Preconception care of women with diabetes

Preconception care in women with diabetes reduces the risk of spontaneous abortion and congenital malformations as a result of improved glycemic control before and during organogenesis. Prepregnancy planning encompasses optimizing glycemic control and also affording the opportunity for genetic counseling, contraceptive selection, management of diabetes complications, and evaluation of psychosocial aspects of pregnancy, childbearing, and diabetes care. The purpose of this article is to provide nurses with current clinical assessment and management strategies of women with diabetes in order to implement a comprehensive individualized preconception plan of care.     

Risk of congenital anomalies detected during antenatal serum screening in women with pregestational diabetes

BACKGROUND: Most studies comparing women with and without pregestational diabetes mellitus have not systematically screened for fetal anomalies in early pregnancy, potentially leading to selection bias. AIM: To evaluate the risk for certain congenital anomalies in women participating in an antenatal maternal screening program. DESIGN: Retrospective cohort study. METHODS: We studied all women who underwent antenatal maternal serum screening in Ontario from 1994 to 2000. Fetal anomalies were documented antenatally by ultrasonography or at autopsy, and postnatally diagnosed birth defects were recorded after 20 weeks gestational age for all live- and stillborn affected infants. We compared the risk of open neural tube defects and urinary tract defects among women with and without pregestational diabetes. RESULTS: Of 413,219 women screened during pregnancy, 2069 (0.5%) had diabetes. Compared to non-diabetic women, the adjusted odds ratios (95%CI) for neural tube and urinary tract defects among women with diabetes were 2.5 (0.9-6.8) and 2.6 (1.4-4.9), respectively. DISCUSSION: Among women who undergo second trimester maternal serum screening, pregestational diabetes is associated with an increased risk of having a fetus with an open neural tube defect or urinary tract disorder.     

Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes

OBJECTIVE: We sought to determine whether a history of gestational diabetes mellitus (GDM) further increases the risk of cardiovascular disease (CVD) in parous women with first-degree relatives with type 2 diabetes. RESEARCH DESIGN AND METHODS: Women with (n = 332) and without (n = 663) a history of GDM were compared regarding 1) the revised National Cholesterol Education Program Adult Treatment Panel III metabolic syndrome criteria, 2) the prevalence of type 2 diabetes, and 3) self-reported CVD. RESULTS: Women with prior GDM were younger (48.6 +/- 0.7 vs. 52.4 +/- 0.6 years [means +/- SE];P < 0.001) and less likely to be postmenopausal (48.3 vs. 57.9%; P < 0.005). Although both groups were obese (BMI 34.4 +/- 1.2 vs. 33.7 +/- 0.6 kg/m(2)), women with prior GDM were more likely to have metabolic syndrome (86.6 vs. 73.5%; P < 0.001) and type 2 diabetes (93.4 vs. 63.3%; P < 0.001). Moreover, they had a higher prevalence of CVD (15.5 vs. 12.4%; adjusted odds ratio 1.85 [95% CI 1.21-2.82];P = 0.005) that occurred at a younger age (45.5 +/- 2.2 vs. 52.5 +/- 1.9 years;P = 0.02) and was independent of metabolic syndrome (1.74 [1.10-2.76]; P = 0.02) and type 2 diabetes (1.56 [1.002-2.43];P < 0.05). CONCLUSIONS: Among women with a family history of type 2 diabetes, those with prior GDM were even more likely to not only have CVD risk factors, including metabolic syndrome and type 2 diabetes, but also to have experienced CVD events, which occurred at a younger age. Thus, women with both a family history of type 2 diabetes and personal history of GDM may be especially suitable for early interventions aimed at preventing or reducing their risk of CVD and diabetes.     

The knowledge of women with diabetes mellitus regarding preconception care and maternal-fetal risks

The objective of this study was to describe the reproductive profile of women with diabetes mellitus (DM) and to identify their knowledge regarding maternal and fetal risks and preconception care. This exploratory study was performed at the Integrated Center for Hypertension and Diabetes, from March to July 2009, on a sample consisting of 106 women. The variables were: number of pregnancies, births and abortions, and planning the pregnancy. The data were collected through interviews that followed a preconceived form. The reproductive profile of women with DM proved to be permeated with risks and showed negative repercussions to maternal and fetal health. Of the 106 (100%) women studied, 44 (41.5%) demonstrated adequate knowledge regarding preconception care, while 58 (54.7%) had limited knowledge regarding maternal and fetal risks. It is necessary to provide information to women with diabetes to promote knowledge of maternal and fetal risks and preconceptional care.     

A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors: a feasibility randomized control trial

OBJECTIVE

To pilot, among women with gestational diabetes mellitus (GDM), the feasibility of a prenatal/postpartum intervention to modify diet and physical activity similar to the Diabetes Prevention Program. The intervention was delivered by telephone, and support for breastfeeding was addressed.

RESEARCH DESIGN AND METHODS

The goal was to help women return to their prepregnancy weight, if it was normal, or achieve a 5% reduction from prepregnancy weight if overweight. Eligible participants were identified shortly after a GDM diagnosis; 83.8% consented to be randomly assigned to intervention or usual medical care (96 and 101 women, respectively). The retention was 85.2% at 12 months postpartum.

RESULTS

The proportion of women who reached the postpartum weight goal was higher, although not statistically significant, in the intervention condition than among usual care (37.5 vs. 21.4%, absolute difference 16.1%, P = 0.07). The intervention was more effective among women who did not exceed the recommended gestational weight gain (difference in the proportion of women meeting the weight goals: 22.5%, P = 0.04). The intervention condition decreased dietary fat intake more than the usual care (condition difference in the mean change in percent of calories from fat: −3.6%, P = 0.002) and increased breastfeeding, although not significantly (condition difference in proportion: 15.0%, P = 0.09). No differences in postpartum physical activity were observed between conditions.

CONCLUSIONS

This study suggests that a lifestyle intervention that starts during pregnancy and continues postpartum is feasible and may prevent pregnancy weight retention and help overweight women lose weight. Strategies to help postpartum women overcome barriers to increasing physical activity are needed.Gestational diabetes mellitus (GDM) is glucose intolerance with onset or first diagnosis during pregnancy (1). GDM complicates between 7–14% of pregnancies in the U.S. (1), and its incidence has increased 35–100% (2). A history of GDM is one of the strongest risk factors for type 2 diabetes (3). Among women with a history of GDM, the cumulative risk of developing type 2 diabetes at 10 years postpartum ranges from 20 to 50% (4,5). There is strong evidence from efficacy trials in at-risk individuals (6–8) that type 2 diabetes is preventable by lifestyle interventions focusing on weight management.Despite this evidence, no lifestyle interventions for diabetes prevention starting during pregnancy and continuing postpartum have been translated for use in women with GDM. There are several reasons for starting an intervention soon after the diagnosis of GDM. First, women who exceed the Institute of Medicine (IOM) guidelines for gestational weight gain (GWG) retain twice as much weight compared with women who gain within the recommendations (9), and this is associated with an increased likelihood of long-term obesity (9–11). Second, a lifestyle intervention that starts soon after the diagnosis of GDM takes advantage of the “teachable moment” of pregnancy; women with GDM may be concerned about their children’s increased risk of adverse health outcomes and their own increased risk of diabetes, which could motivate the adoption of preventive behaviors. Third, GDM patients’ frequent interactions with the health care system during and after pregnancy present an opportunity for such an intervention to be adopted by the health care system. However, participation in such an intervention may not be feasible for women with young children who are also likely to work outside home.The aim of this randomized pilot trial was to evaluate the feasibility of a lifestyle intervention initiated soon after the diagnosis of GDM and continuing postpartum. The primary goals of the intervention were to help women return to their pregravid weight if normal weight before pregnancy or achieve a 5% reduction from their pregravid weight if overweight or obese before pregnancy. The intervention curriculum was adapted from the Diabetes Prevention Program (DPP) (12) but delivered primarily by telephone (instead of individual, in-person counseling sessions) to make it more accessible to pregnant and postpartum women and feasible for the health care system.     

Maternal serum level of resistin is associated with risk for gestational diabetes mellitus:A meta-analysis

BACKGROUND Resistin is most likely involved in the pathogenesis of gestational diabetes mellitus(GDM), but the existing findings are inconsistent.AIM To review the literature investigating the associations of the risk of GDM with serum level of resistin.METHODS A systematic literature search was performed using MEDLINE, EMBASE, and Web of Science(all databases). This meta-analysis included eligible studies that:(1) investigated the relationship between the risk of GDM and serum resistin;(2)included GDM cases and controls without GDM;(3) diagnosed GDM according to the oral glucose-tolerance test;(4) were performed in humans;(5) were published as full text articles in English; and(6) provided data with median and quartile range, median and minimum and maximum values, or mean and standard deviation. The pooled standardized mean difference(SMD) and 95%confidence interval(CI) were calculated to estimate the association between the risk of GDM and serum resistin. To analyze the potential influences of need for insulin in GDM patients and gestational age at blood sampling, we performed a subgroup analysis. Meta-regression with restricted maximum likelihood estimation was performed to assess the potentially important covariate exerting substantial impact on between-study heterogeneity.RESULTS The meta-analysis for the association between serum resistin level and GDM risk included 18 studies(22 comparisons) with 1041 cases and 1292 controls. The total results showed that the risk of GDM was associated with higher serum resistin level(SMD = 0.250, 95%CI: 0.116, 0.384). The "after 28 wk" subgroup, "no need for insulin" subgroup, and "need for insulin" subgroup indicated that higher serum resistin level was related to GDM risk("after 28 wk" subgroup: SMD =0.394, 95%CI: 0.108, 0.680; "no need for insulin" subgroup: SMD = 0.177, 95%CI:0.018, 0.336; "need for insulin" subgroup: SMD = 0.403, 95%CI: 0.119, 0.687). The"before 14 wk" subgroup, "14-28 wk" subgroup, and "no information of need for insulin" subgroup showed a nonsignificant association between serum resistin level and GDM risk("before 14 wk" subgroup: SMD = 0.087, 95%CI:-0.055, 0.230;"14-28 wk" subgroup: SMD = 0.217, 95%CI:-0.003, 0.436; "no information of need for insulin" subgroup: SMD = 0.356, 95%CI:-0.143, 0.855). The postpartum subgroup included only one study and showed that higher serum resistin level was related to GDM risk(SMD = 0.571, 95%CI: 0.054, 1.087) The meta-regression revealed that no need for insulin in GDM patients, age distribution similar between cases and controls, and ELISA all had a significant impact on between-study heterogeneity.CONCLUSION This meta-analysis supports that the maternal serum resistin level is associated with GDM risk.     

Preconception care & pregnancy planning: voices of African American women

PURPOSE: This study aimed to investigate the intersection of women's pregnancy planning beliefs with preconception care barriers. We assessed the meaning of "planned pregnancy" for African American women and explored its connection to preconception experiences. The role of race and economics as contextualizing women's experiences was considered. STUDY DESIGN/METHODS: African American women (n = 168) recruited from health department sites discussed the following questions: "What does the term 'planned pregnancy' mean?" "Would you describe your most recent pregnancy as planned?" Substantive themes were extracted using phenomenological methodology. RESULTS: The following themes emerged: (1) Preconception care: An unfamiliar concept; (2) Planning for pregnancy: A continuum of responses; (3) The psychology of conception: Attitudes, beliefs, and behaviors; (4) The shared nature of pregnancy: It takes two to plan; (5) Birth control: The means to the end; and (6) The context of preconception care: The big picture. CLINICAL IMPLICATIONS: Nurses who care for women in the childbearing years should understand that planning for pregnancy is not a simple cognitive process, and that race and economics play a role in women's beliefs about pregnancy. Preconception care also encompasses the contexts of family, public health, and society. Linking preconception care with all medical encounters is an important but insufficient approach. Nurses should apply their understanding of the biopsychosocial dimensions of health in support of the goals of preconception healthcare. Holistic nursing and public health perspectives should be considered to broaden the scope of preconception interventions and more effectively address social factors that influence preconception care.     

Long-acting injectable progestin contraception and risk of type 2 diabetes in Latino women with prior gestational diabetes mellitus

OBJECTIVE: To investigate the impact of a long-acting injectable progestin, depo-medroxyprogesterone acetate (DMPA), compared with combination oral contraceptives (COCs) on the risk of diabetes in Latino women with prior gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: An observational cohort study of 526 Hispanic women with prior GDM who were not diabetic in their postpartum visit during January 1987 to October 1997 and who elected DMPA (n = 96) or COCs (n = 430) as initial contraception were followed for a maximum of 9.2 years with a median follow-up of approximately 12 months. Oral glucose tolerance tests were performed and choice of contraception method was recorded at each visit as part of routine clinical care. RESULTS: Annual diabetes incidence rates were 19% in the DMPA group and 12% in the COC group, with an unadjusted hazard ratio (HR) of 1.58 (95% CI 1.00-2.50; P = 0.05) for DMPA compared with COCs. Adjustment for baseline imbalances reduced the HR to 1.18 (0.67-2.28; P = 0.57). Additional adjustment for weight gain during follow-up, which was on average 1.8 kg higher in the DMPA group (P < 0.0001), reduced the HR to 1.07. DMPA interacted with baseline serum triglyceride levels and, separately, with breast-feeding to increase the diabetes risk. CONCLUSIONS: DMPA use was associated with an increased risk of diabetes that appeared to be explained by three factors: 1) use in women with increased baseline diabetes risk, 2) weight gain during use, and 3) use with high baseline triglycerides and/or during breast-feeding.     

妊娠期糖尿病孕妇产后转归及保健情况调查

目的：了解妊娠期糖尿病（GDM）孕妇产后2年转归情况、保健现状和产后保健需求,为完善GDM孕妇产后保健、减少不良转归提供参考。方法：通过便利抽样对2年内在天津市某三级甲等医院产科分娩的妊娠期糖尿病孕妇产后转归现状及保健需求进行问卷调查。结果：13.6%GDM孕妇出现产后体质量滞留;56.5%GDM孕妇产后从未监测过血糖,4.2%GDM孕妇在产后不同时间出现了糖耐量受损,1例GDM孕妇产后2年内已确诊2型糖尿病;59.7%GDM孕妇在产后42天内进行了产后保健,34.6%GDM孕妇从未进行过产后保健,36.1%GDM孕妇没有得到任何相关专业人士的指导;GDM孕妇更希望由妇产科医生、助产士、社区保健医生通过孕妇学校课程、宣传手册、微信公众号等线上形式提供新生儿保健指导、膳食指导、运动指导、主要照护者健康教育等保健内容。结论：目前GDM孕妇对血糖变化重视程度较低,自我监测意识较差;产后保健不够系统、规范,未来应进一步加强筛查与管理,以减少GDM产后不良转归的发生。     

Elevated homocysteine as a risk factor for the development of diabetes in women with a previous history of gestational diabetes mellitus: a 4-year prospective study

OBJECTIVE: To investigate the potential use of the plasma homocysteine level as a predictor of diabetes in women with a previous history of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: At 6 weeks' postpartum, baseline examination was performed in 177 GAD-negative subjects. Of these subjects, 7 who were diagnosed with diabetes at baseline were excluded from further evaluation, and 170 with normal or impaired glucose tolerance (IGT) at baseline were followed annually over 4 years. The follow-up examinations included 2-h 75-g oral glucose tolerance tests (OGTTs), lipid profiles, homocysteine levels, anthropometric measurements, history taking, diet, and lifestyle. During the OGTTs, insulin and glucose levels were assayed every 30 min. Plasma homocysteine levels were determined by ion-exchange chromatography. RESULTS: Of the 170 women, 18 (10.6%) converted to diabetes during the 4-year follow-up period. Mean age, BMI, fasting insulin, and total cholesterol at baseline (6 weeks' postpartum test) were similar in the three study groups (i.e., normal, IGT, and diabetes). Fasting glucose levels, insulin-to-glucose ratios, and homocysteine levels were significantly higher in the diabetic group (P < 0.05). Higher glucose at the time of the diagnosis of GDM and higher homocysteine levels at baseline were independently associated with the onset of postpartum diabetes. These relationships were independent of age, BMI, and family history of diabetes. CONCLUSIONS: This prospective study identified homocysteine level as a significant risk factor for development of diabetes in women with previous GDM.     

Features of pregnant women with diabetes mellitus

It is about a quantitative study aimed at knowing the features of 105 pregnant women attended at Hospital de Clínicas de Porto Alegre, Brazil, from January 2000 to January 2001. The results allowed the analysis of the delivery as well as baby conditions in addition to the values of the glycemia profile during the gestation. Moreover, they supplied information regarding the completion of the gestations of diabetic women that have made their pre-natal care at the hospital. These results provide significant input for the health team that attend this group of pregnant women and safety for the team performance and, as a result, for the pregnant women.