Celeste P. Durnwald

Gestational diabetes: Linking epidemiology, excessive gestational weight gain, adverse pregnancy outcomes, and future metabolic syndrome

Gestational diabetes (GDM) affects up to 200,000 deliveries in the United States each year. With the growing obesity epidemic, delayed childbearing, and multiple gestations, the diagnosis of GDM is expected to continue to rise. GDM unmasks a beta-cell defect that persists after pregnancy and typically worsens over time imparting the increased risk of type 2 diabetes mellitus after the index pregnancy. In addition, coexisting obesity and progressive weight gain are additive factors for progression to type 2 DM. Obstetricians play an integral role in informing GDM women about their lifelong risk of type 2 diabetes (T2DM) and can help bridge the care to primary care physicians, as it relates to recommended screening and long-term follow-up.

Glycemic characteristics and neonatal outcomes of women treated for mild gestational diabetes

OBJECTIVE: To estimate the association between fasting and 2-hour postprandial blood glucose levels and neonatal outcomes in women treated for mild gestational diabetes. METHODS: In this secondary analysis of a multicenter randomized treatment trial of mild gestational diabetes, the median fasting and 2-hour postprandial glucose levels were analyzed in 2-week intervals and change over time (slope) was calculated for women with gestational diabetes (abnormal oral glucose tolerance test) and a fasting glucose less than 95 mg/dL who received nutritional management with self blood glucose monitoring and insulin as needed. Regression analyses were performed to estimate the relationship between median fasting and postprandial glucose and neonatal fat mass, cord blood C-peptide, birth weight, large-for-gestational-age neonates, macrosomia (greater than 4,000 g), and neonatal hypoglycemia. RESULTS: Among 460 women with gestational diabetes, median fasting (P<.001), postprandial breakfast (P<.001), and postprandial lunch (P<.001) glucose values declined over the treatment period, whereas postprandial dinner values remained stable (P=.83). Higher median fasting glucose during the first 2 weeks of treatment was significantly associated with increased odds ratios for neonatal fat mass (1.35; 95% CI 1.09–1.66; P=.006) and elevated C-peptide (1.29; CI 1.09–1.52; P=.003). Higher median fasting glucose during the last 2 weeks before delivery was associated with higher rates of large-for-gestational-age neonates (1.27; CI 1.05–1.53; P=.01), macrosomia (1.32; CI 1.04–1.65; P = .02), and elevated C-peptide (1.19; CI 1.03–1.38; P=.02). CONCLUSION: In women treated for mild gestational diabetes, higher fasting glucose during initiation of diet therapy was associated with increased neonatal fat mass and elevated C-peptide and during the last 2 weeks before delivery with macrosomia, large-for-gestational age, and elevated C-peptide. LEVEL OF EVIDENCE: II

Excessive weight gain and hypertensive disorders of pregnancy in the obese patient.

Abstract Objective: To evaluate the association between excessive weight gain and pregnancy-related hypertension (PRH) among obese women (body mass index (BMI) ≥30u2009kg/m2). Methods: We performed a case control study among women with (nu2009=u2009440) and without (nu2009=u2009600) PRH from 2005 to 2007. Height and weight were recorded at initial and final prenatal visits. 695 women had BMI recorded at ≤18 weeks of gestation, of which 257 (36.9%) were obese. Obese women were divided into three categories based on 2009 Institute of Medicine (IOM) guidelines: (1) below recommended amount (under weight gain – UWG); (2) more than recommended (excessive weight gain – EWG) or (3) within recommended amount (normal weight gain – NWG). PRH was defined as gestational hypertension, mild or severe preeclampsia. Patients with and without PRH were prospectively identified. The association between weight gain category and development of PRH was analyzed. Results: We noticed a 1.5-fold higher odds of having PRH with an initial BMI ≥30u2009kg/m2 compared to BMI <30u2009kg/m2 (OR 1.64, 95% CI 1.2–2.2, pu2009=u20090.002). Among obese women, we noted a 2-fold higher odds of having PRH with EWG compared to NWG (OR 2.52, 95% CI 1.2–3.9, pu2009=u20090.012). The increased odds persisted after adjusting for race, chronic hypertension and diabetes, and length of gestation (AOR 2.61, 95% CI 1.4–4.9, pu2009=u20090.003). Among obese women with PRH, those with EWG had a 76% decreased odds of having severe disease compared to NWG (ORu2009=u20090.242 [0.07–0.79], pu2009=u20090.019). Conclusion: We have demonstrated that EWG among obese patients increases overall risk of PRH.

Fetal Links to Chronic Disease: The Role of Gestational Diabetes Mellitus

A growing body of literature suggests that chronic disease has much of its origins in the fetal response to the intrauterine environment, a concept known as fetal programming. Longitudinal studies have demonstrated that higher rates of obesity, impaired glucose tolerance, hypertension, and dyslipidemia are evident in the offspring of diabetic women. This review focuses on the implications of intrauterine exposure to an altered maternal metabolic milieu and the risk of childhood obesity and metabolic dysfunction.

The multidisciplinary approach to the care of the obese parturient

Maternal obesity in pregnancy is associated with increased maternal and fetal risks. Pregnancy management should include counseling, screening, and optimization of maternal health, increased fetal surveillance, and preparation for parturition. A multidisciplinary approach should be implemented including collaboration from obstetricians, nutritionists, anesthesiologists, social workers, and neonatologists to optimize perinatal outcomes. Pregnancy is an ideal window of opportunity to influence both the patients long-term health and the health of the offspring.

The Effect of Early Excessive Weight Gain on the Development of Hypertension in Pregnancy

Backgroundu2003Previous studies have shown an association between total excessive gestational weight gain and hypertension in pregnancy. However, this may be a reflection of excessive water retention associated with the pathophysiology of hypertensive disorders of pregnancy. Early excessive weight gain, prior to the third trimester, results in greater maternal fat deposition and inflammation, which has also been associated with the development of hypertension. By focusing on early excessive weight gain, the association between maternal weight gain and the future development of hypertension can be examined. Objectiveu2003To evaluate the association between early excessive maternal weight gain and the development of hypertension during pregnancy. Study Designu2003This was a secondary analysis of a longitudinal cohort study of 1,441 women without chronic hypertension who were enrolled in a prospective study evaluating maternal angiogenic factors and the prediction of preeclampsia. Initial body mass index (BMI) was calculated by weight and height at the first study visit. Early excessive maternal weight gain was defined as weight gain by 28 weeks that exceeded the Institute of Medicine (IOM) guidelines and was calculated utilizing the maximum amount of weight gain per week recommended by the IOM based on the patients starting BMI (normal: 0.45u2009kg; overweight: 0.32u2009kg; obese: 0.27 kg). Hypertension was defined as a sustained systolic blood pressure of ≥140u2009mm Hg or a diastolic blood pressure of ≥90u2009mm Hg. Logistic regression was used to determine the association between early excessive weight gain, initial BMI, and the development of hypertension, including gestational hypertension and preeclampsia, during pregnancy. Resultsu2003Of 1,441 women, 767 (53.2%) had weight gain that exceeded the IOM guidelines in the first 28 weeks and 154 (10.8%) developed hypertension during pregnancy. Women whose weight gain exceeded the IOM guidelines were more likely to develop hypertension even after adjusting for relevant confounders (12.5 vs. 8.6%; pu2009=u20090.02; adjusted odds ratio [OR]u2009=u20091.70; 95% confidence interval [CI]: 1.18-2.44; pu2009<u20090.01). Obese women had a 2.4-fold increased risk of developing hypertension, even after controlling for excessive weight gain (adjusted ORu2009=u20092.44; 95% CI: 1.66-3.59; pu2009<u20090.01) Conclusionsu2003Early excessive maternal weight gain and initial BMI are independently associated with the diagnosis of a hypertensive disorder of pregnancy. Women should be counseled regarding the benefits of achieving a normal BMI prior to pregnancy and appropriate weight gain during pregnancy, as well as the potential harms of excessive weight gain related to perinatal outcomes.

Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy

Abstract Objective: The objective of this study is to evaluate a woman’s risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy. Methods: A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed. Results: Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (pu2009=u20090.004 and 0.005, respectively) and hypertension later in life (pu2009=u20090.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (pu2009=u20090.006 and 0.002, respectively). Conclusions: Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.

Prenatal care in a specialized diabetes in pregnancy program improves compliance with postpartum testing in GDM women (.)

Abstract Objective: To evaluate whether prenatal care in a specialized diabetes in pregnancy program (DMC) improves compliance with completion of the 2-h 75u2009g oral glucose tolerance test (2HrOGTT) in GDM women. Methods: A retrospective cohort study of GDM women delivering in a university health system between January 2011 and March 2014 was performed. Women were divided into two groups: those receiving care in prenatal clinics over an 18-month period prior to the establishment of the diabetes in pregnancy clinic (pre-DMC) and those receiving prenatal care in a specialized diabetes in pregnancy clinic (post-DMC). The primary outcome was completion of the 2HrOGTT postpartum. Clinical characteristics associated with 2HrOGTT completion were evaluated. Time trend analysis was performed to evaluate month to month variation in 2HrOGTT compliance for secular trends. Results: A total of 292 women were analyzed, 147 post-DMC and 118 pre-DMC. The 2HrOGTT was ordered more frequently in the post-DMC compared to pre-DMC (90.0 versus 53.0%, pu2009<u20090.0001). Rates of completion of the 2HrOGTT were 49.2% post-DMC and 25.0% pre-DMC, pu2009=u20090.007. After adjusting for potential confounders, women who received prenatal care post-DMC were 2.98 times more likely to complete the 2HrOGTT compared to those receiving care pre-DMC (OR 2.98 [1.34, 6.62], pu2009=u20090.007). Conclusions: Providers were 5.9 times more likely to order the recommended testing for GDM women who attended the postpartum visit in the post-DMC period. GDM women who receive prenatal care in a specialized diabetes in pregnancy program are more likely to complete the 2HrOGTT in the postpartum period.

Obesity and the association with maternal mental health symptoms

Abstract Objective: To evaluate the association between maternal obesity and mood disorders including depression, anxiety, stress, and pregnancy-specific stress during pregnancy. Study design: This was a planned secondary analysis of a prospective cohort study investigating factors associated with preterm delivery. The cohort included women who initiated prenatal care before 20 weeks with a singleton pregnancy. Maternal mental health was assessed using four standard psychosocial behavioral measures to screen for depression, pregnancy-specific stress, anxiety, and stress. Screen positive scores for each tool were established based on previously published “high” scores. Results: Of the 1010 women included in the cohort, 355 (35.1%) were obese. There was no significant difference in the number of obese women with stress (64.2% versus 68.4%, pu2009=u20090.18), pregnancy-specific stress (26.2% versus 22.1%, pu2009=u20090.15), or anxiety (38.6% versus 41.2%, pu2009=u20090.42); however, a greater number of obese women did report symptoms consistent with major depression when compared to women with BMIs <30 (30.4% versus 21.2%, pu2009<u20090.01). Conclusion: Obese women had higher rates of depression in early pregnancy compared to nonobese women. As many of the health behavior interventions for obese women during pregnancy have proven ineffective, incorporating depression screening and treatment into prenatal care may improve perinatal outcomes.

Prophylactic Wound Vacuum Therapy after Cesarean Section to Prevent Wound Complications in the Obese Population: A Randomized Controlled Trial (the ProVac Study)

Objective The objective of this study was to perform a randomized controlled feasibility trial investigating negative pressure wound therapy (NPWT) system versus a standard postcesarean wound care (WC) on the development of a postoperative surgical site infection (SSI) and/or a wound dehiscence in obese women. Study Design This is a randomized controlled feasibility trial of obese women undergoing an unscheduled cesarean delivery. Women with an initial body mass index ≥ 30 kg/m2 who were ≥ 4 cm dilated were included. Women were assigned to either a NPWT or standard WC. The primary outcome was a composite of wound morbidity at 4 weeks postpartum including SSI and/or wound opening (clinicaltrials.gov, NCT02128997). Continuous variables were analyzed with t‐test and Wilcoxon rank‐sum tests and categorical variables with Fishers exact test. Results Of 136 women randomized, 67 received NPWT and 69 received standard WC. The 4‐week follow‐up rate was 88%. Maternal clinical and surgical characteristics were similar between the groups. The prevalence of the composite wound morbidity outcome was not different between those with NPWT and standard WC (4.9 vs. 6.9%; p = 0.71). Conclusion Routine clinical use of a NPWT system after cesarean delivery did not result in a significant reduction of wound morbidity over standard WC.