Adverse perinatal outcomes in gestational diabetes mellitus with and without SARS-CoV-2 infection during pregnancy: results from two nationwide registries in Germany.

INTRODUCTION: Pregnancy is a known independent risk factor for a severe course of COVID-19. The relationship of SARS-CoV-2 infection and gestational diabetes mellitus (GDM) on neonatal outcomes is unclear. Our aim was to determine if SARS-CoV-2 infection represents an independent risk factor for adverse perinatal outcomes in pregnancy with GDM. RESEARCH DESIGN AND METHODS: We compared data from two German registries including pregnant women with GDM, established during the SARS-CoV-2 pandemic (COVID-19-Related Obstetric and Neonatal Outcome Study (CRONOS), a multicenter prospective observational study) and already existing before the pandemic (German registry of pregnant women with GDM; GestDiab). In total, 409 participants with GDM and SARS-CoV-2 infection and 4598 participants with GDM, registered 2018-2019, were eligible for analyses. The primary fetal and neonatal outcomes were defined as: (1) combined: admission to neonatal intensive care unit, stillbirth, and/or neonatal death, and (2) preterm birth before 37+0 weeks of gestation. Large and small for gestational age, maternal insulin therapy, birth weight >4500 g and cesarean delivery were considered as secondary outcomes. RESULTS: Women with SARS-CoV-2 infection were younger (32 vs 33 years) and had a higher median body mass index (28 vs 27 kg/m²). In CRONOS, more neonates developed the primary outcome (adjusted OR (aOR) 1.48, 95% CI 1.11 to 1.97) and were born preterm (aOR 1.50, 95% CI 1.07 to 2.10). Fasting glucose was higher in women in CRONOS versus GestDiab (5.4 vs 5.3 mmol/L) considering each 0.1 mmol/L increase was independently associated with a 5% higher risk of preterm birth among women in CRONOS only (aOR 1.05, 95% CI 1.01 to 1.09). CONCLUSIONS: GDM with SARS-CoV-2 infection in pregnancy is associated with an increased risk of adverse fetal and neonatal outcomes as compared with GDM without SARS-CoV-2 infection.

Obesity during Pregnancy and SARS-CoV-2/COVID-19-Case Series of the Registry Study "COVID-19 Related Obstetric and Neonatal Outcome Study" (CRONOS-Network).

(1) Background: Obesity is an increasing challenge in the care of pregnant women. The aim of our study was to investigate whether obesity is an independent risk factor for severe maternal and neonatal outcomes in pregnant women with COVID-19. (2) Methods: Data from the COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS), a prospective multicenter registry for SARS-CoV-2 positive pregnant women, was used to analyze the effect of obesity on selected individual and combined outcome parameters (3) Results: With 20.1%, the prevalence of obesity in the CRONOS registry exceeds the German background rate of 17.5%. Obese women showed significantly higher rates of GDM (20.4% vs. 7.6%; p < 0.001), hypertensive pregnancy disorders (6.2% vs. 2%; p = 0.004) and C-sections (50% vs. 34.5%; p < 0.001). BMI was revealed to be an individual risk factor for the severe combined pregnancy outcome (maternal death, stillbirth or preterm birth < 32 weeks) (OR 1.050, CI 1.005-1.097). (4) Conclusions: Maternal BMI is a predictor for the most severe outcome as maternal or neonatal death and preterm delivery <32 weeks of gestation. Unexpectedly, categorized obesity seems to have limited independent influence on the course and outcome of pregnancies with COVID infections.

Relationship of ANGPTL6 With Neonatal Glucose Homeostasis and Fat Mass Is Disrupted in Gestational Diabetic Pregnancies.

CONTEXT: Angiopoietin-like protein 6 (ANGPTL6) is a hepatokine, which, in animal studies, improves insulin sensitivity and increases energy expenditure to counteract insulin resistance. OBJECTIVE: Evaluate in a human population, the role of serum ANGPTL6 in gestational diabetes mellitus (GDM) or its presence in fetal circulation. RESEARCH DESIGN AND METHODS: A total of 190 women (115 controls and 75 GDM) and their offspring were studied. Insulin, glucose, ANGPTL6, retinol binding protein 4 (RBP4), and retinol, as well as leptin and adiponectin, were determined in maternal serum obtained at term and from umbilical artery blood at delivery. RESULTS: At term, pregnant women with GDM showed higher serum concentrations of ANGPTL6, insulin, homeostatic model assessment, and apo-RBP4 (free RBP4) than controls but not of glucose, which remained similar in both groups. Also, in arterial cord serum, ANGPTL6 concentration was increased in GDM neonates with respect to the control group (201 ±â€…12 ng/mL vs 119 ±â€…8 ng/mL, respectively). No effect of maternal insulin treatment of some GDM mothers in neonates of either sex on ANGPTL6 levels was observed. In GDM, circulating ANGPTL6 showed no correlation with glucose or insulin concentration or with neonatal adiposity. However, in control pregnancies, the variation in glucose concentration was positively correlated with ANGPTL6 concentration, both in maternal and in cord samples, and cord ANGPTL6 was negatively correlated with neonatal fat mass. Furthermore, in control pregnant women, serum concentrations of ANGPTL6 and apo-RBP4 were negatively correlated. CONCLUSION: Serum ANGPTL6 levels are associated with maternal glucose homeostasis and fetal adiposity in normal pregnancy. ANGPTL6 levels in maternal and cord serum GDM pregnancy at term are increased, although its mechanism and physiological role are unknown yet.

Antenatal risk score for prediction of shoulder dystocia with focus on fetal ultrasound data.

BACKGROUND: Shoulder dystocia is one of the most threatening complications during delivery, and although it is difficult to predict, individual risk should be considered when counseling for mode of delivery. OBJECTIVE: This study aimed to develop and validate a risk score for shoulder dystocia based on fetal ultrasound and maternal data from 15,000 deliveries. STUDY DESIGN: Data were retrospectively obtained of deliveries in 3 tertiary centers between 2014 and 2017 for the derivation cohort and between 2018 and 2020 for the validation cohort. Inclusion criteria were singleton pregnancy, vaginal delivery in cephalic presentation at ≥37+0 weeks' gestation, and fetal biometry data available within 2 weeks of delivery. Independent predictors were determined by multivariate regression analysis in the derivation cohort, and a score was developed on the basis of the effect of the predictors. RESULTS: The derivation cohort consisted of 7396 deliveries with a 0.91% rate of shoulder dystocia, and the validation cohort of 7965 deliveries with a 1.0% rate of shoulder dystocia. Among all women, 13.8% had diabetes mellitus, and 12.1% were obese (body mass index ≥30 kg/m2). Independent risk factors in the derivation cohort were: estimated fetal weight ≥4250 g (odds ratio, 4.27; P=.002), abdominal-head-circumference ≥2.5 cm (odds ratio, 3.96; P<.001), and diabetes mellitus (odds ratio, 2.18; P=.009). On the basis of the strength of effect, a risk score was developed: estimated fetal weight ≥4250 g=2, abdominal-head-circumference ≥2.5 cm=2, and diabetes mellitus=1. The risk score predicted shoulder dystocia with moderate discriminatory ability (area under the receiver-operating characteristic curve, 0.69; P<.001; area under the receiver-operating characteristic curve, 0.71; P<.001) and good calibration (Hosmer-Lemeshow goodness-of-fit; P=.466; P=.167) for the derivation and validation cohorts, respectively. With 1 score point, 16 shoulder dystocia cases occurred in 1764 deliveries, with 0.6% shoulder dystocia incidence and a number needed to treat with cesarean delivery to avoid 1 case of shoulder dystocia of 172 (2 points: 38/1809, 2.1%, 48; 3 points: 18/336, 5.4%, 19; 4 points: 10/96, 10.5%, 10; and 5 points: 5/20, 25%, 4); 40.8% of the shoulder dystocia cases occurred without risk factors. CONCLUSION: The presented risk score for shoulder dystocia may act as a supplemental tool for the clinical decision-making regarding mode of delivery. According to our score model, in pregnancies with a score ≤2, meaning having solely estimated fetal weight ≥4250 g, or abdominal-head-circumference ≥2.5, or diabetes mellitus, cesarean delivery for prevention of shoulder dystocia should not be recommended because of the high number needed to treat to avoid 1 case of shoulder dystocia. Conversely, in patients with a score of ≥4 with or without diabetes mellitus, cesarean delivery may be considered. However, in 40% of the shoulder dystocia cases, no risk factors had been present.

Gestational diabetes mellitus and COVID-19: results from the COVID-19-Related Obstetric and Neonatal Outcome Study (CRONOS).

BACKGROUND: Gestational diabetes mellitus is one of the most frequent pregnancy complications with a global prevalence of 13.4% in 2021. Pregnant women with COVID-19 and gestational diabetes mellitus are 3.3 times more likely to be admitted to an intensive care unit than women without gestational diabetes mellitus. Data on the association of gestational diabetes mellitus with maternal and neonatal pregnancy outcomes in pregnant women with SARS-CoV-2 infection are lacking. OBJECTIVE: This study aimed to investigate whether gestational diabetes mellitus is an independent risk factor for adverse maternal and fetal and neonatal outcomes in pregnant women with COVID-19. STUDY DESIGN: The COVID-19-Related Obstetric and Neonatal Outcome Study is a registry-based multicentric prospective observational study from Germany and Linz, Austria. Pregnant women with clinically confirmed COVID-19 were enrolled between April 3, 2020, and August 24, 2021, at any stage of pregnancy. Obstetricians and neonatologists of 115 hospitals actively provided data to the COVID-19-Related Obstetric and Neonatal Outcome Study. For collecting data, a cloud-based electronic data platform was developed. Women and neonates were observed until hospital discharge. Information on demographic characteristics, comorbidities, medical history, COVID-19-associated symptoms and treatments, pregnancy, and birth outcomes were entered by the local sites. Information on the periconceptional body mass index was collected. A primary combined maternal endpoint was defined as (1) admission to an intensive care unit (including maternal mortality), (2) viral pneumonia, and/or (3) oxygen supplementation. A primary combined fetal and neonatal endpoint was defined as (1) stillbirth at ≥24 0/7 weeks of gestation, (2) neonatal death ≤7 days after delivery, and/or (3) transfer to a neonatal intensive care unit. Multivariable logistic regression analysis was performed to evaluate the modulating effect of gestational diabetes mellitus on the defined endpoints. RESULTS: Of the 1490 women with COVID-19 (mean age, 31.0±5.2 years; 40.7% nulliparous), 140 (9.4%) were diagnosed with gestational diabetes mellitus; of these, 42.9% were treated with insulin. Overall, gestational diabetes mellitus was not associated with an adverse maternal outcome (odds ratio, 1.50; 95% confidence interval, 0.88-2.57). However, in women who were overweight or obese, gestational diabetes mellitus was independently associated with the primary maternal outcome (adjusted odds ratio, 2.69; 95% confidence interval, 1.43-5.07). Women who were overweight or obese with gestational diabetes mellitus requiring insulin treatment were found to have an increased risk of a severe course of COVID-19 (adjusted odds ratio, 3.05; 95% confidence interval, 1.38-6.73). Adverse maternal outcomes were more common when COVID-19 was diagnosed with or shortly after gestational diabetes mellitus diagnosis than COVID-19 diagnosis before gestational diabetes mellitus diagnosis (19.6% vs 5.6%; P<.05). Maternal gestational diabetes mellitus and maternal preconception body mass index of ≥25 kg/m2 increased the risk of adverse fetal and neonatal outcomes (adjusted odds ratio, 1.83; 95% confidence interval, 1.05-3.18). Furthermore, overweight and obesity (irrespective of gestational diabetes mellitus status) were influential factors for the maternal (adjusted odds ratio, 1.87; 95% confidence interval, 1.26-2.75) and neonatal (adjusted odds ratio, 1.81; 95% confidence interval, 1.32-2.48) primary endpoints compared with underweight or normal weight. CONCLUSION: Gestational diabetes mellitus, combined with periconceptional overweight or obesity, was independently associated with a severe maternal course of COVID-19, especially when the mother required insulin and COVID-19 was diagnosed with or after gestational diabetes mellitus diagnosis. These combined factors exhibited a moderate effect on neonatal outcomes. Women with gestational diabetes mellitus and a body mass index of ≥25 kg/m2 were a particularly vulnerable group in the case of COVID-19.

Percent error of ultrasound examination to estimate fetal weight at term in different categories of birth weight with focus on maternal diabetes and obesity.

BACKGROUND: Sonography based estimate of fetal weight is a considerable issue for delivery planning. The study evaluated the influence of diabetes, obesity, excess weight gain, fetal and neonatal anthropometrics on accuracy of estimated fetal weight with respect to the extent of the percent error of estimated fetal weight to birth weight for different categories. METHODS: Multicenter retrospective analysis from 11,049 term deliveries and fetal ultrasound biometry performed within 14 days to delivery. Estimated fetal weight was calculated by Hadlock IV. Percent error from birth weight was determined for categories in 250 g increments between 2500 g and 4500 g. Estimated fetal weight accuracy was categorized as accurate ≤ 10% of birth weight, under- and overestimated by > ± 10% - ± 20% and > 20%. RESULTS: Diabetes was diagnosed in 12.5%, obesity in 12.6% and weight gain exceeding IOM recommendation in 49.1% of the women. The percentage of accurate estimated fetal weight was not significantly different in the presence of maternal diabetes (70.0% vs. 71.8%, p = 0.17), obesity (69.6% vs. 71.9%, p = 0.08) or excess weight gain (71.2% vs. 72%, p = 0.352) but of preexisting diabetes (61.1% vs. 71.7%; p = 0.007) that was associated with the highest macrosomia rate (26.9%). Mean percent error of estimated fetal weight from birth weight was 2.39% ± 9.13%. The extent of percent error varied with birth weight with the lowest numbers for 3000 g-3249 g and increasing with the extent of birth weight variation: 5% ± 11% overestimation in the lowest and 12% ± 8% underestimation in the highest ranges. CONCLUSION: Diabetes, obesity and excess weight gain are not necessarily confounders of estimated fetal weight accuracy. Percent error of estimated fetal weight is closely related to birth weight with clinically relevant over- and underestimation at both extremes. This work provides detailed data regarding the extent of percent error for different birth weight categories and may therefore improve delivery planning.

Foetal hyperinsulinaemia and increased fat mass correlate negatively with circulating fatty acid concentrations in neonates of gestational diabetic mothers with dietary-controlled glycaemia.

BACKGROUD: Higher accretion of prenatal fat is associated with a higher proportion of obesity in children. However, most of the data on regulatory factors involved in fetal adipogenesis come from animal studies; in humans there is no evidence on how fetal insulin affects fatty acid concentrations and fetal adiposity. OBJECTIVE: We evaluate the relationship between fetal adipose tissue accretion with insulin and fetal consumption of circulating fatty acid (FA). METHODS: In fasting maternal blood at term and cord samples, from 41 gestational diabetes mellitus women (GDM) and 68 non-diabetic controls, serum compounds were determined. Individual FA were analyzed and expressed as concentrations of FA (mmol/L). RESULTS: Both groups had similar maternal serum glucose, insulin, triacylglycerol (TAG), non-esterified FA (NEFA), glycerol and leptin concentrations, but most individual maternal serum FA were lower in GDM than controls. Neonatal fat mass (FM) was higher in the GDM group even though neonatal birth weights were similar. In GDM cord serum glucose, insulin, NEFA and leptin were higher than controls, but glycerol and all individual FA were lower. In GDM neonates only, a negative correlation was found between each FA and FM, and there was a strong negative correlation between the concentrations of umbilical blood insulin and five major FA. CONCLUSION: Our results show for the first time that hyperinsulinemia in fetuses of GDM women increases FA utilization, which may contribute to to their increased adiposity.

Antenatal risk prediction of shoulder dystocia: influence of diabetes and obesity: a multicenter study.

PURPOSE: To estimate the risk of shoulder dystocia (SD) in pregnancies with/without maternal diabetes or obesity; to identify antenatal maternal and fetal ultrasound-derived risk factors and calculate their contributions. METHODS: A multicenter retrospective analysis of 13,428 deliveries in three tertiary hospitals (2014-2017) with fetal ultrasound data ≤ 14 days prior to delivery (n = 7396). INCLUSION CRITERIA: singleton pregnancies in women ≥ 18 years old; vertex presentation; vaginal delivery at ≥ 37 weeks of gestation. Estimated fetal weight (EFW) and birth weight (BW) were categorized by steps of 250 g. To evaluate risk factors, a model was performed using ultrasound data with SD as the dependent variable. RESULTS: Diabetes was present in 9.3%; BMI ≥ 30 kg/m2 in 10.4% and excessive weight gain in 39.8%. The total SD rate was 0.9%, with diabetes 2.0% and with obesity 1.9%. These increased with BW 4250-4499 g compared to 4000-4249 g in women with diabetes (12.1% vs 1.9%, P = 0.010) and without (6.1% vs 1.6%, P < 0.001) and at the same BW threshold for women with obesity (9.6% vs 0.6%, P = 0.002) or without (6.4% vs 1.8%, P < 0.001). Rates increased similarly for EFW at 4250 g and for AC-HC at 2.5 cm. Independent risk factors for SD were EFW ≥ 4250 g (OR 3.8, 95% CI 1.5-9.4), AC-HC ≥ 2.5 cm (OR 3.1, 95% CI 1.3-7.5) and diabetes (OR 2.2, 95% CI 1.2-4.0). HC/AC ratio, obesity, excessive weight gain and labor induction were not significant. CONCLUSION: Independent of diabetes, which remains a risk factor for SD, a significant increase may be expected if the EFW is ≥ 4250 g and AC-HC is ≥ 2.5 cm.

Obesity and Pregnancy. Guideline of the German Society of Gynecology and Obstetrics (S3-Level, AWMF Registry No. 015-081, June 2019).

Aims Obesity is an increasing problem, even in young women of reproductive age. Obesity has a negative impact on conception, the course of pregnancy, and neonatal outcomes. Caring for obese pregnant women is becoming an increasingly important aspect of standard prenatal care. This guideline aims to improve the care offered to obese pregnant women. Methods This S3-guideline was compiled following a systemic search for evidence and a structured process to achieve consensus. Recommendations Evidence-based recommendations for the care of obese pregnant women were developed, which cover such as areas as preconception counselling, identification of risks, special aspects of prenatal care and prenatal diagnostic procedures, intrapartum management, and long-term effects on mother and child.

Correction to: Pregnant women with gestational diabetes and with well controlled glucose levels have decreased concentrations of individual fatty acids in maternal and cord serum.

The authors regret that the incorrect figure was shown in Fig. 3d. The corrected figure is reproduced here.

Pregnant women with gestational diabetes and with well controlled glucose levels have decreased concentrations of individual fatty acids in maternal and cord serum.

AIMS/HYPOTHESIS: Both arachidonic acid (AA, 20:4 n-6) and docosahexaenoic acid (DHA,22:6 n-3), long-chain polyunsaturated fatty acids (LCPUFA), are involved in fetal development and, based on their percentage compositions, appear to be specifically accumulated in fetal circulation in a proposed phenomenon known as biomagnification. Discrepancies exist in the literature concerning the effect of gestational diabetes mellitus (GDM) on circulating fatty acids. Our objective was to analyse individual fatty acid concentrations in a large cohort of maternal and cord paired serum samples from pregnant women with and without GDM. METHODS: Overnight fasted maternal and cord blood paired samples from 84 women with GDM and well controlled blood glucose levels and 90 healthy pregnant women (controls) were drawn at term. Individual fatty acids within total serum lipids were analysed by gas chromatography and expressed both as concentrations of fatty acid (mmol/l) and as a percentage of total fatty acids. RESULTS: In the serum of overnight fasted pregnant women with GDM, the concentrations of most fatty acids were lower than in control women, except for AA and DHA, which remained the same. The concentrations of most fatty acids in cord serum were also lower in the GDM group than in the control group, except for α-linolenic acid (ALA,18:3 n-3), which was higher in the GDM group. In both groups, the concentrations of all fatty acids were lower in cord serum than in maternal serum. In GDM participants only, a positive and significant correlation between cord and maternal serum concentration of AA and DHA was observed. CONCLUSIONS/INTERPRETATION: The expression of fatty acids in molar concentrations reveals that GDM decreases the concentration of most fatty acids in both maternal and cord serum. There is a high fetal dependence on maternal AA and DHA, but our findings do not support the existence of a fetal biomagnification of those two LCPUFA.

Diabetes in pregnancy: a new decade of challenges ahead.

Every 10 years, the Diabetic Pregnancy Study Group, a study group of the EASD, conducts an audit meeting to review the achievements of the preceding decade and to set the directions for research and clinical practice improvements for the next decade. The most recent meeting focused on the following areas: improving pregnancy outcomes for women with pregestational type 1 diabetes and type 2 diabetes; the influence of obesity and gestational diabetes on pregnancy outcomes; the determinants and assessment of fetal growth and development; and public health issues, including consideration of transgenerational consequences and economic burden. The audit meeting also considered the likely impact of 'omics' on research within the field and the potential of these technologies to enable precision-medicine approaches to management. Through sharing of the findings and ideas of audit meeting participants, the DPSG hopes to promote networking, research and advances in clinical care, to improve outcomes for all women and their offspring affected by diabetes and obesity in pregnancy.

Lack of relationship between cord serum angiopoietin-like protein 4 (ANGPTL4) and lipolytic activity in human neonates born by spontaneous delivery.

BACKGROUND: Ligands of peroxisome-proliferator activated receptors (PPARs), such as non-esterified fatty acids (NEFAs), induce expression of angiopoietin-like protein 4 (ANGPTL4). Recently ANGPTL4 has been reported to be a mediator of intracellular adipose lipolysis induced by glucocorticoids. OBJECTIVE: To determine the concentrations of ANGPTL4 in cord serum of neonates born by spontaneous vaginal delivery (SVD) and by pre-labor cesarean section (CS) from healthy women, and to relate them to parameters of neonatal lipolytic activity at birth. MEASUREMENTS: In 54 neonates born by SVD and in 56 neonates born by CS, arterial cord blood was drawn to determine insulin, cortisol, triacylglycerols (TAGs), glycerol, non-esterified fatty acids (NEFAs), individual fatty acids, ANGPTL4, adiponectin, retinol binding protein 4 (RBP4) and leptin. RESULTS: Birth weight and neonatal fat mass in SVD and CS showed no difference, but the concentrations of glycerol, adiponectin, RBP4, NEFAs and most individual fatty acids were higher in cord serum of neonates born by SVD compared to CS, indicating a higher adipose tissue breakdown in the SVD group. The concentrations of TAG and cortisol were also higher and that of insulin was lower in cord serum of SVD compared to the CS group. However, the concentration in cord serum of ANGPTL4 did not differ between the two groups and no positive correlation with either NEFA or glycerol concentrations were detected. CONCLUSION: ANGPTL4 is known to stimulate lipolysis in adults, but does not appear to mediate the increased activity in SVD, indicating the presence of different regulatory inputs.

Decreased concentrations of the lipoprotein lipase inhibitor angiopoietin-like protein 4 and increased serum triacylglycerol are associated with increased neonatal fat mass in pregnant women with gestational diabetes mellitus.

CONTEXT: Angiopoietin-like protein 4 (ANGPTL4) is an extracellular inhibitor of lipoprotein lipase (LPL) activity. No studies have been done in pregnancy in which hypertriglyceridemia and tissue-specific changes in LPL activity are present. OBJECTIVE: The objective of the study was to determine the relationship between neonatal fat mass (FM) and concentrations of ANGPTL4 and triacylglycerols (TAG) in maternal and cord serum of pregnant women with gestational diabetes mellitus (GDM) compared with controls. DESIGN: Maternal blood samples (control, n = 90, and GDM, n= 80) and umbilical cord blood were drawn before and after vaginal delivery, respectively. Control and GDM subjects were grouped separately into 3 subgroups, according to neonatal FM: 0-25th percentiles, 25th-75th percentiles, and 75th-100th percentiles. OUTCOME MEASURES: Glucose, insulin, TAG, nonesterified fatty acids (NEFAs), and ANGPTL4 were determined in maternal and neonatal serum. RESULTS: Age and pregestational body mass index did not differ between GDM and control women in any subgroups. Maternal serum of GDM pregnant women who delivered the newborn with the highest FM showed the highest concentrations of TAG and NEFAs and lowest concentration of ANGPTL4, despite glucose and insulin concentrations being independent of changes in neonatal FM. However, cord serum of neonates of GDM patients with the highest FM showed higher concentrations of insulin and lower concentrations of TAG than those with lower neonatal FM but no significant differences in NEFAs or ANGPTL4 concentrations. CONCLUSIONS: In well-controlled GDM pregnancies, decreased maternal ANGPTL4 concentrations and a gradient of TAG toward the fetus are related with higher neonatal FM. However, in GDM fetuses with the highest FM, the potential effect of ANGPTL4 inhibiting adipose tissue LPL activity could be overcome by their hyperinsulinemia.

Gestational diabetes mellitus causes changes in the concentrations of adipocyte fatty acid-binding protein and other adipocytokines in cord blood.

OBJECTIVE: To determine the concentrations of adipocyte fatty acid-binding protein (AFABP) and other adipocytokines in maternal and cord serum of pregnant women with gestational diabetes mellitus (GDM) and of control subjects and to relate them to indexes of insulin sensitivity. RESEARCH DESIGN AND METHODS: In 86 control and 98 GDM pregnant women, venous blood was collected before vaginal delivery and arterial blood from cord immediately after delivery. Serum insulin and adipocytokines were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: GDM women had higher prepregnancy BMI, and data were adjusted for it. Maternal serum insulin, insulin-to-glucose ratio, homeostasis model assessment (HOMA), AFABP, and retinol-binding protein 4 (RBP4) were higher and adiponectin was lower in GDM than in control subjects, whereas serum glucose, insulin, insulin-to-glucose ratio, HOMA, nonesterified fatty acids, and RBP4 were higher and glycerol, AFABP, and adiponectin were lower in cord blood serum of GDM than of control subjects. AFABP and adiponectin in cord serum of control subjects were higher than in maternal serum; in GDM women no difference was found for AFABP in cord versus maternal serum, although adiponectin remained higher in cord. Values of leptin in both groups were lower in cord than in maternal serum, and those of RBP4 were lower in only GDM women. CONCLUSIONS: It is suggested that fetal tissues are the main source of cord arterial serum AFABP, and in GDM fetuses AFABP values correlate with adiposity markers. A downregulation of adiponectin and upregulation of RBP4 in GDM mothers and their fetuses may be related to their insulin-resistant condition, whereas changes in AFABP do not seem to be related.

How many sonograms are needed to reliably predict the absence of fetal overgrowth in gestational diabetes mellitus pregnancies?

OBJECTIVE: Serial measurements of the fetal abdominal circumference have been used to guide metabolic management of pregnancies complicated by gestational diabetes mellitus (GDM). A reduction in the number of repeat ultrasound examinations would save resources. Our purpose was to determine the number of serial abdominal circumference measurements per patient necessary to reliably predict the absence of fetal overgrowth. RESEARCH DESIGN AND METHODS: Women who had GDM were asked to return for repeat ultrasound at 3- to 4-week intervals starting at initiation of care (mean 26.9 ± 5.7 weeks). Maternal risk factors associated with fetal overgrowth were determined. RESULTS: A total of 4,478 ultrasound examinations were performed on 1,914 subjects (2.3 ± 1.2 per pregnancy). Of the 518 women with fetal abdominal circumference >90th percentile, it was diagnosed in 73.9% with the first ultrasound examination at entry and in 13.1% with the second ultrasound examination. Of the fetuses, 85.9 and 86.9% of the fetuses were born non-large for gestational age (LGA) when abdominal circumference was <90th percentile at 24-27 weeks and 28-32 weeks, respectively, and 88.0% were born non-LGA when both scans showed normal growth. For those women who had no risk factors for fetal overgrowth (risk factors: BMI >30 kg/m², history of macrosomia, and fasting glucose > 100 mg/dl), the accuracy of prediction of a non-LGA neonate was 90.0, 89.5, and 95.2%. The predictive ability did not increase with more than two normal scans. CONCLUSIONS: The yield of sonographic diagnosis of a large fetus drops markedly after the finding of a fetal abdominal circumference <90th percentile on two sonograms, which excludes with high reliability the risk of a LGA newborn. The ability was enhanced in women who had no risk factors for neonatal macrosomia.

Inflammatory Breast Diseases during Lactation: Milk Stasis, Puerperal Mastitis, Abscesses of the Breast, and Malignant Tumors - Current and Evidence-Based Strategies for Diagnosis and Therapy.

BACKGROUND: Breast diseases during the lactation period are of high importance because they can be an essential cause for early cessation of breastfeeding. METHODS: To provide a comprehensive overview on the current recommendations of diagnostics and therapies, a systematic literature research was performed on a variety of online medical databases. RESULTS: The primary aim of all therapy is a quick reduction of pain to allow continued breastfeeding. Each particular form of breast disease requires a specific therapy. These can range from conservative measures to antibiotics and surgical procedures. All therapeutic measures, including pharmacotherapy, are normally not an indication for cessation of breastfeeding. CONCLUSION: Because the majority of breast diseases during the postnatal period occur only after the women have left the maternity clinics, all involved healthcare workers should educate women especially on preventive measures.

How do we reduce the number of cases of missed postpartum diabetes in women with recent gestational diabetes mellitus?

OBJECTIVE: Up to 30% of women with recent gestational diabetes mellitus (GDM) remain glucose intolerant after delivery. However, the rate of postpartum oral glucose tolerance tests (ppOGTTs) is low. Our aim in this study was to develop a model for risk assessment to target women with high risk for postpartum diabetes. RESEARCH DESIGN AND METHODS: In 605 Caucasian women with GDM, antenatal obstetrical and glucose data and the glucose data of the ppOGTTs performed 13 weeks (median) after delivery were prospectively collected. RESULTS: A total of 132 (21.8%) women had an abnormal ppOGTT (2.8% impaired fasting glucose, 13.6% impaired glucose tolerance, and 5.5% diabetes). Independent risk factors were BMI >or=30 kg/m(2) (prevalence of abnormal ppOGTT 36.0 vs. 17.3%), gestational age at diagnosis <24 weeks (32.4 vs. 18.0%), 1-h antenatal value >200 mg/dl (11.1 mmol/l) (35.2 vs. 14.8%), and insulin therapy (30.3 vs. 14.5%). The prevalence of an abnormal ppOGTT was assessed according to the number of risk factors: 0, 9.2% (14 of 153); 1, 13.4% (25 of 186); 2, 28.5% (43 of 151); 3, 45.6% (26 of 57); and 4, 68.4% (13 of 19). Subjects were divided according to a significant increase of prevalence and risk for a ppOGTT: low risk (59.9% of subjects), <2 risk factors, 11.6%, odds ratio 1.3; intermediate risk, 2 risk factors, 28.5%, 4.0; and high risk, >2 risk factors, 51.3%, 10.5. The intermediate/high-risk group included 86.6% of those with diabetes and 67% of all those with abnormal ppOGTTs. CONCLUSIONS: Women with >or=2 risk factors have a high risk for an abnormal ppOGTT, and 86% of postpartum diabetes is diagnosed within this group. Targeting women for ppOGTTs based on a risk assessment using available antenatal risk factors might reduce the number of missed cases of postpartum diabetes.