L. Carbillon

The Diagnostic and Prognostic Performance of a Selective Screening Strategy for Gestational Diabetes Mellitus According to Ethnicity in Europe

CONTEXT The performance of standard selective screening strategies for gestational diabetes mellitus (GDM) may vary according to ethnicity. OBJECTIVE We aimed to evaluate the diagnostic and prognostic performance of a selective screening tool to determine whether it accurately predicts GDM and events in women of different ethnicities. The tool selectively screens based on patients having one or more of the following risk factors (RFs): body mass index ≥25 kg/m(2), age ≥35 years, family history of diabetes, and personal history of GDM or macrosomia. DESIGN AND SETTING We conducted an observational prospective study at a university hospital. PARTICIPANTS We included 17 344 women of European (30.9%), North African (29.6%), Sub-Saharan African (22.2%), Caribbean (8.7%), Indian-Pakistani-Sri Lankan (5.5%), and Asian (3.3%) ethnicities who were without pregravid diabetes and had singleton deliveries (2002-2010). MAIN OUTCOME MEASURES We universally screened GDM and GDM-related events (pre-eclampsia, birth weight ≥4000 g, or dystocia). RESULTS Independent of confounding factors, North African (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.21-1.52; P < .001) and Indian-Pakistani-Sri Lankan (OR, 2.52; 95% CI, 2.13-3.00; P < .001) women had more GDM than Europeans, whereas Sub-Saharan African women had less (OR, 0.82; 95% CI, 0.71-0.94; P < .01). Having one or more RFs was associated with GDM among Europeans (OR, 1.45; 95% CI, 1.22-1.76), North African (OR, 1.33; 95% CI, 1.13-1.55), Sub-Saharan African (OR, 1.48; 95% CI, 1.20-1.83), and Caribbean (OR, 1.55; 95% CI, 1.12-2.14) women. Having one or more RFs was also associated with GDM-related events only in European (P < .01) and North African (P < .05) women, with the following incidences in Europeans: no GDM/no RF, 6.9%; no GDM/RF, 9.0%; GDM/no RF, 14.7%; and GDM/RF, 12.6%. CONCLUSION Standard selective screening criteria were not predictive of GDM in women from India-Pakistan-Sri Lanka and Asia and were associated with GDM-related events only in European and North African women. However, the women with GDM, who were routinely treated, had a poor prognosis, even for those free of RFs. These results support universal screening, irrespective of ethnicity.

Factors associated with screening for glucose abnormalities after gestational diabetes mellitus: Baseline cohort of the interventional IMPACT study

INTRODUCTION Although it is important to screen women who have had gestational diabetes mellitus (GDM) for abnormal post-partum glucose levels, such testing is rarely performed. The aim of this study was to use data from the first observational phase of the IMPACT study to determine rates of screening within 6 months of delivery in a multiethnic cohort, focusing in particular on the effects of social deprivation and the risk of future diabetes. PATIENTS AND METHODS To investigate the frequency of post-partum screening, charts were analyzed, and all women attending four centres located in a deprived area who had had GDM between January 2009 and December 2010 were contacted by phone. The Evaluation of Precarity and Inequalities in Health Examination Centres (EPICES) deprivation index and Finnish Diabetes Risk Score (FINDRISK) questionnaire were also evaluated. RESULTS Data were evaluable for 589 of the 719 women contacted (mean age: 33.4 ± 5.2 years; mean body mass index: 27.6 ± 5.4 kg/m(2)), and 196 (33.3%) reported having been screened. On multivariate analysis, factors associated with a lack of screening were smoking [odds ratio (OR): 0.42 (0.20-0.90), P<0.05], low consumption of fruit and vegetables [OR: 0.58 (0.39-0.82), P<0.01] and heavier offspring birth weight (P<0.05), although there were no differences in FINDRISK and EPICES scores between screened and unscreened women. CONCLUSION One-third of women who had had GDM reported having been screened for dysglycaemia at 6 months post-partum. However, it is expected that the interventional phase of the IMPACT study will increase screening rates, especially in women with the risk factors associated with lower screening rates during this observational phase.

Screening for dysglycaemia during pregnancy: Proposals conciliating International Association of Diabetes and Pregnancy Study Group (IADPSG) and US National Institutes of Health (NIH) panels

The International Association of Diabetes and Pregnancy Study Group (IADPSG) has proposed that blood glucose levels for the diagnosis of gestational diabetes mellitus (GDM) be the values associated with a 1.75-fold increase in the risk of neonatal complications in the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study. However, this recommendation was not adopted by the US National Institutes of Health (NIH) panel as it would have been responsible for a huge increase in the prevalence of GDM with no clear evidence of a reduction of events at such blood glucose values. Considering this aspect, we now propose the use of a blood glucose threshold combination associated with an odds-ratio of 2.0 for neonatal disorders [fasting plasma glucose (FPG)≥ 95 mg/dL, or a 1-h glucose value after a 75-g oral glucose tolerance test (OGTT)≥ 191 mg/dL or a 2-h glucose value ≥ 162 mg/dL] for GDM diagnosis. This would lead to a lower prevalence of GDM and concentrate medical resources on those with the highest risk of complications. This would also allow the use of a similar FPG value for both the diagnosis and therapeutic target of GDM. The IADPSG also proposed screening for dysglycaemia during early pregnancy, using FPG measurement with a similar threshold after 24 weeks of gestation. We propose the same strategy considering an FPG value ≥ 95 mg/dL as abnormal, but only after confirmatory measurements. We also believe that an OGTT should not be used before 24 weeks of gestation as normal values during that time are as yet unknown.

Psychosocial deprivation in women with gestational diabetes mellitus is associated with poor fetomaternal prognoses: an observational study

Objective To evaluate the prognoses associated with psychosocial deprivation in women with gestational diabetes mellitus (GDM). Design Observational study considering the 1498 multiethnic women with GDM who gave birth between January 2009 and February 2012. Setting Four largest maternity units in the northeastern suburban area of Paris. Participants The 994 women who completed the Evaluation of Precarity and Inequalities in Health Examination Centers (EPICES) questionnaire. Main outcome measure Main complications of GDM (large infant for gestational age (LGA), shoulder dystocia, caesarean section, pre-eclampsia). Results Psychosocial deprivation (EPICES score ≥30.17) affected 577 women (56%) and was positively associated with overweight/obesity, parity and non-European origin, and negatively associated with family history of diabetes, fruit and vegetable consumption and working status. The psychosocially deprived women were diagnosed with GDM earlier, received insulin treatment during pregnancy more often and were more likely to have LGA infants (15.1% vs 10.6%, OR=1.5 (95% CI 1.02 to 2.2), p<0.05) and shoulder dystocia (3.1% vs 1.2%, OR=2.7 (0.97 to 7.2), p<0.05). In addition to psychosocial deprivation, LGA was associated with greater parity, obesity, history of GDM, ethnicity, excessive gestational weight gain and insulin therapy. A multivariate analysis using these covariates revealed that the EPICES score was independently associated with LGA infants (per 10 units, OR=1.12 (1.03 to 1.20), p<0.01). Conclusions In our area, psychosocial deprivation is common in women with GDM and is associated with earlier GDM diagnoses and greater insulin treatment, an increased likelihood of shoulder dystocia and, independently of obesity, gestational weight gain and other confounders with LGA infants.

The impact of ovulation induction and ovarian stimulation on the risk of pregnancy-induced hypertension and on neonatal outcomes: A case/control study

OBJECTIVES To study the role of ovarian stimulation procedures on the risk of pregnancy-induced hypertension, gestational diabetes mellitus and neonatal outcomes according to womens characteristics and the causes of infertility. DESIGN Retrospective, observational, case/control study. PATIENTS Spontaneous pregnancies (group A, n=8107), pregnancies achieved after mild ovarian ovulation induction without other Assisted Reproductive Technology (ART) procedures (group B, n=44), pregnancies after mild ovarian stimulation and ART procedures (group C, n=53) or pregnancies after multi (>2) follicular stimulation with gonadotrophin therapy and ART procedures (group D, n=133); all of the groups had identical protocols for prenatal care. MAIN OUTCOME MEASUREMENTS Pregnancy-induced hypertension (PIH), fetal macrosomia (estimated fetal weight >90th percentile), gestational diabetes mellitus, caesarean section, and neonatal outcomes. RESULTS The incidence rates of PIH (2.7, 11.6, 4.2, and 2.5%) in groups A, B, C and D, respectively, (p=0.004), fetal macrosomia (4.7, 7.0, 20.8, and 7.6%, respectively, p<0.001), caesarean section (21.8, 37.2, 21.7, and 17.6%, respectively, p=0.048), differed among the groups. The high incidence of PIH in pregnancies following ovulation induction was driven by polycystic ovarian syndrome (PCOS) per se. CONCLUSION PCOS per se was associated with more PIH, and ART procedures after mild mono/bi follicular ovarian stimulation were associated with more fetal macrosomia.

Fetal gender is not associated with either gestational diabetes mellitus or placental weight: A cohort study

AIM This study assessed whether male fetal gender increases the risk of maternal gestational diabetes mellitus (GDM) and investigated the association with placental weight. METHODS The study included 20,149 women without pregestational diabetes who delivered singletons at our hospital between January 2002 and December 2010. There was universal screening for GDM, and all placentas were weighed at delivery. RESULTS GDM (affecting 14.2% of women) was not associated with fetal gender (male fetuses in women without and with GDM: 51.8% vs. 51.7%, respectively; P=0.957), and remained likewise after logistic-regression analysis of risk factors for GDM (OR: 1.007, 95% CI: 0.930-1.091; P=0.858). Placental weights were 600±126g, 596±123g, 584±118g and 587±181g in women with GDM/female, GDM/male, no GDM/female and no GDM/male fetuses, respectively (GDM effect: P=0.017; gender effect: P=0.41; GDM * gender effect: P=0.16). CONCLUSION The present results suggest that fetal gender is not associated with GDM and, while placental weights were higher in cases of GDM, there were still no gender effects.

Premature Cardiac Disease and Death After Preterm Preeclampsia in Women Whose Infant Was Small for Gestational Age

Premature Cardiac Disease and Death After Preterm Preeclampsia in Women Whose Infant Was Small for Gestational Age To the Editor I read with great interest the population-based cohort study by Silverberg et al,1 who found that the incidence rate of the composite outcome of heart failure, dysrhythmia, or death was 11.3 per 10 000 person-years among mothers who delivered infants with preterm birth (PTB) or who were severely small for gestational age (SGA) (crude hazard ratio, 2.79; 95% CI, 1.85-4.21) compared with women who delivered infants with term birth without severe SGA. More importantly, the hazard ratio was significantly higher in women with a PTB-SGA infant for the composite cardiac outcome of heart failure, an atrial or ventricular dysrhythmia, or coronary artery disease and was markedly attenuated when adjusted for maternal age, income quintile, preeclampsia/eclampsia, diabetes, chronic hypertension, obesity, dyslipidemia, drug dependence or smoking, and kidney disease before and after delivery. From this finding, the authors conclude that the association between preeclampsia and postpregnancy cardiovascular risk was partly due to prepregnancy risk factors. However, it seems important to underscore that the preeclampsia/eclampsia rate was higher both in the subgroup of women with an infant with PTB and severe SGA (676 of 2816 women [24.0%]) and in the subgroup with an infant with PTB without severe SGA (4077 of 45 134 [9.0%]) vs the preeclampsia/eclampsia rate in the subgroup with an infant with term birth without severe SGA (6898 of 619 311 [1.1%]).1 Silverberg et al1 rightly assume that unlike spontaneous PTB, clinician-initiated PTB was likely due to preeclampsia and poor fetal growth arising from placental vascular disease. But because these authors used a more pathological cutoff point of less than the 5th percentile to denote SGA (“severe SGA”), it may also be assumed that using the 10th percentile cutoff point would have identified more women as having an infant with PTB-SGA/fetal growth restriction, specifically in women with preeclampsia and infants with PTB (9.0%). Indeed, infants with SGA (defined as infants with a birthweight <10th percentile) and preeclampsia are more likely to coexist in preterm births compared with term births (38.6% at <34 weeks2), both arising from placental vascular disease. Lastly, maternal overweight and obesity (which are not reported in the subgroups by Silverberg et al1) may be a strong confounding factor. On one hand, body mass index is associated with increased risks of preterm delivery3; on the other hand, the presence and duration of overall and abdominal obesity is associated with subclinical coronary heart disease.4

P55 Un tiers des femmes ayant eu un diabète gestationnel en Seine Saint Denis déclarent avoir réalisé un dépistage d’une dysglycémie dans le post-partum. Premiers résultats de l’enquête IMPACT

Introduction Les femmes ayant eu un diabete gestationnel (DG) ont un risque accru de developper en post-partum un diabete de type 2. Une etape essentielle de la demarche de prevention implique de depister une anomalie glycemique en post-partum. Il semble que cette etape soit peu realisee meme s’il existe peu de donnees disponibles. Nous menons actuellement en Seine-Saint Denis l’etude IMPACT dont l’objectif est d’apprecier l’impact d’une campagne d’information sur la realisation de ce depistage. Nous rapportons ici les resultats preliminaires de la phase retrospective qui indiquera le taux de realisation du depistage avant la campagne d’information. Patients et methodes Le recrutement portera sur 1 000 femmes ayant eu un DG lors de leur derniere grossesse et ayant accouche entre mars 2009 et mars 2011 dans les 4 principales maternites du departement (Hopitaux De La Fontaine, Jean Verdier, Prive de Seine-Saint Denis, Robert Ballanger) qui sont contactees par telephone pour savoir si le depistage a ete pratique en post-partum, ses modalites et resultats. Nous recueillons des donnees demographiques, anthropometriques et socio-economiques. Resultats A ce jour, 580 femmes ont repondu au questionnaire. Le DG avait ete diagnostique avant 24 semaines d’amenorrhee (SA) (11 %), entre 24–28 SA (42 %) ou apres 28 SA (47 %), et traite par insuline pour 24 % d’entre elles. 36 % des femmes ont eu une complication pendant leur grossesse (preeclampsie 3 %, cesarienne 25 %, macrosomie 7 %, dystocie des epaules 1 %). Un total de 180 (31 %) femmes declarent avoir effectue un depistage dans les 6 mois suivant l’accouchement, par glycemie a jeun (75 %) et/ou post-prandiale (31 %), charge en glucose (G0–G120 : 5 %), HbA1c (0,5 %). Cependant seulement 14 % connaissent le resultat. Conclusion Ces donnees certes declaratives indiquent qu’1/3 seulement des femmes auraient realise le depistage d’une dysglycemie dans les 6 premiers mois du post-partum et que seulement 14 % d’entre elles en connaissent le resultat.