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A prospective cohort study of postpartum glucose metabolic disorders in early versus standard diagnosed gestational diabetes mellitus

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Abstract Early gestational diabetes mellitus (eGDM) is diagnosed when fasting plasma glucose before 24 weeks of gestation (WG) is ≥ 5.1 mmol/L, whilst standard GDM is diagnosed between 24 and 28 WG by oral glucose tolerance test (OGTT). eGDM seems to have worse obstetric outcomes than standard GDM. We compared the rates of postpartum glucose metabolism disorders between women with early versus standard GDM in this prospective study on women with GDM from three university hospitals between 2014 and 2016. Patients were included if they were
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Scientic Reports | (2021) 11:10430 | 
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A prospective cohort study
of postpartum glucose metabolic
disorders in early versus standard
diagnosed gestational diabetes
mellitus
Valeria Cosma1, Jeanne Imbernon1, Léonore Zagdoun2, Pierre Boulot3, Eric Renard4,
Cécile Brunet4, Pierre Mares5, Michel Rodier1, Sarah Kabani6, Christophe Demattei6 &
Anne‑Marie Guedj1*
Early gestational diabetes mellitus (eGDM) is diagnosed when fasting plasma glucose before 24 weeks
of gestation (WG) is ≥ 5.1 mmol/L, whilst standard GDM is diagnosed between 24 and 28 WG by
oral glucose tolerance test (OGTT). eGDM seems to have worse obstetric outcomes than standard
GDM. We compared the rates of postpartum glucose metabolism disorders between women with
early versus standard GDM in this prospective study on women with GDM from three university
hospitals between 2014 and 2016. Patients were included if they were < 24 WG with at least one risk
factor for GDM and excluded if they had type 2 diabetes. Patients were assigned to Group 1 (G1) for
eGDM according to IADPSG: fasting blood glucose < 24 WG between 5.1 and 7 mmol/L. Group 2 (G2)
consisted of patients presenting a standard GDM at 24–28 WG on OGTT results according to IADPSG:
T0 ≥ 5.1 mmol/L or T60 ≥ 10.0 mmol g/L or T120 ≥ 8.5 mmol/L. The primary outcome was postpartum
OGTT result. Five hundred patients were analysed, with 273 patients undergoing OGTT at 4–18 weeks
postpartum: 192 patients in G1 (early) and 81 in G2 (standard). Patients in G1 experienced more insulin
therapy during pregnancy than G2 (52.2% versus 32.5%, p < 0.001), but no patients were taking insulin
postpartum in either group. G1 patients experienced less preterm labour (2.6% versus 9.1%, p = 0.043),
more induced deliveries (38% versus 25%, p = 0.049) and reduced foetal complications (29.2% versus
42.0%, p = 0.048). There was no signicant dierence in the rate of postpartum glucose metabolism
disorders (type 2 diabetes, impaired glucose tolerance, impaired fasting glycaemia) between groups:
48/192 (25%) in G1 and 17/81 (21%) in G2, p = 0.58. Thus the frequency of early postpartum glucose
metabolism disorders is high, without dierence between eGDM and standard GDM. This supports
measurement of fasting plasma glucose before 24 WG and the threshold of 5.1 mmol/L seems
appropriate until verication in future studies.
Trial registration: NCT01839448, ClinicalTrials.gov on 22/04/2013.
In line with the diagnostic criteria of e International Association of Diabetes in Pregnancy Study Group
(IADPSG)1 and the French recommendations2, targeted screening of gestational diabetes mellitus has been rec-
ommended for all high-risk women since 2010 in France, with a fasting plasma glucose test before 24 WG. e
aim of this screening is to diagnose pre-existing diabetes (> 7mmol/L), but if the fasting glycaemia is between
5.1mmol/L and 7mmol/L, a diagnosis of early GDM (eGDM) is made. If the fasting glucose is < 5.1mmol/L, an
OPEN
Department of Endocrine and Metabolic Diseases, CHU Nimes, Univ Montpellier, Place du Professeur
              Department
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         Department
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oral glucose tolerance test (OGTT) is performed between 24 and 28 WG and the diagnosis of standard GDM is
made if at least one value is abnormal (T0 ≥ 5.1mmol/L, T60 ≥ 10.0mmol/L and T120 8.5mmol/L).
eGDM emerges in a dysmetabolic environment and could represent an intermediary between pre-existing
diabetes and standard GDM3. It is characterised by a high and early insulin resistance from the rst trimester
of pregnancy, but can also arise from defective beta-cell function as interpreted by abnormal insulin sensitivity
tests4. e risk factors are similar to those of type 2 diabetes: advanced age, family history of diabetes, personal
history of GDM or previous macrosomia3. However, its medical care is controversial and the fasting plasma
glucose threshold of 5.1mmol/L has been decided arbitrarily. Indeed, it comes from the HAPO study5 and
corresponds to the threshold of a fasting plasma glucose between 24 and 32 WG associated with an increased
obstetrical risk of 1.75 times compared to a normal pregnancy. e cut-o of 5.1mmol/L has been generalised
to the rst trimester for simplicity, but has not been evaluated in prospective studies. In addition, the HAPO
study shows a continuum between the fasting plasma glucose level and the incidence of obstetrical complications.
is argues against applying a single threshold5. e literature shows contradictory results on the persistence of
eGDM, with some studies demonstrating that less than 50% of eGDM persists between 24 and 28 WG6,7, whereas
one pilot study found that 89% of women with eGDM also returned positive results at 24–28 WG8. Interestingly,
this study showed a potential benet from early diagnosis and prompt treatment on reducing the cases of large for
gestational age babies, but oset by an increase in babies hospitalised in neonatal intensive care. Several studies
have shown no maternofoetal benet from treated early GDM versus treated standard GDM, especially regard-
ing foetal macrosomia9 (7). Indeed, overtreatment of eGDM could be dangerous for the foetus10, and the risk/
benet ratio of eGDM screening has not been studied. e eects of eGDM are unknown, especially regarding
obstetric outcomes and metabolic future of the mother and the baby.
us our study aims to deepen the knowledge of the metabolic impact of eGDM in the early postpartum
state in mothers. Our objective is to compare the rate of early postpartum glucose metabolism disorders aer
eGDM and standard GDM.
Methods
is prospective and multicentric study was conducted in the Gynaecology and Endocrinology Departments
at the University Hospital of Nîmes, the University Hospital of Montpellier and Regional Hospital of Arles,
France from March 2014 until October 2016. e study was approved by the research ethics committee CPP
Sud Mediterranee III and was performed in accordance with the declaration of Helsinki; it was registered on
clinicaltrials.gov (NCT01839448) on 22/04/2013. Participants were pregnant women of less than 24 WG who
had at least one risk factor for gestational diabetes: age > 35years old; BMI > 25kg/m2; family history of type
2 diabetes; personal history of GDM; or a previous macrosomic baby. Eligible patients had to meet criteria of
gestational diabetes diagnosis according to the IADPSG, be aged > 18, be available for a 10month follow-up and
give informed consent. ey were excluded if they had a pre-existing type 2 diabetes (known or discovered dur-
ing the pregnancy), had a contraindication or a medical interaction with one of the treatments of the study, were
treated with corticosteroids or beta-mimetic drugs in the week before the blood test (fasting plasma glucose or
OGTT), or could not read French uently.
Participants were seen by their midwives or gynaecologists before 24 WG. If they had at least one risk factor
of GDM, they were informed about the study, the importance of the postpartum OGTT and their written con-
sent was collected. ey were then prescribed a blood test with fasting plasma glucose, to be done at their local
laboratory before 24 WG. Group one (G1) consisted of patients presenting an eGDM according to IADPSG: fast-
ing blood glucose on venous samples before 24 WG between 5.1mmol/L and 7mmol/L inclusive. If the fasting
blood glucose before 24 WG was < 5.1mmol/L, a 75g OGTT was performed on venous samples between 24 and
28 WG. Group two (G2) consisted of patients presenting a standard GDM at 24–28 WG according to IADPSG:
T0 ≥ 5.1mmol/L or T60 ≥ 10.0mmolg/L or T120 ≥ 8.5mmol/L.
e medical care was identical in the two groups during pregnancy, starting with a consultation in the endo-
crinology service. Information about GDM and dietary advice based on 200g carbohydrates intake a day was
provided and patients were issued with a capillary blood glucose monitoring system with instructions to perform
six tests per day. e patients were seen again aer 8days to check their blood glucose regulation. e glycaemic
objectives were fasting plasma glucose < 5.2mmol/L and 2h post-prandial plasma glucose < 6.6mmol/L. For
patients with non-controlled blood glucose, insulin therapy was initiated and the patients were seen aer 8days,
then followed every 2weeks. For patients with controlled blood glucose, the capillary blood glucose monitoring
was reduced to four controls a day, 3days a week, and they were seen every month.
Aer delivery, the patients were contacted by telephone at 4, 6 and 8weeks postpartum to remind them to
do the 75g OGTT before 12weeks postpartum at their local laboratory. A nal visit with the diabetologist was
made aer the OGTT to interpret the results and to determine follow-up.
Outcomes. e main outcome was the result of the 75g OGTT taken at 4–12weeks postpartum in both
early and standard GDM in order to compare the rate of glucose metabolism disorders (type 2 diabetes, impaired
glucose tolerance, impaired fasting glycaemia). e secondary endpoints were: the rate of each glucose metab-
olism disorder; the rate of obstetrical and maternal complications (caesarean section, gestational hyperten-
sion, preeclampsia, urinary tract infection, macrosomia, dystocia, transfer to neonatology, respiratory distress,
gestational death, infections and preterm delivery); the presence of risk factors of GDM; macrosomia (birth
weight > 4000g), malformations, neonatal asphyxia, respiratory distress, hypoglycaemia, hypocalcaemia, hyper-
bilirubinemia, infant death, transfer to Neonatal Intensive Care Unit in both early and standard GDM; a nal
study outcome was to determine a threshold of fasting plasma glucose before 24 WG to predict the occurrence
of glucose metabolism disorder in the postpartum period.
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OGTT analysis. e 75g OGTT was performed on patients in their laboratory of choice using a standard-
ised protocol. e patient should be fasting for 12h, at rest and avoid smoking before the exam. e patient
ingests 75g of glucose. Blood glucose is measured prior to ingestion (T0), at 60min (T60) and at 120min (T120)
via venous sampling. e blood is collected in a tube with a coagulation activator (SST).
e glucose metabolism disorders were dened as: type 2 diabetes (dened by a T120 11.1mmol/L);
Impaired Glucose Tolerance (dened by 7.8 ≤ T120 < 11.1mmol/L); Impaired Fasting Glycaemia (dened by 5.5
≤ T0 < 7mmol/L according to the American Diabetes Association11). Gestational hypertension was diagnosed
when systolic and/or diastolic arterial blood pressure ≥ 140/90mmHg aer 20 WG and preeclampsia dened by
gestational hypertension combined with proteinuria 0.3g/24h. Macrosomia was dened as a weight ≥ 4kg.
GDM risk factors recorded were: age > 35years old; BMI > 25kg/m2; family history of type 2 diabetes; personal
history of GDM; or a previous macrosomic baby. Proteinuria was tested in patients with hypertension using
Multistix (Siemens), and if positive veried on miction samples with laboratory tests. Weight before pregnancy
was self-declared by the patient, and then measured at each follow-up visit. New-born outcomes were taken from
the patient le completed by the paediatric team.
Statistical analyses. e sample size was calculated based on previous studies dening GDM using a fast-
ing glycaemia cut-o of 6.1 or 6.3mmol/L1214. e anticipated repartition was one third of patients in G1 and
two thirds in G22, with an expected 55% postpartum glucose metabolism disorder in G1 and 35% in G22,13,14.
To reach an alpha risk of 5% and a statistical power of 90%, 261 patients were needed (87 in G1 and 174 in G2).
Due to the high risk of missing data, it was decided to include 500 patients in total (167 in G1 and 333 in G2).
e statistical analyses were conducted by BESPIM of University Hospital of Nîmes and all analyses were car-
ried out using R 3.5.1 (R Development Core Team 2018. R Foundation for statistical computing, Vienne, Austria).
Categorical variables were compared using Chi2 or Fisher’s exact test when appropriate. e quantitative variables
were compared using Student’s t test for Gaussian continuous variables and Wilcoxon–Mann–Whitney’s test
for non-Gaussian continuous variables. Analysis of the primary outcome was adjusted on factors that were not
comparable between the two groups in a multivariate logistic regression. Fasting glycaemia before 24 WG was
analysed by receiver operating characteristic (ROC) curve in both groups to determine the optimal predictive
threshold for postpartum glucose metabolic disorders.
Results
Five hundred patients were included in the study: 317 at the University Hospital of Nîmes, 168 at Regional Hos-
pital of Arles and 15 at University Hospital of Montpellier. Patients screened due to risk factors for GDM, but not
fullling the criteria for inclusion into G1 or G2 (no GDM diagnosis at either time point) were not included in
the study and thus the number of these patients and their characteristics was not noted. One patient was excluded
due to lack of a signed consent form, leaving 353 in G1 and 146 in G2. For the analysis of the primary objective,
data from 54% of G1 participants (n = 192) and 55% of G2 (n = 81) were usable (Fig.1). Patients in G1 underwent
the fasting glycaemia at a median of 9.3 [5.7;11.7] WG, and G2 patients took the OGTT at a median of 24.3
[22.7;25.6] WG. e characteristics and medical history of both groups were similar (Table1) except for initial
BMI, which was signicantly higher in women in G1 (29.42 ± 5.55kg/m2 versus 26.53 ± 4.45kg/m2, p < 0.001).
In total,284 participants underwent a postpartum OGTT, at a medium term of 10.7weeks for G1 and
10.4week for G2. However, 31% of tests were performed later than 12weeks, thus it was decided to extend
the limit of testing until 18weeks. e 10 patients who took the test beyond 18weeks were not included in the
analysis and neither was one patient for whom the 120-min OGTT result was missing. Finally, 273 participants
were assessed for the primary outcome: 192 in G1 and 81 in G2. e global rate of glucose metabolism disorders
in the early postpartum period did not dier between the two groups: 25% (48/192) in G1 versus 21% (17/81) in
G2, p = 0.58 (Table2). Similarly, there was no dierence in the rate of each type of glucose metabolism disorder
between groups: no cases of type 2 diabetes in either group; 9.4% (18/192) impaired glucose tolerance in G1
versus 8.6% (7/81) in G2, p = 1; and 18.8% (36/192) impaired fasting glycaemia in G1 versus 14.8% (12/81) in
G2, p = 0.54. No patients were under insulin treatment. Details of pre- and postpartum glycaemia are listed in
Supplementary Table1. Analysis of primary outcome was adjusted on BMI and history of GDM in a multivariate
logistic regression. e global rate of glucose metabolism disorders in the early postpartum period did not dier
between the two groups aer adjustment (p = 0.685).
During pregnancy, the G1 patients experienced more insulin therapy than G2 (52.2% versus 32.5%, p < 0.001),
less preterm labour (2.6% versus 9.1%, p = 0.043), less weight gain (6.82 ± 6.22 versus 9.03 ± 5.77kg, p = 0.006)
and more induced deliveries (38% versus 25%, p = 0.049) (Table3).
A signicant dierence was seen for a reduction of foetal complications in the eGDM group: 29.2% in G1
versus 42.0% in G2, p = 0.048. No signicant dierence for other obstetrical outcomes was found between the
two groups (Table3).
Analysis of the ROC curve did not identify a discriminatory fasting plasma glucose threshold to predict
post-partum dysglycaemia: the area under the curve was 0.579, 95% CI = [0.498;0.660].
ere were several dierences between the ‘analysed’ (n = 273) vs ‘non-analysed’ (n = 226) patients. Compared
to the patients analysed, the patients who did not undergo a postpartum OGTT were signicantly younger in
G1 (31.99 ± 5.45 versus 33.51 ± 5.03years old, p < 0.05), had more personal history of macrosomia in G1 (22.4%
versus 15.1% p < 0.05) and in G2 (18.5% versus 8.6%, p < 0.05), less insulin therapy in G1 (41.4% versus 52.2%.
p < 0.05), more weight gain in G1 (8.48 ± 6.38 versus 6.82 ± 6.22kg. p < 0.05) and in G2 (10.78 ± 5.09 versus
9.03 ± 5.77. p < 0.05) and more failure of labour induction in G1 (29.6% versus 10%. p < 0.05) (Table1).
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Discussion
Our results show a high rate of glucose metabolism disorders in the early postpartum period, with the same
prevalence in eGDM (25%) as in standard GDM (21%). Considering the high prevalence of eGDM in our popula-
tion and the fact that less than 50% of early GDM persists aer 24 WG6,7, screening before 24 WG appears to be
valuable to avoid missing glucose metabolism disorders in many women at high risk in postpartum. is high
rate of GDM in our study, particularly in early pregnancy, is likely at least partially due to the risk factor-based
screening based on the French recommendations, which dier from the systematic screening recommended
by the IADPSG. Measuring fasting plasma glucose levels before 24 WG using a threshold of 5.1mmol/l seems
justied in terms of screening for maternal glucose disorders in postpartum.
e impact of early diagnosis of GDM on immediate postpartum dysglycaemia (impaired tolerance glucose
and diabetes) versus standard GDM has been reported by Sweeting in 201615. e distribution between normal
plasma glucose values, impaired glucose tolerance, and diabetes identied by the OGTT performed 3months
postpartum signicantly diered according to onset of GDM: GDM < 12 WG (normal glucose tolerance 79%,
impaired glucose tolerance 11%, and diabetes 11%); GDM 12–23 WG (71%, 24%, and 5%, respectively); and
GDM > 24 WG (85%, 14%, and 1%, respectively). Hence, the proportion of dysglycaemia was 22% in women
with GDM < 12WG, but only 15% in GDM > 24 WG. In a study evaluating pathophysiological characteristics of
pregnant women diagnosed with GDM according to IADPSG criteria, the women with eGDM had decreased
insulin sensitivity which remained signicant aer adjustment for BMI, age, and history of GDM16.
eGDM was particularly prevalent in our study, representing 70.7% of all GDM. e prevalence of eGDM seen
here is higher than in the existing literature: eGDM represents 10.3% of total GDM (universal screening method)
Risk factors
> 35 years old
BMI >25
Family history of type 2 diabetes
Previous gestaonal diabetes
Consultaon and fasng
glycaemia before 24 WG
Inclusion
in G1
n=353
Inclusion
in G2
n=146
5.1 mmol/L≤G < 7 mmol/LG < 5.1 mmol/L
OGTT between 24-28 WG
≥5.1 mmol/L at T0
10 mmol/L at 1hr
≥8.5 mmol/L at 2hr
Not
included
Paents followed up
unl delivery without
major protocol
deviaon (n=339)
Paents followed up
unl delivery without
major protocol
deviaon (n=135)
OGTT 4-18 weeks
postpartum
n=192 (54%)
OGTT 4-18 weeks
postpartum
n=81 (55%)
Lost to follow-up n=7
Protocol deviaons n=7
Lost to follow-up n=139
Protocol deviaons n=
8
Protocol deviaons n=11
Lost to follow-up n=51
Protocol deviaons n=3
Yes No
Figure1. Flow chart. OGTT: oral glucose tolerance test, G: glycaemia.
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Table 1. Patient characteristics. Statistically signicant p values between groups are given in bold. Data
are presented as number (%), average ± standard deviation or median [Q1; Q3](min; max). *p < 0.05 for the
comparison between Non-analysed and Analysed patients.
Characteristics Group 1 (n = 353) Group 2 (n = 146) p
Age
Total population (n = 499) 32.82 ± 5.27 32.48 ± 5.29 0.52
Non-analysed patients (n = 226) 31.99 ± 5.45 31.91 ± 5.66 0.92
Analysed p atients (n = 273) 33.51 ± 5.03* 32.94 ± 4.96 0.39
Weight at the beginning of pregnancy (kg)
Total population (n = 499) 78.7 ± 16.12 70.27 ± 13.37 < 0.001
Non-analysed patients (n = 226) 78.98 ± 16.05 69.57 ± 15.11 < 0.001
Analysed p atients (n = 273) 78.47 ± 16.21 70.83 ± 11.86 < 0.001
Current weight (kg)
Total population (n = 499) 82.16 ± 15.59 78.01 ± 13.13 0.003
Non-analysed patients (n = 226) 82.91 ± 15.61 78.41 ± 15.06 0.050
Analysed p atients (n = 273) 81.55 ± 15.59 77.69 ± 11.37 0.027
Height (m)
Total population (n = 499) 1.63 ± 0.06 1.64 ± 0.06 0.48
Non-analysed patients (n = 226) 1.64 ± 0.06 1.64 ± 0.06 0.63
Analysed p atients (n = 273) 1.63 ± 0.07 1.64 ± 0.06 0.59
BMI before pregnancy (kg/m2)
Total population (n = 499) 29.43 ± 5.67 26.19 ± 4.83 < 0.001
Non-analysed patients (n = 226) 29.43 ± 5.83 25.76 ± 5.27 < 0.001
Analysed p atients (n = 273) 29.42 ± 5.55 26.53 ± 4.45 < 0.001
Family history type 2 diabetes
Total population (n = 499) 162 (45.9%) 74 (50.7%) 0.38
Non-analysed patients (n = 226) 74 (46.0%) 34 (52.3%) 0.47
Analysed p atients (n = 273) 88 (45.8%) 40 (49.4%) 0.69
Obstetrical history
Total population (n = 499) 292 (82.7%) 114 (78.1%) 0.28
Non-analysed patients (n = 226) 134 (83.2%) 49 (75.4%) 0.24
Analysed p atients (n = 273) 158 (82.3%) 65 (80.2%) 0.82
If yes:
Parity
Total population (n = 499) 1 [1;2] (0;7) 1 [1;2] (0;6) 0.10
Non-analysed patients (n = 226) 1 [1;2] (0;7) 1 [1;2] (0;6) 0.35
Analysed p atients (n = 273) 1 [1;2] (0;4) 1 [1;2] (0;5) 0.18
Gestations
Total population (n = 499) 2 [1;3] (1;7) 2 [1;3] (1;8) 0.81
Non-analysed patients (n = 226) 2 [1;4] (1;7) 2 [1;3] (1;8) 0.36
Analysed p atients (n = 273) 2 [1;3] (1;7) 2 [1;3] (1;8) 0.54
History of caesarean
Total population (n = 499) 75 (21.2%) 25 (17.1%) 0.36
Non-analysed patients (n = 226) 35 (21.7%) 12 (18.5%) 0.71
Analysed p atients (n = 273) 40 (20.8%) 13 (16.0%) 0.46
History of foetal macrosomia
Total population (n = 499) 65 (18.4%) 19 (13.0%) 0.18
Non-analysed patients (n = 226) 36 (22.4%)* 12 (18.5%)* 0.64
Analysed p atients (n = 273) 29 (15.1%)* 7 (8.6%)* 0.21
History of GDM
Total population (n = 499) 87 (24.6%) 24 (16.4%) 0.06
Non-analysed patients (n = 226) 40 (24.8%) 13 (20%) 0.55
Analysed p atients (n = 273) 47 (24.5%) 11 (13.6%) 0.06
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in the university hospital of Bondy (n = 9795)9, 27.4% in an Australian study (n = 4873)15, 34% in Qatar (n = 801)17,
48.9% (risk factor screening method) in the university hospital of Lille (n = 334)10 and 48.8% more recently in
Italy (n = 3974)18. In addition to the dierent screening methods used, the dierence in prevalence could be
explained by confounding risk factors not recorded here (e.g. ethnic origins, exposure to nutritional factors, or
local endocrine disruptors)19. A higher incidence of GDM diagnosed in early versus standard screening was also
seen in a study in another group of patients at high risk of gestational diabetes due to obesity (15% early versus
12.1% standard)20. A Japanese study also found a much higher incidence of eGDM in a population of patients
diagnosed with GDM (63.6% < 15 WG versus 36.4% between 24 and 28 WG)21. e high rate of eGDM found is
not likely to be due to incorrect blood glucose measurements. Fasting glycaemia was tested on venous samples
in laboratories conforming with standard practice, negating the need for rechecking at the hospital. Recently,
Nakanishi etal. found that women with positive OGTT results taken before 20 WG showed normal results by
24–28 WG in 47%22, as previously shown6,7. However, the discrepancies between the early and later tests were
particularly marked for women where only the fasting result was abnormal in the early test.
In our study, no participant was diagnosed with type 2 diabetes in the early postpartum period. ree pos-
sibilities are likely; rst, many patients did not complete the postpartum OGTT (41% in G1 and 37% in G2).
ese non-analysed patients had a higher metabolic risk than the ones analysed; they more frequently had a
history of macrosomia and had a signicantly higher weight gain during pregnancy. us it is possible that we
missed some patients exhibiting type 2 diabetes in this group. Also, our diagnostic criterion for type 2 diabetes
was a glycaemia two hours aer oral glucose load ≥ 11.1mmol/L. e fasting plasma glucose ≥ 7mmol/L was not
considered as a criterion in this study, whereas one patient in each group exceeded this threshold. ese patients
were referred to their general practitioner for follow-up, but the data on a second fasting plasma glucose value
were not collected as part of this study to establish the diagnosis of type 2 diabetes. It is also possible that type
2 diabetes develops aer 18weeks postpartum. In a systematic review including eight studies and 4026 women
with GDM dened with numerous criteria, women with eGDM had a two-fold increased risk of incident type
2 diabetes from 6weeks to 20years aer delivery compared to subjects with “late” GDM (relative risk (RR) 2.13
(95% CI 1.52–3.56))23.
ere was a reduction of foetal complications in the eGDM group. is could be the result of a better gly-
caemic control due to more insulin therapy in G1 and a lower gestational weight gain in G1. Previously, a better
glycaemic control was observed by Vambergue etal.24 in eGDM: average HbA1c was 5.1 ± 0.4% (32 ± 4mmol/
mol) in eGDM versus 5.3 ± 0.5% (34 ± 4mmol/mol) in standard GDM (p < 0.001) with HbA1c ≥ 6% (42mmol/
mol) in 2.3% of eGDM versus 6.5% of standard GDM (p < 0.05). Nevertheless, a continuum of risk in terms of
maternal outcome has been demonstrated, with eGDM linked to worse outcome than standard GDM, and for
some neonatal outcomes eGDM showed an equal or increased risk than pre-existing type 2 diabetes15. However,
the benet of screening and treatment of eGDM in terms of foetal outcomes cannot be conrmed by our study
as the sample size was determined for the primary objective; many more participants would have been necessary
to unveil dierences in neonate outcomes. is is particularly true for macrosomia (> 4000g) for which the ratio
was identical in both groups (Table3).
Several characteristics of the eGDM group were signicantly dierent to the standard GDM group, likely due
to the methodological dierences in including patients into these groups at the dierent time points. Patients in
the eGDM group had higher pre-pregnancy BMI and lower gestational weight gain, yet higher post-pregnancy
weight. e early group also showed a higher rate of insulin therapy, a higher rate of labour inductions and Cae-
sarean and less pre-term labour. Whilst not meeting the threshold for signicance, there was trend for women
with a history of GDM to have eGDM in this study, in line with Harreiter etal. who found an odds ratio of 2.74 for
eGDM in this population4. ese dierent baseline, pregnancy and maternal characteristics have been highlighted
in other studies on early versus later GDM diagnosis, and are highly co-dependent. Initial higher BMI associated
with lower gestational weight gain and more Caesarean sections has been described in a Japanese study25. e
authors suggested that earlier initiation of treatment was benecial in the early group, reducing the number of
large-for-gestational age infants. Early diagnosis has been consistently linked to increased insulin therapy15,20,26,27.
e higher pre-pregnancy BMI is likely responsible for the worse outcomes in the eGDM group, as this is a risk
factor for Caesarean section and hypotensive disorders25 and provokes greater insulin requirements, leading to
worse dysglycaemia15. In the DALI study analysing pregnant women with a minimum BMI of 29kg/m2, women
with the highest BMI were more likely to be diagnosed with eGDM28. e dierent characteristics of the eGDM
group, whereby increased and/or earlier initiation of insulin therapy can protect against potential poor mater-
nofoetal outcomes, provide further justication for early screening.
e main limit of our study was the “lost to follow up” bias (41% G1 and 35% G2), although this rate remains
less than in other studies, where drop-out is frequently > 50%23. Participants largely dropped out aer delivery,
possibly because of a lack of time with their new-born babies, a fear of the side eects of the glucose load,
Table 2. Abnormal postpartum glucose metabolism. Data are presented as number (%).
Group 1 (n = 192) Group 2 (n = 81) p
Abnormal postpartum glucose metabolism 48 (25.0%) 17 (21.0%) 0.58
Type 2 diabetes (OGTT: T120 > 11.1mmol/L) 0 (0%) 0 (0%)
Glucose Intolerance (OGTT: T120 min: ≥ 7.8mmol/L and < 11.1 /L 18 (9.4%) 7 (8.6%) 1
Abnormal fasting blood glucose (OGTT: T0 min: > 5.5mmol/L and ≤ 7.7mmol/L 36 (18.8%) 12 (14.8%) 0.54
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Pregnancy and delivery characteristics Group 1 (n = 353) Group 2 (n = 146) p
Term (WG)
Total population (n = 499) 39.09 ± 1.92 39.42 ± 1.4 0.14
Non-analysed patients (n = 226) 39.14 ± 2.08 39.48 ± 1.33 0.35
Analysed p atients (n = 273) 39.05 ± 1.78 39.37 ± 1.47 0.26
Insulin therapy
Total population (n = 499) 169 (49.1%) 49 (34.8%) 0.005
Non-analysed patients (n = 226) 63 (41.4%) 24 (37.5%) 0.65
Analysed p atients (n = 273) 106 (52.2%)* 25 (32.5%) < 0.001
Preeclampsia
Total population (n = 499) 9 (2.6%) 1 (0.7%) 0.29
Non-analysed patients (n = 226) 4 (2.7%) 0 0.32
Analysed p atients (n = 273) 5 (2.6%) 1 (1.3%) 0.68
rombocytopenia
Total population (n = 499) 10 (2.9%) 4 (2.8%) 1
Non-analysed patients (n = 226) 4 (2.7%) 0 0.32
Analysed p atients (n = 273) 6 (3.2%) 4 (5.2%) 0.48
Gestational hypertension
Total population (n = 499) 11 (3.2%) 2 (1.4%) 0.36
Non-analysed patients (n = 226) 5 (3.4%) 1 (1.6%) 0.67
Analysed p atients (n = 273) 6 (3.2%) 1 (1.3%) 0.68
Preterm labour
Total population (n = 499) 10 (2.9%) 10 (7.1%) 0.045
Non-analysed patients (n = 226) 5 (3.3%) 3 (4.7%) 0.70
Analysed p atients (n = 273) 5 (2.6%) 7 (9.1%) 0.043
Urinary tract infection
Total population (n = 499) 11 (3.2%) 6 (4.3%) 0.59
Non-analysed patients (n = 226) 5 (3.3%) 4 (6.3%) 0.46
Analysed p atients (n = 273) 6 (3.2%) 2 (2.6%) 1
Weight gain during pregnancy (kg)
Total population (n = 499) 7.56 ± 6.33 9.82 ± 5.52 < 0.001
Non-analysed patients (n = 226) 8.48 ± 6.38 10.78 ± 5.09 0.003
Analysed p atients (n = 273) 6.82 ± 6.22* 9.03 ± 5.77* 0.006
Labour induction
Total population (n = 499) 127 (36.8%) 43 (29.9%) 0.15
Non-analysed patients (n = 226) 54 (35.3%) 23 (35.9%) 1
Analysed p atients (n = 273) 73 (38.0%) 20 (25%) 0.049
Failed labour induction
Total population (n = 499) 23 (18.5%) 5 (11.9%) 0.47
Non-analysed patients (n = 226) 16 (29.6%) 3 (13.6%) 0.24
Analysed p atients (n = 273) 7 (10%)* 2 (10%) 1
Dystocia
Total population (n = 499) 31 (9.5%) 16 (11.6%) 0.50
Non-analysed patients (n = 226) 15 (10.6%) 7 (11.1%) 1
Analysed p atients (n = 273) 16 (8.6%) 9 (12%) 0.49
Caesarean
Total population (n = 499) 109 (31.6%) 23 (16%) < 0.001
Non-analysed patients (n = 226) 56 (36.6%) 9 (14.1%) 0.001
Analysed p atients (n = 273) 53 (27.6%) 14 (17.5%) 0.09
Planned caesarean
Total population (n = 499) 46 (42.2%) 10 (43.5%) 1
Non-analysed patients (n = 226) 22 (39.3%) 6 (66.7%) 0.16
Analysed p atients (n = 273) 24 (45.3%) 4 (28.6%) 0.36
Obstetrical outcomes
Maternal complications
Total population (n = 499) 63 (18.3%) 21 (14.6%) 0.36
Non-analysed patients (n = 226) 29 (19.1%) 7 (10.9%) 0.17
Continued
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the pain involved in giving a blood sample or fear of having an abnormal result29. e inversion between the
expected ratio G2/G1 = 2 and the observed ratio G1/G2 = 2.4 provoked a slight decrease of the power: using the
initial hypothesis of an expected 55% postpartum glucose metabolism disorder in G1 and 35% in G2, the power
decreases from 90 to 87%. is limited decrease is due to the stability of the total number G1 + G2 (273 patients
instead of 261 needed).
Our study has several strengths. It is the rst study in France assessing glucose metabolism disorders in the
early postpartum period, where early and standard GDM are dened according to current guidelines. Due to
numerous telephone reminders, the postpartum OGTT was completed for more than half of the patients, which
is far higher than the national average (< 20% within the rst 3months postpartum)30. is study is a prospec-
tive and multicentric trial, which guarantees a high standard of proof, and enough patients to make statistically
signicant inferences.
Our results show a high frequency of early postpartum glucose disorders, for both early and standard GDM.
eGDM accounts for two thirds of our patients, although less than 50% of those cases would be expected to persist
aer 24 WG. us, it appears important to continue to screen those with eGDM to identify any patients with high
metabolic risk in the early postpartum period. is supports the measurement of fasting blood glucose before 24
WG in high-risk women and application of the current threshold of 5.1mmol/L in terms of maternal outcomes.
An analysis of women enrolled into the DALI trial found that the IADPSG criteria appeared suitable for use in
early pregnancy, despite the lack of validation4. is study also highlighted the dierence in prevalence found
when using fasting glycaemia alone in comparison with the other time points of the 75g OGTT, with 78.5%
patients diagnosed with eGDM based on abnormal fasting glucose levels alone and only 21.5% with abnormal
results at 60 and/or 120min. However, this study is not directly comparable to ours as diagnosis was based on
the WHO 2013 criteria.
is study cannot conclude on the benet of screening GDM before 24 WG in terms of improved obstetrical
outcomes as a much larger cohort would have been required. However, a randomised controlled trial has recently
shown that a panel of maternal and neonatal outcomes was no dierent in a group of high-risk women diagnosed
through screening at 14–20 WG versus those screened at 24–28 WG20. Furthermore, a large prospective trial has
shown variable pregnancy outcomes according to degree of insulin resistance in GDM, in which GDM with high
insulin resistance confers greater risk of poor pregnancy outcomes31. is is similar to the ndings of Sweeting
etal. who found that pre-term delivery, rates of Caesarean section and hypertension were as bad in women with
eGDM as in those with type 2 diabetes15. Finally the European DALI trial across nine countries found no signi-
cant dierence in any of the pregnancy outcomes between those diagnosed with eGDM, standard or later GDM or
with normal glucose tolerance28. Other on-going prospective trials such as the EDoGDM (NCT02740283)32 and
the follow-up to the TOBOGM33 pilot study will provide further information of the foetal outcomes aer eGDM.
In conclusion, the frequency of early postpartum glucose metabolism disorders is high, particularly impaired
fasting glycaemia. However, there is no signicant dierence in frequency of these disorders between eGDM and
standard GDM. ese results support measurement of fasting plasma glucose before 24 WG in at-risk patients.
Further studies are needed to conrm the threshold value for elevated glycameia in early pregnancy and to better
characterise the foetal and maternal outcomes.
Data availability
Data are available upon reasonable request to the corresponding author.
Received: 24 November 2020; Accepted: 15 April 2021
Pregnancy and delivery characteristics Group 1 (n = 353) Group 2 (n = 146) p
Analysed p atients (n = 273) 34 (17.7%) 14 (17.5%) 1
Macrosomia (birth weight ≥ 4000g)
Total population (n = 499) 32 (9.4%) 12 (8.3%) 0.85
Non-analysed patients (n = 226) 18 (11.8%) 6 (9.5%) 0.80
Analysed p atients (n = 273) 14 (7.4%) 6 (7.4%) 1
Foetal complications
Total population (n = 499) 106 (30.7%) 53 (36.6%) 0.24
Non-analysed patients (n = 226) 50 (32.7%) 19 (29.7%) 0.75
Analysed p atients (n = 273) 56 (29.2%) 34 (42.0%) 0.048
Birth weight (g)
Total population (n = 499) 3344.07 ± 555.88 3337.87 ± 454.01 0.41
Non-analysed patients (n = 226) 3415.41 ± 582.2 3338.02 ± 446.56 0.10
Analysed p atients (n = 273) 3287 ± 528.52 3337.75 ± 462.55 0.72
Table 3. Pregnancy and delivery characteristics and obstetrical outcomes. Statistically signicant p values
between groups are given in bold. Data are presented as number (%) or average ± standard deviation. *p < 0.05
for the comparison between Non-analysed and Analysed patients.
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Acknowledgements
e authors thank Carey Suehs for help draing the protocol and Dorian Multedo for data management.
Author contributions
V.C. and E.R. contributed to study design, data acquisition and critical revision of the manuscript. C.B., J.I., L.Z.,
P.B., P.M. and M.R. were involved in data acquisition and revising the manuscript. S.K. helped to interpret the
data and co-wrote the rst version of the manuscript. C.D. performed the statistical analysis and revised the
manuscript. A.M.G. conceived and coordinated the study, interpreted the data, helped to dra the manuscript and
is responsible for the integrity of the work as a whole. All authors reviewed the nal version of the manuscript.
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is study was funded by an internal grant from the CHU Nimes-Montpellier. e study sponsor/funder was
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... However, some pregnant women have high blood sugar in the early stages of pregnancy due to a missed diagnosis of pregestational diabetes mellitus (PGDM), which has a high prevalence in China [7,8]. Early screening for GDM is recommended for pregnant women with risk factors to improve pregnancy outcomes [9][10][11][12][13][14]. ...
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... Cosma et al. did not report any difference in postpartum hyperglycemia between 192 women with eGDM (elevated FPG as per IADPSG criteria) and 81 women with cGDM diagnosed as per the one-step criterion. However, the eGDM group had less incidence of preterm labor, more induced deliveries, and reduced fetal problems [54]. More studies are required to analyze the association between postpartum dysglycemia and eGDM. ...
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Preexisting diabetes mellitus (DM) should be ruled out early in pregnancy in those at risk. During screening, a significant proportion of women do not reach the threshold for overt DM but fulfill the criteria used for diagnosing conventional gestational DM (cGDM). There is no consensus on the management of pregnancies with intermediate levels of hyperglycemia thus diagnosed. We have used the term early gestational DM (eGDM) for this condition and reviewed the currently available literature. Fasting plasma glucose (FPG), oral glucose tolerance test, and glycated hemoglobin (HbA1c) are the commonly employed screening tools in early pregnancy. Observational studies suggest that early pregnancy FPG and Hba1c correlate with the risk of cGDM and adverse perinatal outcomes. However, specific cut-offs, including those proposed by the International Association of the Diabetes and Pregnancy Study Group, do not reliably predict the development of cGDM. Emerging data, though indicate that FPG ≥ 92 mg/dL (5.1 mmol/L), even in the absence of cGDM, signals the risk for perinatal complication. Elevated HbA1c, especially a level ≥ 5.9%, also correlates with the risk of cGDM and worsened outcome. HbA1c as a diagnostic test is however besieged with the usual caveats that occur in pregnancy. The studies that explored the effects of intervention present conflicting results, including a possibility of fetal malnutrition and small-for-date baby in the early treatment group. Diagnostic thresholds and glycemic targets in eGDM may differ, and large multicenter randomized controlled trials are necessary to define the appropriate strategy.
... Regardless of GDM status, maternal triglyceride levels, particularly in the third trimester, were found to be strong predictors of birth weight [55]. GDM is characterized by resistance to insulin and tolerance to glucose, which may persist after delivery [61,62] results exhibit a high frequency of early postpartum glucose abnormalities, for both early and typical GDM. [48] illustrated that even brief exposure to maternal diabetes during early development is enough to induce permanent changes in DNA methylation and expression of genes that control insulin secretion, implying a methylation-mediated epigenetic mechanism for GDM-induced intergenerational glucose intolerance. ...
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... Regardless of GDM status, maternal triglyceride levels, particularly in the third trimester, were found to be strong predictors of birth weight [55]. GDM is characterized by resistance to insulin and tolerance to glucose, which may persist after delivery [61,62] results exhibit a high frequency of early postpartum glucose abnormalities, for both early and typical GDM. [48] illustrated that even brief exposure to maternal diabetes during early development is enough to induce permanent changes in DNA methylation and expression of genes that control insulin secretion, implying a methylation-mediated epigenetic mechanism for GDM-induced intergenerational glucose intolerance. ...
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Full-text available
Maternal health associated with Gestational Diabetes Mellitus (GDM) has been gaining significant research attention due to its severe risk and adverse health effects. GDM is the leading health disease in pregnant women. It is the most common metabolic disease and it can affect up to 25% of women during pregnancy. Pregnancy is a sensitive period that impacts both pregnant women and their unborn children's long-term health. It is a well-known fact that the leading causes of disease and mortality worldwide are diabetes mellitus and cancer, and specifically, women with diabetes mellitus are at a higher risk of developing breast cancer (BC). Women who have diabetes are equally vulnerable to reproductive diseases. Reproductive dysfunctions with diabetes are mainly attributed to coexisting polycystic ovarian syndrome (PCOS), obesity, and hyperinsulinemia, etc. Moreover, India has long been recognized as the world's diabetic capital, and it is widely acknowledged that particularly pregnant and lactating women are among the most affected by diabetes. In India, one-third (33%) of women with GDM had a history of maternal diabetes. Nevertheless, the latest research suggests that gestational diabetes is also a risk factor for cardiometabolic diseases of the mother and offspring. Therefore, in the 21st century, GDM imposes a major challenge for healthcare professionals. We intend to explore the role of diabetes on female reproductive function throughout various stages of life in the perspective of the changing prognosis, prevalence, and prevention of GDM.
Preprint
Full-text available
Objective:To study the prediction of gestational diabetes mellitus (GDM) in high-risk pregnant women by testing the 1-hour (1hPG) and 2-hour plasma glucose (2hPG) after an oral glucose tolerance test and the glycated hemoglobin (HbA1c) in early pregnancy (6-14 weeks). Methodology:We recruited 1311 pregnant women at high risk for diabetes from the Obstetrics Clinic of Daxing District People's Hospital between June 2017 and December 2019. Fasting blood glucose (FPG) and HbA1c were tested and a 75 g oral glucose tolerance test (OGTT) with 1-hour blood glucose (1hPG) and 2-hour blood glucose (2hPG) was performed during the first trimester of pregnancy. The women were seen at 24-28 weeks to follow-up for GDM. We calculated the receiver operating characteristic (ROC) and the area under the ROC curve (AUC) to determine the predictive values for early pregnancy FPG, 1hPG, 2hPG, and HbA1c for GDM in high-risk pregnant women. Results:The prevalence of pregestational diabetes mellitus among pregnant women at high risk of diabetes was 5.6%, and GDM was 24.7%. The AUCs for the predictive value of FPG, 1hPG, 2hPG, and HbA1c in high-risk pregnant women were 0.64, 0.76, 0.71, and 0.67, respectively. The AUC for 1hPG prediction of GDM in high-risk pregnant women is greater than FPG, 2hPG, and HbA1c. All differences were statistically significant. Conclusion:FPG, 1hPG, 2hPG, and HbA1c measured in the first trimester pregnancy of high-risk women are significant predictors of GDM. 1hPG was the most significant predictive value for GDM in high-risk pregnant women.
Article
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Aims/hypothesis This study aimed to determine the characteristics and pregnancy outcomes across different subtypes of gestational diabetes mellitus (GDM) based on insulin resistance. Methods GDM subtypes were defined in 1813 pregnant women from a multicentre prospective cohort study, stratified according to insulin resistance, based on Matsuda index below the 50th percentile of women with normal glucose tolerance (NGT), during a 75 g OGTT at 24–28 weeks’ gestation. GDM was diagnosed in 12.4% (n = 228) of all participants based on the 2013 WHO criteria. Results Compared with women with NGT (1113 [61.4%] of the total cohort) and insulin-sensitive women with GDM (39 [17.1%] women with GDM), women with GDM and high insulin resistance (189 [82.9%] women with GDM) had a significantly higher BMI, systolic BP, fasting plasma glucose (FPG), fasting total cholesterol, LDL-cholesterol and triacylglycerol levels in early pregnancy. Compared with women with NGT, insulin-sensitive women with GDM had a significantly lower BMI but similar BP, FPG and fasting lipid levels in early pregnancy. Compared with women with NGT, women with GDM and high insulin resistance had higher rates of preterm delivery (8.5% vs 4.7%, p = 0.030), labour induction (42.7% vs 28.1%, p < 0.001), Caesarean section (total Caesarean sections: 28.7% vs 19.4%, p = 0.004; emergency Caesarean sections: 16.0% vs 9.7%, p = 0.010), neonatal hypoglycaemia (15.4% vs 3.5%, p < 0.001) and neonatal intensive care unit admissions (16.0% vs 8.9%, p = 0.003). In multivariable logistic regression analyses using different models to adjust for demographics, BMI, FPG, HbA1c, lipid levels and gestational weight gain in early pregnancy, preterm delivery (OR 2.41 [95% CI 1.08, 5.38]) and neonatal hypoglycaemia (OR 4.86 [95% CI 2.04, 11.53]) remained significantly higher in women with GDM and high insulin resistance compared with women with NGT. Insulin-sensitive women with GDM had similar pregnancy outcomes as women with NGT. The need for insulin treatment during pregnancy and the rate of glucose intolerance in the early postpartum period were not significantly different among the GDM subtypes. Conclusions/interpretation GDM with high insulin resistance represents a more adverse metabolic profile with a greater risk of adverse pregnancy outcomes.
Article
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Aims To compare pregnancy outcomes between women with gestational diabetes (GDM) diagnosed early and late in pregnancy in Japan. Materials and Methods We examined women diagnosed with GDM in this multi‐institutional retrospective study. Women were divided into two groups by gestational age at diagnosis: <24 weeks of gestation (early group, 14.4 ± 4.2 weeks) and ≥24 weeks of gestation (late group, 29.6 ± 3.4 weeks). Dietary counseling with self‐monitoring of blood glucose with or without insulin therapy was initiated for both groups. Pregnancy outcomes were compared between the groups. Results Data from 600 early and 881 late group participants from 40 institutions were included. Although pre‐pregnancy body mass index (BMI) was higher in the early group than in the late group, gestational weight gain was lower in the early group. Hypertensive disorders of pregnancy (HDP) and cesarean section were more prevalent in the early than in the late group (9.3% vs. 4.8%, p < 0.001; 34.2% vs. 32.0%, p < 0.001, respectively). The prevalence of large‐for‐gestational‐age infants was higher in the late than in the early group (24.6% vs. 19.7%, respectively, p = 0.025). There was no significant difference in other neonatal adverse outcomes between the groups. Multiple logistic regression analysis revealed that early group, nulliparity, and pre‐pregnancy BMI were associated with HDP. Conclusions These results suggest that maternal complications, including HDP and cesarean delivery, were higher in the early group than in the late group. Earlier intervention for GDM may be associated with a reduction in large‐for‐gestational‐age infants. This article is protected by copyright. All rights reserved.
Article
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Background and aims: Screening for Gestational Diabetes (GDM) is usually recommended between 24 and 28 weeks of pregnancy; however available evidence suggests that GDM may be already present before recommended time for screening, in particular among high-risk women as those with prior GDM or obesity. The purpose of this retrospective study was to evaluate whether early screening (16-18 weeks) and treatment of GDM may improve maternal and fetal outcomes. Methods and results: In 290 women at high-risk for GDM, we analyzed maternal and fetal outcomes, according to early or standard screening and GDM diagnosis time. Early screening was performed by 50% of high-risk women. The prevalence of GDM was 62%. Among those who underwent early screened, GDM was diagnosed at the first evaluation in 42.7%. Women with early diagnosis were more frequently treated with insulin and had a slightly lower HbA1c than women with who were diagnosed late. No differences were observed in the prevalence of Cesarean section, operative delivery, gestational age at the delivery, macrosomia, neonatal weight, Ponderal Index and Large-for-Gestational-Age among women with early or late GDM diagnosis or NGT. However, compared to NGT women, GDM women, irrespective of the time of diagnosis, had a lower gestational weight gain, lower prevalence of macrosomia (3.9% vs. 11.4%), small (1.7% vs. 8.3%) as well as large for gestational age (3.3% vs. 16.7%), but higher prevalence of pre-term delivery (8.9% vs. 2.7%). Conclusion: Early vs. standard screening and treatment of GDM in high-risk women is associated with similar short-term maternal-fetal outcomes, although women with an early diagnosis were treated to a greater extent with insulin therapy.
Article
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Objective To compare pregnancy outcomes in patients with early versus usual gestational diabetes mellitus (GDM). Design A retrospective cohort study. Settings The Women’s Hospital, Hamad Medical Corporation, Qatar. Participants GDM women who attended and delivered in the Women’s Hospital, between January and December 2016. GDM was diagnosed based on the 2013-WHO criteria. The study included 801 patients; of which, 273 E-GDM and 528 U-GDM. Early GDM (E-GDM) and usual GDM (U-GDM) were defined as GDM detected before and after 24 weeks’ gestation, respectively. Outcomes Maternal and neonatal outcomes and the impact of timing of GDM-diagnosis on pregnancy outcomes. Results At conception, E-GDM women were older (mean age 33.5±5.4 vs 32.0±5.4 years, p<0.001) and had higher body mass index (33.0±6.3 vs 31.7±6.1 kg/m ² , p=0.0059) compared with U-GDM. The mean fasting, and 1-hour blood glucose levels were significantly higher in E-GDM vs U-GDM, respectively (5.3±0.7 vs 4.0±0.7 mmol/L, p<0.001 and 10.6±1.7 vs 10.3±1.6 mmol/L, p<0.001). More patients in the U-GDM were managed on diet alone compared with E-GDM (53.6% vs 27.5%, p<0.001). E-GDM subjects gained less weight per week compared with U-GDM (0.02±0.03 vs 0.12±0.03 kg/week, p=0.0274). Maternal outcomes were similar between the two groups apart from a higher incidence of preterm labour (25.5% vs 14.4%; p<0.001) and caesarean section (52.4% vs 42.8%; p=0.01) in E-GDM vs U-GDM, respectively. After correction for covariates; gestational age at which GDM was diagnosed was associated with increased risk of macrosomia (OR 1.06, 95% CI 1.00 to 1.11; p<0.05) and neonatal hypoglycaemia (OR 1.05, 95% CI 1.00 to 1.11; p<0.05). Conclusion Our data support the concept of early screening and treatment of GDM in high-risk patients. More data are needed to examine the optimal time for screening.
Article
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The aim of this systematic review is to look at the barriers to uptake and interventions to improve uptake of postnatal screening in women who have had gestational diabetes mellitus (GDM). Increasing postnatal screening rates could lead to timely interventions that could reduce the incidence of type 2 diabetes mellitus (T2DM), the associated long-term health complications, and the financial burden of T2DM. A systematic review of the literature was undertaken. PubMed, Embase, Medline, CINAHL and the Cochrane library databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were used to identify relevant manuscripts. Data extractions and quality assessments were performed by one reviewer and checked by a second reviewer. Eleven primary studies of various research design and three systematic reviews were included. We identified seven themes within these studies and these were described in two categories, barriers and interventions. There appeared to be no single intervention that would overcome all the identified barriers, however, reminders to women and healthcare professionals appear to be most effective. Uptake rates of testing for T2DM are low in women with GDM. Interventions developed with consideration of the identified barriers to uptake could promote greater numbers of women attending for follow-up.
Article
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Gestational diabetes mellitus (GDM) is a serious pregnancy complication, in which women without previously diagnosed diabetes develop chronic hyperglycemia during gestation. In most cases, this hyperglycemia is the result of impaired glucose tolerance due to pancreatic β-cell dysfunction on a background of chronic insulin resistance. Risk factors for GDM include overweight and obesity, advanced maternal age, and a family history or any form of diabetes. Consequences of GDM include increased risk of maternal cardiovascular disease and type 2 diabetes and macrosomia and birth complications in the infant. There is also a longer-term risk of obesity, type 2 diabetes, and cardiovascular disease in the child. GDM affects approximately 16.5% of pregnancies worldwide, and this number is set to increase with the escalating obesity epidemic. While several management strategies exist—including insulin and lifestyle interventions—there is not yet a cure or an efficacious prevention strategy. One reason for this is that the molecular mechanisms underlying GDM are poorly defined. This review discusses what is known about the pathophysiology of GDM, and where there are gaps in the literature that warrant further exploration.
Article
Introduction This study aimed to assess the validity of applying the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria for the diagnosis of gestational diabetes mellitus (GDM) at any time during pregnancy. Research design and methods This multicenter cohort study was conducted at five Japanese facilities from January 2018 to April 2019. The study cohort included women at a high risk of GDM who met one or more of the following IADPSG criteria during early pregnancy: fasting plasma glucose (FPG) ≥92 mg/dL and 75 g oral glucose tolerance test (OGTT) value of ≥180 mg/dL at 1 hour, or ≥153 mg/dL at 2 hour (hereafter early-onset GDM). Women diagnosed with early-onset GDM were followed up without therapeutic intervention and underwent the 75 g OGTT again during 24–28 weeks of gestation. Those exhibiting the GDM patterns on the second 75 g OGTT were diagnosed with true GDM and treated, whereas those exhibiting the normal patterns were diagnosed with false positive early GDM and received no therapeutic intervention. Results Of the 146 women diagnosed with early-onset GDM, 69 (47%) had normal 75 g OGTT values at 24–28 weeks of gestation, indicating a false-positive result. FPG levels were significantly higher in the first 75 g-OGTT test than in the second 75 g-OGTT test (93 mg/dL and 87.5 mg/dL, respectively; p<0.001). FPG levels were high in 86 (59%) women with early-onset GDM during early pregnancy but in only 39 (27%) women during mid-pregnancy. Compared with false positive early GDM, true GDM was more frequently associated with adverse pregnancy outcomes. Conclusions Although women with early-onset GDM were followed up without treatment, the results of repeated 75 g OGTT during mid-pregnancy were normal in about 50%. Our data did not support the adoption of IADPSG thresholds for the diagnosis of GDM prior to 20 weeks of gestation.
Article
Background: Although in 2013 the American College of Obstetricians and Gynecologists recommended early screening for gestational diabetes in obese women, no studies demonstrate an improvement in perinatal outcomes with this strategy. Objective: We sought to determine if early screening for gestational diabetes improves perinatal outcomes in obese women. Study design: Randomized controlled trial comparing early gestational diabetes screening (14-20 weeks) to routine screening (24-28 weeks) in obese women (BMI≥30 kg/m2) at two tertiary care centers in the US. Screening was performed using a 50-g, 1-hr glucose challenge test followed by a 100-g, 3-hr glucose tolerance test if initial screen ≥135 mg/dL. Gestational diabetes was diagnosed using Carpenter-Coustan criteria. Women not diagnosed at 14-20 wks were rescreened at 24-28 wks. Exclusion criteria were pre-existing diabetes, major medical illness, bariatric surgery, and prior cesarean. The primary outcome was a composite of macrosomia (>4000g), primary cesarean, hypertensive disease of pregnancy, shoulder dystocia, neonatal hyperbilirubinemia, and neonatal hypoglycemia (assessed within 48 hours of birth). Results: A total of 962 women were randomized, and outcomes were available for 922. Of these 922, 459 (49.8%) to early screen and 463 (50.2%) to routine screen. Baseline characteristics were balanced between groups. In the early screening group, 69 (15.0%, 95% CI 11.9-18.6%) were diagnosed with gestational diabetes: 29 (6.3%, 95% CI 4.3-8.9%) <20 wks and 40 (8.7%, 95% CI 6.3-11.7%) >24 wks. Of those randomized to routine screening, 56 (12.1%, 95% CI 9.3-15.4%) had gestational diabetes. Early screening did not reduce the incidence of the primary outcome (56.9% in early screen vs 50.8% in routine screen, p=0.07, RR 1.12, 95% CI 0.99-1.26). Conclusion: Early screening for gestational diabetes in obese women did not reduce the composite perinatal outcome.
Article
Aims: In addition to screening for hyperglycaemia during pregnancy after 24 weeks of gestation (WG), the current guidelines also suggest screening in early pregnancy and referring women with early gestational diabetes mellitus (eGDM) or overt diabetes (OD) for immediate care. Our aim was to evaluate this strategy. Methods: This study evaluated, at our hospital (2012-2016), whether the incidence of a predefined composite outcome (preeclampsia, large-for-gestational-age infant, shoulder dystocia) and secondary outcomes was different when women were screened only after 22WG ('late screening only') or before 22WG and treated for eGDM or OD if present, with repeat screening after 22WG if absent ('early ± late screening'). Results: Early ± late screening (n = 4605, 47.0%) increased between 2012 and 2016 (P < 0.0001) and was associated with more risk factors for GDM than late screening only. Glycaemic status differed in both groups (early ± late screening: eGDM 10.3%, GDM 12.1%, OD 0.9% vs. late screening only: GDM 16.8%, OD 1.2%; P < 0.001), with a higher rate of insulin therapy (8.9% vs. 6.0%; P < 0.001) and less gestational weight gain (11.1 ± 5.4 kg vs. 11.4 ± 5.5 kg; P = 0.013) in the early ± late screening group. Rates of those meeting the composite criterion were similar in both groups [11.6% vs. 12.0%, respectively; odds ratio (OR): 1.040, 95% confidence interval (CI): 0.920-1.176; P = 0.53] and remained comparable after adjusting for Propensity Scores (OR: 1.046, 95% CI: 0.924-1.185; P = 0.4790). Rates for secondary outcomes were also similar in both groups. Conclusion: While a strategy including early measurement of fasting plasma glucose during pregnancy increases the incidence and care of hyperglycaemia during pregnancy, it may not significantly improve pregnancy outcomes.
Article
Objectif Les recommandations du diabète gestationnel (DG) permettent d’identifier soit des patientes dépistées précocement « DG précoce » soit des patientes dépistées après 24 SA identifiées comme « DG tardif ». Il semble qu’il y ait un consensus pour définir le « DG précoce »lorsque le diagnostic est posé avant 20 SA. L’objectif principal est de comparer les issues de grossesses parmi les 2 populations. Patient et méthodes Étude rétrospective de patientes DG selon l’IADPSG entre le 1/02/2011 et le 31/12/2016. La prise en charge a été faite selon les recommandations. L’association entre le moment du diagnostic et la macrosomie a été étudiée avec une régression logistique avec ajustement sur les facteurs confondants. Résultats Les DG précoces représentent 48,9 % des patientes (n = 1445), et 1503 patientes ont un « DG tardif ». Les DG précoces ont un IMC pré-gestationnel plus élevé que les « DG tardif » (p < 0,001). L’HbA1c est plus basse dans le groupe « DG précoce » (p < 0,001). Environs 41,2 % des DG précoces ont eu une insulinothérapie versus 22,4 % dans le groupe DG tardif (p < 0,001). Les taux de LGA sont respectivement de 17,69 % versus 17,70 % dans les 2 groupes. Après ajustement, aucune association n’était retrouvée entre le moment du diagnostic et la macrosomie (OR = 1,07, IC 95 % : 0,88–1,30) avec catégorie de diagnostic précoce en référence. Discussion Cette étude réalisée dans une large cohorte montre que le moment du diagnostic de DG « précoce versus tardif » ne semble pas modifier le risque de LGA.