Search

Key Points: Question: Does early metformin initiation improve glycemic control and reduce insulin use in pregnant individuals with gestational diabetes? Findings: In this randomized clinical trial, the composite outcome of insulin initiation and a fasting glucose level of 5.1 mmol/L (92 mg/dL) or greater at gestation weeks 32 or 38 was not significantly different between groups. Secondary outcomes of maternal glycaemic control, weight gain, and infant size were lower in the metformin group. There was no difference in maternal or neonatal morbidities. Meaning: Early metformin initiation did not reduce the occurrence of the combination of a fasting glucose level of 5.1 mmol/L or greater at gestation weeks 32 or 38 or insulin initiation. Ongoing review of rates of small for gestational age should continue when using metformin. Importance: Gestational diabetes is a common complication of pregnancy and the optimal management is uncertain. Objective: To test whether early initiation of metformin reduces insulin initiation or improves fasting hyperglycemia at gestation weeks 32 or 38. Design, Setting, and Participants: Double-blind, placebo-controlled trial conducted in 2 centers in Ireland (one tertiary hospital and one smaller regional hospital). Participants were enrolled from June 2017 through September 2022 and followed up until 12 weeks' postpartum. Participants comprised 510 individuals (535 pregnancies) diagnosed with gestational diabetes based on World Health Organization 2013 criteria. Interventions: Randomized 1:1 to either placebo or metformin (maximum dose, 2500 mg) in addition to usual care. Main Outcomes And Measures: The primary outcome was a composite of insulin initiation or a fasting glucose level of 5.1 mmol/L or greater at gestation weeks 32 or 38. Results: Among 510 participants (mean age, 34.3 years), 535 pregnancies were randomized. The primary composite outcome was not significantly different between groups and occurred in 150 pregnancies (56.8%) in the metformin group and 167 pregnancies (63.7%) in the placebo group (between-group difference, −6.9% [95% CI, −15.1% to 1.4%]; relative risk, 0.89 [95% CI, 0.78-1.02]; P =.13). Of 6 prespecified secondary maternal outcomes, 3 favored the metformin group, including time to insulin initiation, self-reported capillary glycemic control, and gestational weight gain. Secondary neonatal outcomes differed by group, with smaller neonates (lower mean birth weights, a lower proportion weighing >4 kg, a lower proportion in the >90% percentile, and smaller crown-heel length) in the metformin group without differences in neonatal intensive care needs, respiratory distress requiring respiratory support, jaundice requiring phototherapy, major congenital anomalies, neonatal hypoglycemia, or proportion with 5-minute Apgar scores less than 7. Conclusion and relevance: Early treatment with metformin was not superior to placebo for the composite primary outcome. Prespecified secondary outcome data support further investigation of metformin in larger clinical trials. Trial Registration: ClinicalTrials.gov Identifier: NCT02980276; EudraCT: 2016-001644-19 This randomized clinical trial compares use of metformin vs placebo in treating the maternal and neonatal outcomes associated with gestational diabetes. [ABSTRACT FROM AUTHOR]

Introduction: Type 1 diabetes mellitus occurs in one in every 275 pregnancies and can result in increased morbidity and mortality for both mother and baby. Several pregnancy complications can be reduced or prevented by attendance at pre‐pregnancy care (PPC). Despite this, less than 40% of pregnant women with pre‐gestational diabetes receive formal PPC. The aim of this scoping review is to identify the barriers to PPC attendance among women with type 1 diabetes. Methods: We conducted a scoping review by searching five databases (Ebsco, Embase, Ovid and PubMed for literature and the ProQuest for any grey/unpublished literature) for studies in English between 2000 and 2022. Studies that evaluated attendance at PPC for women with type 1 diabetes were included. Results: There are multiple barriers to PPC attendance, and many of these barriers have been unchanged since the 1990s. Identified barriers can be grouped under patient‐centered and clinician‐centered headings. Patient factors include knowledge and awareness, unplanned pregnancies, negative perceptions of healthcare and communication issues, unclear attendance pathways and logistical issues including time off work and childcare. Clinician factors include physician knowledge, time constraints and lack of comfort discussing pregnancy/contraception. Conclusion: This review highlights the ongoing problem of poor attendance at PPC and identifies key barriers to be addressed when developing and implementing PPC programs for women with type 1 diabetes. [ABSTRACT FROM AUTHOR]

Context and Aim: Metformin has been used in pregnancy since the 1970s. It is cheap, widely available and is acceptable to women. Despite its increasing use, controversy remains surrounding its benefits and risks. Metformin effectively reduces hyperglycaemia for the mother during pregnancy and it reduces rates of macrosomia and neonatal hypoglycaemia. However, concern exists surrounding an increase in the rate of SGA births and obesity in childhood. We aim to review the evidence and expert opinion behind metformin in pregnancy through to the post-partum period. Methods: We performed a literature review of relevant studies from online databases using a combination of keywords. We also searched the references of retrieved articles for pertinent studies. Results: There is strong evidence that metformin is safe in early pregnancy with no risk of congenital malformations. If used throughout pregnancy, it is likely to lead to reduced maternal weight gain and reduced insulin dose in women with type 2 diabetes. In infants, metformin reduces hypoglycaemia and macrosomia but may increase the rate of infants born SGA. There is some evidence of an increased risk of obesity and altered fat distribution in offspring. Metformin appears well tolerated in pregnancy and is more acceptable to women than insulin therapy. Conclusion: Due to increasing rates of maternal obesity, GDM and type 2 diabetes, metformin use in pregnancy is increasing. Overall, it appears safe and effective but further research is needed to examine mechanisms linking metformin to obesity reported during childhood in some follow-up studies. [ABSTRACT FROM AUTHOR]

The article presents the decade to find the solution for gestational diabetes mellitus screening and treatments. Topics include the diabetic pregnancies being affected by gestational diabetes mellitus (GDM), the evidence was clear that treatment of even mild GDM had beneficial effects on both maternal and neonatal outcomes, and the instrumental in encouraging clinicians to offer detection and intervention for GDM.

A randomized controlled trial demonstrates that using lower glycaemic criteria for diagnosing and treating gestational diabetes mellitus than currently used increases disease prevalence but does not reduce the risk of large-for-gestational-age infants across a population. However, individuals with mild hyperglycaemia who would otherwise remain undiagnosed experienced important health benefits from treatment. [ABSTRACT FROM AUTHOR]

The aim of this literature review was to identify breastfeeding practices that support women with diabetes to breastfeed. A search was undertaken of CINAHL and Medline databases to identify studies that inform breastfeeding practice for women with diabetes. This resulted in 14 studies (19 records). Most studies focused on women with GDM and T1D with some consideration of T2D. The review has been organised using Maslow's Hierarchy of Needs, to enable a clear focus on the needs of women while identifying supportive practices. The key findings of this review are that breastfeeding as the first feed and exclusive breastfeeding are beneficial to meeting physiological needs. Preparations such as having food nearby and having someone to call on can help meet the woman's safety and security needs. A sense of love and belonging is supported by the practice of an early first breastfeed, but antenatal breast milk expression is currently not recommended. The woman's self-esteem can be enhanced through informed multidisciplinary support. Finally, self-actualisation or success with breastfeeding has been achieved by women with diabetes. Common breastfeeding concerns rather than diabetes have been identified as reasons for cessation of breastfeeding. Practices that support women deal with these concerns are recommended. [ABSTRACT FROM AUTHOR]

The article presents the roadmap for research in diabetes in pregnancy for the coming decade. Topics include the most accurate estimates for the global burden of diabetes in pregnancy (DiP) comes from the International Diabetes Federation (IDF), the women with established pregestational diabetes (PGDM) and in women with gestational diabetes (GDM), and the women with PGDM attending antenatal clinics have type 2 diabetes.

Background: Universal screening using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria has identified a prevalence of gestational diabetes mellitus (GDM) of 12.4% in women living in Ireland. Women with prior GDM are at increased risk of developing type 2 diabetes later in life. A number of risk factors linked to the development of type 2 diabetes are potentially modifiable through lifestyle and behaviour changes, and medical management. No previous Irish studies have adequately investigated the efficacy of lifestyle intervention programmes in reducing these risk factors in women with prior GDM. Through a two-group, parallel randomised controlled trial (RCT), this study aims to assess the clinical impact, cost-effectiveness and psychological experience of the Croí MyAction intensive lifestyle modification programme for women with prior GDM.Methods/design: A total of 54 women with a history of GDM and persistent post-partum glucose dysfunction (impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)), are randomly assigned to a control arm (n=27) or to the Croí MyAction intervention group (n=27). The control arm receives usual health care advice--written information on diet and lifestyle changes for reducing diabetes risks and visits with general practitioners as required. The intervention group receives usual health care as per the control group in addition to attending a 12-week intensive lifestyle modification programme known as Croí MyAction. Croí MyAction involves 2.5 hour sessions once per week (for 12 weeks) comprising a group exercise programme, group health promotion or education seminars, and one-to-one meetings with a multidisciplinary health care team to personalise risk factor reductions. Randomisation and allocation to the intervention arms is carried out by an independent researcher, ensuring that the allocation sequence is concealed from study researchers until the interventions are assigned. The primary analysis is based on glucose dysfunction, comparing a mean reduction in fasting plasma glucose (FPG) levels on a 75 gram oral glucose tolerance test (OGTT) in the two groups at a one-year, post-intervention follow-up. The trial is funded by the Irish Health Research Board (HRB). Ethics approval was obtained on 27 March 2012 from the Clinical Research Ethics Committee, Galway University Hospitals, Health Service Executive of Ireland (Ref: C.A.691).Trial Registration: Current Controlled Trials ISRCTN41202110. [ABSTRACT FROM AUTHOR]

It has been conclusively established that treatment of hypertension in patients with type 2 (non-insulin-dependent) diabetes mellitus will significantly reduce the incidence of stroke, heart failure and progression of diabetic complications. β-Blockers are effective antihypertensive agents which, in long term studies, have proven beneficial in reducing important clinical end-points. However nonselective β-blockers may have a negative effect on lipid profiles and contribute to hypoglycaemic unawareness, thus preventing their use in some patients with diabetes mellitus. The development of newer and more selective β-blockers has overcome many of these problems. In addition, some of the newer agents have novel properties such as release of nitric oxide, which theoretically would make them more attractive in patients with diabetes mellitus. Overall, the adverse metabolic effects of β-blockers do not appear to be important in clinical practice and these agents should no longer be contraindicated in patients with type 2 diabetes mellitus. Their proven cardiovascular benefits would seem to easily tip the balance in favour of their use. [ABSTRACT FROM AUTHOR]

Background: Adopting the WHO protocol for glucose analysis is arguably impractical in the routine clinical setting. Deviations may develop due to a lack of understanding regarding the impact of glycolysis on the accuracy of results. Aim: We sought to assess the stability of glucose in two different blood collection tubes (BCT), BD Vacutainer® FX 'Fl-Ox' and Greiner Vacuette® FC-Mix 'FC-Mix' stored at room temperature (RT:18–22°C) and 4°C over 8.5 days. Method: Each participant provided venous whole blood collected into 51 BCTs; 'Fl-Ox' (n = 26) and 'FC-Mix' (n = 25). One Fl-Ox sample from each participant was handled according to the WHO recommended method. The remaining BCTs were stored at 4°C/RT prior to analyses at designated study timepoints. Glucose was measured using the hexokinase assay on the Cobas® 8000 platform. Results: Participants (n = 8, Male = 2) were aged 24–56 years. Plasma glucose measured in FI-Ox BCTs according to the WHO sample-handling method had a median concentration of 5.73 mmol/L (Range: 5.39–10.37 mmol/L). Glucose decreased by greater than minimal difference (>0.26 mmol/L) in blood collected into Fl-Ox and stored @4°C/RT within 24 h of phlebotomy. FC-Mix BCT maintained glucose <0.26 mmol/L @4°C over a period of 8.5 days and up to 4 days @RT when compared to the WHO recommended method. Conclusion: Glucose in FC-Mix BCT stored @4°C demonstrated the best agreement with results determined using the WHO specifications. When FC-Mix tubes were stored @RT, glucose was stable for 4 days. These findings suggest that the FC-Mix BCT effectively inhibits glycolysis and should be introduced into routine clinical practice. [ABSTRACT FROM AUTHOR]

A response from the author of the article "ATLANTIC-DIP: prevalence of metabolic syndrome and insulin resistance in women with previous gestational diabetes mellitus by International Association of Diabetes in Pregnancy Study Groups criteria" in the 2015 issue is presented.

Aims: Gestational diabetes (GDM) is associated with the development of postpartum (PP) glucose intolerance. Plasma glycated CD59 (pGCD59) is an emerging biomarker for the detection of hyperglycaemia. The aim of this study was to assess the ability of PP pGCD59 to predict the development of PP GI as defined by the 2 h 75 g OGTT using the ADA criteria, in a cohort of women diagnosed with prior GDM in the index pregnancy using the 2 h 75 g OGTT at 24–28 weeks of gestation according to the World Health Organization (WHO) 2013 criteria. Methods: Of the 2017 pregnant women recruited prospectively 140 women with gestational diabetes had samples for pGCD59 taken PP at the time of the OGTT. The ability of pGCD59 to predict the results of the PP OGTT was assessed using nonparametric receiver operating characteristic (ROC) curves. Results: Women with PP glucose intolerance had significantly higher PP pGCD59 levels compared to women with normal glucose tolerance PP (3.8 vs. 2.7 SPU). PP pGCD59 identified women who developed glucose intolerance PP with an AUC of 0.80 (95% CI: 0.70–0.91). A PP pGCD59 cut‐off value of 1.9 SPU generated a sensitivity of 100% (95% CI: 83.9–100), specificity of 16.9% (95% CI: 9.8–26.3), positive predictive value of 22.1% (95% CI: 21.0–22.6), and negative predictive value of 100% (95% CI: 87.4–100). PP fasting plasma glucose generated an AUC of 0.96 (95% CI: 0.89–0.99) for the identification of PP glucose intolerance. Conclusion: Our study found that PP pGCD9 may be a promising biomarker to identify women not requiring PP glucose intolerance screening using the traditional OGTT. While the diagnostic accuracy of pGCD59 is good, fasting plasma glucose remains a better test for the identification of PP glucose intolerance. [ABSTRACT FROM AUTHOR]

In the article, the authors discuss the developments in global health care. They focus on the prevalence of macrosomia and its effects on adverse maternal and perinatal outcomes in developing countries in Asia, Africa and Latin America. They cite the study conducted by Ai Koyanagi and colleagues on the World Health Organization's (WHO) Global Survey on Maternal and Perinatal Health to examine the issue.

Hyperglycemia in pregnancy (HIP) is recognized as a major underlying cause of pregnancy complications and a contributing cause to health risks throughout the subsequent life of both mothers and babies, with amplification of the global epidemic of non-communicable diseases. Although some aspects of these associations are well described, detailed understanding of basic pathophysiologic mechanisms is lacking. Improved fundamental scientific knowledge must be developed to allow logical strategies for prevention and treatment. During pregnancy, much work is required to replace current empirical approaches to diagnosis and treatment of HIP with evidence based protocols, pragmatically adapted to differing health care and health economic contexts. Further, a life cycle approach to HIP, the risk of immediate pregnancy complications and later health risks to mother and baby must be developed and implemented across a wide range of health care environments. This document aims to outline key focus areas for further basic, epidemiologic, clinical and implementation research in this important area. [ABSTRACT FROM AUTHOR]

OBJECTIVE-- Prospective evaluation of pregnancy outcomes in pregestational diabetes along the Atlantic seaboard 2006-2007. RESEARCH DESIGN AND METHODS-- The Atlantic Diabetes in Pregnancy group, representing five antenatal centers in a wide geographical location, was established in 2005. All women with diabetes for >6 months before the index pregnancy were included. Results were collected electronically via the DIAMOND Diabetes Information System. Pregnancy outcome was compared with background rates. RESULTS -- There were 104 singleton pregnancies. The stillbirth rate (25/1,000) was 5 times, perinatal mortality rate (25/1,000) 3.5 times, and congenital malformation rate (24/1,000) 2 times that of the background population. A total of 28% of women received prepregnancy care, 43% received prepregnancy folic acid, and 51% achieved an A1C ≥7% at first antenatal visit. CONCLUSIONS-- Women are not well prepared for pregnancy, and outcomes are suboptimal. A regional prepregnancy care program and centralized glucose management are urgently needed. [ABSTRACT FROM AUTHOR]

Metformin is used worldwide in the treatment of type 2 diabetes and has been used in the treatment of diabetes in pregnancy since the 1970s. It is highly acceptable to patients due to its ease of administration, cost and adverse effect profile. It is effective in reducing macrosomia, large-for-gestational-age infants and reduces maternal weight gain. Despite its many advantages, metformin has been associated with reductions in foetal size and has been associated with an increase in infants born small-for-gestational-age in certain cohorts. In this article, we review its efficacy, adverse effects and long-term follow-up before, during and after pregnancy for both mother and infant. We also evaluate the other forms of treatment for gestational diabetes, including oral therapies, insulin therapy and emerging treatments. [ABSTRACT FROM AUTHOR]

Aim: Even though most pregnancies are uneventful, occasionally complications do occur. Gestational diabetes is linked to an increased risk of adverse pregnancy outcomes. Early identification of women at risk of experiencing adverse outcomes, ideally through a single blood test, would facilitate early intervention. Plasma glycated CD59 (pGCD59) is an emerging biomarker which has shown promise in identifying hyperglycaemia during pregnancy and has been associated with the risk of delivering an LGA infant. The aim of this study was to explore the ability of the first- and second-trimester pGCD59 to predict adverse pregnancy outcomes. Methods: This was a prospective study of 378 pregnant women. Samples for pGCD59 were taken at the first antenatal visit and at the time of the 2 h 75 g OGTT (24–28 weeks of gestation). Adjusted receiver operating characteristic curves were used to evaluate the ability of pGCD59 to predict maternal and neonatal outcomes. Results: First-trimester pGCD59 levels were higher in women with gestational diabetes who delivered a macrosomic infant (4.2 ± 0.7 vs. 3.5 ± 1.0 SPU, p < 0.01) or an LGA infant (4.3 ± 0.3 vs. 3.6 ± 1.0 SPU, p = 0.01) compared to women with GDM that did not experience these outcomes. Second-trimester pGCD59 levels were higher in women that developed polyhydramnios (2.9 ± 0.4 vs. 2.5 ± 1.1 SPU, p = 0.03). First- and second-trimester pGCD59 predicted pregnancy-induced hypertension with good accuracy (AUC:0.85, 95%CI:0.78–0.91; AUC: 0.80, 95%CI: 0.73–0.88, respectively) and neonatal hypoglycaemia with fair to good accuracy (AUC:0.77, 95%CI: 0.54–0.99, AUC:0.81, 95%CI:0.62–0.99). Conclusions: This study has shown that pGCD59 has the potential to predict adverse pregnancy outcomes. Prospective studies with a larger number of cases are necessary to fully explore and validate the potential of this emerging biomarker in predicting adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Aims To examine clinical parameters, glycemic control, folic acid supplementation, and the presence of other chronic diseases during early pregnancy in the EVOLVE study population (women with pre-existing diabetes treated with injectable glucose-lowering drugs). Methods Cross-sectional baseline evaluation of EVOLVE: an international, multicenter, non-interventional study investigating the safety of injectable glucose-lowering drugs in pregnant women with pre-existing type 1 (T1D) or type 2 diabetes (T2D). Data were collected at enrollment visit interviews before gestational week 16. Results In total, 2383 women from 17 mainly European countries were enrolled in the study: 2122 with T1D and 261 with T2D; mean age was 31 and 33 years, and duration of diabetes was 15 and 6 years, respectively. For women with T1D or T2D, 63% and 75%, respectively, received basal and rapid-acting insulin, 36% and 3% rapid-acting insulin only, 0.7% and 14.0% basal insulin only, 0.2% and 5.4% premix insulin, 0.0% and 1.2% injectable glucagon-like peptide-1 receptor agonist treatment without insulin. In women with T1D or T2D, respectively, during early pregnancy, 59% and 62% had HbA1c <7.0% (53 mmol/mol); 16% and 36% reported not taking folic acid before or during early pregnancy. Overall, >40% of women had ≥1 chronic concomitant condition (predominantly thyroid disease or hypertension). Retinopathy was the most commonly reported diabetic complication. The most commonly reported previous pregnancy complication was miscarriage. Conclusions Baseline data from this large multinational population of women with pre-existing diabetes indicate that sub-optimal glycemic control, poor pregnancy planning, and chronic concomitant conditions were common in early pregnancy. [ABSTRACT FROM AUTHOR]

Background: Pregnancy induces physiological changes which affect biochemical and haematological parameters. As the significance of laboratory test results change throughout pregnancy, the reference interval (RI) or key result interpretive guide should be specific to pregnancy. This study sought to establish trimester-specific-RIs for routine biochemical and haematological tests in healthy white European women with singleton pregnancies with comparison to RIs for non-pregnant European adults.Methods: A retrospective analysis of a prospective longitudinal single-centre study of healthy pregnant women conducted between November 2018 and December 2020 in a tertiary academic hospital with approximately 3000 births annually. Inclusion criteria: signed informed consent, age ≥18 years, white European, body mass index (BMI) <25 kg/m2, blood pressure <140/90mmHg, non-smoker, no previous pathology or gestational diabetes. Trimester defined as T1: up to 13 weeks + 6 days, T2: 14-27 weeks + 6 days and T3: ≥28-41 weeks + 6 days. Baseline demographics, anthropometric and laboratory measurements were recorded. In total, 31 biochemical and 10 haematological ISO15189:2012 accredited tests were measured using Roche Cobas® and Sysmex XN-9100™ analysers, respectively. RIs were established according to the International Federation of Clinical Chemistry (IFCC) recommended method.Results: Apparently healthy pregnant women (n = 124) with bio-banked serum samples in each trimester were recruited. At the booking visit, 49.2% (n = 61) of participants were nulliparous, with median age of 34.4 (IQR: 31.3-37.3) years, gestational age of 89 (IQR: 84-93) days, BMI of 22.5 (IQR: 21.0-23.7) kg/m2 and systolic and diastolic blood pressure of 116 (110-125) mmHg and 67 (61-75) mmHg, respectively.Conclusions: Normative trimester-specific biological intervals for routinely requested biochemical and haematological medical laboratory tests were established. These RIs will be invaluable to result interpretation and the management of pregnant women. [ABSTRACT FROM AUTHOR]

Examines the role of beta blockers on the treatment of hypertension in diabetes mellitus in Great Britain. Rate of heart attack in patients treated with beta blockers; Incidence of coronary artery disease in patients with hypertension and diabetes mellitus; Effects of antihypertensive therapy on coronary heart diseases treatment.

The aim of this study was to evaluate the ability of second trimester plasma glycated CD59 (pGCD59), a novel biomarker, to predict the results of the 2 h 75 g oral glucose tolerance test at 24–28 weeks of gestation, employing the 2013 World Health Organisation criteria. This was a prospective study of 378 pregnant women. The ability of pGCD59 to predict gestational diabetes (GDM) was assessed using adjusted ROC curves for maternal age, BMI, maternal ethnicity, parity, previous GDM, and family history of diabetes. The pGCD59 levels were significantly higher in women with GDM compared to women with normal glucose tolerance (p = 0.003). The pGCD59 generated an adjusted AUC for identifying GDM cases of 0.65 (95%CI: 0.58–0.71, p < 0.001). The pGCD59 predicted GDM status diagnosed by a fasting glucose value of 5.1 mmol/L with an adjusted AUC of 0.74 (95%CI: 0.65–0.81, p < 0.001). Analysis of BMI subgroups determined that pGCD59 generated the highest AUC in the 35 kg/m2 ≤ BMI < 40 kg/m2 (AUC: 0.84 95%CI: 0.69–0.98) and BMI ≥ 40 kg/m2 (AUC: 0.96 95%CI: 0.86–0.99) categories. This study found that second trimester pGCD59 is a fair predictor of GDM status diagnosed by elevated fasting glucose independent of BMI and an excellent predictor of GDM in subjects with a very high BMI. [ABSTRACT FROM AUTHOR]

Background: Selection tools for medicine must achieve political validity and enjoy stakeholder acceptability. This qualitative study aimed to establish the perspectives of doctors, from various clinical specialities, on HPAT-Ireland, a new selection tool for undergraduate medical students. Methods: Fifteen doctors participated over three iterative cycles of recruitment, interviewing and analysis. Prior to interview, participants sat a practice HPAT-Ireland test. HPAT-Ireland has three sections: (1) Logical reasoning/problem solving; (2) Interpersonal understanding and (3): Non-verbal reasoning. Summary of results: Three themes emerged: job relatedness; utility of HPAT-Ireland and diversity. Sections 1 and 2 were considered very job related however Section 3 was widely criticised for lacking clinical relevance. Doctors did not think that the test would reliably predict future performance. However, one-third felt it was acceptable as a selection tool in conjunction with academic record. Those who found it unacceptable were influenced by its perceived narrow focus, limited job relatedness, potential for socioeconomic bias, impact on gender and potential for negative influence on student diversity. Conclusions: A selection tool that does not enjoy the confidence of the medical profession is unlikely to achieve political validity and may ultimately fail, regardless of other objective measures of its effectiveness such as predictive validity. [ABSTRACT FROM AUTHOR]

OBJECTIVE--The optimal screening regimen for gestational diabetes mellitus (GDM) remains controversial. Risk factors used in selective screening guidelines vary. Given that universal screening is not currently adopted in our European population, we aimed to evaluate which selective screening strategies were most applicable. RESEARCH DESIGN AND METHODS--Between 2007 and 2009, 5,500 women were universally screened for GDM, and a GDM prevalence of 12.4% using International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria was established. We retrospectively applied selective screening guidelines to this cohort. RESULTS--When we applied National Institute for Health and Clinical Excellence (NICE), Irish, and American Diabetes Association (ADA) guidelines, 54% (2,576), 58% (2,801), and 76% (3,656) of women, respectively, had at least one risk factor for GDM and would have undergone testing. However, when NICE, Irish, and ADA guidelines were applied, 20% (120), 16% (101), and 5% (31) of women, respectively, had no risk factor and would have gone undiagnosed. Using a BMI ≥30 kg/m² for screening has a specificity of 81% with moderate sensitivity at 48%. Reducing the BMI to ≥25 kg/m² (ADA) increases the sensitivity to 80% with a specificity of 44%. Women with no risk factors diagnosed with GDM on universal screening had more adverse pregnancy outcomes than those with normal glucose tolerance. CONCLUSIONS--This analysis provides a strong argument for universal screening. However, if selective screening were adopted, the ADA guidelines would result in the highest rate of diagnosis and the lowest number of missed cases. [ABSTRACT FROM AUTHOR]

Objective: To compare the risk of severe adverse pregnancy complications in women with preexisting diabetes.Research Design and Methods: Multinational, prospective cohort study to assess the prevalence of newborns free from major congenital malformations or perinatal or neonatal death (primary end point) following treatment with insulin detemir (detemir) versus other basal insulins.Results: Of 1,457 women included, 727 received detemir and 730 received other basal insulins. The prevalence of newborns free from major congenital malformations or perinatal or neonatal death was similar between detemir (97.0%) and other basal insulins (95.5%) (crude risk difference 0.015 [95% CI -0.01, 0.04]; adjusted risk difference -0.003 [95% CI -0.03, 0.03]). The crude prevalence of one or more congenital malformations (major plus minor) was 9.4% vs. 12.6%, with a similar risk difference before (-0.032 [95% CI -0.064, 0.000]) and after (-0.036 [95% CI -0.081, 0.009]) adjustment for confounders. Crude data showed lower maternal HbA1c during the first trimester (6.5% vs. 6.7% [48 vs. 50 mmol/mol]; estimated mean difference -0.181 [95% CI -0.300, -0.062]) and the second trimester (6.1% vs. 6.3% [43 vs. 45 mmol/mol]; -0.139 [95% CI -0.232, -0.046]) and a lower prevalence of major hypoglycemia (6.0% vs. 9.0%; risk difference -0.030 [95% CI -0.058, -0.002]), preeclampsia (6.4% vs. 10.0%; -0.036 [95% CI -0.064, -0.007]), and stillbirth (0.4% vs. 1.8%; -0.013 [95% CI -0.024, -0.002]) with detemir compared with other basal insulins. However, differences were not significant postadjustment.Conclusions: Insulin detemir was associated with a similar risk to other basal insulins of major congenital malformations, perinatal or neonatal death, hypoglycemia, preeclampsia, and stillbirth. [ABSTRACT FROM AUTHOR]

Background: Although previous studies evaluated the association of maternal health parameters with neonatal adiposity, little is known regarding the complexity of the relationships among different maternal health parameters throughout pregnancy and its impact on neonatal adiposity.Objectives: To evaluate the direct and indirect associations between maternal insulin resistance during pregnancy, in women with obesity, and neonatal adiposity. In addition, associations between maternal fasting glucose, triglycerides (TG), non-esterified fatty acids (NEFA), and neonatal adiposity were also assessed.Methods: This is a longitudinal, secondary analysis of the DALI study, an international project conducted in nine European countries with pregnant women with obesity. Maternal insulin resistance (HOMA-IR), fasting glucose, TG, and NEFA were measured three times during pregnancy (<20, 24-28, and 35-37 weeks of gestation). Offspring neonatal adiposity was estimated by the sum of four skinfolds. Structural equation modelling was conducted to evaluate the direct and indirect relationships among the variables of interest.Results: Data on 657 mother-infant pairs (50.7% boys) were analysed. Neonatal boys exhibited lower mean sum of skinfolds compared to girls (20.3 mm, 95% CI 19.7, 21.0 vs 21.5 mm, 95% CI 20.8, 22.2). In boys, maternal HOMA-IR at <20 weeks was directly associated with neonatal adiposity (β = 0.35 mm, 95% CI 0.01, 0.70). In girls, maternal HOMA-IR at 24-28 weeks was only indirectly associated with neonatal adiposity, which implies that this association was mediated via maternal HOMA-IR, glucose, triglycerides, and NEFA during pregnancy (β = 0.26 mm, 95% CI 0.08, 0.44).Conclusions: The timing of the role of maternal insulin resistance on neonatal adiposity depends on fetal sex. Although the association was time-dependent, maternal insulin resistance was associated with neonatal adiposity in both sexes. [ABSTRACT FROM AUTHOR]

Purpose: An outcomes' evaluation of a community-based cardiovascular disease (CVD) prevention program in persons with newly diagnosed type 2 diabetes. Design: A prospective, observational study. Setting: A community-setting in Ireland. Participants: Persons with newly diagnosed type 2 diabetes, aged 40 years or older, and 2 or more cardiovascular risk factors. Intervention: A 16-week community-based, cardiovascular prevention program, with health promotion seminars, group exercise, and individual consultations, delivered by a multidisciplinary team. Measures: Medical, lifestyle, and well-being measures. Analysis: Changes in categorical and continuous variables were analyzed using the paired exact test and the t test/Wilcoxin matched-pairs test, respectively. Results: In total, 218 persons (134 men) participated, mean age was 59.8 (10.2) years. Completion rate was 75.2% (n = 164). The proportion achieving target glycosylated hemoglobin (HbA1c) increased from 53% at baseline to 75% (P <.001) at end of program. Systolic and diastolic blood pressures reduced by 8.8 mm Hg (95% CI: −11.2 to −6.4, P <.001) and 5.2 mm Hg (95% CI: −6.9 to −3.5, P <.001), respectively. Mean low-density lipoprotein cholesterol reduced from 2.45 to 2.05 mmol/L (P <.001). Significantly higher proportions met recommended targets in diet (6.9% vs 43.4%, P <.001) and physical activity (9.2% vs 56.6%, P <.001). Psychosocial measures significantly improved at end of program. The majority of improvements were sustained at 1 year. Conclusion: Participation in this CVD prevention program was associated with significant improvements in glycemia and CVD risk factors in newly diagnosed patients with type 2 diabetes. [ABSTRACT FROM AUTHOR]

Background: Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes including increased rates of caesarean section birth, macrosomia, congenital malformation, prematurity, admission to the neonatal intensive care unit and stillbirth. As a result, there has been an increase in interventions to improve outcomes in both mother and infant. To date, meaningful comparisons between these studies are limited due to heterogeneity in outcome selection and reporting. The aim of this study is to develop a core outcome set (COS) for randomised controlled trials evaluating the effectiveness of interventions for the treatment of pregnant women with PGDM.Methods: The study consists of three steps. The first step is a systematic review of the literature to assess outcomes reported in randomised controlled trials assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. The second step is a three round, online Delphi survey to prioritise these outcomes. In this step, stakeholders (including women with PGDM, healthcare workers, researchers and policymakers) will be asked to rank the importance of outcomes for inclusion in the COS using a 9-point Likert type scale. Outcomes that meet the inclusion criteria after completion of the Delphi surveys will be brought to the consensus meeting. The consensus meeting will be the third and final step, where the COS will be finalised. The consensus meeting will include members from each stakeholder group.Discussion: This paper describes the process used to develop a COS for the reporting of studies evaluating the effectiveness of interventions in pregnant women with PGDM. The COS will enable greater comparison between and information synthesis across RCTs in the treatment of PGDM. In addition, this COS will also help improve trial reporting and minimise research waste by prioritising the collection and reporting of outcomes that matter to all relevant stakeholder groups.Trial Registration: This COS has been registered with the Core Outcome Measures in Effectiveness Trials (COMET) initiative ( http://www.comet-initiative.org/studies/details/1425 ) on the 4th of November 2019. The systematic review component of this study has also been registered with the International Prospective Register of Systematic Reviews (PROSPERO) ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020173549 ). [ABSTRACT FROM AUTHOR]

Core Outcome Sets (COS) contain an agreed minimum set of outcomes to be measured and reported in all studies in a specific area, with the objective of standardizing outcome reporting. COS may minimize research waste by identifying outcomes important to key stakeholders, allowing for improved evidence synthesis, and facilitating translation of research findings to clinical practice. Over the past 5 years, there has been significant progress in developing COS relevant to studies of diabetes in pregnancy. This review summarizes work in this area, reviews the role of patient and public involvement in COS development, and suggests areas for future research. [ABSTRACT FROM AUTHOR]

Summary: Objectives: To investigate the importance of time in pregnancy and neonatal sex on the association between maternal metabolic parameters and neonatal sum of skinfolds. Methods: This was a longitudinal, secondary analysis of the vitamin D and lifestyle intervention for gestational diabetes mellitus study, conducted in nine European countries during 2012 to 2015. Pregnant women with a pre‐pregnancy body mass index (BMI) of ≥29 kg/m2 were invited to participate. We measured 14 maternal metabolic parameters at three times during pregnancy: <20 weeks, 24 to 28 weeks, and 35 to 37 weeks of gestation. The sum of four skinfolds assessed within 2 days after birth was the measure of neonatal adiposity. Results: In total, 458 mother‐infant pairs (50.2% female infants) were included. Insulin resistance (fasting insulin and HOMA‐index of insulin resistance) in early pregnancy was an important predictor for boys' sum of skinfolds, in addition to fasting glucose and maternal adiposity (leptin, BMI and neck circumference) throughout pregnancy. In girls, maternal lipids (triglycerides and fatty acids) in the first half of pregnancy were important predictors of sum of skinfolds, as well as fasting glucose in the second half of pregnancy. Conclusions: Associations between maternal metabolic parameters and neonatal adiposity vary between different periods during pregnancy. This time‐dependency is different between sexes, suggesting different growth strategies. [ABSTRACT FROM AUTHOR]

Objective: In our randomized controlled trial, we investigated the impact of healthy eating (HE) aiming for restricted gestational weight gain (GWG) and physical activity (PA) interventions on maternal and neonatal lipid metabolism.Research Design and Methods: Obese pregnant women (n = 436) were included before 20 weeks' gestation and underwent glucose testing (oral glucose tolerance test) and lipid profiling at baseline and 24-28 and 35-37 gestational weeks after an at least 10-h overnight fast. This secondary analysis had a factorial design with comparison of HE (n = 221) versus no HE (n = 215) and PA (n = 218) versus no PA (n = 218). Maternal changes in triglycerides (TG), LDL cholesterol, HDL cholesterol, free fatty acids (FFAs), and leptin from baseline to end of pregnancy and neonatal outcomes were analyzed using general linear models with adjustment for relevant parameters.Results: At 24-28 weeks' gestation, FFAs (mean ± SD, 0.60 ± 0.19 vs. 0.55 ± 0.17 mmol/L, P < 0.01) were increased after adjustment for FFA at baseline, maternal age, BMI at time of examination, gestational week, insulin resistance, self-reported food intake, self-reported physical activity, and maternal smoking, and GWG was lower (3.3 ± 2.6 vs. 4.3 ± 2.8 kg, P < 0.001, adjusted mean differences -1.0 [95% CI -1.5; -0.5]) in HE versus no HE. Fasting glucose levels (4.7 ± 0.4 vs. 4.6 ± 0.4 mmol/L, P < 0.05) and 3-β-hydroxybutyrate (3BHB) (0.082 ± 0.065 vs. 0.068 ± 0.067 mmol/L, P < 0.05) were higher in HE. Significant negative associations between carbohydrate intake and FFA, 3BHB, and fasting glucose at 24-28 weeks' gestation were observed. No differences between groups were found in oral glucose tolerance test or leptin or TG levels at any time. Furthermore, in PA versus no PA, no similar changes were found. In cord blood, elevated FFA levels were found in HE after full adjustment (0.34 ± 0.22 vs. 0.29 ± 0.16 mmol/L, P = 0.01).Conclusions: HE intervention was associated with reduced GWG, higher FFAs, higher 3BHB, and higher fasting glucose at 24-28 weeks of gestation, suggesting induction of lipolysis. Increased FFA was negatively associated with carbohydrate intake and was also observed in cord blood. These findings support the hypothesis that maternal antenatal dietary restriction including carbohydrates is associated with increased FFA mobilization. [ABSTRACT FROM AUTHOR]

Diabetes in pregnancy (DIP) is associated with an increased risk of adverse pregnancy outcomes. Unfortunately guidelines and clinical practices vary significantly and a number of key issues remain under debate. These include: glucose cut-offs for diagnosis; the approaches of universal versus selective screening; appropriate timing of screening; and acceptability of various screening strategies to the population at risk. Economic considerations are also of importance, but unfortunately data outlining the best approach from this viewpoint are limited. In this paper, we review each of these topics and examine associated barriers and challenges associated with various strategies from a European perspective. We also address options which potentially may have a future role in the care of these women including alternative diagnostic biomarkers. [ABSTRACT FROM AUTHOR]

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated. Despite many small randomized controlled trials of glucose-lowering medication treatment in GDM, our understanding of medication management of GDM is incomplete as evidenced by discrepancies among professional society treatment guidelines. The comparative effectiveness of insulin, metformin, and glyburide remains uncertain, particularly with respect to long-term outcomes. Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches. Further research on these topics is likely to improve our understanding of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children. [ABSTRACT FROM AUTHOR]

Aims: To assess if pregnancy outcomes for women with GDM treated with insulin (GDM-I) are comparable to outcomes for women with GDM treated with medical nutritional therapy (MNT) (GDM-M).Materials and Methods: This retrospective cohort study included 752 women with GDM-I and 567 women with GDM-M. Maternal and foetal outcomes were examined.Results: Women with GDM-I had a greater risk of polyhydramnios (aOR 2.33, 95%CI 1.31-4.14) and were more likely to deliver by caesarean section (CS) (aOR 1.67, 95%CI 1.25-2.23). Their offspring had higher rates of macrosomia (22.2% vs 12.7%; p < .01), large for gestational age (LGA) (19.7% vs 12.5%; p < .01) and were more likely to require neonatal intensive care unit (NICU) admission (aOR 4.88, 95%CI 3.54-6.73). There was no difference between the groups in rates of pre-eclampsia (PET), pregnancy-induced hypertension (PIH), infant mortality, congenital malformations, neonatal hypoglycaemia, prematurity and rates of small for gestational age (SGA).Conclusions: GDM-I and GDM-M mothers have similar rates of maternal medical morbidities. Despite this, the rate of delivery by CS remains greater, possibly driven by physician choice for elective intervention in the GDM-I group. Despite insulin therapy, offspring of GDM-I mothers experience higher rates of macrosomia, LGA and NICU admissions. This may be related to the higher baseline risk profile in GDM-I women, to sub-optimal glycaemic control, excessive gestational weight gain (GWG) or higher baseline BMI of the mother. Addressing baseline maternal BMI, limiting excessive GWG and tightening glycaemic control in GDM-I women may translate to better pregnancy outcomes. [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]

Aims: To evaluate the ability of first trimester plasma glycated CD59 (pGCD59) to predict gestational diabetes mellitus (GDM) at 24-28 weeks of gestation.Methods: Prospectively, in 378 pregnant women, GDM was diagnosed using the one step 2 h 75 g oral glucose tolerance test adjudicated by the World Health Organisation (WHO) 2013 criteria. The ability of pGCD59 to predict GDM was assessed using receiver operating characteristic (ROC) curves adjusted for maternal age, body mass index (BMI), maternal ethnicity, parity, previous GDM, family history of diabetes mellitus and week of gestation at time of pGCD59 sampling.Results: pGCD59 generated an adjusted area under the curve (AUC) of (a) 0.63 (95 %CI:0.56-0.70, p < 0.001) for predicting GDM, and (b) 0.71 (95 %CI:0.62-0.79, p < 0.001 for GDM diagnosed with a fasting plasma glucose (FPG) ≥ 5.1 mmol/L. Sensitivity analysis of BMI subgroups showed that pGCD59 generated the highest AUC in the 35 kg/m2 ≤ BMI < 40 kg/m2 (AUC:0.85, 95 %CI:0.70-0.98) and BMI ≥ 40 kg/m2 (AUC:0.88, 95 %CI:0.63-0.99) categories.Conclusions: Early in pregnancy, pGCD59 may be a good predictor of GDM in women with a high BMI and a fair predictor of GDM diagnosed by an elevated FPG independent of BMI. [ABSTRACT FROM AUTHOR]

Aims: To examine the clinical outcomes of screening for gestational diabetes mellitus (GDM) in primary care versus secondary care, in the Irish healthcare system.Design and Methods: A parallel group randomised controlled trial (RCT) of screening for GDM in primary versus secondary care was used to examine (i) prevalence, (ii) gestational week of screen, (iii) time to access specialist care, and (iv) maternal and neonatal outcomes. In total 781 women were recruited for screening in primary care (n=391) or secondary care (n=390).Results: The prevalence of GDM and gestational week of screen were similar in both locations. There was a trend towards a longer time to access diabetes care in primary care (24days) versus secondary care (19days), a difference of 5days (p=0.09). Women screened in primary care also showed a trend towards a higher rate of large for gestational age (LGA) infants (20%) than those screened in secondary care (14.7%), (p=0.09). There were no differences between groups in maternal outcomes.Conclusions: This RCT suggests that screening for GDM in secondary care may be associated with potentially faster time to access specialist antenatal diabetes care and possibly lower LGA rates. Further research is needed to clarify these findings and to improve the delay in accessing specialist care requires an urgent focus. Further research is needed to test these findings in other health systems. [ABSTRACT FROM AUTHOR]

Paralleling the global epidemic of obesity figures in the general population, the incidence of maternal obesity (BMI>30kg/m(2) at the start of pregnancy) has been rising over the last world. While most European countries do not systematically report obesity figures in their pregnant population, the prevalence of maternal obesity varies from 7 to 25% and seems strongly related to social and educational inequalities. Obesity during pregnancy represents an important preventable risk factor for adverse pregnancy outcomes and is associated with negative long-term health outcomes for both mothers and offspring. These effects are often aggravated by the high incidence of abnormal glucose tolerance and excessive gestational weight gain found in this group. The main controversies around the management of the obese pregnant women are related to (1) the value of repeated weighing during pregnancy, (2) the optimal gestational weight gain to advise and the lifestyle messages to deliver in order to achieve this, (3) the optimal strategy and timing of screening for gestational diabetes (GDM) and (4) the optimal timing and mode of delivery. These controversies are reviewed in this review, with the exception of screening for gestational diabetes that is discussed extensively elsewhere in this issue (Benhalima et al.). An agenda for research is proposed with the hope that it will catch the attention of policy-makers and funders and ultimately lead to the development of European-wide evidence-based guidelines for clinicians. [ABSTRACT FROM AUTHOR]

Objectives: More uniformity is necessary in screening and diagnosis for gestational diabetes (GDM) across Europe. The European Board and College of Obstetrics and Gynaecology (EBCOG) has recently recommended to use the 2013 World Health Organization (WHO) criteria for the diagnosis of GDM. We evaluated the uptake of these EBCOG recommendations in guidelines for GDM screening across Europe.Methods: Between September and November 2015, an online survey on the current national or regional recommendations for GDM screening was directed to the 33 European countries that are members of EBCOG.Results: There was a response rate of 84.8% (28 countries). From Belgium, data were separately obtained from the Dutch-and the French-speaking parts and from the UK data were also obtained from Scotland, leading to data from 30 responders. The response rates were high in Central Europe (100%), Northern Europe (100%) and Southern Europe (85.7%) with lower response rates in Eastern Europe (71.4%). 82.1% of guidelines recommend screening for unknown diabetes at first prenatal visit and 67.9% recommend to screen for GDM before 24 weeks of pregnancy. All guidelines recommend to screen for GDM ≥24 weeks, based on risk factors in 64.3% and by universal screening in 35.7%. The most commonly used diagnostic criteria for GDM are the 2013 WHO criteria in 67.9%, the 1999 WHO criteria in 10.7%, the European Association for the Study of Diabetes criteria in 7.1% and the Carpenter & Coustan criteria in 7.1%. Of all societies advising the use of the 2013 WHO criteria, 52.6% recommends this based on risk factors, 10.5% recommends universal screening in a two-step strategy and 36.8% recommends a universal one-step approach with a 75g OGTT.Conclusions: Our survey shows that the majority of European societies now advise to use the 2013 WHO criteria for GDM. However, only 36.8% recommends a universal one-step approach with a 75g OGTT with the majority of societies recommending screening based on risk factors. The use of common diagnostic criteria for GDM by the majority of societies is an important first step towards achieving uniformity in GDM screening across Europe. [ABSTRACT FROM AUTHOR]

The incidence of gestational diabetes (GDM) is rising globally and it represents an important modifiable risk factor for adverse pregnancy outcomes. GDM is also associated with negative long-term health outcomes for both mothers and offspring. Acceptance and implementation of the 2013 World Health Organization (WHO) criteria varies globally and within Europe. There is at present no consensus on the optimal approach to GDM screening in Europe. More uniformity in GDM screening across Europe will lead to an opportunity for more timely diagnosis and treatment for GDM in a greater number of women. More targeted research is necessary to evaluate optimal screening strategies based on the 2013 WHO criteria across different European populations with a focus on implementation strategy. Future research should address these important questions so that solid recommendations for GDM screening can be made to European health organizations based on screening uptake rates, maternal well-being, maternal and neonatal health outcomes, equity and cost-effectiveness. Here we describe the ongoing controversy on GDM screening and diagnosis, and provide an overview of important topics for future research concerning GDM screening in Europe. [ABSTRACT FROM AUTHOR]

Background: The incidence of gestational diabetes mellitus (GDM)--hyperglycemia with onset or first recognition during pregnancy--is increasing and will have a significant impact on diabetes services. This study aimed to determine the feasibility and acceptability of using telemedicine in the diabetes care of women with GDM and the possibility of replacing alternate (one in every two) diabetes review appointments with telemedicine.Subjects and Methods: A feasibility study for a randomized controlled trial was conducted across two sites. Fifty women with GDM were randomized to usual care (n = 26) or usual care plus telemedicine (n = 24). Telemedicine entailed weekly blood pressure and weight measurements and transmission of these data, along with blood glucose readings, for review by the healthcare team. Patients were contacted about these results as necessary. Patients completed questionnaires to measure their satisfaction with telemedicine or blood glucose monitoring. The intervention group and healthcare providers also took part in qualitative interviews. Analysis involved descriptive statistics for the satisfaction questionnaires and framework analysis for the qualitative interviews.Results: Eighty-nine percent of patients were satisfied with telemedicine and would use it again. Both HCPs and patients found the equipment easy to use and were positive about using it to replace alternate diabetes review appointments in the future. If used in this way, healthcare providers felt that protected time in which to perform the telemedicine review would be necessary.Conclusions: Telemedicine may help meet the growing demand on diabetes services due to increasing numbers of women being diagnosed with GDM. [ABSTRACT FROM AUTHOR]

Background: There is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related quality of life (HRQOL) for the mother in the short or long term. In this study we examined HRQOL in a group of women who had GDM in the index pregnancy 2 to 5 years previously and compared it to a group of women with normal glucose tolerance (NGT) in the index pregnancy during the same time period.Methods: The sample included 234 women who met International Association of Diabetes Study Groups (IADPSG) criteria for GDM in the index pregnancy and 108 who had NGT. The sample was drawn from the ATLATIC-DIP (Diabetes In Pregnancy) cohort - a network of antenatal centers along the Irish Atlantic seaboard serving a population of approximately 500,000 people. HRQOL was measured using the visual analogue component of the EQ-5D-3 L instrument in a cross-sectional survey.Results: The difference in HRQOL between GDM and NGT groups was not significant when adjusted for the effects of the covariates. HRQOL was negatively affected by increased BMI and abnormal glucose tolerance post-partum in the NGT group. Moderate alcohol consumption was positively associated with HRQOL in the NGT group only. The negative association with smoking on HRQOL was substantially higher in the GDM group.Conclusions: A diagnosis of GDM does not appear to have an adverse effect on HRQOL, 2 to 5 years after the index pregnancy. On the contrary, its diagnosis might lead to the development of coping strategies, which, consequently attenuates the adverse effect of the subsequent acquisition of abnormal glucose tolerance post-partum on HRQOL. Women whose pregnancy was affected by GDM are more susceptible to the adverse effects on HRQOL of alcohol use and tobacco smoking. [ABSTRACT FROM AUTHOR]

OBJECTIVE Ways to prevent gestational diabetes mellitus (GDM) remain unproven. We compared the impact of three lifestyle interventions (healthy eating [HE], physical activity [PA], and both HE and PA [HE+PA]) on GDM risk in a pilot multicenter randomized trial. RESEARCH DESIGN AND METHODS Pregnant women at risk for GDM (BMI ≥29 kg/m²) from nine European countries were invited to undertake a 75-g oral glucose tolerance test before 20 weeks' gestation. Those without GDM were randomized to HE, PA, or HE+PA. Women received five face-to-face and four optional telephone coaching sessions, based on the principles of motivational interviewing. A gestational weight gain (GWG) <5 kg was targeted. Coaches received standardized training and an intervention toolkit. Primary outcome measures were GWG, fasting glucose, and insulin sensitivity (HOMA) at 35-37 weeks. RESULTS Among the 150 trial participants, 32% developed GDM by 35-37 weeks and 20% achieved GWG <5 kg. HE women had less GWG (-2.6 kg [95% CI -4.9, -0.2]; P = 0.03) and lower fasting glucose (-0.3mmol/L [-0.4,-0.1]; P = 0.01) than those in the PA group at 24-28 weeks. HOMA was comparable. No significant differences between HE+PA and the other groups were observed. CONCLUSIONS An antenatal HE intervention is associated with less GWG and lower fasting glucose comparedwith PA alone. These findings require a larger trial for confirmation but support the use of early HE interventions in obese pregnant women. [ABSTRACT FROM AUTHOR]

Objective. To evaluate a 12-week group-based lifestyle intervention programme for women with prediabetes following gestational diabetes (GDM). Design. A two-group, mixed methods randomized controlled trial in which 50 women with a history of GDM and abnormal glucose tolerance postpartum were randomly assigned to intervention (n=24) or wait control (n=26) and postintervention qualitative interviews with participants. Main Outcome Measures. Modifiable biochemical, anthropometric, behavioural, and psychosocial risk factors associated with the development of type 2 diabetes. The primary outcome variable was the change in fasting plasma glucose (FPG) from study entry to one-year follow-up. Results. At one-year follow-up, the intervention group showed significant improvements over the wait control group on stress, diet self-efficacy, and quality of life. There was no evidence of an effect of the intervention on measures of biochemistry or anthropometry; the effect on one health behaviour, diet adherence, was close to significance. Conclusions. Prevention programmes must tackle the barriers to participation faced by this population; home-based interventions should be investigated. Strategies for promoting long-term health self-management need to be developed and tested. [ABSTRACT FROM AUTHOR]

Background: Women with pregnancy complicated by pregestational diabetes experience increased rates of adverse pregnancy outcomes. Prepregnancy care is the targeted support and additional care offered to those women who are planning pregnancy and is associated with improved outcomes. However, there is significant heterogeneity in the outcomes measured and reported in studies evaluating the effects of prepregnancy care, which makes meaningful comparison difficult. The aim of this article is to present a protocol for a study to develop a Core Outcome Set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes mellitus. Methods/Design: This study will include a systematic review of the literature to identify outcomes that have previously been reported in studies evaluating prepregnancy care for women with pregestational diabetes. We will then prioritise these outcomes from the perspective of key stakeholders, including women with pregestational diabetes as well as clinicians, using a Delphi survey. A final consensus meeting will be held with stakeholders to review and finalise the outcomes. Discussion: The expectation is that the COS will always be collected and reported in all clinical trials, audits of practice and other forms of research that involve prepregnancy care programs for women with pregestational diabetes. This will facilitate comparing and contrasting of studies and allow for combining of appropriate studies with the ultimate goal of improved patient care. [ABSTRACT FROM AUTHOR]

Background: Women with pregnancy complicated by pregestational diabetes experience increased rates of adverse pregnancy outcomes. Prepregnancy care is the targeted support and additional care offered to those women who are planning pregnancy and is associated with improved outcomes. However, there is significant heterogeneity in the outcomes measured and reported in studies evaluating the effects of prepregnancy care, which makes meaningful comparison difficult. The aim of this article is to present a protocol for a study to develop a Core Outcome Set (COS) for trials and other studies evaluating the effectiveness of prepregnancy care for women with pregestational diabetes mellitus. Methods/Design: This study will include a systematic review of the literature to identify outcomes that have previously been reported in studies evaluating prepregnancy care for women with pregestational diabetes. We will then prioritise these outcomes from the perspective of key stakeholders, including women with pregestational diabetes as well as clinicians, using a Delphi survey. A final consensus meeting will be held with stakeholders to review and finalise the outcomes. Discussion: The expectation is that the COS will always be collected and reported in all clinical trials, audits of practice and other forms of research that involve prepregnancy care programs for women with pregestational diabetes. This will facilitate comparing and contrasting of studies and allow for combining of appropriate studies with the ultimate goal of improved patient care. [ABSTRACT FROM AUTHOR]

The aim of this observational study was to evaluate screening and progression of diabetic retinopathy during pregnancy in women with pregestational diabetes attending five antenatal centres along the Irish Atlantic seaboard. An adequate frequency of screening was defined as at least two retinal evaluations in separate trimesters. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of diabetic macular edema on at least one eye. Women with pregestational diabetes who delivered after 22 gestational weeks (n=307) were included. In total, 185 (60.3%) had an adequate number of retinal examinations. Attendance at prepregnancy care was associated with receiving adequate screening (odds ratio 6.23; CI 3.39–11.46 (P<0.001)). Among those who received adequate evaluations (n=185), 48 (25.9%) had retinopathy progression. Increasing booking systolic blood pressure (OR 1.03, CI 1.01–1.06, P=0.02) and greater drop in HbA1c between first and third trimesters of pregnancy (OR 2.05, CI 1.09–3.87, P=0.03) significantly increased the odds of progression. A significant proportion of women continue to demonstrate retinopathy progression during pregnancy. This study highlights the role of prepregnancy care and the importance of close monitoring during pregnancy and identifies those patients at the highest risk for retinopathy progression. [ABSTRACT FROM AUTHOR]

Background: Pregnancy in women with type 1 (T1DM) or type 2 diabetes (T2DM) is associated with increased risk. These conditions are managed similarly during pregnancy, and compared directly in analyses, however they affect women of different age, body mass index and ethnicity. Methods: We assess if differences exist in pregnancy outcomes between T1DM and T2DM by comparing them directly and with matched controls. We also analyze the effect of glycemic control on pregnancy outcomes and analyze predictive variables for poor outcome. Results: We include 323 women with diabetes and 660 glucose-tolerant controls. T2DM women had higher BMI, age and parity with a shorter duration of diabetes and better glycemic control. Preeclampsia occurred more in women with T1DM only. Rates of elective cesarean section were similar between groups but greater than in controls, emergency cesarean section was increased in women with type 1 diabetes. Maternal morbidity in T1DM was double that of matched controls but T2DM was similar to controls. Babies of mothers with diabetes were more likely to be delivered prematurely. Neonatal hypoglycemia occurred more in T1DM than T2DM and contributed to a higher rate of admission to neonatal intensive care for both groups. Adverse neonatal outcomes including stillbirths and congenital abnormalities were seen in both groups but were more common in T1DM pregnancies. HbA1C values at which these poor outcomes occurred differed between T1 and T2DM. Conclusions: Pregnancy outcomes in T1DM and T2DM are different and occur at different levels of glycemia. This should be considered when planning and managing pregnancy and when counseling women. [ABSTRACT FROM AUTHOR]

Background: To provide the optimum level of healthcare, it is important that the supply of well-trained doctors meets the demand. However, despite many initiatives, Ireland continues to have a shortfall of physicians, which has been projected to persist. Our study aimed to investigate the migration intentions of Irish medical students and identify the factors that influence their decisions in order to design appropriate interventions to sustain the supply of trained doctors in order to maintain a viable medical system. Methods: An online cross-sectional survey was undertaken of all Irish medical students studying in the Republic of Ireland. The survey included nominal, ordinal, and scale items to determine migration intentions, factors influencing their decisions, and understanding of the Irish healthcare system. Results: A total of 2 273 medical students responded (37% response rate), of whom 1 519 were classified as Irish medical students (having completed secondary school in Ireland). Of these, 88% indicated they were either definitely migrating or contemplating migrating following graduation or completion of the pre-registration intern year. Forty percent expressed an intention of returning to Ireland within 5 years. The factors most influencing their decision to leave were career opportunities (85%), working conditions (83%), and lifestyle (80%). Conclusion: The migration intentions expressed in this study predict an immediate and severe threat to the sustainability of the Irish healthcare service. Urgent interventions such as providing information about career options and specialty training pathways are required. These must begin in the undergraduate phase and continue in postgraduate training and are needed to retain medical school graduates. [ABSTRACT FROM AUTHOR]

Women with previous gestational diabetes (GDM) are a high-risk group for future development of diabetes, metabolic syndrome, and cardiovascular disease. The new International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria significantly increase the number of women diagnosed with GDM. The long-term metabolic outcome in these women is unknown. We set out to determine the prevalence of metabolic syndrome, using adult treatment panel-III criteria; and insulin resistance, using HOMA2-IR, in white European women with previous GDM. Using a cohort design, we invited women meeting IADPSG GDM criteria across four Irish antenatal centres between 2007 and 2010 to participate. Two hundred and sixty-five women with previous values meeting IADPSG criteria for GDM participated (44 % of the population eligible for participation). Mean age was 36.7 years (SD 5.0). These women were compared with a randomly selected control group of 378 women (mean age 37.6 years, SD 5.1) known to have normal glucose tolerance (NGT) in pregnancy during the same period. A total of 25.3 % of women with previous IADPSG-defined GDM met metabolic syndrome criteria, compared to 6.6 % of women with NGT [at 2.6 (SD 1.0) vs. 3.3 years (SD 0.7) post-partum]. The prevalence of HOMA2-IR >1.8 was higher in women with previous IADPSG-defined GDM (33.6 vs. 9.1 % with NGT, p < 0.001). Women with previous GDM by IADPSG criteria demonstrate a greater than threefold prevalence of metabolic syndrome compared to women with NGT in pregnancy. Efforts to prevent projected long-term consequences of this should focus on interventions both in the preconception and post-partum periods. [ABSTRACT FROM AUTHOR]