight gain (GWG) or higher baseline BMI of the mother. Addressing baseline maternal BMI, limiting excessive GWG and tightening glycaemic control in GDM-I women may translate to better pregnancy outcomes.

ATLANTIC DIP: Insulin Therapy for Women With IADPSG-Diagnosed Gestational Diabetes Mellitus. Does It Work?

INTRODUCTION: Approximately 40% of women with gestational diabetes mellitus (GDM) diagnosed using International Association of the Diabetes and Pregnancy Study Group (IADPSG) criteria require insulin therapy. OBJECTIVE: We assessed whether the outcomes for women with GDM treated with insulin are comparable to women with normal glucose tolerance (NGT). MATERIALS AND METHODS: This retrospective cohort study included 752 women with insulin-treated GDM and 2496 women with NGT during pregnancy. Maternal and fetal outcomes were examined. RESULTS: Infants of women with insulin-treated GDM had rates of macrosomia [adjusted odds ratio (aOR), 1.19; 95% confidence interval (CI), 0.87 to 1.63; P = 0.26], large for gestational age (LGA) (aOR, 1.07; 95% CI, 0.77 to 1.47; P = 0.67), and small for gestational age (SGA) (aOR, 0.70; 95% CI, 0.38 to 1.38; P = 0.26) similar to women with NGT. They were more likely to be hypoglycemic at birth (aOR, 6.85; 95% CI, 2.31 to 20.28; P < 0.01) and to require neonatal intensive care unit care (NICU) (aOR, 12.09; 95% CI, 8.72 to 16.76; P < 0.01), predominantly for nonmedical reasons. Maternal rates of hypertensive disorders (preeclampsia: aOR, 0.64; 95% CI, 0.34 to 1.12; P = 0.17; pregnancy-induced hypertension: aOR, 1.11; 95% CI, 0.74 to 1.66; P = 0.60) and hemorrhage (ante partum hemorrhage: aOR, 0.56; 95% CI, 0.19 to 1.58; P = 0.27; postpartum hemorrhage: aOR, 1.17; 95% CI, 0.68 to 2.03; P = 0.55) were similar between groups, but the risk of polyhydramnios was increased in the GDM cohort (aOR, 7.75; 95% CI, 3.96 to 15.16; P < 0.01). CONCLUSIONS: Insulin treatment of IADPSG-diagnosed GDM results in rates of macrosomia, LGA, SGA, and maternal hypertensive disorders similar to those of women with NGT. Although NICU admissions are greater in the GDM cohort, they are primarily for nonmedical reasons. Neonatal hypoglycemia and polyhydramnios remain greater among women with insulin-treated GDM.

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

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

Screening for gestational diabetes mellitus in primary versus secondary care: The clinical outcomes of a randomised controlled trial.

AIMS: To examine the clinical outcomes of screening for gestational diabetes mellitus (GDM) in primary care versus secondary care, in the Irish healthcare system. DESIGN AND METHODS: A parallel group randomised controlled trial (RCT) of screening for GDM in primary versus secondary care was used to examine (i) prevalence, (ii) gestational week of screen, (iii) time to access specialist care, and (iv) maternal and neonatal outcomes. In total 781 women were recruited for screening in primary care (n=391) or secondary care (n=390). RESULTS: The prevalence of GDM and gestational week of screen were similar in both locations. There was a trend towards a longer time to access diabetes care in primary care (24days) versus secondary care (19days), a difference of 5days (p=0.09). Women screened in primary care also showed a trend towards a higher rate of large for gestational age (LGA) infants (20%) than those screened in secondary care (14.7%), (p=0.09). There were no differences between groups in maternal outcomes. CONCLUSIONS: This RCT suggests that screening for GDM in secondary care may be associated with potentially faster time to access specialist antenatal diabetes care and possibly lower LGA rates. Further research is needed to clarify these findings and to improve the delay in accessing specialist care requires an urgent focus. Further research is needed to test these findings in other health systems.

A Prepregnancy Care Program for Women With Diabetes: Effective and Cost Saving.

CONTEXT: Only a minority of women with diabetes attend prepregnancy care service and the economic effects of providing this service are unclear. OBJECTIVE: The objective of the study was to design, put into practice, and evaluate a regional prepregnancy care program for women with types 1 and 2 diabetes. DESIGN: This was a prospective cohort and cost-analysis study. SETTING: The study was conducted at antenatal centers along the Irish Atlantic Seaboard. PARTICIPANTS: Four hundred fourteen women with type 1 or 2 diabetes participated in the study. INTERVENTIONS: The intervention for the study was a newly developed prepregnancy care program. MAIN OUTCOME MEASURES: The program was assessed for its effect on the risk of adverse pregnancy outcomes. The difference between program delivery cost and the excess cost of treating adverse outcomes in nonattendees was evaluated. RESULTS: In total, 149 (36%) attended: this increased from 19% to 50% after increased recruitment measures in 2010. Attendees were more likely to take preconception folic acid (97.3% vs 57.7%, P < .001) and less likely to smoke (8.7% vs 16.6%, P = .03) or take potentially teratogenic medications at conception (0.7 vs 6.0, P = .008). Attendees had lower glycated hemoglobin levels throughout pregnancy (first trimester glycated hemoglobin 6.8% vs 7.7%, P < .001; third trimester glycated hemoglobin 6.1% vs 6.5%, P = .001), and their offspring had lower rates of serious adverse outcomes (2.4% vs 10.5%, P = .007). The adjusted difference in complication costs between those who received prepregnancy care vs usual antenatal care only is €2578.00. The average cost of prepregnancy care delivery is €449.00 per pregnancy. CONCLUSIONS: This regional prepregnancy care program is clinically effective. The cost of program delivery is less than the excess cost of managing adverse pregnancy outcomes.

Perspectives on the provision of GDM screening in general practice versus the hospital setting: a qualitative study of providers and patients.

OBJECTIVE: A novel gestational diabetes mellitus (GDM) screening programme which involved offering screening at the patient's general practitioner (GP) compared with the traditional hospital setting was trialled. This study investigates perspectives of involved stakeholders on the provision of GDM screening at both settings. DESIGN: Thematic analysis of the perspectives of stakeholders involved in the receiving and provision of GDM screening in both the GP and hospital settings drawn from focus groups and interviews. PARTICIPANTS: 3 groups of participants are included in this research--patient participants, GP screening providers and hospital screening providers. All were recruited from a larger sample who participated in a randomised controlled screening trial. Purposeful sampling was utilised to select participants with a wide variety of perspectives on the provision of GDM screening. SETTING: Participants were recruited from a geographical area covered by 3 hospitals in Ireland. RESULTS: 4 themes emerged from thematic analysis--namely (1) travel distance, (2) best care provision, (3) sense of ease created and (4) optimal screening. CONCLUSIONS: The influence of travel distance from the screening site is the most important factor influencing willingness to attend for GDM screening among women who live a considerable distance from the hospital setting. For patients who live equidistance from both settings, other factors are important; namely the waiting facilities including parking, perceived expertise of screening provider personnel, access to emergency treatment if necessary, accuracy of tests and access to timely results and treatment. Optimal screening for GDM should be specialist led, incorporate expert advice of GDM screening, treatment and management, should be provided locally, offer adequate parking and comfort levels, provide accurate tests, and timely access to results and treatment. Such a service should result in improved rates of GDM screening uptake. TRIAL REGISTRATION NUMBER: ISRCTN41202110.

Ten Years of Optimizing Outcomes for Women With Type 1 and Type 2 Diabetes in Pregnancy-The Atlantic DIP Experience.

CONTEXT: Pregnancy for women with type 1 or type 2 diabetes is a time of increased risk for both mother and baby. The Atlantic Diabetes in Pregnancy program provides coordinated, evidence-based care for women with diabetes in Ireland. Founded in 2005, the program now shares outcomes over its first decade in caring for pregnant women with diabetes. OBJECTIVE: The objective was to assess improvements in clinical outcomes after the introduction of interventions. DESIGN, SETTING, PARTICIPANTS: We retrospectively examined 445 pregnancies in women with type 1 and type 2 diabetes and compared them over two timepoints, 2005­2009 and 2010­2014. INTEVENTIONS: Interventions introduced over that time include: provision of combined antenatal/diabetes clinics, prepregnancy care, electronic data management, local clinical care guidelines, professional and patient education materials, an app, and a web site. MAIN OUTCOMES: Pregnancy outcomes were measured. RESULTS: The introduction of the Atlantic Diabetes in Pregnancy program has been associated with a reduction in adverse neonatal outcomes. There has been a reduction in congenital malformations (5 to 1.8%; P = .04), stillbirths (2.3 vs 0.4%; P = .09), despite an upward trend in maternal age (mean age, 31.7 vs 33 years), obesity (29 vs 43%; body mass index >30 kg/m2), and excessive gestational weight gain (24 vs 38%; P = .002). These improvements in outcomes occur alongside an increase in attendance at prepregnancy care (23 to 49%; P < .001), use of folic acid (45 vs 71%; P < .001), and sustained improvement in glycemic control. CONCLUSIONS: Changing the process of clinical care delivery and utilizing evidence-based interventions in a pragmatic clinical setting improves pregnancy outcomes for women with pregestational diabetes. We now need to target optimization of maternal body mass index before pregnancy and put a greater focus on gestational weight gain through education and monitoring.

Treatment With Diet and Exercise for Women With Gestational Diabetes Mellitus Diagnosed Using IADPSG Criteria.

CONTEXT: Prevalence of gestational diabetes mellitus (GDM) and obesity continue to increase. OBJECTIVE: This study aimed to ascertain whether diet and exercise is a successful intervention for women with GDM and whether a subset of these women have comparable outcomes to those with normal glucose tolerance (NGT). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of five antenatal centers along the Irish Atlantic seaboard of 567 women diagnosed with GDM and 2499 women with NGT during pregnancy. INTERVENTION: Diet and exercise therapy on diagnosis of GDM were prescribed and multiple maternal and neonatal outcomes were examined. RESULTS: Infants of women with GDM were more likely to be hypoglycemic (adjusted odds ratio [aOR], 7.25; 95% confidence interval [CI], 2.94-17.9) at birth. They were more likely to be admitted to the neonatal intensive care unit (aOR, 2.16; 95% CI, 1.60-2.91). Macrosomia and large-for-gestational-age rates were lower in the GDM group (aOR, 0.48; 95% CI, 0.37-0.64 and aOR, 0.61; 95% CI, 0.46-0.82, respectively). There was no increase in small for gestational age among offspring of women with GDM (aOR, 0.81; 95% CI, 0.49-1.34). Women with diet-treated GDM and body mass index (BMI) < 25 kg/m(2) had similar outcomes to those with NGT of the same BMI group. Obesity increased risk for poor pregnancy outcomes regardless of diabetes status. CONCLUSION: Medical nutritional therapy and exercise for women with GDM may be successful in lowering rates of large for gestational age and macrosomia without increasing small-for-gestational-age rates. Women with GDM and a BMI less than 25 kg/m(2) had outcomes similar to those with NGT suggesting that these women could potentially be treated in a less resource intensive setting.