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Therapeutic Strategies for Diabetes in Pregnancy

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Endocrinology & Metabolism".

Deadline for manuscript submissions: closed (10 April 2018) | Viewed by 44568

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Special Issue Editor

Dr. Rachel McGrath

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Guest Editor

Senior Research Fellow - Department of Endocrinology, Royal North Shore Hospital, Sydney, AustraliaClinical Senior Lecturer - Northern Clinical School, University of Sydney, Sydney, Australia
Interests: diabetes in pregnancy, including type 1 and type 2 diabetes in pregnancy, and gestational diabetes. I am particularly interested in the association between maternal glycaemic variability and foetal overgrowth.

Special Issue Information

Dear Colleagues,

Hyperglycaemia in pregnancy, comprising pre-existing type 1 or type 2 diabetes in pregnancy and gestational diabetes, is rising in incidence and is associated with an increased likelihood of adverse perinatal outcomes. Women with diabetes in pregnancy are at greater risk of pre-term delivery, complications in delivery and unplanned caesarean sections, and poor neonatal outcomes, such as macrosomia, birth injuries and hypoglycaemia. Furthermore, in utero exposure to hyperglycaemia can lead to a predisposition towards obesity and chronic disease in adult life.

The management of diabetes in pregnancy comprises a multi-disciplinary approach, wherein diabetes educators, dieticians, midwives, obstetricians and endocrinologists play a pivotal role. However, due to a combination of factors including more stringent diagnostic criteria and higher rates of risk factors for gestational diabetes in women of reproductive age, there is an increasing strain on the healthcare system to provide care to women with diabetes in pregnancy. Thus, it is of significant clinical importance that new therapeutic strategies are devised, such that optimal care is provided to pregnant women with diabetes and better perinatal outcomes can be achieved.

The care of both pre-existing diabetes in pregnancy and gestational diabetes overlap and span the entire prenatal and antenatal period. Pre-pregnancy optimisation of glycaemic control is fundamental to avoiding the risk of congenital anomalies in women with type 1 and type 2 diabetes; likewise, maintaining a body weight and BMI in the healthy range is important for all women entering pregnancy. Achieving target blood glucose levels and minimising glycaemic excursions through frequent blood glucose monitoring, appropriate dietary changes and use of anti-hyperglycaemic medications, such as metformin and insulin, are also central features of diabetes in pregnancy management. Furthermore, early identification of women at increased risk of gestational diabetes as well as those with unrecognised diabetes in pregnancy, such that education and intervention can be provided, contribute towards minimisation of pregnancy complications and improved outcomes for both mother and neonate.

This Special Issue of the Journal of Clinical Medicine will detail the most recent advances in therapies for diabetes in pregnancy, as well as provide an up-to-date overview of strategies that can be employed to ensure this population of women with high-risk pregnancies, and their neonates, have the best outcomes.

Dr. Rachel McGrath
Guest Editor

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Keywords

gestational diabetes
pre-existing diabetes in pregnancy
glycemic control
perinatal outcomes
antenatal diabetes care
birth weight

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Published Papers (6 papers)

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Research

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9 pages, 221 KiB

Open AccessArticle

Clinical Implications of the NICE 2015 Criteria for Gestational Diabetes Mellitus

by Meena Bhatia, Lucy H. Mackillop, Katy Bartlett, Lise Loerup, Yvonne Kenworthy, Jonathan C. Levy, Andrew J. Farmer, Carmelo Velardo, Lionel Tarassenko and Jane E. Hirst

J. Clin. Med. 2018, 7(10), 376; https://doi.org/10.3390/jcm7100376 - 22 Oct 2018

Cited by 17 | Viewed by 5142

Abstract

Background: In response to concerns that the International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria labeled too many women with gestational diabetes mellitus (GDM) without evidence of clinical or economic benefit, NICE recommended a change in diagnostic criteria in 2015. Aim: To compare diabetes associated maternal and neonatal complications in pregnancies complicated by GDM diagnosed using IADPSG criteria only, to those with GDM diagnosed using both IADPSG and NICE 2015 criteria. GDM screening was risk factor based. Methods: This was a secondary analysis of a trial of women with GDM diagnosed by the IADPSG criteria (fasting blood glucose (BG) ≥ 5.1 mmol/L, 1 h ≥ 10.0 mmol/L and 2 h ≥ 8.5 mmol/L). Outcomes were compared for two groups: NICE + IADPSG defined as those with GDM diagnosed by both the NICE 2015 and IADPSG criteria (fasting BG ≥ 5.6 mmol/L, 2 h ≥ 8.5 mmol/L); and IADPSG-ONLY (fasting BG 5.1 mmol/L to 5.5 mmol/L, and/or 1-hour ≥10.0 mmol/L, and 2 h ≥ 8.5 mmol/L). We were not able to obtain data for women with a 2-h value between BG 7.8–8.4 mmol/L (i.e., NICE-ONLY; NICE 2015 positive and IADPSG negative). All women were treated for GDM using targets of fasting BG < 5.3 mmol/L and 1-h post prandial BG < 7.8 mmol/L respectively. Results: Of 159 women, 65 (40.9%) were NICE + IADPSG and 94 (59.1%) IADPSG-ONLY. Hypoglycaemic medication use was similar in both groups: 52.3% NICE + IADPSG, 46.8% IADPSG-ONLY, OR 1.0 (0.5–1.9). The IADPSG-ONLY group delivered later than the NICE + IADPSG group; 39.0 weeks (sd 1.4) compared to 38.2 weeks (sd 2.5), p value 0.02. Fewer caesarean sections occurred in IADPSG-ONLY group 30.9% vs. 52.3%, OR 0.4 (0.2–0.9). Birthweight, large for gestational age, and other neonatal complications were not significantly different between groups. Conclusions: Gestational diabetes-associated perinatal complications were similar in both groups. The IADPSG criteria detect women with evidence of ongoing hyperglycaemia who may benefit from treatment during pregnancy. Full article

(This article belongs to the Special Issue Therapeutic Strategies for Diabetes in Pregnancy)

9 pages, 489 KiB

Open AccessArticle

Outcomes for Women with Gestational Diabetes Treated with Metformin: A Retrospective, Case-Control Study

by Rachel T. McGrath, Sarah J. Glastras, Emma S. Scott, Samantha L. Hocking and Gregory R. Fulcher

J. Clin. Med. 2018, 7(3), 50; https://doi.org/10.3390/jcm7030050 - 9 Mar 2018

Cited by 12 | Viewed by 7711

Abstract

Metformin is increasingly being used a therapeutic option for the management of gestational diabetes mellitus (GDM). The aim of this study was to compare the maternal characteristics and perinatal outcomes of women with GDM treated with metformin (with or without supplemental insulin) with those receiving other management approaches. A retrospective, case-control study was carried out and 83 women taking metformin were matched 1:1 with women receiving insulin or diet and lifestyle modification alone. Women managed with diet and lifestyle modification had a significantly lower fasting plasma glucose (p < 0.001) and HbA1c (p < 0.01) at diagnosis of GDM. Furthermore, women managed with metformin had a higher early pregnancy body mass index (BMI) compared to those receiving insulin or diet and lifestyle modification (p < 0.001). There was no difference in mode of delivery, birth weight or incidence of large- or small-for-gestational-age neonates between groups. Women receiving glucose lowering therapies had a higher rate of neonatal hypoglycaemia (p < 0.05). The incidence of other adverse perinatal outcomes was similar between groups. Despite their greater BMI, women with metformin-treated GDM did not have an increased risk of adverse perinatal outcomes. Metformin is a useful alternative to insulin in the management of GDM. Full article

(This article belongs to the Special Issue Therapeutic Strategies for Diabetes in Pregnancy)

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7 pages, 205 KiB

Open AccessArticle

Association of Maternal Factors with Perinatal Complications in Pregnancies Complicated with Diabetes: A Single-Center Retrospective Analysis

by Sho Endo, Yoshifumi Saisho, Kei Miyakoshi, Daigo Ochiai, Tadashi Matsumoto, Yoshinaga Kawano, Masanori Mitsuishi, Junichiro Irie, Masami Tanaka, Shu Meguro, Mamoru Tanaka and Hiroshi Itoh

J. Clin. Med. 2018, 7(1), 5; https://doi.org/10.3390/jcm7010005 - 2 Jan 2018

Cited by 5 | Viewed by 4547

Abstract

Objective: The aim of this study was to clarify the association of maternal factors with perinatal complications in pregnancies complicated with type 1 (T1D) or type 2 diabetes (T2D). Methods: We conducted a retrospective chart review and enrolled 26 Japanese pregnant women with diabetes who received perinatal care at our hospital between 2008 and 2015. Perinatal complications were defined as one or more of the following: miscarriage, fetal death, fetal dysfunction, fetal structural anomaly, small-for-gestational age, large-for-gestational age (LGA), premature birth, neonatal hypoglycemia, pregnancy-induced hypertension (PIH), deterioration of maternal kidney function, and urgent Caesarean section (CS). The associations between perinatal complications and maternal factors were examined. Results: Approximately 70% and 50% of women with T1D and T2D experienced perinatal complications, respectively. LGA, neonatal hypoglycemia, and urgent CS were major perinatal complications in women with T1D, while PIH and urgent CS were major complications in those with T2D. In women with T1D, pre-gestational HbA1c was significantly higher in women with perinatal complications than in those without. In women with T2D, pre-gestational body mass index was significantly higher in women with perinatal complications than in those without. Conclusions: These findings suggest that while pre-gestational glycemic control remains the most important issue in women with T1D, pre-gestational weight control in addition to glycemic control should be greater emphasized in women with T2D to reduce the risk of perinatal complications. Full article

(This article belongs to the Special Issue Therapeutic Strategies for Diabetes in Pregnancy)

Review

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9 pages, 219 KiB

Open AccessReview

Consensus in Gestational Diabetes MELLITUS: Looking for the Holy Grail

by Mukesh M. Agarwal

J. Clin. Med. 2018, 7(6), 123; https://doi.org/10.3390/jcm7060123 - 28 May 2018

Cited by 22 | Viewed by 4036

Abstract

The world’s pre-eminent diabetes, obstetric, endocrine, and health organizations advocate a plethora of diverse algorithms for the screening, diagnosis, management, and follow-up of gestational diabetes mellitus (GDM). Additionally, there are regional recommendations of local health societies. Several of these proposals for GDM are contentious because some of them were developed from unscientific studies, based on expert-opinion, catered to preserve resources, and subjectively modified for convenience. Due to the wide variety of choices available, the approach to GDM can be extremely diverse even within the same hospital. This lack of consensus creates major problems in addressing prevalence, complications, efficacy of treatment, and follow-up of GDM. Moreover, it becomes nearly impossible to compare the numerous studies. Furthermore, the lack of consensus confuses the health care providers of obstetric health who look to the experts for guidance. Therefore, a clear, objective, “evidence-based” global approach, which is simple, easy to follow, and validated by corroborative research, is crucial. We contend that, despite decades of research, a single acceptable global guideline is not yet on the horizon. Full article

(This article belongs to the Special Issue Therapeutic Strategies for Diabetes in Pregnancy)

16 pages, 3058 KiB

Open AccessReview

The Emerging Role of Biomarkers in the Diagnosis of Gestational Diabetes Mellitus

by Natassia Rodrigo and Sarah J. Glastras

J. Clin. Med. 2018, 7(6), 120; https://doi.org/10.3390/jcm7060120 - 23 May 2018

Cited by 60 | Viewed by 13993

Abstract

Gestational diabetes mellitus (GDM) is a common complication of pregnancy; its rising incidence is a result of increased maternal obesity and older maternal age together with altered diagnostic criteria identifying a greater proportion of pregnant women with GDM. Its consequences are far-reaching, associated with poorer maternal and neonatal outcomes compared to non-GDM pregnancies, and GDM has implications for metabolic health in both mother and offspring. Objective markers to identify women at high risk for the development of GDM are useful to target therapy and potentially prevent its development. Established clinical risk factors for GDM include overweight/obesity, age, ethnicity, and family history of diabetes, though they lack specificity for its development. The addition of biomarkers to predictive models of GDM may improve the ability to identify women at risk of GDM prior to its development. These biomarkers reflect the pathophysiologic mechanisms of GDM involving insulin resistance, chronic inflammation, and altered placental function. In addition, the role of epigenetic changes in GDM pathogenesis highlights the complex interplay between genetic and environmental factors, potentially offering further refinement of the prediction of GDM risk. In this review, we will discuss the clinical challenges associated with the diagnosis of GDM and its current pathophysiologic basis, giving rise to potential biomarkers that may aid in its identification. While not yet validated for clinical use, we explore the possible clinical role of biomarkers in the future. We also explore novel diagnostic tools, including high throughput methodologies, that may have potential future application in the identification of women with GDM. Full article

(This article belongs to the Special Issue Therapeutic Strategies for Diabetes in Pregnancy)

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13 pages, 756 KiB

Open AccessReview

Controversies and Advances in Gestational Diabetes—An Update in the Era of Continuous Glucose Monitoring

by Marina P. Carreiro, Anelise I. Nogueira and Antonio Ribeiro-Oliveira

J. Clin. Med. 2018, 7(2), 11; https://doi.org/10.3390/jcm7020011 - 25 Jan 2018

Cited by 29 | Viewed by 8194

Abstract

Diabetes in pregnancy, both preexisting type 1 or type 2 and gestational diabetes, is a highly prevalent condition, which has a great impact on maternal and fetal health, with short and long-term implications. Gestational Diabetes Mellitus (GDM) is a condition triggered by metabolic adaptation, which occurs during the second half of pregnancy. There is still a lot of controversy about GDM, from classification and diagnosis to treatment. Recently, there have been some advances in the field as well as recommendations from international societies, such as how to distinguish previous diabetes, even if first recognized during pregnancy, and newer diagnostic criteria, based on pregnancy outcomes, instead of maternal risk of future diabetes. These new recommendations will lead to a higher prevalence of GDM, and important issues are yet to be resolved, such as the cost-utility of this increase in diagnoses as well as the determinants for poor outcomes. The aim of this review is to discuss the advances in diagnosis and classification of GDM, as well as their implications in the field, the issue of hyperglycemia in early pregnancy and the role of hemoglobin A1c (HbA1c) during pregnancy. We have looked into the determinants of the poor outcomes predicted by the diagnosis by way of oral glucose tolerance tests, highlighting the relevance of continuous glucose monitoring tools, as well as other possible pathogenetic factors related to poor pregnancy outcomes. Full article

(This article belongs to the Special Issue Therapeutic Strategies for Diabetes in Pregnancy)

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