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Aims: The aim of this study was to examine the influence of immigration status and region of origin on the risk of type 2 diabetes in women with prior gestational diabetes (GDM). Methods: This retrospective population‐based cohort study included women with gestational diabetes (GDM) aged 16 to 50 years in Ontario, Canada, who gave birth between 2006 and 2014. We compared the incidence of type 2 diabetes after delivery between long‐term residents and immigrants—overall, by time since immigration and by region of—using Cox regression adjusted for age, year, neighbourhood income, rurality, infant birth weight and presence of hypertensive disorders of pregnancy (HDP). Results: Among 38,515 women with prior GDM (42% immigrants), immigrants had a significantly higher risk of type 2 diabetes compared with long‐term residents (adjusted hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.13–1.26), with no meaningful difference based on time since immigration. The highest adjusted relative risks of type 2 diabetes compared with long‐term residents were found for immigrants from Sub‐Saharan Africa (HR 1.63, 95% CI 1.40–1.90), Latin America/Caribbean (HR 1.44, 95% CI 1.28–1.62) and South Asia (HR 1.34, 95% CI 1.25–1.44). Conclusions: Immigration is associated with a significantly higher risk of type 2 diabetes after GDM, particularly for women from certain low‐ and middle‐income countries. Diabetes prevention strategies will need to consider the unique needs of immigrants from these regions. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: Maternal hyperglycaemia alone does not explain the incidence of large offspring amongst women with type 1 diabetes. The objective of the study was to determine if there is an association between placental function, as measured by angiogenic factors, and offspring birthweight z score in women with type 1 diabetes. Methods: This cohort study included samples from 157 Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes (CONCEPTT) trial participants. Correlations were estimated between birthweight z score and placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1) levels measured at baseline and at 24 and 34 weeks of gestation. Linear regression was used to assess the relationship between birthweight z score and placental health, as measured by PlGF and sFlt-1/PlGF ratio, stratified by glycaemic status (continuous glucose monitoring and HbA1c measures) and adjusted for potential confounders of maternal BMI, smoking and weight gain. Higher PlGF levels and lower sFlt-1/PlGF ratios represent healthy placentas, while lower PlGF levels and higher sFlt-1/PlGF ratios represent unhealthy placentas. Results: Among CONCEPTT participants, the slopes relating PlGF levels to birthweight z scores differed according to maternal glycaemia at 34 weeks of gestation (p = 0.003). With optimal maternal glycaemia (HbA1c < 48 mmol/mol [6.5%]/ or continuous glucose monitoring time above range ≤ 30%), birthweight z scores were reduced towards zero (normal weight) with increasing PlGF values (representing a healthy placenta), and increased with decreasing PlGF values. With suboptimal glycaemic status (HbA1c ≥ 48 mmol/mol [6.5%] or time above range > 30%), increasing PlGF values were associated with heavier infants. Those with a healthy placenta (PlGF > 100) and suboptimal glycaemic control had a higher mean z score (2.45) than those with an unhealthy placenta (mean z score = 1.86). Similar relationships were seen when using sFlt-1/PlGF ratio as a marker for a healthy vs unhealthy placenta. Conclusions/interpretation: In women with type 1 diabetes, infant birthweight is influenced by both glycaemic status and placental function. In women with suboptimal glycaemia, infant birthweight was heavier when placentas were healthy. Suboptimal placental function should be considered in the setting of suboptimal glycaemia and apparently 'normal' birthweight. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: We performed a systematic review and meta-analysis to determine whether exposure to maternal pre-existing diabetes in pregnancy is associated with neurocognitive or behavioural outcomes in offspring. Methods: We searched MEDLINE, EMBASE, PsychINFO, the Cochrane Database of Systematic Reviews and Scopus for studies that examined any neurocognitive or behavioural outcomes in offspring of mothers with pre-existing diabetes in pregnancy in accordance with a published protocol (PROSPERO CRD42018109038). Title and abstract review, full-text review and data extraction were performed independently and in duplicate. Risk of bias was assessed using the Newcastle–Ottawa scale. Meta-analyses of summary measures were performed using random-effects models. Results: Nineteen articles including at least 18,681 exposed and 2,856,688 control participants were identified for inclusion. Exposure to maternal pre-existing diabetes in pregnancy was associated with a lower pooled intelligence quotient in the offspring (pooled weighted mean difference −3.07 [95% CI −4.59, −1.55]; I2 = 0%) and an increased risk of autism spectrum disorders (effect estimate 1.98 [95% CI 1.46, 2.68]; I2 = 0%). There was also an increased risk of attention deficit/hyperactivity disorder (pooled HR 1.36 [95% CI 1.19, 1.55]; I2 = 0%), though this was based on only two studies. Although most studies were found to be high quality in terms of participant selection, in many studies, comparability of cohorts and adequacy of follow-up were sources of bias. Conclusions/interpretation: There is evidence to suggest that in utero exposure to maternal pre-existing diabetes is associated with some adverse neurocognitive and behavioural outcomes. It remains unclear what the role of perinatal factors is and the degree to which other environmental factors contribute to these findings. [ABSTRACT FROM AUTHOR]

Background: Cold-induced thermogenesis is known to improve insulin sensitivity, which may become increasingly relevant in the face of global warming. The aim of this study was to examine the relation between outdoor air temperature and the risk of gestational diabetes mellitus.Methods: We identified all births in the Greater Toronto Area from 2002 to 2014 using administrative health databases. Generalized estimating equations were used to examine the relation between the mean 30-day outdoor air temperature before the time of gestational diabetes mellitus screening and the likelihood of diagnosis of gestational diabetes mellitus based on a validated algorithm using hospital records and physician service claims.Results: Over the 12-year period, there were 555 911 births among 396 828 women. Prevalence of gestational diabetes mellitus was 4.6% among women exposed to extremely cold mean outdoor air temperatures (≤ -10°C) in the 30-day period before screening and increased to 7.7% among those exposed to hot mean 30-day temperatures (≥ 24°C). Each 10°C increase in mean 30-day temperature was associated with a 1.06 (95% confidence interval [CI] 1.04-1.07) times higher odds of gestational diabetes mellitus, after adjusting for maternal age, parity, neighbourhood income quintile, world region and year. A similar effect was seen for each 10°C rise in outdoor air temperature difference between 2 consecutive pregnancies for the same woman (adjusted odds ratio 1.06, 95% CI 1.03-1.08).Interpretation: In our setting, there was a direct relation between outdoor air temperature and the likelihood of gestational diabetes mellitus. Future climate patterns may substantially affect global variations in the prevalence of diabetes, which also has important implications for the prevention and treatment of gestational diabetes mellitus. [ABSTRACT FROM AUTHOR]

Background: Women with type 1 diabetes strive for optimal glycemic control before and during pregnancy to avoid adverse obstetric and perinatal outcomes. For most women, optimal glycemic control is challenging to achieve and maintain. The aim of this study is to determine whether the use of real-time continuous glucose monitoring (RT-CGM) will improve glycemic control in women with type 1 diabetes who are pregnant or planning pregnancy.Methods/design: A multi-center, open label, randomized, controlled trial of women with type 1 diabetes who are either planning pregnancy with an HbA1c of 7.0 % to ≤10.0 % (53 to ≤ 86 mmol/mol) or are in early pregnancy (<13 weeks 6 days) with an HbA1c of 6.5 % to ≤10.0 % (48 to ≤ 86 mmol/mol). Participants will be randomized to either RT-CGM alongside conventional intermittent home glucose monitoring (HGM), or HGM alone. Eligible women will wear a CGM which does not display the glucose result for 6 days during the run-in phase. To be eligible for randomization, a minimum of 4 HGM measurements per day and a minimum of 96 hours total with 24 hours overnight (11 pm-7 am) of CGM glucose values are required. Those meeting these criteria are randomized to RT- CGM or HGM. A total of 324 women will be recruited (110 planning pregnancy, 214 pregnant). This takes into account 15 and 20 % attrition rates for the planning pregnancy and pregnant cohorts and will detect a clinically relevant 0.5 % difference between groups at 90 % power with 5 % significance. Randomization will stratify for type of insulin treatment (pump or multiple daily injections) and baseline HbA1c. Analyses will be performed according to intention to treat. The primary outcome is the change in glycemic control as measured by HbA1c from baseline to 24 weeks or conception in women planning pregnancy, and from baseline to 34 weeks gestation during pregnancy. Secondary outcomes include maternal hypoglycemia, CGM time in, above and below target (3.5-7.8 mmol/l), glucose variability measures, maternal and neonatal outcomes.Discussion: This will be the first international multicenter randomized controlled trial to evaluate the impact of RT- CGM before and during pregnancy in women with type 1 diabetes.Trial Registration: ClinicalTrials.gov Identifier: NCT01788527 Registration Date: December 19, 2012. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Ivanisevic and Djelmis publishing descriptions of the cohort of pregnant women with type 1 diabetes (T1D) (2). Topics include suboptimal glycemia and higher cord C-peptide, consistent with fetal hyperinsulinemia, and striking rates of neonatal morbidity; and fetal C-peptide crossing the placenta into maternal circulation in late pregnancy.

Pregnancy in the setting of type 1 diabetes is associated with an increased risk of adverse outcomes for both mother and fetus. Adequate glycaemic control has been shown to result in improved outcomes, but the strict glycaemic targets required in pregnancy are often difficult to achieve. The development of novel technologies for insulin delivery aim to assist in achieving excellent glycaemic control, while attempting to minimize the significant risk of hypoglycaemia that exists in pregnancy. This review will discuss the use of insulin pump therapy, continuous glucose monitoring and closed loop insulin delivery in the setting of pregestational diabetes, highlighting some of the potential advantages of these technologies. Novel insulin delivery devices have been shown to be safe in the setting of pregnancy, but proper randomized controlled trials are still needed to determine if they are superior to traditional insulin delivery mechanisms. [ABSTRACT FROM AUTHOR]

Objectives. Women with pregestational diabetes are advised to plan their pregnancies to optimize glycemia and reduce fetal complications. We evaluated the adequacy of pregnancy planning effort and medical planning in pregnant women with type 1 and type 2 diabetes. Methods. This retrospective cohort study surveyed pregnant women with pregestational diabetes mellitus between 2006 and 2008 in Ontario, Canada. We evaluated three measures of pregnancy planning: pregnancy planning effort, medical planning based on prepregnancy glycemic control, and folic acid use. We compared women with type 1 and type 2 diabetes and explored predictors of pregnancy planning. Results. Of the 163 women studied (89 type 1, 74 type 2 diabetes), 47%% reported high pregnancy planning effort, 58%% reported attempts to optimize glycemic control, and 56%% took folic acid before pregnancy. Of those who reported high pregnancy planning, 20%% did not medically plan their pregnancies. Rates were similar between women with type 1 and type 2 diabetes. The most important predictor of pregnancy planning was having discussed plans with their physician. Conclusions. Our findings suggest that pregnancy planning is suboptimal in women with both type 1 and type 2 diabetes, highlighting a need to improve preconception counseling for all women with pregestational diabetes. [ABSTRACT FROM AUTHOR]

Background: It is generally appreciated that gestational diabetes is a risk factor for type 2 diabetes. However, the precise relation between these 2 conditions remains unknown. We sought to determine the incidence of diabetes mellitus after diagnosis of gestational diabetes. Methods: We used a population-based database to identify all deliveries in the province of Ontario over the 7-year period from Apr. 1, 1995, to Mar. 31, 2002. We linked these births to mothers who had been given a diagnosis of gestational diabetes through another administrative database that records people with diabetes on the basis of either physician service claims or hospital admission records. We examined database records for these women from the time of delivery until Mar. 31, 2004, a total of 9 years. We determined the presence of diabetes mellitus according to a validated administrative database definition for this condition. Results: We identified 659 164 pregnant women who had no pre-existing diabetes. Of these, 21 823 women (3.3%) had a diagnosis of gestational diabetes. The incidence of gestational diabetes rose significantly over the 9-year study period, from 3.2% in 1995 to 3.6% in 2001 (p < 0.001). The probability of diabetes developing after gestational diabetes was 3.7% at 9 months after delivery and 18.9% at 9 years after delivery. After adjustment for age, urban or rural residence, neighbourhood income quintile, whether the woman had a previous pregnancy, whether the woman had hypertension after the index delivery, and primary care level before the index delivery, the most significant risk factor for diabetes was having had gestational diabetes during the index pregnancy (hazard ratio 37.28, 95% confidence interval 34.99-40.88; p < 0.001). Age, urban residence and lower income were also important factors. When analyzed by year of delivery, the rate of development of diabetes was higher among the latest subcohort of women with gestational diabetes (delivery during 1999-2001) than among the earliest subcohort (delivery during 1995 or 1996) (16% by 4.7 years after delivery v. 16% by 9.0 years). Interpretation: In this large population-based study, the rate of development of diabetes after gestational diabetes increased over time and was almost 20% by 9 years. This estimate should be used by clinicians to assist in their counselling of pregnant women and by policy-makers to target these women for screening and prevention. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- To determine whether women with pregestational diabetes obtained long-term benefits from an intensive diabetes management program during pregnancy. RESEARCH DESIGN AND METHODS -- Women with pregestational diabetes who had attended an intensive diabetes management program in pregnancy between 1991 and 1999 were interviewed regarding diabetes self-management behaviors and current glycemic control. A retrospective chart review was done to obtain information on self-management behaviors at entry to the program and at delivery and compared with the present. RESULTS -- Comparing entry to the program to delivery, all diabetes self-management behaviors improved significantly, including frequency of self-monitoring of blood glucose, frequency of insulin injections, and frequency and complexity of insulin dose adjustment (IDA). HbA1c (A1C) also improved significantly from entry to delivery (mean 0.073-0.060) (P < 0.0001). Comparing entry to the present, frequency of insulin injections improved significantly (P = 0.0004), frequency of IDA improved significantly (P = 0.004), and complexity of IDA improved significantly (P = 0.0032). However, there was no significant change in frequency of self-monitoring of blood glucose (P = 0.766) from before pregnancy to the present, and A1C significantly worsened by 0.015 (P < 0.0001, 95% CI 0.009-0.021) from entry to the program to the present. CONCLUSIONS -- Women participating in an intensive diabetes management program during pregnancy improve significantly from entry to delivery in diabetes self-management behaviors and glycemic control and, in the long term, retain some of these behaviors and knowledge. However, this is not reflected in an improved A1C level. This may be explained by the loss of contact with the diabetes care team and/or the discontinuation of frequent self-monitoring of blood glucose--a critical behavior necessary for achieving optimal glycemic control. [ABSTRACT FROM AUTHOR]

Aims: The risk of microvascular disease has been thought to commence with the onset of overt diabetes. Women with gestational diabetes have only had a short-term exposure to frank hyperglycemia, but, due to underlying β-cell dysfunction, they may also have had long-term exposure to mild degrees of hyperglycemia. The aim of the study was to determine whether women with gestational diabetes are at increased risk for microalbuminuria and retinopathy compared to women with normal glucose tolerance in pregnancy.Methods: We recruited women aged ≥ 25 years with singleton pregnancies at 32 to 40 weeks' gestational age, with and without gestational diabetes. Women with hypertension, preeclampsia, or pre-gestational diabetes were excluded.Results: Of 372 women included in the study, 195 had gestational diabetes. The prevalence of microalbuminuria was 15% among those with gestational diabetes versus 6% in those with normal glucose tolerance (adjusted odds ratio 2.4, 95% confidence interval 1.1 to 5.2, p = 0.006). Diastolic blood pressure and HbA1c were associated with microalbuminuria. The prevalence of retinopathy did not differ between groups (10% versus 11%).Conclusions: Women with gestational diabetes have an increased risk of microalbuminuria in the third trimester, despite having been exposed to only a brief period of overt hyperglycemia. [ABSTRACT FROM AUTHOR]

The authors offer a response to comments on their article on the progeny, perspective, and a personalized approach to metformin for gestational diabetes mellitus. Topics discussed include potential differences in offspring effects from metformin in an intrauterine environment of maternal nutrient excess, maternal obesity's higher risk of placental insufficiency and restrictive nutrition, and the continuing discernment on childhood effects when metformin is given to mothers.

The authors present a response to a comment on the study regarding use of insulin pump or multiple daily injections in type 1 diabetes (T1D) pregnancy glycemic outcomes. The authors agree that more data are needed regarding the optimal implementation of insulin pump therapy during T1D. However, owing to some psycho social complexity, the authors claim that it is not practical to collect detailed data on patient-clinician relationship regarding insulin pump usage.

Focuses on the idea that the prevalence of type two diabetes in pregnancy is underestimated, and that adverse maternal and fetal outcomes are as significant in these women as those in pregnant women with type one diabetes. Correct identification of type two diabetes in pregnancy; Maternal and fetal complications.