Recurrent gestational diabetes: risk factors, diagnosis, management, and implications

Gestational diabetes mellitus (GDM) should be regarded as a sentinel event in a woman's life that presents challenges and disease prevention opportunities to all providers of health care for women of reproductive age. Prediabetic risk factors are rising in prevalence and include dietary and lifestyle habits, which when superimposed on genetic predisposition contribute to the rising prevalence of type 2 diabetes and GDM. There is growing evidence that treatment of GDM matters, with a continuum of adverse pregnancy outcome risks proportional to degrees of maternal glucose intolerance. GDM in an index pregnancy increases the risk of recurrent GDM in subsequent pregnancies, and recurrence rates of up to 70% have been reported. GDM recurrence rates are influenced by maternal health characteristics and past pregnancy history. The risk of later metabolic syndrome and type 2 diabetes is increased in women with a history of GDM and women should be screened for postpartum glucose intolerance. Opportunities to prevent recurrent GDM and later type 2 diabetes require attention to risk factors and plasma glucose status with identification of impaired fasting glucose or impaired glucose tolerance.     

妊娠期糖尿病产后发展为2型糖尿病的相关因素研究进展

妊娠期糖尿病（GDM）是产科常见并发症,会增加妊娠风险。由于生活方式和饮食结构的改变,GDM发病率逐年上升。大部分GDM患者产后短期内血糖会恢复正常,但生活中远期发生2型糖尿病（T2DM）的风险并未降低,GDM妇女已经成为日后发生糖尿病、代谢综合征的潜在危险人群。GDM发展为T2DM的相关危险因素很多,如高龄、肥胖和糖尿病家族史,另外空腹血糖水平、孕期胰岛素治疗、早发型GDM也逐渐被重视。通过认识GDM发展为T2DM的相关危险因素和包括临床特征、生化指标、基因等多种早期预测标志物,预测T2DM发生的风险,以利于提高公众风险意识及GDM妇女产后随访,可以提前进行生活方式干预或药物治疗,预防和延缓T2DM的发生,改善健康结局。     

Systematic Review of Lifestyle Interventions for Gestational Diabetes Mellitus in Pregnancy and the Postpartum Period

ObjectiveTo examine the characteristics and effectiveness of lifestyle interventions for gestational diabetes mellitus (GDM) in pregnancy and the postpartum period to prevent Type 2 diabetes.Data SourcesWe conducted searches in seven databases, including Ovid MEDLINE, CINAHL, Ovid Embase, Cochrane Central, Web of Science, Ovid PsycInfo, and ProQuest Dissertations and Theses for articles published from inception to January 2021.Study SelectionWe included articles on controlled intervention studies in which researchers evaluated a lifestyle intervention provided during pregnancy and the postpartum period for women with or at risk for GDM that were published in English.Data ExtractionTwelve articles that were reports of seven studies met the inclusion criteria. In some cases, more than one article was selected from the same study. For example, articles reported different outcomes from the same study. We extracted data with the use of a data collection form and compared and synthesized data on study design, purpose, sample, intervention characteristics, recruitment and retention, and outcomes.Data SynthesisAll seven studies focused on weight management and/or healthy lifestyle behaviors (diet and physical activity). Outcomes included glucose regulation, weight, lifestyle behaviors, and knowledge. The interventions varied in duration/dosage, strategies, and modes of delivery. In four studies, researchers reported interventions that had significant effects on improving glucose regulation and/or weight change. Some characteristics from the four effective interventions included goal setting, individualized care, and good retention rates. In the other three studies, limitations included low rates of participant retention, lack of personalized interventions, and limited population diversity or lack of culturally sensitive care.ConclusionLifestyle interventions provided during and after pregnancy to reduce the risk associated with GDM have the potential to improve outcomes. Health care counseling to promote healthy lifestyle behaviors related to the prevention of Type 2 diabetes is needed at different stages of maternity care for women with GDM. Additional high-quality studies are needed to address the limitations of current studies.     

Dietary advices on carbohydrate intake for pregnant women with type 1 diabetes

The impact of the quality and quantity of carbohydrate intake on glycaemic control and pregnancy outcome was evaluated with focus on pregnant women with type 1 diabetes. For women with type 1 diabetes, a gestational weight gain within the lower range of the guidelines of the Institute of Medicine (IOM) is generally recommended. A low-glycaemic index diet is considered safe, and has shown, positive effects on the glycaemic control and pregnancy outcomes for both healthy women, those with type 2 diabetic and gestational diabetes (GDM). In general, carbohydrate counting does improve glycaemic control in type 1 diabetes. A moderately low carbohydrate diet with a carbohydrate content of 40% of the calories results in better glycaemic control and comparable obstetric outcomes in type 2 diabetes and GDM when compared to a diet with a higher carbohydrate content, and is regarded safe in diabetic pregnancy. In type 1 diabetes pregnancy, a moderately low carbohydrate diet with 40% carbohydrates has been suggested; however, a minimum intake of 175?g carbohydrate daily is recommended. Despite limited evidence the combination of a low-glycaemic index diet with a moderately low carbohydrate intake, using carbohydrate counting can be recommended for pregnant women with type 1 diabetes.     

妊娠期糖尿病健康生活方式管理

妊娠期糖尿病是妊娠期常见并发症,生活方式干预是妊娠期糖尿病的重要治疗措施。规范、专业、多学科团队协作的孕期健康生活方式管理有助于调控血糖,改善妊娠期糖尿病不良妊娠结局及母儿预后。     

Gestational diabetes

Gestational diabetes mellitus (GDM) is the commonest medical condition in pregnancy. It is associated with a range of maternal and infant complications including large-for-gestational-age, stillbirth, pre-term birth, shoulder dystocia, caesarean section, and neonatal hypoglycaemia. Increasingly, longer-term metabolic risks are also being recognized for women who have GDM and their children. Because the relationship between maternal glucose and complications is linear, the appropriate thresholds for diagnosis and treatment remain controversial. Because screening for and treating, GDM can improve outcomes for women and their children, optimizing management warrants widespread attention and implementation. Diet and lifestyle interventions offer sufficient treatment for the majority of women with GDM, however evidence to support specific dietary interventions, and to support either oral hypoglycaemic agents or insulin as the preferred pharmacotherapy is inconsistent. This review provides an up-to-date summary of evidence related to prevention, screening, diagnosis, management, and follow-up of GDM.     

Promoting health after gestational diabetes: a National Diabetes Education Program call to action

The National Diabetes Education Program joins the American College of Obstetricians and Gynecologists (the College) to promote opportunities for obstetrician-gynecologists (ob-gyns) and other primary care providers to better meet the long-term health needs of women with prior gestational diabetes mellitus (GDM) and their children. Up to one third of GDM women may have diabetes or prediabetes postpartum, yet only about half of these women are tested postpartum, and about a quarter are tested 6-12 weeks postpartum. Women with GDM face a lifelong increased risk for subsequent diabetes, primarily type 2 diabetes mellitus. Timely testing for prediabetes may provide an opportunity for ob-gyns to prevent or delay the onset of type 2 diabetes mellitus through diet, physical activity, weight management, and pharmacologic intervention. The College and the American Diabetes Association recommend testing women with a history of GDM at 6-12 weeks postpartum. If the postpartum test is normal, retest every 3 years and at the first prenatal visit in a subsequent pregnancy. If prediabetes is diagnosed, test annually. Because children of GDM pregnancies face an increased risk for obesity and type 2 diabetes mellitus, families need support to develop healthy eating and physical activity behaviors. Current criteria indicate that GDM occurs in 2% to 10% of all pregnancies. If new GDM diagnostic criteria are used, the frequency of GDM may increase to about 18% of pregnancies annually. The projected increase in the number of women with GDM and the potential subsequent associated risks underscore the need for proactive long-term primary care treatment of the mother and her children.     

Interconception Care for Women With Prior Gestational Diabetes Mellitus

The diagnosis of gestational diabetes mellitus (GDM) signals greater pregnancy risk but also increased lifelong risk of developing diabetes and cardiovascular disease. In women with GDM, insulin resistance exceeds that observed in normal pregnancy and to varying degrees may persist or worsen after birth. Therefore, during postpartum and interconception periods, women with a history of GDM must be monitored for manifestations of increasing insulin resistance, hyperglycemia, dyslipidemia, hypertension, and increased adiposity. Care of women with prior GDM in the postpartum and interconception periods affords clinicians a unique opportunity for targeted screening and health promotion. The objective of this review was to synthesize evidence related to interconception care for women following a pregnancy complicated by GDM and to suggest principles of care: 1) case finding and multiple patient/clinician reminders for women with prior GDM are necessary so that screening occurs in the postpartum through interconception periods; 2) monitoring of metabolic (glucose) and cardiovascular risk (lipids, blood pressure, adiposity) should occur at regular intervals and more often in women with additional risk factors such as insulin use during pregnancy, early diagnosis of GDM, obesity, prediabetes, and dyslipidemia; 3) breastfeeding and use of long‐term contraception should be encouraged; and 4) lifestyle modifications that are effective in preventing and delaying disease should be encouraged.     

Pregnancy resolutions among pregnant teens: termination,parenting or adoption?

Women with gestational diabetes mellitus (GDM) and their offsprings are at increased risk of future type 2 diabetes and metabolic abnormalities. Early diagnosis and proper management of GDM, as well as, postpartum follow-up and preventive care is expected to reduce this risk. However, no large scale prospective studies have been done particularly from the developing world on this aspect. The objective of this study is to identify and follow a cohort of pregnant women with and without GDM and their offspring to identify determinants and risk factors for GDM, for various pregnancy outcomes, as well as, for the development of future diabetes and metabolic abnormalities. This is a prospective cohort study involving pregnant women attending prenatal clinics from urban, semi-urban and rural areas in the greater Chennai region in South India. Around 9850 pregnant women will be screened for GDM. Socio-economic status, demographic data, obstetric history, delivery and birth outcomes, perinatal and postnatal complications, neonatal morbidity, maternal postpartum and offsprings follow-up data will be collected. Those diagnosed with GDM will initially be advised routine care. Those unable to reach glycaemic control with diet alone will be advised to take insulin. Postpartum screening for glucose abnormalities will be performed at months 3 and 6 and then every year for 10 years. The offsprings will be followed up every year for anthropometric measurements and growth velocity, as well as, plasma glucose, insulin and lipid profile. In addition, qualitative research will be carried out to identify barriers and facilitators for early GDM screening, treatment compliance and postpartum follow-up and testing, as well as, for continued adherence to lifestyle modifications. The study will demonstrate whether measures to improve diagnosis and care of GDM mothers followed by preventive postpartum care are possible in the routine care setting. It will also map out the barriers and facilitators for such initiatives and provide new evidence on the determinants and risk factors for both GDM development and occurrence of adverse pregnancy outcomes and development of future diabetes and metabolic abnormalities in the GDM mother and her offspring.     

Natural course of gestational diabetes mellitus: long term follow up of women in the SPAWN study

Objectives Long term follow up women with gestational diabetes mellitus (GDM).
Design Case–control study.
Setting Academic obesity unit.
Population Women earlier identified as having gestational diabetes mellitus.
Method Twenty-eight women diagnosed with GDM in 1984–1985, and a control group (   n = 52  ) who gave birth at the same time performed a 2-h oral glucose tolerance test 15 years later. Basic anthropometry and questions about various aspects of eating and exercise habits were furthermore obtained.
Results Ten women (35%) in the GDM group were diagnosed with type 2 diabetes mellitus and none in the control group (   P < 0.001  ). Mean BMI in the diabetic group was  27.4 kg/m²  and in the non-diabetic GDM group  24.6 kg/m² ( P < 0.05)  . The mean weight gain since the first child was 8.4 kg in all GDM versus 8.1 kg in controls (ns). The women who developed type 2 diabetes mellitus, however, gained 15.1 kg since the birth of their first child (   P < 0.05  ).
Conclusions Women who are diagnosed with GDM have a considerably higher risk of developing type 2 diabetes mellitus later in life. Despite a close medical monitoring during pregnancy, the further follow up within the health care system and information about long term consequences of GDM for later type 2 diabetes mellitus development seems to be generally lacking. More active strategies for future weight control and lifestyle advice after delivery might therefore be indicated for women with GDM.     

Maternal obesity and pregnancy complications: a review

Obesity in women of reproductive age is increasing at an unprecedented rate in western societies. Maternal obesity is associated with an unequivocal increase in maternal and fetal complications of pregnancy. Excessive maternal weight gain in pregnancy also appears to be an independent risk factor, regardless of prepregnancy weight. Few guidelines exist regarding appropriate weight gain in pregnancy in obese women. We review the association of maternal obesity with pregnancy complications. We also suggest that appropriate diet and lifestyle intervention can enable women with severe prepregnancy obesity to safely achieve quite strict targets for limited weight gain in pregnancy.     

Beliefs about health and illness in women managed for gestational diabetes in two organisations

OBJECTIVE: to explore beliefs about health, illness and health care in women with gestational diabetes mellitus (GDM) managed in two different organisations based on diabetology or obstetrics. DESIGN: an explorative qualitative study using semi-structured interviews. SETTING: clinic A: a specialist diabetes clinic with regular contact with a diabetologist and antenatal care provided by a midwife; clinic B: a specialist maternity clinic providing regular contact with a midwife, a structured programme for self-monitoring of blood glucose and insulin treatment, and a 1-day diabetes class by an obstetrician, a diabetologist, a midwife and a dietician. The clinics were located at two different university hospitals in Sweden. PARTICIPANTS: a consecutive sample of Swedish women diagnosed with GDM; 13 managed in clinic A and 10 managed in clinic B. MEASUREMENT AND FINDINGS: women described their perceptions of as well-being, being healthy and freedom from disease. All respondents reported a delay in the provision of information about GMD and an information gap about GDM and the management of the condition, from diagnosis until the start of treatment at the specialist clinic. Respondents from clinic A expressed fear about future development of type 2 diabetes. Women from clinic B discussed different causes of GDM, and many claimed that health-care staff informed them that GDM was a transient condition during pregnancy. Respondents from clinic A reported a conflict in their treatment of pregnancy and GDM as two different conditions. KEY CONCLUSIONS: beliefs differed and were related to the health-care model chosen. Women with GDM monitored at a specialist maternity clinic believed GDM to be a transient condition during pregnancy only, whereas women monitored at a diabetes specialist clinic expressed fear about a future risk of developing type 2 diabetes. IMPLICATIONS FOR PRACTICE: relevant information about GDM should be provided without delay after initial diagnosis and thereafter repeatedly. It is important to recognise the context of information given on GDM, as it will substantially influence the beliefs and attitudes of women towards GDM as a transient condition during pregnancy or as a potential risk factor for diabetes.     

Overweight and obese in gestational diabetes: the impact on pregnancy outcome

OBJECTIVE: We sought to investigate the relationship between prepregnancy weight, treatment modality (diet or insulin), level of glycemic control, and pregnancy outcome. STUDY DESIGN: We recruited women with gestational diabetes (GDM) from inner city prenatal clinics. All women were instructed in the use of an intensified management protocol using memory reflectance meters. Outcomes were analyzed according to maternal prepregnancy body mass index (BMI, kg/m 2 ) categories: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI > or =30), and by diet or insulin therapy and glycemic control (mean blood glucose <100 mg/dL = good control). Pregnancy outcome variables included a composite outcome (at least 1 of the following: neonatal metabolic complications, large-for-gestational age or macrosomic infants, NICU admission for >24 hours, and the need for respiratory support) (not including oxygen therapy). In addition to composite outcome, a bivariate analysis was performed for each single variable, including preeclampsia and cesarean section delivery. RESULTS: Four thousand and one women were enrolled. Obese women who achieved targeted levels of glycemic control had comparable pregnancy outcomes to normal weight and overweight women only when they were treated with insulin. Normal weight women treated with diet therapy who achieved targeted levels of glycemic control had good outcomes, but obese women treated with diet therapy who achieved targeted levels of glycemic control, nevertheless, had a 2- to 3-fold higher risk for adverse pregnancy outcome when compared with overweight and normal weight patients with well-controlled GDM. Women with GDM who failed to achieve established levels of glycemic control had significantly higher adverse pregnancy outcomes in all 3 maternal weight groups. CONCLUSION: In obese women with BMI > or =30 with GDM, achievement of targeted levels of glycemic control was associated with enhanced outcome only in women treated with insulin.     

Long-term outcomes in mothers diagnosed with gestational diabetes mellitus and their offspring

Mothers with gestational diabetes mellitus (GDM) are at high lifetime risk of developing type 2 diabetes mellitus. The magnitude of risk for cardiovascular disease after GDM is less well established. Recently, intervention trials using lifestyle modification or medications used to treat type 2 DM have successfully prevented/delayed development of DM in women after GDM. Offspring of mothers with GDM are at risk for development of obesity and abnormal glucose metabolism during childhood, adolescence, and adulthood. Factors responsible for these risks are not fully understood. Having fetal hyperinsulinism is a risk factor for development of both obesity and abnormal glucose metabolism, and might be implicated in pathophysiology. It remains to be established whether the long-term effects of exposure to diabetes mellitus during intrauterine development can be prevented.     

First trimester depression scores predict development of gestational diabetes mellitus in pregnant rural Appalachian women

Gestational diabetes (GDM) occurs in up to 9% of pregnancies. Perinatal depression affects up to 20% of women during pregnancy, and can extend into the postpartum period. A number of studies have linked depression and diabetes, however, whether this applies to GDM or which might come first is less understood. The purpose of this study was to examine the potential relationship between depression identified in the first trimester of pregnancy and the subsequent development of GDM. Women without pre-existing Type I/II diabetes (n?=?1021) were evaluated for depression during the first trimester of pregnancy, and medical records were reviewed to identify a positive history of diabetes. Women identified as depressed during the first trimester were more likely to have GDM compared to those not depressed. After controlling for demographic factors and weight-related variables level of depression in the first trimester still predicted later GDM development. Depression identified in early pregnancy may predict increased risk of subsequent GDM development. Due to the numerous maternal, fetal and neonatal complications associated with GDM, early recognition is essential to promote the best possible outcomes for mother and infant. Recognizing depression as a possible risk factor for GDM development could lead to earlier screening and preventative measures.     

妊娠期糖尿病患者的产后管理策略

妊娠期糖尿病(gestational diabetes mellitus,GDM)患者及其子代均是2型糖尿病(type 2 diabetes mellitus,T2DM)患病的高危人群,针对这一群体进行合理干预,是预防T2DM的第一道防线.产后血糖监测和随访管理具有重要社会价值和经济效益.本文通过强化GDM母儿远期不良...     

Identifying postpartum intervention approaches to prevent type 2 diabetes in women with a history of gestational diabetes

Background

Women who develop gestational diabetes mellitus (GDM) have an increased risk for the development of type 2 diabetes. Despite this "window of opportunity," few intervention studies have targeted postpartum women with a history of GDM. We sought perspectives of women with a history of GDM to identify a) barriers and facilitators to healthy lifestyle changes postpartum, and b) specific intervention approaches that would facilitate participation in a postpartum lifestyle intervention program.

Methods

We used mixed methods to gather data from women with a prior history of GDM, including focus groups and informant interviews. Analysis of focus groups relied on grounded theory and used open-coding to categorize data by themes, while frequency distributions were used for the informant interviews.

Results

Of 38 women eligible to participate in focus groups, only ten women were able to accommodate their schedules to attend a focus group and 15 completed informant interviews by phone. We analyzed data from 25 women (mean age 35, mean pre-pregnancy BMI 28, 52% Caucasian, 20% African American, 12% Asian, 8% American Indian, 8% refused to specify). Themes from the focus groups included concern about developing type 2 diabetes, barriers to changing diet, and barriers to increasing physical activity. In one focus group, women expressed frustration about feeling judged by their physicians during their GDM pregnancy. Cited barriers to lifestyle change were identified from both methods, and included time and financial constraints, childcare duties, lack of motivation, fatigue, and obstacles at work. Informants suggested facilitators for lifestyle change, including nutrition education, accountability, exercise partners/groups, access to gyms with childcare, and home exercise equipment. All focus group and informant interview participants reported access to the internet, and the majority expressed interest in an intervention program delivered primarily via the internet that would include the opportunity to work with a lifestyle coach.

Conclusion

Time constraints were a major barrier. Our findings suggest that an internet-based lifestyle intervention program should be tested as a novel approach to prevent type 2 diabetes in postpartum women with a history of GDM.

Trial Registration

ClinicalTrials.gov: NCT01102530

     

Impact of overt diabetes diagnosed in pregnancy in a multi-ethnic cohort in Spain

Overt diabetes (ODM) is defined as women without diabetes meeting the criteria for diabetes at the first antenatal visit. The risk of obstetric complications increases linearly with maternal glycemia and poorer maternal-fetal outcomes than in gestational diabetes (GDM) may be expected. Studies focusing on ODM pregnancy outcomes are lacking. We aimed to analyze maternal characteristics and pregnancy outcomes in ODM women compared with those with GDM. A retrospective cohort study of women giving birth between January 2010 and April 2013 was conducted. Participants with pre-gestational diabetes were excluded. All women underwent screening for GDM at the 24th–28th weeks of gestation or at the first prenatal visit in those with risk factors. HbA1c and a fasting glucose were measured in GDM women to rule out ODM. Of the 5,633 women included, 572 (10%) were diagnosed with GDM and 50 (0.88%) with ODM. Almost 95% of ODM women were from ethnic minorities. After adjustment for confounding factors, ODM women showed increased rates of premature birth (23.1% vs. 6.7%, p?<?.001), emergent cesarean section (41.0% vs. 19.5%, p?=?.049), preeclampsia (22% vs. 3.7%, p?<?.001) and large-for-gestational-age babies (40.0% vs. 14.8%, p?=?.008) compared with GDM. In conclusion, ODM is associated with poorer obstetric outcomes than GDM and affects mainly women from ethnic minorities.     

妊娠期糖尿病口服降糖药的应用评价

妊娠期糖尿病患者是2型糖尿病的高危人群,两者存在发病机制的关联性和病程的续贯性。治疗原则相同,通过饮食、运动和药物治疗控制血糖。妊娠患者在选择治疗药物时,应考虑到对胎儿的影响。传统观点视胰岛素为治疗妊娠期糖尿病的唯一选择,口服降糖药可透过胎盘致胎儿低血糖、畸形等且远期影响不明确,所以其临床应用受到限制。妊娠期口服降糖药的动物实验和临床研究显示,二甲双胍、格列本脲及阿卡波糖未发现致畸作用。目前降糖药治疗妊娠期糖尿病还处于不成熟阶段,评价其治疗价值仍需大量临床资料积累和前瞻性研究。     

Interactions among insulin resistance,inflammation factors,obesity-related gene polymorphisms,environmental risk factors,and diet in the development of gestational diabetes mellitus

Purpose: The aim of this study was to investigate the correlations and interactions between the polymorphisms of insulin resistance-related genes (ADIPOQ rs2241766), inflammation factors (TNF-α rs1800629, IL-6 rs1800795), obesity-related genes (GNB3 rs5443, ADRB rs1042714), and risk factors for gestational diabetes mellitus (GDM) such as diet structure in the development of GDM.

Materials and methods: This research was conducted among women who visited the third-affiliate hospital of Zhengzhou University for pregnancy checkups from 1 June 2014 to 30 December 2014. Based on the results of a 75-g glucose tolerance test (OGTT), 140 pregnant women with GDM were randomly selected as a part of the GDM group and140 healthy, pregnant women as part of the control group. Relevant clinical and laboratory data for the child and the mother including her pregnancy outcomes and the delivery mode were collected for the epidemiological survey.

Results: The results showed that risk factors for GDM are advanced age, the hepatitis B virus, family history of diabetes, high body mass index before pregnancy, and weight gain of ≥10?kg before 24-week gestation. We found that diet structures were severely unbalanced. The polymorphisms rs2241766 and rs5443 were found to potentially be associated with GDM; moreover, a positive interaction was demonstrated between rs2241766 and age, and a negative interaction was demonstrated with weight gain of ≥10?kg before 24-week gestation.

Conclusion: Our findings demonstrate that both environmental risk factors and genetic background contribute to the development of GDM.