Harold David McIntyre

Hyperglycemia and adverse pregnancy outcomes

BACKGROUND It is controversial whether maternal hyperglycemia less severe than that in diabetes mellitus is associated with increased risks of adverse pregnancy outcomes. METHODS A total of 25,505 pregnant women at 15 centers in nine countries underwent 75-g oral glucose-tolerance testing at 24 to 32 weeks of gestation. Data remained blinded if the fasting plasma glucose level was 105 mg per deciliter (5.8 mmol per liter) or less and the 2-hour plasma glucose level was 200 mg per deciliter (11.1 mmol per liter) or less. Primary outcomes were birth weight above the 90th percentile for gestational age, primary cesarean delivery, clinically diagnosed neonatal hypoglycemia, and cord-blood serum C-peptide level above the 90th percentile. Secondary outcomes were delivery before 37 weeks of gestation, shoulder dystocia or birth injury, need for intensive neonatal care, hyperbilirubinemia, and preeclampsia. RESULTS For the 23,316 participants with blinded data, we calculated adjusted odds ratios for adverse pregnancy outcomes associated with an increase in the fasting plasma glucose level of 1 SD (6.9 mg per deciliter [0.4 mmol per liter]), an increase in the 1-hour plasma glucose level of 1 SD (30.9 mg per deciliter [1.7 mmol per liter]), and an increase in the 2-hour plasma glucose level of 1 SD (23.5 mg per deciliter [1.3 mmol per liter]). For birth weight above the 90th percentile, the odds ratios were 1.38 (95% confidence interval [CI], 1.32 to 1.44), 1.46 (1.39 to 1.53), and 1.38 (1.32 to 1.44), respectively; for cord-blood serum C-peptide level above the 90th percentile, 1.55 (95% CI, 1.47 to 1.64), 1.46 (1.38 to 1.54), and 1.37 (1.30 to 1.44); for primary cesarean delivery, 1.11 (95% CI, 1.06 to 1.15), 1.10 (1.06 to 1.15), and 1.08 (1.03 to 1.12); and for neonatal hypoglycemia, 1.08 (95% CI, 0.98 to 1.19), 1.13 (1.03 to 1.26), and 1.10 (1.00 to 1.12). There were no obvious thresholds at which risks increased. Significant associations were also observed for secondary outcomes, although these tended to be weaker. CONCLUSIONS Our results indicate strong, continuous associations of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels.

The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care#

In addition to the authors, t he following people provided important contributions during the creation of the document. Thanks go to international experts: Tao Duan, Huixia Yang, Andre Van Assche, Umberto Simeoni, Tahir Mahmood, Biodun Olagbuji, Eugene Sobngwi, Maicon Falavigna, Rodolfo Martinez, Carlos Ortega, Susana Salzberg, Jorge Alvariñas, Gloria Lopez Steward, Silvia Lapertosa, Roberto Estrade, Cristina Faingold, Silvia García, Argyro Syngelaki, Stephen Colagiuri, Yoel Toledano, Mark Hanson, and Blami Dao. Special thanks, for FIGO guidance and coordination, go to President Sabaratnam Arulkumaran, President Elect CN Purandare, Chief Executive Hamid Rushwan, and Chair of the SMNH Committee, William Stones. The following external groups evaluated the document and support its contents: European Board and College of Obstetrics and Gynaecology (EBCOG), The Society of Obstetricians and Gynaecologists of Canada (SOGC), Chinese Society of Perinatal Medicine, Diabetic Pregnancy Study Group (DPSG), African Federation of Obstetrics and Gynaecology (AFOG), South Asian Federation of Obstetrics and Gynecology (SAFOG), Australian Diabetes in Pregnancy Society (ADIPS), International Association of Diabetes in Pregnancy Study Groups (IADPSG), European Association of Perinatal Medicine (EAPM), Diabetes in Pregnancy Study Group of India (DIPSI), and the Diabetes in Pregnancy Study Group of Latin America. In addition to the FIGO Executive Board, all relevant FIGO Committees and Working Groups contributed to and supported the document. Acknowledgments

Glycemia and Its Relationship to Outcomes in the Metformin in Gestational Diabetes Trial

OBJECTIVE To determine how glucose control in women with GDM treated with metformin and/or insulin influenced pregnancy outcomes. RESEARCH DESIGN AND METHODS Women randomly assigned to metformin or insulin treatment in the Metformin in Gestational Diabetes (MiG) trial had baseline glucose tolerance test (OGTT) results and A1C documented, together with all capillary glucose measurements during treatment. In the 724 women who had glucose data for analysis, tertiles of baseline glucose values and A1C and of mean capillary glucose values during treatment were calculated. The relationships between maternal factors, glucose values, and outcomes (including a composite of neonatal complications, preeclampsia, and large-for-gestational-age [LGA] and small-for-gestational-age infants) were examined with bivariable and multivariate models. RESULTS Baseline OGTT did not predict outcomes, but A1C predicted LGA infants (P = 0.003). During treatment, fasting capillary glucose predicted neonatal complications (P < 0.001) and postprandial glucose predicted preeclampsia (P = 0.016) and LGA infants (P = 0.001). Obesity did not influence outcomes, and there was no interaction between glycemic control, randomized treatment, or maternal BMI in predicting outcomes. The lowest risk of complications was seen when fasting capillary glucose was <4.9 mmol/l (mean ± SD 4.6 ± 0.3 mmol/l) compared with 4.9–5.3 mmol/l or higher and when 2-h postprandial glucose was 5.9–6.4 mmol/l (6.2 ± 0.2 mmol/l) or lower. CONCLUSIONS Glucose control in women with gestational diabetes mellitus treated with metformin and/or insulin is strongly related to outcomes. Obesity is not related to outcomes in this group. Targets for fasting and postprandial capillary glucose may need to be lower than currently recommended.

The diagnosis of gestational diabetes mellitus: new paradigms or status quo?

The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study showed significant perinatal risks at levels of maternal hyperglycemia below values that are diagnostic for diabetes. A Consensus Panel of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) reviewed HAPO Study results and other work that examined associations of maternal glycemia with perinatal and long-term outcomes in offspring and published recommendations for diagnosis and classification of hyperglycemia in pregnancy in 2010. Subsequently, some commentaries and debate challenged the IADPSG recommendations. In this review, we provide details regarding some points that were considered by the IADPSG Consensus Panel but not published and address the following issues: 1) what should be the frequency of gestational diabetes mellitus (GDM); 2) were appropriate outcomes and odds ratios used to define diagnostic thresholds for GDM; 3) to improve perinatal outcome, should the focus be on GDM, obesity, or both; 4) should results of randomized controlled trials of treatment of mild GDM influence recommendations for diagnostic thresholds; and, 5) other issues related to diagnosis of GDM. Other groups are independently considering strategies for the diagnosis of GDM. However, after careful consideration of these issues, we affirm our support for the recommendations of the IADPSG Consensus Panel.

Pilot Study of an Individualised Early Postpartum Intervention to Increase Physical Activity in Women with Previous Gestational Diabetes

Optimal strategies to prevent progression towards overt diabetes in women with recent gestational diabetes remain ill defined. We report a pilot study of a convenient, home based exercise program with telephone support, suited to the early post-partum period. Twenty eight women with recent gestational diabetes were enrolled at six weeks post-partum into a 12 week randomised controlled trial of Usual Care (n = 13) versus Supported Care (individualised exercise program with regular telephone support; n = 15). Baseline characteristics (Mean ± SD) were: Age  33 ± 4  years; Weight 80 ± 20 kg and Body Mass Index (BMI) 30.0 ± 9.7 kg/m2. The primary outcome, planned physical activity {Median (Range)}, increased by 60 (0–540) mins/week in the SC group versus 0 (0–580) mins/week in the UC group (P = 0.234). Walking was the predominant physical activity. Body weight, BMI, waist circumference, % body fat, fasting glucose and insulin did not change significantly over time in either group. This intervention designed to increase physical activity in post-partum women with previous gestational diabetes proved feasible. However, no measurable improvement in metabolic or biometric parameters was observed over a three month period.

Gestational Diabetes Mellitus: NICE for the U.S.?: A comparison of the American Diabetes Association and the American College of Obstetricians and Gynecologists guidelines with the U.K. National Institute for Health and Clinical Excellence guidelines

OBJECTIVE To compare recent U.S. and U.K. guidelines on gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS The guidelines from the American Diabetes Association, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Clinical Excellence (NICE) in the U.K. were collated and compared using a general inductive approach. RESULTS There are substantial differences in the recommendations between the U.K. and the U.S. guidelines. Of particular note are the reduced sensitivities of the early and later antenatal and postnatal screening and diagnostic criteria. NICE undertook a cost-effectiveness analysis using lower prevalence estimates and limited outcomes and still showed screening for GDM to be cost-effective. CONCLUSIONS The latest NICE recommendations appear to reduce access to proven, cost-effective management of GDM, an issue relevant in the current U.S. health care policy debate.

Clinical management of pregnancy in the obese mother: before conception, during pregnancy, and post partum

The global epidemic of obesity has led to an increasing number of obese women of reproductive age. Obesity is associated with reduced fertility, and pregnancies complicated by maternal obesity are associated with adverse outcomes, including increased risk of gestational diabetes, pre-eclampsia, preterm birth, instrumental and caesarean births, infections, and post-partum haemorrhage. The medical and obstetric management of obese women is focused on identifying, addressing, and preventing some of these associated complications, and is a daunting challenge given the high percentage of patients with obesity and few therapeutic options proven to improve outcomes in this population. The UKs National Institute for Health and Care Excellence guidelines and the American College of Obstetricians and Gynecologists recommend that all pregnant women follow a healthy diet, and consider at least half an hour of moderate physical activity per day during pregnancy. However, although obese women are often directed to seek the advice of a nutritionist and to limit gestational weight gain, guidelines for the management of pregnancy and delivery in this high-risk group are lacking. The post-partum period represents an important opportunity to optimise maternal health before the next pregnancy. As many of the physiological changes of pregnancy associated with maternal obesity are present from early pregnancy onward, reducing maternal obesity before conception is probably the best strategy to decrease the health burden associated with maternal obesity.

Diagnosis of GDM: a suggested consensus.

Despite recent attempts at building consensus, an internationally consistent definition of gestational diabetes mellitus (GDM) remains elusive. Within and between countries, there is disagreement between obstetric, medical, and endocrine groups as to the diagnosis and management of GDM. The current article aims to discuss the background to the controversy of GDM diagnosis and to address issues related to the detection and treatment of GDM in low-, middle-, and high-resource settings. The criteria recommended by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG), the American Diabetes Association (ADA), and the World Health Organization (WHO) are endorsed. We also wish to put into perspective the importance of GDM, both during and after pregnancy, in terms of its relationship to overall womens health.

Testing for Gestational Diabetes Mellitus in Australia

The American Diabetes Association published new recommendations for the detection and diagnosis of gestational diabetes mellitus in 2011 (1). These criteria were based on the consensus opinion of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) (2). The Australasian Diabetes in Pregnancy Society (ADIPS) has posted new guidelines (www.adips.org) to replace those used since 1991 (3). The ADIPS guidelines endorse the method of testing and the diagnostic criteria used by the American Diabetes Association. These are early testing for women with high risk factors; no preliminary glucose challenge test; and for all women not known to have diabetes, a 75-g oral glucose tolerance test at 24–28 weeks’ gestation, with gestational diabetes mellitus diagnosed if one of …

Gestational Diabetes Mellitus: NICE for the US? A comparison of ADA and ACOG guidelines with the UK NICE guidelines

OBJECTIVE To compare recent U.S. and U.K. guidelines on gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS The guidelines from the American Diabetes Association, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Clinical Excellence (NICE) in the U.K. were collated and compared using a general inductive approach. RESULTS There are substantial differences in the recommendations between the U.K. and the U.S. guidelines. Of particular note are the reduced sensitivities of the early and later antenatal and postnatal screening and diagnostic criteria. NICE undertook a cost-effectiveness analysis using lower prevalence estimates and limited outcomes and still showed screening for GDM to be cost-effective. CONCLUSIONS The latest NICE recommendations appear to reduce access to proven, cost-effective management of GDM, an issue relevant in the current U.S. health care policy debate.