Incidence of postpartum glucose intolerance among women with gestational diabetes in Siriraj Hospital

Objectives: To determine the incidence of postpartum glucose intolerance among women with gestational diabetes (GDM) and its associated factors. Materials and Methods:A total of 110 GDM women who delivered at Siriraj Hospital were enrolled. A 2-hour 75-gram glucose tolerance test was offered at 6-12 weeks postpartum to determine the incidence of glucose intolerance, which includes impaired glucose tolerance (IGT), and type 2 diabetes (T2DM). Demographic data, GDM risks and diagnosis data, and delivery data were collected. Incidence of glucose intolerance was estimated. Comparison was made between glucose intolerance groups to determine possible associated factors.Results: Mean age was 33.7±5.1 years, and 46% were nulliparous. According to pre-pregnancy BMI, 45.5% were overweight/obese, and 24.5% gained weight greater than recommendation. Majority was GDM A1 (85.5%), and 63.6% were diagnosed before 20 weeks of gestation. Mean postpartum follow up time was at 6.2±0.9 weeks. Incidence of postpartum IGT and T2DM were 35.5% and 10% respectively. No difference was found between groups in terms of pre-pregnancy BMI, gestational weight gain, weight retention, and severity of GDM. However, HbA1c level was significantly greater among women with postpartum T2DM than IGT and normal results (6.1±0.5%, 5.6±0.4%, and 5.4±0.3% respectively, p<0.001). HbA1c level of ≥ 6% significantly increased the chance of T2DM (33.3% vs. 53.4%, p=0.001).Conclusion: Among GDM pregnant women, incidence of postpartum glucose intolerance was 45.5% (35.5% IGT and 10% T2DM). HbA1c level of ≥ 6% significantly increased the chance of postpartum T2DM

Nomograms of Iranian fetal middle cerebral artery Doppler waveforms and uniformity of their pattern with other populations' nomograms

<p>Abstract</p> <p>Background</p> <p>Doppler flow velocity waveform analysis of fetal vessels is one of the main methods for evaluating fetus health before labor. Doppler waves of middle cerebral artery (MCA) can predict most of the at risk fetuses in high risk pregnancies. In this study, we tried to obtain normal values and their nomograms during pregnancy for Doppler flow velocity indices of MCA in 20 – 40 weeks of normal pregnancies in Iranian population and compare their pattern with other countries' nomograms.</p> <p>Methods</p> <p>During present descriptive cross-sectional study, 1037 normal pregnant women with 20^th–40^thweek gestational age were underwent MCA Doppler study. All cases were studied by gray scale ultrasonography initially and Doppler of MCA afterward. Resistive Index (RI), Pulsative Index (PI), Systolic/Diastolic ratio (S/D ratio), and Peak Systolic Velocity (PSV) values of MCA were determined for all of the subjects.</p> <p>Results</p> <p>Results of present study showed that RI, PI, S/D ratio values of MCA decreased with parabolic pattern and PSV value increased with simple pattern, as gestational age progressed. These changes were statistically significant (P = 0.000 for all of indices) and more characteristic during late weeks of pregnancy.</p> <p>Conclusion</p> <p>Values of RI, PI and S/D ratio indices reduced toward the end of pregnancy, but PSV increased. Despite the trivial difference, nomograms of various Doppler indices in present study have similar pattern with other studies.</p

Risk factor screening to identify women requiring oral glucose tolerance testing to diagnose gestational diabetes : a systematic review and meta-analysis and analysis of two pregnancy cohorts

BACKGROUND: Easily identifiable risk factors including: obesity and ethnicity at high risk of diabetes are commonly used to indicate which women should be offered the oral glucose tolerance test (OGTT) to diagnose gestational diabetes (GDM). Evidence regarding these risk factors is limited however. We conducted a systematic review (SR) and meta-analysis and individual participant data (IPD) analysis to evaluate the performance of risk factors in identifying women with GDM. METHODS: We searched MEDLINE, Medline in Process, Embase, Maternity and Infant Care and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2016 and conducted additional reference checking. We included observational, cohort, case-control and cross-sectional studies reporting the performance characteristics of risk factors used to identify women at high risk of GDM. We had access to IPD from the Born in Bradford and Atlantic Diabetes in Pregnancy cohorts, all pregnant women in the two cohorts with data on risk factors and OGTT results were included. RESULTS: Twenty nine published studies with 211,698 women for the SR and a further 14,103 women from two birth cohorts (Born in Bradford and the Atlantic Diabetes in Pregnancy study) for the IPD analysis were included. Six studies assessed the screening performance of guidelines; six examined combinations of risk factors; eight evaluated the number of risk factors and nine examined prediction models or scores. Meta-analysis using data from published studies suggests that irrespective of the method used, risk factors do not identify women with GDM well. Using IPD and combining risk factors to produce the highest sensitivities, results in low specificities (and so higher false positives). Strategies that use the risk factors of age (>25 or >30) and BMI (>25 or 30) perform as well as other strategies with additional risk factors included. CONCLUSIONS: Risk factor screening methods are poor predictors of which pregnant women will be diagnosed with GDM. A simple approach of offering an OGTT to women 25 years or older and/or with a BMI of 25kg/m2 or more is as good as more complex risk prediction models. Research to identify more accurate (bio)markers is needed. Systematic Review Registration: PROSPERO CRD42013004608

The London exercise and pregnant smokers (LEAP) trial: A randomised controlled trial of physical activity for smoking cessation in pregnancy with an economic evaluation

Background: Smoking during pregnancy is the main preventable cause of poor birth outcomes. Improved methods are needed to help women to stop smoking during pregnancy. Pregnancy provides a compelling rationale for physical activity (PA) interventions as cessation medication is contraindicated or ineffective, and an effective PA intervention could be highly cost-effective.&nbsp; Objective: To examine the effectiveness and cost-effectiveness of a PA intervention plus standard behavioural support for smoking cessation relative to behavioural support alone for achieving smoking cessation at the end of pregnancy.&nbsp; Design: Multicentre, two-group, pragmatic randomised controlled trial and economic evaluation with follow-up at the end of pregnancy and 6 months postnatally. Randomisation was tratified by centre and a computer-generated sequence was used to allocate participants using a 1: 1 ratio. Setting: 13 hospitals offering antenatal care in the UK.&nbsp; Participants: Women between 10 and 24 weeks&rsquo; gestation smoking five or more cigarettes a day before pregnancy and one or more during pregnancy.&nbsp; Interventions: Participants were randomised to behavioural support for smoking cessation (control) or behavioural support plus a PA intervention consisting of supervised treadmill exercise plus PA consultations. Neither participants nor researchers were blinded to treatment allocation.&nbsp; Main outcome measures: The primary outcome was self-reported, continuous smoking abstinence between a quit date and end of pregnancy, validated by expired carbon monoxide and/or salivary cotinine. Secondary outcomes were maternal weight, depression, birth outcomes, withdrawal symptoms and urges to smoke. The economic evaluation investigated the costs of the PA intervention compared with the control intervention.&nbsp; Results: In total, 789 women were randomised (n = 394 PA, n = 395 control). Four were excluded post randomisation (two had been enrolled twice in sequential pregnancies and two were ineligible and randomised erroneously). The intention-to-treat analysis comprised 785 participants (n = 392 PA, n = 393 control). There was no significant difference in the rate of abstinence at the end of pregnancy between the PA group (7.7%) and the control group (6.4%) [odds ratio for PA group abstinence 1.21, 95% confidence interval (CI) 0.70 to 2.10]. For the PA group compared with the control group, there was a 33% (95% CI 14% to 56%), 28% (95% CI 7% to 52%) and 36% (95% CI 12% to 65%) significantly greater increase in self-reported minutes of moderate- and vigorous-intensity PA from baseline to 1 week, 4 weeks and 6 weeks respectively. Accelerometer data showed that there was no significant difference in PA levels between the groups. There were no significant differences between the groups for change in maternal weight, depression, withdrawal symptoms or urges to smoke. Adverse events and birth outcomes were similar between the groups except for there being significantly more caesarean births in the control group than in the PA group (28.7% vs. 21.3%; p &lt; 0.023). The PA intervention was less costly than the control intervention by &pound;35 per participant. This was mainly attributable to increased health-care usage in the control group. However, there was considerable statistical uncertainty around this estimate.&nbsp; Conclusions: During pregnancy, offering an intervention combining supervised exercise and PA counselling does not add to the effectiveness of behavioural support for smoking cessation. Only 10% of participants had PA levels accessed by accelerometer and it is, therefore, unclear whether or not the lack of an effect on the primary outcome is the result of insufficient increases in PA. Research is needed to identify the smoking populations most suitable for PA interventions and methods for increasing PA adherence.&nbsp; Trial registration: Current Controlled Trials ISRCTN48600346

Macrosomia and large for gestational age in Asia:One size does not fit all

Macrosomia, usually defined as infant birth weight of >= 4000 g, does not consider gestational age, sex, or country/region-specific differences in mean birth weight and maternal body weight. This issue is particularly relevant for Asia, where 60% of the world's population lives, due to variations in maternal size and birth weights across populations. Large for gestational age (LGA), defined as birth weight > 90th centile, is a more sensitive measure as it considers gestational age and sex, though it is dependent on the choice of growth charts. We aimed to review reporting of macrosomia and LGA in Asia. We reviewed the literature on prevalence and risk of macrosomia and LGA in Asia over the last 29 years. Prevalence of macrosomia ranged from 0.5% (India) to 13.9% (China) while prevalence of LGA ranged from 4.3% (Korea) to 22.1% (China), indicating substantial variation in prevalence within and between Asian countries. High pre-pregnancy body mass index, excessive gestational weight gain, and impaired glucose tolerance conferred risk of macrosomia/LGA. Incidence of macrosomia and LGA varies substantially within and between Asian countries, as do the growth charts and definitions. The latter makes it impossible to make comparisons but suggests differences in intrauterine growth between populations. Reporting LGA, using standardized country/regional growth charts, would better capture the incidence of high birth weight and allow for comparison and identification of contributing factors. Better understanding of local drivers of excessive intrauterine growth could enable development of improved strategies for prevention and management of LGA

Relationship between 50-g glucose challenge test and large for gestational age infants among pregnant women without gestational diabetes

The study aimed to compare the incidence of large for gestational age (LGA) infants between women with a false positive and normal glucose challenge test (GCT), and to evaluate the factors associated with LGA. A total of 480 pregnant women at risk for gestational diabetes mellitus (GDM); 160 with a false positive GCT and 320 with normal GCT results were included. The incidence of LGA and other pregnancy outcomes were compared between the two groups. Possible associated factors for LGA were also evaluated. Women with a false positive GCT were significantly older and more likely to be multiparous. The incidence of LGA was comparable between the false positive and normal GCT groups (15.6% vs. 13.1%, p = .456). Other pregnancy outcomes were also comparable. Logistic regression analysis showed that pre-pregnancy underweight significantly reduced the risk of LGA (adjusted OR 0.25, 95% CI 0.07–0.87, p = .029) while a second trimester weight gain >7 kg significantly increased the risk of LGA (adjusted OR 3.13, 95% CI 1.67–5.89, p 7 kg significantly increased the risk of LGA. What the implications are of these findings for clinical practice and/or further research? As a gestational weight gain is modifiable, behavioural and a dietary intervention as well as a close monitoring of the weight gain could help in lowering the risk of LGA, even in the absence of GDM. Further studies which are more widely generalisable are needed to elucidate the relationship between 50 g GCT and the adverse outcomes and to investigate the benefits of a specific intervention among this specific group of women

A specific protocol to shorten the decision-to-delivery interval for emergency caesarean section

The achievement of recommended decision-to-delivery interval (DDI) of ≤30 minutes in emergency caesarean section (CS) is relatively low in developing countries. This study was aimed to compare DDI in emergency CS before and after the implementation of a specific care process improvement protocol, called ‘code blue’. A total of 300 women underwent emergency CS were included; 150 consecutive cases before (during 2015–2016) and the other 150 consecutive cases after (during 2017–2018) ‘code blue’ implementation. Timing of decision-to-delivery process was compared. The results showed that median DDI was significantly shorter after ‘code blue’ implementation (22 vs. 52.5 minutes, p<.001). DDI of ≤30 minutes was achieved in 80% of the women under ‘code blue’ compared to 8% before implementation (p<.001). Significant improvements were observed regardless of decision time. Pregnancy and neonatal outcomes were comparable between the two periods. The implementation of ‘code blue’ protocol for emergency CS results in significantly shorter DDI and other time intervals. Impact Statement What is already known on this subject? Achievement of recommended decision-to-delivery interval (DDI) of ≤30 minutes in emergency caesarean section is relatively low in developing countries. Various setting-specific care improvement processes have been reported to shorten DDI. What do the results of this study add? A multidisciplinary care improvement process (‘code blue’) that developed according to specific evidence and based on a hospital’s context can significantly shorten DDI as well as other time intervals in women requiring emergency CS. What are the implications of these findings for clinical practice and/or further research? The ‘code blue’ protocol could be used as a model for other hospitals and health care settings to develop their own specific quality improvement process in order to shorten DDI for emergency CS. Collaboration and communication between all staff members could help in better identification of significant barriers as well as development of appropriate solutions. Further studies are also needed to determine whether the shortened DDI could improve neonatal outcomes

Prevalence of early-onset GDM and associated risk factors in a university hospital in Thailand

This retrospective cohort study aimed to determine prevalence of GDM diagnosed before 24 weeks of gestation (early-onset GDM) and evaluate associated risk factors and compare pregnancy outcomes between different GDM status. A total of 1200 pregnant women attending antenatal clinic before 24 weeks of gestation were included. GDM screening was offered during first visit and repeat during 24–28 weeks of gestation, using 50-g GCT and 100-g OGTT. GDM was diagnosed in 110 women (13.9%) and early-onset GDM was found in 57 women (9.2%), which accounted for 65.9% of all GDM. Early-onset GDM had significant lower gestational weight gain and higher rates of preeclampsia, LGA infants, and NICU admission. Independent associated factors for early-onset GDM were age ≥30 years (aOR 4.89, 95%CI: 2.08–11.50, p < .001), and previous GDM (aOR 12.26, 95%CI: 3.86–38.93, p < .001) while DM in family was the only independent factor for late-onset GDM (aOR 2.53, 95%CI: 1.42–4.51, p = .002).IMPACT STATEMENT What is already known on this subject? Reported prevalence of early-onset GDM varies between studies, depending on the screening strategy and criteria used. Despite treatment, early-onset GDM has been associated with increased adverse maternal and neonatal outcomes in many previous studies. The risks associated with early-onset GDM and the evidence for benefit of early treatment are still unclear. What do the results of this study add? The results showed that early-onset GDM accounted for majority (65.9%) of all GDM. Despite treatment, early-onset GDM increased risk of preeclampsia, LGA infants, and NICU admission. Independent associated factors for early-onset GDM were age ≥30 years, and previous GDM while DM in family was the only independent factor for late-onset GDM. What are the implications of these findings for clinical practice and/or further research? Early GDM screening and intensive management, especially in high-risk women, should be implemented to minimise the risks of adverse outcomes. Further studies are needed to determine appropriate criteria to define early-onset GDM and to identify women at higher risk in different population and settings with different screening strategies. Effective management and approaches for this subgroup of GDM should also be further investigated