Scientific Evidence for Different Options for GDM Screening and Management: Controversies and Review of the Literature.

Background. Gestational diabetes (GDM) affects up to 7% of pregnant women and is associated with several maternal and perinatal morbidities. International organizations suggest several different recommendations regarding how to screen and to manage GDM. Objective. We aimed to analyze the most important and employed guidelines about screening and management of GDM and we investigated existing related literature. Results. We found several different criteria for screening for GDM, for monitoring GDM, and for starting pharmacological therapy. When using IADPSG criteria, GDM rate increased, perinatal outcomes improved, and screening became cost-effective. Compared to no treatment, treatment of women meeting criteria for GDM by IADPSG criteria but not by other less strict criteria has limited evidence for an effect on adverse pregnancy outcomes

Very tight vs. tight control: what should be the criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy? Evidence from randomized controlled trials

INTRODUCTION: There is inconclusive evidence from randomized controlled trials (RCTs) to support any specific criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy. Our objective was to analyze the criteria for dose adjustment of pharmacologic treatment for diabetes mellitus (DM) in pregnancy. MATERIAL AND METHODS: Data sources: MEDLINE, OVID and Cochrane Library were searched from their inception to September 2017. Selection criteria included all trials of DM in pregnancy managed by oral hypoglycemic agents or insulin reporting criteria for pharmacologic therapy dose adjustment. RCTs in women with pregestational DM and gestational DM (GDM) were included. For each trial, data regarding glucose values used for pharmacologic therapy dose adjustment were extracted and carefully reviewed. RESULTS: Of 51 RCTs on therapy for GDM or pregestational DM, 17 (4230 women) were included as they reported criteria for pharmacologic therapy dose adjustment. Most of them (88%, 15/17) included women with GDM only. For RCTs including women with GDM, 12/16 (75%) used the two-step approach, three (19%) the one-step approach and one (6%) either the one- or two-step approach. Regarding the type of initial therapy, 13 (77%) RCTs used different types and doses of insulin; nine (53%) used metformin; five (30%) used glyburide; and one (6%) used placebo. In most RCTs, glucose monitoring was assessed four times daily, i.e. fasting (all RCTs) and two hours (15 RCTs, 88%) after each of the three main meals - breakfast, lunch, and dinner. For fasting glucose target, all used a value 50%, one (6%) >30%, and one (6%) >20% of the values higher than the target value; one (6%) used the appearance of glycosuria. CONCLUSIONS: When evaluating RCTs which included criteria for pharmacologic GDM therapy dose adjustment, the most common criterion for diagnosis was the two-step test, and the most common used therapies were insulin and metformin. Regarding glucose monitoring, the most common frequency was four times per day, fasting and two hours after each main meal, using as target glucose values 95 and 120 mg/dL, respectively. Importantly, we found six different criteria for pharmacologic GDM therapy dose adjustment, with the majority using very tight criteria of either one or two values per week higher than the target values, of which two-thirds used only one value, and one-third used two values

Chewing gum improves postoperative recovery of gastrointestinal function after cesarean delivery: a systematic review and meta-analysis of randomized trials

OBJECTIVE: To examine whether chewing gum hastens the return of gastrointestinal function after a cesarean delivery. METHODS: All randomized controlled trials comparing the use of chewing gum in the immediate postoperative recovery period (i.e. intervention group) with a control group were included in the meta-analysis. The primary outcome was the time to first flatus in hours. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). RESULTS: Seventeen trials, including 3041 women, were analyzed. Trials were of moderate to low quality with different inclusion criteria. In most of the included trials chewing gum was given right after delivery, three times a day for 30 min each and until the first flatus. Women who were randomized to the chewing gum group had a significantly lower mean time to first flatus (MD - 6.49 h, 95%CI -8.65 to -4.33), to first bowel sounds (MD - 8.48 h, 95%CI -9.04 to -7.92), less duration of stay (MD - 0.39 days, 95%CI -0.78 to -0.18), lower time to first feces (MD - 9.57 h, 95% CI -10.28 to 8.87) and to the first feeling of hunger (MD - 2.89 h, 95%CI -4.93 to -0.85), less number of episodes of nausea or vomiting (RR 0.33, 95%CI 0.12 to 0.87), less incidence of ileus (RR 0.39, 95%CI 0.19 to 0.80) and significantly higher satisfaction. CONCLUSIONS: Gum chewing starting right after cesarean delivery three times a day for about 30 min until the first flatus is associated with early recovery of bowel motility. As this is a simple, generally inexpensive intervention, providers should consider implementing cesarean postoperative care with gum chewing

One-step versus two-step diagnostic testing for gestational diabetes: a randomized controlled trial

OBJECTIVE: To evaluate the incidence of gestational diabetes mellitus (GDM) using the one-step as compared with the two-step approach. STUDY DESIGN: This was a parallel group nonblinded randomized trial conducted at Thomas Jefferson University Hospital (TJUH) in Philadelphia, Pennsylvania from June 2016 to December 2016. The primary outcome was GDM incidence in the one-step compared to the two-approach. Pregnant women without a history of pregestational diabetes were offered screening for GDM at gestational age 24-28 weeks. Obese women, defined as having a BMI ≥30 kg/m2, as well as those with a history of a pregnancy complicated by GDM, a history of a macrosomic baby (>4000 g), or with polycystic ovarian syndrome (PCOS), were offered early screening at their initial prenatal visit, and screening was repeated at 24-28 weeks if initially normal. Women were excluded if they had pre-existing diabetes or had a history of bariatric surgery. Women who were eligible were randomized in a 1:1 ratio to either the one-step or two-step approaches. A sample size of 142 women was planned per group. Women randomized to the one-step approach, after an overnight fast, were given a 2-h glucose tolerance test, which consisted of a 75-g glucose load. Blood glucose levels were measured fasting, at 1 h and 2 h after the glucose load. Diagnostic cutoffs for GDM diagnosis were one value of either fasting ≥92 mg/dL, 1 h ≥180 mg/dL, or 2 h ≥153 mg/dL, respectively. Women randomized to the two-step approach were given a nonfasting 50-g glucose load, and the blood glucose level was measured an hour after the glucose load. If that value was ≥135 mg/dL, the patient had a 3-h glucose tolerance test consisting of a 100-g glucose load. Diagnostic cutoffs for GDM diagnosis for this 3-h test were ≥2 abnormal values of fasting ≥95 mg/dL, 1 h ≥180 mg/dL, 2 h ≥155 mg/dL and 3 h ≥140 mg/dL, respectively. All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated. RESULTS: Two hundred eighty-four women agreed to take part in the study and underwent randomization from June 2015 to December 2015. Of them, 249 completed the screening and were followed up for the primary endpoint. Out of the 249 women who completed the screening, 123 were assigned to the one-step group and 126 to the two-step group. GDM occurred in 10 women (8.1%) in the one-step group, and 7 women (5.6%) in the two-step group (p = .42). Preeclampsia, preterm birth (PTB), induction of labor, mode of delivery and incidence of gestational age (OASIS) were not significantly different. Perinatal outcomes were similar as well. CONCLUSIONS: Screening for GDM with one-step, compared with the two-step approach, resulted in a similar incidence of GDM

One step versus two step approach for gestational diabetes screening: systematic review and meta-analysis of the randomized trials

INTRODUCTION: To compare both the prevalence of gestational diabetes mellitus (GDM) as well as maternal and neonatal outcomes by either the one-step or the two-step approaches. MATERIAL AND METHODS: Electronic databases were searched from their inception until June 2017. We included all randomized controlled trials (RCTs) comparing the one-step with the two-step approaches for the screening and diagnosis of GDM. The primary outcome was the incidence of GDM. RESULTS: Three RCTs (n = 2333 participants) were included in the meta-analysis. 910 were randomized to the one step approach (75 g, 2 hrs), and 1423 to the two step approach. No significant difference in the incidence of GDM was found comparing the one step versus the two step approaches (8.4 versus 4.3%; relative risk (RR) 1.64, 95%CI 0.77-3.48). Women screened with the one step approach had a significantly lower risk of preterm birth (PTB) (3.7 versus 7.6%; RR 0.49, 95%CI 0.27-0.88), cesarean delivery (16.3 versus 22.0%; RR 0.74, 95%CI 0.56-0.99), macrosomia (2.9 versus 6.9%; RR 0.43, 95%CI 0.22-0.82), neonatal hypoglycemia (1.7 versus 4.5%; RR 0.38, 95%CI 0.16-0.90), and admission to neonatal intensive care unit (NICU) (4.4 versus 9.0%; RR 0.49, 95%CI 0.29-0.84), compared to those randomized to screening with the two step approach. CONCLUSIONS: The one and the two step approaches were not associated with a significant difference in the incidence of GDM. However, the one step approach was associated with better maternal and perinatal outcomes

Fetal brain hemodynamics in pregnancies at term: correlation with gestational age, birthweight and clinical outcome

Introduction: The primary aim of this study was to ascertain the strength of association between cerebral blood flow assessed in anterior (ACA), middle (MCA), and posterior (PCA) cerebral arteries and the following clinical outcomes: small for gestational age (SGA), induction of labor (IOL) for oligohydramnios and caesarean section (CS) for nonreassuring fetal status (NRFS) during labor. Material and methods: Retrospective analysis of prospectively collected data on consecutive singleton pregnancies from 40 0/7 to 41 6/7 week of gestation. UA, ACA, MCA, PCA pulsatility index (PI) were measured from 40 weeks of gestations. Furthermore, the ratios between cerebral blood flow and UA (CPR, ACA/UA and PCA/UA) were calculated and correlated with the observed outcomes. Results: Two hundred twenty-four singleton pregnancies were included in the study. Mean PI of either ACA (p = .04), MCA (p = .008), and PCA (p = .003) were lower in the SGA compared to non-SGA group; furthermore, mean PCA PI was significantly lower than MCA PI (p = .04). Furthermore, CPR (p = .016), ACA/UA (p = .02), and PCA/UA (p = .003) were significantly lower in the SGA group compared to controls. UA, ACA, MCA, and PCA PI were higher in women undergoing IOL for oligohydramnios compared to controls. Logistic regression analysis showed that CPR and PCA/UA ratio were independently associated with SGA. SGA, ACA PI, and ACA/UA were independently associated with CS for NRFS. Finally, birthweight centile, were independently associated with IOL oligohydramnios. Despite this, the predictive accuracy of Doppler in detecting any of the explored outcome was only poor to moderate. Conclusion: Redistribution of cerebral blood flow at term is significantly associated with SGA, IOL for oligohydramnios and CS for NRFS in labor. However, the predictive accuracy of Doppler at term is only poor to moderate, thus advising against its use in clinical practice as a standalone screening test for adverse perinatal outcome in pregnancies at term. Key Message Redistribution of cerebral blood flow at term is significantly associated with SGA, IOL for oligohydramnios and CS for NRFS in labor