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Hyperglycemia is the commonest medical condition affecting pregnancy and its incidence is increasing globally in parallel with the twin epidemics of diabetes and obesity. Both pre-pregnancy diabetes and gestational diabetes are associated with short term pregnancy complications, with the risk of immediate complications generally broadly rising with more severe hyperglycemia. In this article we firstly consider these risks and their optimal management during pregnancy and then broaden our scope to consider the long-term implications of hyperglycemia in pregnancy as it relates to overall maternal and offspring health in a life course perspective.

The optimal process for detecting and treating gestational diabetes mellitus (GDM) remains controversial, with wide variances in practice within and between countries. A recent pragmatic randomized controlled trial (RCT) undertaken by Hillier et al. [1] in the USA has raised renewed worldwide interest in and discussion of GDM diagnosis.

Background and aims The early life predictors of changes in the blood pressures of offspring between childhood and young adulthood have not been well defined. Thus, this study aimed to determine the life course association of offspring's blood pressure with prenatal and early infancy lifestyle, and other factors taking advantage of a large community-based, longitudinal study of a birth cohort in Australia – the MUSP study. Methods The systolic and diastolic blood pressure (SBP, DBP) was measured for 3793, 3782, 2628 and 1780 offspring of the Australian longitudinal cohort study at 5, 14, 21 and 30 years of their age, respectively. Individual PP and mean arterial pressure (MAP) was equated, and Generalized Estimating Equations with time (age) and predictor interaction modelling were performed. Results Blood pressures of the offspring increased significantly between 5 and 30 years. Early life factors such as pre-pregnancy overweight/obesity, and hypertensive disorder in pregnancy were significantly positively associated, and duration of gestation and pre-pregnancy thinness of the mothers negatively associated with this life course increase in the offspring's blood pressure. Rapid increase in body weight from birth to 5 years had a strong association with increasing blood pressures components throughout their life course. Conclusions Several maternal pre-pregnancy and pregnancy factors along with the early life growth characteristics of offspring are important predictors of increase in blood pressure of the offspring from their childhood to adulthood.

To assess associations of hyperglycemia in pregnancy with the risk of postpartum hemorrhage (PPH) in a prospective cohort of Indigenous and non-Indigenous women, compared with normoglycemia.Data were from 1102 (48% Indigenous) women of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study. Age-adjusted associations of gestational diabetes mellitus (GDM) or pre-existing type 2 diabetes mellitus (T2DM), obstetric and demographic covariables with PPH (blood loss ≥500 ml) were assessed using logistic regression. Multivariable-adjusted models included Indigenous ethnicity, diabetes type and their interaction.A higher proportion of Indigenous women developed PPH than non-Indigenous women (32% versus 22%; P 0.001). Compared with non-Indigenous women with normoglycemia, risks of PPH for Indigenous women with GDM or T2DM were higher (odds ratio [OR] 1.83, 95% confidence intervals [CI] 1.11-3.02, and OR 1.72, 95% CI 0.99-3.00 after age adjustment, OR 1.84, 95% CI 1.06-3.19, and OR 1.33, 95% CI 0.70-2.54 after adjustment for school education and delivery mode, and OR 1.62, 95% CI 0.95-2.77, and OR 0.99, 95% CI 0.53-1.86 after adjustment for birth weight). Importantly, Indigenous women without hyperglycemia in pregnancy were not at increased risk of PPH.The significantly higher rates of PPH experienced by Indigenous women compared with non-Indigenous women may be explained by a greater effect of GDM among Indigenous women that was only partly accounted for by birth weight.

Hyperglycemia is common during pregnancy, involving multisystem adaptations. Pregnancy-induced metabolic changes increase insulin resistance. Pregnancy-induced insulin resistance adds to preexisting insulin resistance. Preexisting pancreatic β-cell defect compromises the ability to enhance insulin secretion, leading to hyperglycemia. Women with type 2 DM have similar rates of major congenital malformations, stillbirth, and neonatal mortality, but an even higher risk of perinatal mortality. In utero type 2 DM exposure confers greater risk and reduces time to development of type 2 DM in offspring. Preconception care to improve metabolic control in women with type 2 diabetes is critical.

In Australia's Northern Territory, Indigenous mothers account for 33% of births and have high rates of hyperglycemia in pregnancy. The prevalence of type 2 diabetes (T2D) in pregnancy is up to 10-fold higher in Indigenous than non-Indigenous Australian mothers, and the use of metformin is common. We assessed birth outcomes in relation to metformin use during pregnancy from a clinical register.The study included women with gestational diabetes (GDM), newly diagnosed diabetes in pregnancy (DIP), or pre-existing T2D from 2012 to 2016. Data were analyzed for metformin use in the third trimester. Regression models were adjusted for maternal age, body mass index, parity, and insulin use.Of 1649 pregnancies, 814 (49.4%) were to Indigenous women, of whom 234 (28.7%) had T2D (vs 4.6% non-Indigenous women; P 0.001). Metformin use was high in Indigenous women (84%-90% T2D, 42%-48% GDM/DIP) and increased over time in non-Indigenous women (43%-100% T2D, 14%-35% GDM/DIP). Among Indigenous women with GDM/DIP, there were no significant differences between groups with and without metformin in cesarean section (51% vs 39%; adjusted odds ratio [aOR] 1.25, 95% confidence interval [CI] 0.87-1.81), large for gestational age (24% vs 13%; aOR 1.5, 95% CI 0.9-2.5), or serious neonatal adverse events (9.4% vs 5.9%; aOR 1.32, 95% CI 0.68-2.57). Metformin use was independently associated with earlier gestational age (37.7 vs 38.5 weeks), but the risk did not remain independently higher after exclusion of women managed with medical nutrition therapy alone, and the increase in births37 weeks was not significant on multivariate analysis.We found no clear evidence of any adverse outcomes related to the use of metformin for the treatment of hyperglycemia in pregnancy.摘要: 背景 在澳大利亚北部地区, 原住民母亲的婴儿出生率占33%, 她们妊娠期间出现高血糖的风险很高。原住民母亲在妊娠期间的2型糖尿病(T2D)患病率与非原住民澳大利亚母亲相比较要高10倍, 并且经常使用二甲双胍治疗。我们利用临床登记表数据评估了妊娠期间使用二甲双胍治疗与出生结果之间的关系。 方法 这项研究从2012至2016年纳入了妊娠糖尿病(gestational diabetes, GDM)、妊娠期新诊断糖尿病(newly diagnosed diabetes in pregnancy, DIP)以及既往已经存在T2D的妇女。对妊娠晚期使用二甲双胍的数据进行了分析。根据母亲年龄、体重指数、产次以及胰岛素使用情况校正了回归模型。 结果 在1649名孕妇中有814名(49.4%)为原住民妇女, 其中234名(28.7%)为T2D(非原住民妇女T2D比例为4.6%；P 0.001)。原住民妇女的二甲双胍使用率更高(在T2D中为84%-90%, 在GDM/DIP中为42%-48%), 并且在非原住民妇女中随着时间的推移使用率在上升(在T2D中为43%-100%, 在GDM/DIP中为14%-35%)。在合并GDM/DIP的原住民妇女中, 使用二甲双胍治疗组与不使用二甲双胍治疗组之间的剖宫产率(分别为51%与39%; 校正后的odds ratio [aOR]为1.25, 95%置信区间[CI]为0.87-1.81)、出现大胎龄率(分别为24%与13%；aOR为1.5, 95% CI为0.9-2.5)、新生儿出现严重不良事件率(分别为9.4%与5.9%；aOR为1.32, 95% CI为0.68-2.57)都没有显著性差异。使用二甲双胍治疗与胎龄更小(分别为37.7与38.5周)独立相关, 但是将单独接受药物营养治疗的妇女排除之后, 这种风险没有独立地处于较高的水平, 并且多变量分析显示37周的出生率并没有显著地升高。 结论 我们没有发现任何与妊娠期间高血糖妇女使用二甲双胍治疗出现不良结果相关的明确证据。.

BackgroundThere is a high burden of gestational diabetes (GDM) and type 2 diabetes in pregnancy for Aboriginal and Torres Strait Islander women. Postpartum diabetes programs have the potential to prevent recurrent GDM and improve management of type 2 diabetes. However, data on such programs are limited, particularly in the Indigenous context. We aimed to explore Aboriginal Australian women’s and health providers’ preferences for a program to prevent and improve diabetes after pregnancy.MethodsA phenomenological methodology underpinned semi-structured in-depth interviews with eleven Aboriginal women and seven health professionals across the Northern Territory from October 2019- February 2020. Interviews were analysed using an inductive analysis framework to address the barriers and enablers of proposed diabetes prevention programs identified by participants.ResultsIdentified structural barriers to lifestyle change included: food insecurity, persuasive marketing of unhealthy food options, lack of facilities and cultural inappropriateness of previous programs. Enablers to lifestyle change included: a strong link between a healthy lifestyle and connection with Country, family and community. Suggested strategies to improve lifestyle included: co-designed cooking classes or a community kitchen, team sports and structural change (targeting the social determinants of health). Lifestyle change was preferred over metformin to prevent and manage diabetes after pregnancy by participants and health care providers.ConclusionsWe recommend individual level programs be designed alongside policies that address systemic inequalities. A postpartum lifestyle program should be co-designed with community members and grounded in Aboriginal conceptions of health to adequality address the health disparities experienced by Aboriginal people in remote communities.

Aims/hypothesis: Women with gestational diabetes mellitus (GDM) and obesity experience lower rates of breastfeeding. Little is known about breastfeeding among mothers with type 2 diabetes. Australian Indigenous women have a high prevalence of type 2 diabetes in pregnancy. We aimed to evaluate the association of hyperglycaemia, including type 2 diabetes, with breastfeeding outcomes. Methods: Indigenous (n = 495) and non-Indigenous (n = 555) participants of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort included women without hyperglycaemia in pregnancy (n = 222), with GDM (n = 684) and with type 2 diabetes (n = 144). The associations of hyperglycaemia in pregnancy and breastfeeding at hospital discharge, 6 weeks and 6 months post-partum were evaluated with logistic regression, after adjustment for maternal obesity, ethnicity, maternal and neonatal characteristics. Results: Indigenous women were more likely to predominantly breastfeed at 6 weeks across all levels of hyperglycaemia. Compared with women with no hyperglycaemia in pregnancy, women with type 2 diabetes had lower odds for exclusive breastfeeding at discharge (adjusted OR for exclusive breastfeeding 0.4 [95% CI 0.2, 0.8] p = 0.006). At 6 weeks and 6 months, the relationship between type 2 diabetes and predominant breastfeeding was not statistically significant (6 weeks 0.7 [0.3, 1.6] p = 0.40, 6 months 0.8 [0.4, 1.6] p = 0.60). Women with gestational diabetes were as likely to achieve predominant breastfeeding at 6 weeks and 6 months as women without hyperglycaemia in pregnancy. Conclusions/interpretation: Indigenous women had high rates of breastfeeding. Women with type 2 diabetes had difficulty establishing exclusive breastfeeding at hospital discharge. Further research is needed to assess the impact on long-term breastfeeding outcomes Refereed/Peer-reviewed

There is increasing evidence that miRNAs, which are enriched in nanovesicles called exosomes, are important regulators of gene expression. When compared with normal pregnancies, pregnancies with gestational diabetes mellitus (GDM) are associated with skeletal muscle insulin resistance as well as increased levels of circulating placental exosomes. Here we investigated whether placental exosomes in GDM carry a specific set of miRNAs associated with skeletal muscle insulin sensitivity. Exosomes were isolated from chorionic villous (CV) explants from both women with Normal Glucose Tolerant (NGT) and GDM pregnancies. Using miRNA sequencing, we identified a specific set of miRNAs selectively enriched with exosomes and compared with their cells of origin indicating a specific packaging of miRNAs into exosomes. Gene target and ontology analysis of miRNA differentially expressed in exosomes secreted in GDM compared with NGT are associated with pathways regulating cell migration and carbohydrate metabolism. We determined the expression of a selected set of miRNAs in placenta, plasma, and skeletal muscle biopsies from NGT and GDM. Interestingly, the expression of these miRNAs varied in a consistent pattern in the placenta, in circulating exosomes, and in skeletal muscle in GDM. Placental exosomes from GDM pregnancies decreased insulin-stimulated migration and glucose uptake in primary skeletal muscle cells obtained from patients with normal insulin sensitivity. Interestingly, placental exosomes from NGT increase migration and glucose uptake in response to insulin in skeletal muscle from diabetic subjects. These findings suggest that placental exosomes might have a role in the changes on insulin sensitivity in normal and GDM pregnancies.

Aims: To determine among First Nations and Europid pregnant women the cumulative incidence and predictors of postpartum type 2 diabetes and prediabetes and describe postpartum cardiovascular disease (CVD) risk profiles. Methods: PANDORA is a prospective longitudinal cohort of women recruited in pregnancy. Ethnic-specific rates of postpartum type 2 diabetes and prediabetes were reported for women with diabetes in pregnancy (DIP), gestational diabetes (GDM) or normoglycaemia in pregnancy over a short follow-up of 2.5 years (n = 325). Pregnancy characteristics and CVD risk profiles according to glycaemic status, and factors associated with postpartum diabetes/prediabetes were examined in First Nations women. Results: The cumulative incidence of postpartum type 2 diabetes among women with DIP or GDM were higher for First Nations women (48%, 13/27, women with DIP, 13%, 11/82, GDM), compared to Europid women (nil DIP or GDM p < 0.001). Characteristics associated with type 2 diabetes/prediabetes among First Nations women with GDM/DIP included, older age, multiparity, family history of diabetes, higher glucose values, insulin use and body mass index (BMI). Conclusions: First Nations women experience a high incidence of postpartum type 2 diabetes after GDM/DIP, highlighting the need for culturally responsive policies at an individual and systems level, to prevent diabetes and its complications. Refereed/Peer-reviewed

The purpose of this study was to examine the association of parental pre-pregnancy weight and body mass index (BMI) on offspring weight and BMI change from childhood to adulthood.

Summary Background and objectives Parental body mass index (BMI) is strongly linked with the development of offspring overweight and obesity. However, there are a limited number of studies focusing on the association of parental body mass index before pregnancy on offspring growth and body composition in early life, particularly in developing countries. Methods Data from the University Sains Malaysia (USM) Pregnancy Cohort which consists of 153 mother-offspring pairs were used. Data were collected using interview-administered questionnaires and anthropometric measurements were also obtained. Multiple linear regression and generalised equation estimation (GEE) were used to examine the direction and impact of the association between parental BMI and child growth and body composition (weight for age, height for age, body mass index for age, weight for height and fat mass at age 2m, 6m, and 12m). Potential confounders, including validated measures of maternal diets and physical activity during pregnancy, were considered. Results Of 153 parents, one-quarter of the mothers and 42.2% of the fathers, respectively, were overweight or obese before pregnancy. A significant association was found between maternal BMI and child's weight for height z -score (WHZ) and body mass index for age z -score (BAZ). Conclusions Having high pre-pregnancy BMI may increase BMI and WAZ of offspring in early life. Findings from this study emphasise the importance of monitoring maternal weight status, particularly before and during pregnancy and early life of offspring among Malaysians.

Molecules produced by adipose tissue (AT) function as an endocrine link between maternal AT and fetal growth by regulating placental function in normal women and women with gestational diabetes mellitus (GDM).We hypothesized that AT-derived exosomes (exo-AT) from women with GDM would carry a specific set of proteins that influences glucose metabolism in the placenta.Exosomes were isolated from omental AT-conditioned media from normal glucose tolerant (NGT) pregnant women (n = 65) and pregnant women with GDM (n = 82). Sequential window acquisition of all theoretical fragment ion spectra mass spectrometry was used to construct a small ion library from AT and exosomal proteins, followed by ingenuity pathway analysis to determine the canonical pathways and biofunctions. The effect of exosomes on human placental cells was determined using a Human Glucose Metabolism RT2 Profiler PCR array.The number of exosomes (vesicles/μg of tissue/24 hours) was substantially (1.7-fold) greater in GDM than in NGT, and the number of exosomes correlated positively with the birthweight Z score. Ingenuity pathway analysis of the exosomal proteins revealed differential expression of the proteins targeting the sirtuin signaling pathway, oxidative phosphorylation, and mechanistic target of rapamycin signaling pathway in GDM compared with NGT. GDM exo-AT increased the expression of genes associated with glycolysis and gluconeogenesis in placental cells compared with the effect of NGT exo-AT.Our findings are consistent with the possibility that AT exosomes play an important role in mediating the changes in placental function in GDM and might be responsible for some of the adverse consequences in this pregnancy complication, such as fetal overgrowth.

The International Journal of Gynecology and Obstetrics regrets that, in the above article, an error appeared in the 5.3.4 Measurement of uterine artery pulsatility index section on page 17, 5th paragraph, second last sentence: The first-trimester abnormal UTPI is defined as less than the 90th percentile, achieving a detection rate of 48%, at 8% false-positive rate, for the identification of early-onset PE. should have been: The first-trimester abnormal UTPI is defined as greater than the 90th percentile, achieving a detection rate of 48%, at 8% false-positive rate, for the identification of early-onset PE. Affiliation of the author, Mary D'Alton has been corrected to the following: Obstetrician and Gynecologist in-Chief, Columbia University Irving Medical Center, NewYork-Presbyterian The online version is corrected with the above changes after first online publication. We apologize for the inconvenience caused.

Prenatal exposure to alcohol has adverse ramifications on foetal development resulting in developmental abnormalities and major congenital anomalies. Experimental studies have documented effects on kidney structure and function among offspring exposed to alcohol during foetal life; however, human evidence is scarce. Thus, the present study aimed to determine the development of CKD among a cohort of 30-year-old Australian offspring whose mothers reported consumption of alcohol during pregnancy. The study sample comprised 1626 offspring of the birth the Australia cohort study (MUSP) who serum creatinine was assessed at 30 years old and CKD was categorised from stage 1 to stage 5 based on their level of eGFR following the CKD-EPI definition. Seven percent (n = 111) of offspring had mild to moderate (stage 2 and 3) CKD at 30 years. The overall adjusted odds of CKD were 2.01 (95% CI 0.97 to 4.13) for offspring of moderate to heavy drinking mothers in late pregnancy, 1.60 (0.70 to 3.37) for early pregnancy and 1.18 (0.72 to 1.94) for pre-pregnancy. The association was higher for female offspring-2.69 (1.02 to 7.14) for late pregnancy and 2.95 (1.12 to 7.80) for early pregnancy. Higher but insignificant odds were found for male offspring at late pregnancy 1.44 (0.46 to 4.47) only. Maternal alcohol exposure during early and late pregnancy is associated with development of mild to moderate CKD in their offspring at 30 years. This association is stronger for female than male offspring.

Despite recent attempts at building consensus, an internationally consistent definition of gestational diabetes mellitus (GDM) remains elusive. Within and between countries, there is disagreement between obstetric, medical, and endocrine groups as to the diagnosis and management of GDM. The current article aims to discuss the background to the controversy of GDM diagnosis and to address issues related to the detection and treatment of GDM in low-, middle-, and high-resource settings. The criteria recommended by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG), the American Diabetes Association (ADA), and the World Health Organization (WHO) are endorsed. We also wish to put into perspective the importance of GDM, both during and after pregnancy, in terms of its relationship to overall women's health.

Aims. To develop a program to support behaviour changes for women with a history of Gestational Diabetes Mellitus (GDM) and a Body Mass Index (BMI) > 25 kg/m2to delay or prevent Type 2 Diabetes Mellitus.Methods. Women diagnosed with GDM in the previous 6 to 24 months and BMI > 25 kg/m2were randomized to an intervention (I) (n=16) or a control (C) (n=15) group. The intervention was a pedometer program combined with nutrition coaching, with the primary outcome increased weight loss in the intervention group. Secondary outcomes included decreased waist and hip measurements, improved insulin sensitivity and body composition, increased physical activity, and improved self-efficacy in eating behaviours.Results. Median (IQR) results were as follows: weight: I −2.5 (2.3) kg versus C +0.2 (1.6) kg (P=0.009), waist: I −3.6 (4.5) cm versus C −0.1 (3.6) cm (P=0.07), and hip: I −5.0 (3.3) cm versus C −0.2 (2.6) cm (P=0.002). There was clinical improvement in physical activity and eating behaviours and no significant changes in glucose metabolism or body composition.Conclusion. A pedometer program and nutrition coaching proved effective in supporting weight loss, waist circumference, physical activity, and eating behaviours in women with previous GDM.

It is unclear whether any breastfeeding or a certain duration of breastfeeding is protective against the development of diabetes in adult offspring.We followed a sub-sample of 3,595 offspring born in the Mater Hospital in Brisbane, Australia between 1981 and 1983 and for whom we had doctor diagnosed self-reported diabetes at age 21 years and maternal reported duration of breastfeeding at 6-month post-natal follow-up. Multiple logistic regression was used to examine the independent associations of duration of breastfeeding (never breastfeed, breastfed4 months and breastfed ≥4 months) with offspring diabetes by age 21 years.Of 3,595 young adults, 45 (1.25 %) developed diabetes by age 21 years. The odds ratio of experiencing diabetes was 0.58 (95 % CI 0.29, 1.16) for offspring who were breastfed4 months, and it was 0.29 (95 % CI 0.13, 0.63), for offspring who were breastfed at least 4 months compared to the never breastfed offspring. Adjusting for potential confounding and mediating factors including maternal age, education, pre-pregnancy body mass index (BMI), smoking, offspring sports, TV and their BMI at 21 years did not substantially alter this association.Findings of this study suggest that infants who are breastfed for longer than 4 months have a substantial protective effect against the development of diabetes in young adulthood, which is independent of current BMI. Promoting breastfeeding for a minimum of 4 months may be a useful strategy for the prevention of diabetes among young adults.

Little is known about pulse pressure (PP) during early life and its association with renal function at young adulthood. This study describes an early life course association of PP with adult renal function at 30 years from a large community-based birth cohort study in Australia.Sample comprises 1169 young adults aged 30 years from the Mater-University of Queensland Study of Pregnancy, whose blood pressure was recorded in at least three follow-ups (5, 14, 21, and 30 years) and renal function was assessed at 30 years. Estimated glomerular filtration rate was estimated to determine the stages of chronic kidney disease (CKD). A group-based trajectory modelling was developed to identify patterns of PP from childhood to adulthood. Multiple logistic regression was used to determine whether PP trajectories predict adult CKD.In total, 7% of participants (91) had mild CKD. Three PP trajectories were identified: 16% were in the high PP trajectory group characterized by substantial increase in PP over time; 58% were in the middle group who had lower PP at 5 years, which increased at 14 years and then gradually declined at 21 and 30 years, and the remaining 26% were in a lower group which remained static. In the adjusted model, significantly higher odds were found for the high [odds ratio: 2.42 (95% confidence interval: 1.02-5.74)] and middle [2.23 (1.19-4.19)] PP trajectory groups for development of mild CKD at 30 years compared with the low (static) group.Early life high and middle PP trajectories predict the risk of subclinical renal insufficiency by age 30 years.

Aims To assess outcomes of women in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort with gestational diabetes mellitus (GDM) managed by lifestyle modification compared with women without hyperglycaemia in pregnancy. Methods Indigenous (n = 97) and Europid (n = 113) women managed by lifestyle modification were compared to women without hyperglycaemia (n = 235). Multivariate linear and logistic regressions assessed whether GDM-lifestyle women had poorer outcomes compared to women without hyperglycaemia. Results Women with GDM-lifestyle had higher body mass index and lower gestational weight gain than women without hyperglycaemia. On univariate analysis, gestational age at delivery was lower and induction rates were higher in women with GDM-lifestyle than without hyperglycaemia. On multivariable regression, GDM-lifestyle was associated with lower gestational age at delivery (by 0.73 weeks), lower birthweight z-score (by 0.26, p = 0.007), lower likelihood of large for gestational age (LGA) [OR (95% CI): 0.55 (0.28, 1.02), p = 0.059], and greater likelihood of labour induction [2.34 (1.49, 3.66), p Conclusion Women with GDM managed by lifestyle modification had higher induction rates and their offspring had lower birthweight z-scores, with a trend to lower LGA than those without hyperglycaemia in pregnancy. Further studies are indicated to explore reasons for higher induction rates.

ObjectiveThe objective of this study was to describe the age and sex-specific prevalence of renal insufficiency, and observe its trends over a decade at an urban Bangladesh setup.MethodThis was a cross-sectional study, in which we observed the Estimated Glomerular Filtration Rate (eGFR) of 218,888 adults, aged ≥19 years, who had submitted their blood specimen to the Clinical Biochemistry Laboratory of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) during the years 2006-2015. We applied CKD-EPI definition in estimating eGFR using their age-and sex-specific serum creatinine concentrations. Based on the eGFR, we classified the population into five stages of renal insufficiency (stage-1 to stage-5), at age intervals of five-years. Data were analysed using the Linear Regression and Multinomial Logistic Regression models.ResultsFemales constituted 43% (n = 94,931) of the study population; and 34% (n = 42,576) of the males and 31% (n = 29,830) of the females had their serum creatinine concentrations above the upper limit of the laboratory reference cut-off. The overall prevalence of stage-2 to stage-5 renal insufficiency were 24% (n = 52,126), 17% (n = 38,539), 8% (n = 16,504) and 6% (n = 12,665) respectively; the prevalence were 23% (n = 1,890), 19% (n = 1,579), 9% (n = 769) and 9% (n = 770) respectively in 2006, and 24% (n = 10,062), 17% (n = 6,903), 6% (n = 2,537) and 5% (n = 1,924) respectively in 2015. The prevalence was higher among the females. At least 2% of the adults, younger than ConclusionThis study observed high prevalence of stage-2 to stage-5 renal insufficiency in Bangladeshi populations, irrespective of age, and especially among the females.

Several factors including placental hormones (PH) released from the human placenta have been associated with the development of insulin resistance and gestational diabetes mellitus (GDM). However, circulating levels of PH does not correlate well with maternal insulin sensitivity across gestation, suggesting that other, previously unrecognized, mechanisms may be involved. The levels of circulating exosomes are higher in GDM compared to normal. GDM derived exosomes produce greater release of pro-inflammatory cytokines from endothelial cells compared to exosomes from normal, suggesting that their contents may differ compared to normal pregnancies. Using a quantitative, information-independent acquisition (Sequential Windowed Acquisition of All Theoretical Mass Spectra [SWATH]) approach, differentially abundant circulating exosome proteins are identified in women with normal glucose tolerance (NGT) and GDM at the time of GDM diagnosis. A total of 78 statistically significant proteins in the relative expression of exosomal proteins in GDM are compared with NGT. Bioinformatic analysis shows that the exosomal proteins in GDM target pathways are mainly associated with energy production, inflammation, and metabolism. Finally, an independent cohort of patients is used to validate some of the proteins identified by SWATH. The data obtained may be of utility in elucidating the underlying physiological mechanisms associated with insulin resistance in GDM.

Sulfate is an important nutrient for fetal growth and development. The fetus has no mechanism for producing its own sulfate and is therefore totally reliant on sulfate from the maternal circulation via placental sulfate transport. To build a model of directional sulfate transport in the placenta, we investigated the relative abundance of the 10 known sulfate transporter mRNAs in human placenta from uncomplicated term pregnancies. SLC13A4 and SLC26A2 were the most abundant sulfate transporter mRNAs, which localized to syncytiotrophoblast and cytotrophoblast cells, respectively. These findings indicate important physiological roles for SLC13A4 and SLC26A2 in human placental sulfate transport.

Pregnancy in women with type 1 diabetes mellitus (T1DM) is generally associated with increased insulin requirements.To determine the frequency and significance of declining insulin requirements in late gestation in women with T1DM.We conducted a retrospective review of 54 women seen at our institution from 2006 to 2010 with a diagnosis of T1DM pre-pregnancy and presentation for antenatal care prior to 28 weeks. Information was collected regarding patient demographics, insulin dose and pregnancy outcome. A 15% difference in weight-adjusted basal insulin from 30 weeks gestation to delivery was considered significant.Five women (9.3%) had a fall of 15% or more and 23 (42.5%) had a rise of 15% or more rise in insulin requirements. There were fewer neonatal intensive care admissions but more infants with an APGAR8 at 5 min in women with a fall in insulin requirements. These differences were not evident when the data were re-analysed by quartiles of change.In most women with T1DM, insulin requirements show little change from 30 weeks gestation until delivery. Almost 10% of women had a significant fall in insulin requirements which did not correlate with adverse neonatal outcome. These results require validation in a larger, prospective trial.

Most women with type 1 diabetes mellitus (T1DM) have increased insulin requirements during pregnancy. However, a minority of women have a fall in insulin requirements. When this occurs in late gestation, it often provokes concern regarding possible compromise of the feto-placental unit. In some centres, this is considered as an indication for delivery, including premature delivery. There are, however, many other factors that affect insulin requirements in pregnancy in women with type 1 diabetes mellitus and the decline in insulin requirements may represent a variant of normal pregnancy. If there is no underlying pathological process, expedited delivery in these women is not warranted and confers increased risks to the newborn. We will explore the factors affecting insulin requirements in gestation in this review. We will also discuss some novel concepts regarding beta-cell function in pregnancy.

Diabet. Med. 29, e199e204 (2012) Abstract Aims To assess associations between maternal serum vitamin D concentration and glucose metabolism in a cohort of pregnant women living in an Australian subtropical environment. Methods Cross-sectional assessment of 25-hydroxy vitamin D concentrations in 399 Hyperglycemia and Adverse Pregnancy Outcome ancillary study participants, treated at an obstetric teaching hospital in Brisbane, Australia. All patients underwent a blinded 75-g oral glucose tolerance test at 2432 (target 28) weeks gestation. Results The mean (+/- standard deviation) fasting plasma glucose was 4.5 +/- 0.4 mmol/l. Mean (+/- standard deviation) serum 25-hydroxy vitamin D was 132.5 +/- 44.0 nmol/l. A difference of one standard deviation in maternal 25-hydroxy vitamin D was inversely related to fasting glucose (fasting glucose lower by 0.047 mmol/l, P = 0.012) when assessed with multiple linear regression after adjusting for confounders. Maternal 25-hydroxy vitamin D correlated with beta-cell function as estimated by the log-transformed homeostasis model assessment beta-cell function equation (r = 0.131, P = 0.009), but not with the homeostasis model assessment of insulin resistance. Conclusions An association between mid-gestational 25-hydroxy vitamin D and fasting glucose was confirmed in a largely normoglycaemic and vitamin D-replete pregnant population. The correlation between 25-hydroxy vitamin D and beta-cell function suggests that vitamin D may influence glucose metabolism through this mechanism. Intervention studies are required to determine causality and the role of vitamin D replacement in deficient individuals.

Summary Background Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries. Methods Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated. Findings Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m 2 ) was the highest ranking modifiable risk factor, with PARs of 8–18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7–11% and 4–7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries. Interpretation The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries. Funding The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.

The purpose of this research was to assess the ability of ductus venosus (DV) Doppler velocimetry to predict adverse perinatal outcome in pregnancies complicated by pre-existing diabetes mellitus.This was a prospective study conducted at a tertiary referral obstetric facility in Brisbane, Australia. The study group included women with pregestational diabetes mellitus who delivered in the hospital between 1 January 1995 and 31 December 2006. The DV Doppler index was defined as abnormal if the DV peak velocity index for veins (PVIV) was equal to or greater than the 95(th) percentile for gestation. Adverse perinatal outcome included one or more of the following criteria: small-for-gestational-age infant; Cesarean section for non-reassuring fetal status; fetal acidemia at delivery; a 1-min Apgar score ofor= 3; a 5-min Apgar score of7; hypoxic ischemic encephalopathy; and stillbirth or neonatal death. The maternal characteristics and perinatal outcomes of pregnancies with normal or abnormal DV Doppler indices were compared.Eighty-two pregestational diabetic pregnancies were studied and an abnormal DV-PVIV was identified in 25 (30.5%). Adverse perinatal outcome was identified in eight of 25 (32.0%) pregnancies with an abnormal DV-PVIV compared to seven of 57 (12.3%) pregnancies with a normal DV-PVIV (P0.05). The sensitivity of the DV-PVIV in predicting adverse perinatal outcomes in pregestational diabetic pregnancies was 53.3%, the specificity was 74.6%, the positive predictive value was 32.0% and the negative predictive value was 87.7%.It may be useful to include DV-PVIV in the antenatal screening of pregnancies complicated by pregestational diabetes.

The parallel epidemics of obesity and Type 2 diabetes (T2DM) are progressing rapidly in Australia. The high prevalence of obesity and sedentary lifestyle in the population, compounded by later child bearing, has led to an increase in the prevalence of T2DM pre-dating pregnancy. In some centers, pregnant women with T2DM now outnumber those with type 1 diabetes (T1DM). Although there is controversy as to whether T2DM is associated with worse outcomes than T1DM in pregnancy, modern reports clearly acknowledge the seriousness of this condition. There is a clear association between obesity and adverse pregnancy outcomes (cesarean section, gestational diabetes, hypertensive disorders, birth defects and prematurity). Aside from obesity and the metabolic syndrome, additional factors may contribute to these adverse outcomes: A lack of preconception planning, a failure to achieve tight glycaemic control early in pregnancy and socio-economic disadvantage. It's likely that obesity and diabetes have compounding effects on pregnancy outcomes. In this review, we evaluate both the underlying pathogenesis of T2DM and obesity in the pregnancy context and the adverse clinical maternal and perinatal outcomes described in pregnancies complicated by maternal T2DM and obesity. We highlight the need for a comprehensive strategy to improve clinical outcomes in these pregnancies.

While the association between low birth weight (LBW;2500 g) and development of adult chronic renal disease (CKD) is inconsistently reported, less information is available regarding association of high birth weight (HBW; ≥4000 g) with CKD. We undertook a systematic review and meta-analysis on studies published before 30 September 2015 and report associations between birth weight and renal function. Blood (glomerular filtration rate (GFR)) and urine (microalbuminuria/albumin excreation rate (AER)/urinary albumin creatinine ratio (ACR)) parameters were used to define CKD. Three different effect size estimates were used (odds ratio, regression coefficient and mean difference). The odds of developing CKD in the life course among those born LBW was 1.77 (95% CI: 1.42, 2.20) times and 1.68 (1.27, 2.33) times, assessed by blood and urine parameters respectively. Higher risk was also observed among Asian and Australian populations (blood: OR 2.68; urine: OR 2.28), individuals aged ≤30 years (blood: OR 2.30; urine: OR 1.26), and ≥50 years (blood: OR 3.66; urine: OR 3.10), people with diabetes (blood: OR 2.51), and aborigines (urine: OR 2.32). There was no significant association between HBW and CKD. For every 1 kg increase in BW, the estimated GFR increased by 2.09 mL/min per 1.73 m(2) (1.33-2.85), and it was negatively associated with LogACR (ß -0.07, 95% CI: -0.14, 0.00). LBW inborn had lower mean GFR -4.62 (-7.10, -2.14) compared with normal BW. Findings of this study suggest that LBW increased the risk of developing CKD, and HBW did not show any significant impact.

To describe glycaemia in both breastfeeding women and artificially feeding women with Type 1 diabetes, and the changes in glycaemia induced by suckling.A blinded continuous glucose monitor was applied for up to 6 days in eight breastfeeding and eight artificially feeding women with Type 1 diabetes 2-4 months postpartum. Women recorded glucose levels, insulin dosages, oral intake and breastfeeding episodes. A standardized breakfast was consumed on 2 days. A third group (clinic controls) were identified from a historical database.Carbohydrate intake tended to be higher in breastfeeding than artificially feeding women (P = 0.09) despite similar insulin requirements. Compared with breastfeeding women, the high blood glucose index and standard deviation of glucose were higher in artificially feeding women (P = 0.02 and 0.06, respectively) and in the clinical control group (P = 0.02 and 0.05, respectively). The low blood glucose index and hypoglycaemia were similar. After suckling, the low blood glucose index increased compared with before (P0.01) and during (P0.01) suckling. Hypoglycaemia (blood glucose4.0 mmol/l) occurred within 3 h of suckling in 14% of suckling episodes, and was associated with time from last oral intake (P = 0.04) and last rapid-acting insulin (P = 0.03). After a standardized breakfast, the area under the glucose curve was positive. In breastfeeding women the area under the glucose curve was positive if suckling was avoided for 1 h after eating and negative if suckling occurred within 30 min of eating.Breastfeeding women with Type 1 diabetes had similar hypoglycaemia but lower glucose variability than artificially feeding women. Suckling reduced maternal glucose levels but did not cause hypoglycaemia in most episodes.

Clinical practice guidelines for diabetes include dietary guidelines to address the increased risk of cardiovascular disease.To identify impact of flexible insulin education with an active promotion of dietary freedom on energy and macronutrient intake and achievement of nutrient recommendations in adults with Type 1 diabetes.Dietary assessment was performed prior to and 12months following flexible insulin education. Nutrient intake and the proportion achieving the European Association for the Study of Diabetes (EASD) nutrient guidelines were compared at baseline and post course.Dietary data were available for 46 participants. Post course reductions were seen in median [IQR] energy kcal/d (1799 [1521-1931] to 1592 [1378-1940], p=0.002), fibre g/1000kcal (14 [12-16] to 13 [11-15], p=0.047), protein g/day (89 ([78-108] to 82 [74-93], p=0.001) and carbohydrate g/day (198 [172-330] to 162 [143-204], p=0.001). The proportion experiencing at least 1 severe hypoglycaemia event over 12months was significantly reduced (χ(2)=7.7, p=0.006) from baseline (n=13, 26%) to post course (n=3, 6%). Achievement of EASD guidelines was poor and did not change post course.Flexible insulin education with an active promotion of dietary freedom does not appear to 'worsen' the achievement of EASD nutrition guidelines in adults with Type 1 diabetes. On the contrary, the dietary changes observed were reductions in energy, carbohydrate and protein intake. Flexible insulin education may offer benefits in enabling reduced energy intake without increasing hypoglycaemia.

Aims: To evaluate structured type 1 diabetes education delivered in routine practice throughout Australia. Methods: Participants attended a five-day training program in insulin dose adjustment and carbohydrate counting between April 2007 and February 2012. Using an uncontrolled before-and-after study design, we investigated: HbA1c (% and mmol/mol); severe hypoglycaemia; diabetes ketoacidosis (DKA) requiring hospitalisation, and diabetes-related distress (Problem Areas in Diabetes scale; PAID), weight (kg); body mass index. Data were collected pre-training and 6-18 months post-training. Change in outcome scores were examined overall as well as between groups stratified by baseline HbA1c quartiles. Data are mean ± SD or % (n). Results: 506 participants had data eligible for analysis. From baseline to follow-up, significant reductions were observed in the proportion of participants reporting at least one severe hypoglycaemic event (24.7% (n = 123) vs 12.1% (n = 59), p < 0.001); and severe diabetes-related distress (29.3% (n = 145) vs 12.6% (n = 60), p < 0.001). DKA requiring hospitalisation in the past year reduced from 4.1% (n = 20) to 1.2% (n = 6). For those with above target baseline HbA1c there was a small, statistically significant improvement (n = 418, 8.4 ± 1.1% (69 ± 12 mmol/mol) to 8.2 ± 1.1% (66 ± 12 mmol/mol). HbA1c improvement was clinically significant among those in the highest baseline quartile (n = 122, 9.7 ± 1.1% (82 ± 11 mmol/mol) to 9.0 ± 1.2% (75 ± 13 mmol/mol), p < 0.001). Conclusions: The proportion of participants reporting severe hypoglycaemia, DKA and severe diabetes-related distress was at least halved, and HbA1c reduced by 0.7% (7 mmol/mol) among those with highest baseline levels. Structured type 1 diabetes education delivered in routine practice offers clinically important benefits for those with greatest clinical need.

Background Sulfate is important for fetal growth and development. During pregnancy, the fetus relies on sulfate from the maternal circulation. We report reference intervals for maternal plasma sulfate levels and fractional excretion index (FEI) for sulfate in pregnancy, as well as sulfate levels in cord blood from term pregnancies. Methods Plasma and urine were collected from 103 pregnant women of 10-20 weeks gestation and 106 pregnant women of 30-37 weeks gestation. Venous cord plasma was collected from 80 healthy term babies. Sulfate levels were measured by ion chromatography. Plasma and urinary creatinine levels were used to calculate FEI sulfate in pregnant women. Analyses provide reference intervals, and explored the relationship between maternal sulfate data with several prenatal factors. Results Median maternal plasma sulfate levels were 452 μmol/L and 502 μmol/L at 10-20 and 30-37 weeks gestation, respectively, and inversely correlated with FEI sulfate median values of 0.15 and 0.11. Overall reference intervals were 305-710 and 335-701 μmol/L (2.5th; 97.5th percentile; for 10-20 and 30-37 weeks gestation, respectively) for maternal plasma sulfate, and 0.06-0.31 and 0.05-0.28 for maternal FEI sulfate. Term venous cord plasma sulfate median levels were significantly (p = 0.038) higher in female babies (375 μmol/L) when compared to male babies (342 μmol/L), with an overall reference interval of 175-603 μmol/L. Conclusions We provide the first reference intervals for maternal plasma sulfate levels and FEI sulfate, as well as cord plasma sulfate levels. These findings provide reference data for further studies of sulfate levels in both mother and child. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0526-z) contains supplementary material, which is available to authorized users.

Objective: Cardiac impairment is frequently found in babies of diabetic mothers. It is still controversial whether this is due to poor glucose control. The aim of this study is to compare the cardiac function in fetuses of well- and poorly-controlled pre-gestational diabetic pregnancy in third trimester. Methods: Women with type 1 pre-gestational diabetes were enrolled at 30–32 weeks. Cardiac size and interventricular septal wall thickness were measured by M-mode at end-diastolic phase. The right and left ventricular ejection fractions were calculated. At the mitral and tricuspid valves inflow, the ratio between early ventricular filling and active atrial filling (E/A) at both atrioventricular valves were measured by Doppler echocardiography. Peak velocities of ascending aorta and pulmonary artery were assessed. The angle of isonation was kept at 6.5%) were compared with those with satisfactorily controlled diabetes (HbA1c ≤6.5%). Results: A total of 21 women with pre-gestational diabetes were recruited for this study. Eight women with well-controlled diabetes were compared with 9 women who had poorly-controlled diabetes. HbA1c in the poorly-controlled group was 7.3% and in the well-controlled group it was 5.4% (p < 0.001). There was no difference between the two groups in cardiac size, interventricular septal wall thickness, ejection fraction, aorta and pulmonary artery peak flow velocities. The right atrioventricular E/A ratio was significantly lower among the poorly-controlled diabetic pregnancies (0.71 vs. 0.54; p < 0.05). Conclusion: Fetuses of poorly-controlled diabetic mothers had a lower right atrioventricular E/A ratio. This may be due to metabolic acidosis, non-hypertrophic cardiac dysfunction or fetal polycythemia.

Objectives To assess the detection rate of congenital fetal malformations and specific problems related to routine ultrasound screening in women with pre-existing diabetes. Methods A retrospective study was carried out to assess the performance of routine ultrasound screening in women with pre-existing diabetes (Types 1 and 2) within a tertiary institution. The incidence, type and risk factors for congenital fetal malformations were determined. The detection rate of fetal anomalies for diabetic women was compared with that for the low-risk population. Factors affecting these detection rates were evaluated. Results During the study period, 12 169 low-risk pregnant women and 130 women with pre-existing diabetes had routine ultrasound screening performed within the institution. A total of 10 major anomalies (7.7%) and three minor anomalies (2.3%) were present in the fetuses of the diabetic women. Central nervous system and cardiovascular system anomalies accounted for 60% of the major anomalies. Peri-conceptional hemoglobin A 1 c of more than 9% was associated with a high prevalence of major anomalies (14311000). Women who had fetuses with major anomalies bad a significantly higher incidence of obesity (78% vs. 37%; P < 0.05). Ultrasound examination of these diabetic pregnancies showed high incidences of suboptimal image quality (37%), incomplete examinations, and repeat examinations (17%). Compared to the 'low-risk' non-diabetic population from the same institution, the relative risk for a major congenital anomaly among the diabetic women was 5.9-fold higher (95% confidence interval, 2.9-11.9). The detection rate for major fetal anomalies was significantly lower for diabetic women (30% vs. 73%; P < 0.01), and the mean body mass index for the diabetic group was significantly higher (29 vs. 23 kg/m(2); P < 0.001). Conclusion The incidence of congenital anomalies is higher in diabetic pregnancies. Unfortunately, the detection rate for fetal anomalies by antenatal ultrasound scan was significantly, worse than that for the low-risk population. This is likely to be related to the maternal body habitus and unsatisfactory examinations. Methods to overcome these difficulties are discussed.

Our objectives were to evaluate the psychosocial impact of a novel education programme, comprising an abbreviated curriculum based on the ‘core elements’ of insulin self-management education, with a view to identifying education options for those unable to attend a five-day Dose Adjustment for Normal Eating (DAFNE) programme. The novel programme was developed by DAFNE course facilitators and trialled using participants naive to flexible multiple daily injection (MDI) education. Post-course treatment satisfaction, wellbeing and diabetes distress were compared to baseline. Twenty-one adults attended the programme and 16 participants returned three months post-course. Significant improvements were seen in W-BQ12 total score, PAID score and DTSQ, equivalent to those observed following participation in the five-day programme. It was concluded that short course flexible MDI education is well tolerated by adults with type 1 diabetes, with improvements in treatment satisfaction and psychosocial outcome that are consistent with the five-day DAFNE programme. Further investigation of the longer-term impact on psychosocial and glycaemic outcomes of this novel curriculum is warranted. Copyright © 2017 John Wiley & Sons.

Gestational diabetes mellitus (GDM) affects 5-8% of pregnant women in Australia and is linked to adverse maternal and neonatal outcomes. Earlier diagnosis and treatment has been suggested to improve these outcomes. To describe the experience of a change in GDM screening policy at a large tertiary hospital. A 6-month audit was performed following a policy change involving introduction of screening for all women early in pregnancy (by either random blood glucose level (BGL) or oral glucose tolerance testing (OGTT), depending on their perceived risk of developing GDM), followed by universal OGTT at 26-28 weeks' gestation. The prevalence of GDM (including changes expected from new Australasian Diabetes in Pregnancy Society (ADIPS) criteria), maternal and neonatal outcomes and adherence to new screening policy are reported. The prevalence of GDM was 7.9% (1.6% early, 6.3% later diagnoses). More women with early diagnoses required insulin. Early testing with random BGL for low-risk women only identified 1.7% of those with GDM. Early OGTT for high-risk women identified 24.9% of GDM diagnoses. Adherence to the new screening protocol was generally poor, with 26% adherence at booking, 64% at 26 weeks' gestation and 27% with unknown GDM status. While early testing with OGTT for high-risk women may be helpful, the value of early testing with random BGL for low-risk women is questionable. The new ADIPS criteria are likely to increase the number of women diagnosed with GDM (with an emphasis on earlier diagnosis), but the absolute increase remains small.

Dr. Ryan (1) questions the arguments advanced in favor of the American Diabetes Association (ADA)/International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic process and criteria for gestational diabetes mellitus (GDM) (2) and vigorously supports a “minimal change” approach to GDM diagnosis. Several of his points deserve comment. With respect to “two-step” testing, O’Sullivan’s (3) initial cohort of 752 women did undergo a nonfasting, 1-h 50-g glucose “challenge” test (GCT) prior to their 100-g oral glucose tolerance test (OGTT). However, the OGTT was performed on all women (752 /986) who attended for testing , irrespective of …

Background Failure to return to pregnancy weight by 6 months postpartum is associated with long-term obesity, as well as adverse health outcomes. This research evaluated a postpartum weight management programme for women with a body mass index (BMI) > 25 kg m–2 that combined behaviour change principles and a low-intensity delivery format with postpartum nutrition information. Methods Women were randomised at 24–28 weeks to control (supported care; SC) or intervention (enhanced care; EC) groups, stratified by BMI cohort. At 36 weeks of gestation, SC women received a ‘nutrition for breastfeeding' resource and EC women received a nutrition assessment and goal-setting session about post-natal nutrition, plus a 6-month correspondence intervention requiring return of self-monitoring sheets. Weight change, anthropometry, diet, physical activity, breastfeeding, fasting glucose and insulin measures were assessed at 6 weeks and 6 months postpartum. Results Seventy-seven percent (40 EC and 41 SC) of the 105 women approached were recruited; 36 EC and 35 SC women received a programme and 66.7% and 48.6% completed the study, respectively. No significant differences were observed between any outcomes. Median [interquartile range (IQR)] weight change was EC: −1.1 (9.5) kg versus SC: −1.1 (7.5) kg (6 weeks to 6 months) and EC: +1.0 (8.7) kg versus SC: +2.3 (9) kg (prepregnancy to 6 months). Intervention women breastfed for half a month longer than control women (180 versus 164 days; P = 0.10). An average of 2.3 out of six activity sheets per participant was returned. Conclusions Despite low intervention engagement, the high retention rate suggests this remains an area of interest to women. Future strategies must facilitate women's engagement, be individually tailored, and include features that support behaviour change to decrease women's risk of chronic health issues.

OBJECTIVE:: To examine the association between the mode of delivery and the risk of offspring obesity by age 21 years using a large community-based birth cohort study in Australia. METHODS:: We followed-up a subsample of 2,625 offspring for whom we had measured physical assessments, including height and weight at 21 years and hospital-recorded mode of delivery, in the Mater Hospital in Brisbane, Australia, between 1981 and 1983. Body mass index (BMI) and waist circumference were measured at 21 years. Multivariable regression analysis was used to examine the independent associations of mode of delivery with offspring BMI and waist circumference. RESULTS:: In the cohort, 12.1% were born by cesarean delivery. Maternal and birth factors independently associated with the mode of delivery were age, overweight and obesity status, smoking status during pregnancy, hypertensive disorder during pregnancy, and neonatal low birth weight. By 21 years, 21.5% of offspring were overweight and 12.4% were obese. Offspring overweight and obesity status, as well as BMI and waist circumference, were not associated with the mode of delivery. CONCLUSIONS:: Findings of this study do not support the idea that cesarean delivery has increased the risk of long-term offspring obesity.

The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study has provided an opportunity to assess the relative associations of maternal glycemia measured at an oral glucose tolerance test (mean 28 weeks gestation) and maternal body mass index with a range of adverse pregnancy outcomes, without many of the potential confounding factors seen in previous studies. The HAPO study confirmed independently significant associations between maternal BMI and birthweight >90th centile, frequency of primary cesarean section, neonatal hypoglycemia, neonatal hyperinsulinemia, preeclampsia, and neonatal adiposity. The combination of maternal obesity and gestational diabetes was associated with higher frequencies of adverse outcomes than either variable in isolation.

Subclinical hypothyroidism (SCH), thyroid autoimmunity and isolated maternal hypothyroxinaemia are diagnoses made on laboratory findings. The two former conditions are commonly identified in the general population, while the term isolated maternal hypothyroxinaemia was developed to highlight potential neurodevelopmental risks in progeny. Each entity has been associated with either obstetric, perinatal and/or child developmental harm in observational studies, although few interventional trials have been performed to guide diagnostic and therapeutic approaches. Once diagnosed, treatment of SCH is recommended by endocrine groups to limit potential risk, given that harm from appropriate therapy is unlikely. Screening for thyroid disorders in pregnancy has traditionally been controversial. Definitive trials are expected to report over coming years and updated consensus guidelines will hopefully resolve this issue.

OBJECTIVE To determine how glucose control in women with GDM treated with metformin and/or insulin influenced pregnancy outcomes. RESEARCH DESIGN AND METHODS Women randomly assigned to metformin or insulin treatment in the Metformin in Gestational Diabetes (MiG) trial had baseline glucose tolerance test (OGTT) results and A1C documented, together with all capillary glucose measurements during treatment. In the 724 women who had glucose data for analysis, tertiles of baseline glucose values and A1C and of mean capillary glucose values during treatment were calculated. The relationships between maternal factors, glucose values, and outcomes (including a composite of neonatal complications, preeclampsia, and large-for-gestational-age [LGA] and small-for-gestational-age infants) were examined with bivariable and multivariate models. RESULTS Baseline OGTT did not predict outcomes, but A1C predicted LGA infants (P = 0.003). During treatment, fasting capillary glucose predicted neonatal complications (P < 0.001) and postprandial glucose predicted preeclampsia (P = 0.016) and LGA infants (P = 0.001). Obesity did not influence outcomes, and there was no interaction between glycemic control, randomized treatment, or maternal BMI in predicting outcomes. The lowest risk of complications was seen when fasting capillary glucose was CONCLUSIONS Glucose control in women with gestational diabetes mellitus treated with metformin and/or insulin is strongly related to outcomes. Obesity is not related to outcomes in this group. Targets for fasting and postprandial capillary glucose may need to be lower than currently recommended.

Gestational diabetes mellitus (GDM) and pre-gestational diabetes are known to pose risks to the mother and developing fetus, often related to abnormal fetal growth. One potential mediator of maternal effects on fetal growth is Placental Growth Hormone (PGH). PGH is produced by the syncytiotrophoblast and found predominantly in the maternal circulation. It progressively replaces pituitary growth hormone (hGH) in the human maternal circulation from mid-gestation onwards, peaking towards term. PGH appears to be an important potential regulator of maternal insulin resistance in human pregnancy and may influence fetal growth both by modifying substrate availability and through paracrine actions in the placental bed. The details of PGH regulation remain relatively poorly understood, but current evidence does suggest a central role in growth restricted pregnancies. There is currently less evidence of a pathophysiologic role in production of the macrosomic fetal phenotype commonly seen in response to hyperglycaemia, although our recent in vitro studies do raise the possibility of feto-placental feedback as a mechanism of growth modulation.

To investigate the issues that confront women when addressing overweight and obesity before conception.Questionnaire-based study of 412 unselected women in early pregnancy.255 women who attended a public, antenatal "first visit" clinic at a major urban obstetric hospital in Brisbane and 157 women who presented to a private obstetrician in Brisbane for a routine ultrasound scan during a 6-week period in 2006 were surveyed.Preconception health activities, prepregnancy body mass index (BMI), self-reported weight category, attempts to lose weight before pregnancy, and weight loss advice received before pregnancy.Folic acid supplementation was reported by 56% of participants, and 53% attended a preconception health check. Of women who provided details of height and prepregnancy weight, 30% were overweight or obese before pregnancy. However, 23 of 65 women with a BMI in the overweight range categorised themselves as normal weight (36%), and only 8 of 50 women with a BMI in the obese range categorised themselves as obese (16%). As BMI increased, more women reported trying to lose weight (P0.001) and reported receiving advice regarding weight loss (P0.001). Prepregnancy weight loss was reported by 52 of 115 overweight and obese women (45%).Potential barriers to addressing overweight and obesity before pregnancy include poor uptake of routine prepregnancy health activities, inaccurate self-categorisation of weight, unsuccessful weight loss attempts and inadequate advice regarding prepregnancy weight loss.