First Trimester Maternal Glycated Hemoglobin and Sex Hormone-Binding Globulin Do Not Predict Third Trimester Glucose Intolerance of Pregnancy.

Early pregnancy prediction of third trimester glucose intolerance may identify a population of women whose trajectory toward gestational diabetes mellitus (GDM) is modifiable. We assessed whether first trimester glycated hemoglobin (HbA1c) and sex hormone-binding globulin (SHBG), markers of insulin resistance, predicted third trimester glucose intolerance. Nondiabetic women with singleton pregnancies enrolled in a prospective observational study, 11 0/7 to 14 6/7 weeks. At enrollment, maternal characteristics, medical history, and blood samples were collected for HbA1c and SHBG. Two-step GDM screening was performed, 22 0/7 to 33 6/7 weeks. A 50 g oral glucose tolerance test ≥130 mg/dL defined screen positive, or glucose intolerance. Carpenter-Coustan criteria diagnosed GDM. Means HbA1c and SHBG were compared between glucose-intolerant versus normoglycemic women, and GDM versus no GDM women. We report unadjusted and adjusted odds ratios (OR; 95% confidence interval [CI]) of regression analyses. Adjusted models include race, enrollment body mass index, and history of GDM. Among 250 women, 29% were glucose intolerant and 6% had GDM. Among glucose-intolerant women, HbA1c was higher (5.3 ± 0.3 vs. 5.1 ± 0.3, P = .01) and associated with glucose intolerance in unadjusted, but not adjusted, models (OR: 2.9, 95% CI: 1.2-7.1; adjusted odds ratio [aOR]: 2.0, 95% CI: 0.7-5.4). Among GDM women, HbA1c was higher (5.4 ± 0.4 vs 5.2 ± 0.3, P = .002) and SHBG was lower (228 ± 72 vs 288 ± 93 mmol/L, P = .02). The HbA1c predicted GDM in unadjusted (OR: 13.2, 95% CI: 2.6-68.0) but not adjusted (aOR: 6.7, 95% CI: 0.8-55.2) models. Although metabolic alterations may well precede third trimester glucose intolerance, neither HbA1c of SHBG remained an independent predictor of glucose intolerance or GDM in adjusted models.

Maternal fat, but not lean, mass is increased among overweight/obese women with excess gestational weight gain.

BACKGROUND: Weight gain in pregnancy is an essential physiologic adaptation that supports growth and development of a fetus and is distributed among lean mass that includes total body water and fat mass gains. Although gestational weight gain provides a source of energy for the mother and fetus, excess gestational weight gain may underlie reported associations between parity and future metabolic disorders and is linked to postpartum weight retention and insulin resistance. Although weight gain often is proposed as a modifiable variable to mitigate adverse maternal and offspring health outcomes, our knowledge of specific maternal body composition changes with weight gain and the potential metabolic consequences is limited. Furthermore, although gestational weight gain alters maternal body composition, the impact of excess weight gain on fat and lean mass is not well-studied. Understanding the accrual of fat and lean body mass may improve our understanding of the role of excessive gestational weight gain and metabolic dysfunction. OBJECTIVE: The purpose of our study was to quantify the relationship between gestational weight gain and maternal fat and lean body mass accrual and to compare fat and lean body mass accrual according to the 2009 Institute of Medicine Guidelines for Gestational Weight Gain in Pregnancy adherence. We hypothesized that exceeding current weight gain guidelines would be associated with greater fat, compared with lean body, mass accrual. STUDY DESIGN: This is a secondary analysis of a randomized controlled trial of 49 overweight/obese women; all 49 are included in this secondary analysis. Maternal weight and body composition were collected in early (13 0/6 to 16 6/7 weeks gestation) and late (34 0/7 to 36 6/7 weeks gestation) pregnancy with the use of air densitometry. Correlations were drawn between gestational weight gain and change in fat and lean body mass. We compared change in fat and lean body mass by adherence to the 2009 Institute of Medicine Guidelines for Gestational Weight Gain in Pregnancy. Nonparametric tests and chi-square analyses were performed; a probability value of <.05 was significant. RESULTS: Early pregnancy body mass index was 30.3 kg/m(2) (interquartile range [IQR], 28.5-35.2 kg/m(2)); women gained 9.0 kg (IQR, 5.3-13.2 kg). Overweight and obese women were equally likely to gain excess weight (48% vs 35%; P = .6). Weight gain correlated strongly with fat mass change (r = 0.87; P < .001); women with excess vs adequate vs inadequate weight gain had greater fat mass change overall (5.2 [IQR, 4.2-8.1] vs 0.2 [IQR, -0.4-2.2] vs -2.7 [IQR, -5.2- -0.7] kg, respectively; P < .001) and in all pairwise comparisons. Weight gain also correlated with lean body mass change (r = 0.52; P = .001), but women with excess vs adequate weight gain had similar lean body mass change (8.4 [IQR, 7.2-10.1] vs 7.8 [IQR, 6.0-8.7] kg; P = .1). CONCLUSION: Excess gestational weight gain is associated primarily with maternal fat, but not with lean body mass accrual. Our results may help explain the reason that excess gestational weight gain or fat mass accrual is associated with long-term obesity, metabolic dysfunction, and cardiovascular disease risk.

Are the metabolic changes of pregnancy reversible in the first year postpartum?

AIMS/HYPOTHESIS: Maternal metabolic alterations are essential to achieve healthy pregnancy outcomes, but increasing maternal parity may be associated with long-term metabolic dysfunction risk. As existing data are limited by study design, our aim was to employ robust metabolic measures to determine whether or not physiological pregnancy alterations in maternal metabolic function persist at 1 year postpartum. METHODS: We evaluated 21 healthy women, of whom 11 had an interval pregnancy (IP) and assessment at preconception, during pregnancy and 1 year postpartum, and 10 had no IP and assessment at baseline and a 1 year interval. Assessment measures included body composition, insulin sensitivity and response, and basal metabolic rate. For each measure, IP vs no IP and time intervals within each group were compared using nonparametric analyses, reporting median (IQR). RESULTS: IP and no IP women were similar at enrolment, and no IP women had similar metabolic profiles at enrolment and the 1 year interval. IP women exhibited expected metabolic changes during pregnancy compared with preconception. In IP women, preconception and postpartum measures, including fat mass (20.7 [13.7-37.4] kg vs 18.4 [13.8-41.3] kg; p = 0.2), total insulin response (AUC 11,459 [9,230-13,696] pmol/ml × min vs 11,522 [5,882-17,404] pmol/ml × min; p = 0.9), insulin sensitivity (0.12 [0.06-0.13] mg [kg fat-free mass (FFM)](-1) min(-1) vs 0.11 [0.10-0.15] mg [kg FFM](-1) min(-1); p = 0.1) and basal metabolic rate (0.092 [0.092-0.105] kJ min(-1) FFM vs 0.096 [0.088-0.096] kJ min(-1) FFM; p = 0.5), were similar. CONCLUSIONS/INTERPRETATION: Our findings suggest pregnancy might not irreversibly alter maternal metabolic profile, measured at preconception through to 1 year postpartum. This result might be explained by a return to pre-pregnancy weight.

First-trimester maternal serum C-reactive protein as a predictor of third-trimester impaired glucose tolerance.

OBJECTIVE: We evaluated whether first-trimester high-sensitivity C-reactive protein (hsCRP), a suggested marker of pregnancy-associated hyperglycemia, predicts third-trimester impaired glucose tolerance (IGT) in a secondary analysis of a prospective cohort of nondiabetic singletons enrolled at <26 weeks gestation. STUDY DESIGN: We measured the association between hsCRP collected at <14 weeks among women classified as IGT (gestational diabetes screening results, 135 to <200 mg/dL) and those among normoglycemic women. Multivariable modeling estimated the association between log hsCRP and IGT, adjusted for maternal body mass index (BMI). RESULTS: Among 300 women, 13% (39 of 300) had IGT. The hsCRP was positively associated with glucose (P = .005). Compared with normoglycemic women, women with IGT had higher log hsCRP (0.87 ± 0.66 vs 0.67 ± 0.60, P = .04), but the association was not significant in adjusted models (adjusted odds ratio 1.20, 95% confidence interval 0.65-2.21). The hsCRP did not predict third-trimester IGT in this analysis when BMI is considered. CONCLUSION: Early identification of women at risk of IGT remains a priority, but the contribution of maternal BMI appears greater than hsCRP.

Excess Maternal Weight Gain and Large for Gestational Age Risk among Women with Gestational Diabetes.

OBJECTIVE: To determine whether, among women with gestational diabetes (GDM), gestational weight gain above Institute of Medicine (IOM) guidelines increases the risk of large for gestational age (LGA) neonates. STUDY DESIGN: We conducted a retrospective cohort study of singleton term pregnancies with GDM delivered at University of North Carolina Women's Hospital, Chapel Hill, NC from January 2002 to May 2010. We used Poisson regression modeling to estimate LGA risk (birth weight > 90th percentile for gestational age), by body mass index class and adherence to 2009 IOM weight gain guidelines. Women meeting IOM guidelines were the referent group. Final adjusted models included race/ethnicity, medical management of GDM, and gestational age at delivery. RESULTS: Among the 466 women studied, mean ± standard deviation birth weight was 3,526 ± 544 g; 18% (82/466) delivered LGA neonates. Birth weight was greatest among women exceeding, compared with meeting or gaining less than, IOM guidelines (3,703 ± 545 vs. 3,490 ± 505 vs. 3,328 ± 503, p = 0.001). Exceeding IOM guideline was associated with LGA among obese women (adjusted risk ratio 2.62, 95% confidence interval 1.25, 5.50) but not among overweight or normal weight women. CONCLUSION: Targeting gestational weight gain, a modifiable risk factor, independent of GDM treatment, may decrease LGA risk. Women with GDM may benefit from tailored weight gain recommendations.

Abnormal cervical cancer screening in pregnancy and preterm delivery.

BACKGROUND: Preterm delivery is a major cause of neonatal morbidity and mortality. Human papillomavirus (HPV) infection is common in reproductive-aged women. We hypothesised that abnormal cervical cancer screening tests, as a proxy for HPV infection, would be associated with preterm delivery. METHODS: We conducted a retrospective cohort study of women delivering liveborn singletons beyond 20 weeks gestation, who had a Papanicolaou (Pap) test within 1 year prior to delivery. Women with abnormal Pap or positive high-risk HPV tests, classified as having 'abnormal screening', were compared with women classified as having 'normal screening' in bivariate analysis for overall preterm delivery at less than 37 weeks gestation. Using Poisson regression, we report unadjusted (RR) and adjusted (aRR) risk ratios for spontaneous preterm delivery due to preterm labour and preterm premature rupture of membranes. RESULTS: Among 2686 women meeting criteria for analysis, 213 (8%) had abnormal screening. Women with abnormal screening, compared with normal screening, were not more likely to deliver preterm (12.2% vs. 9.8%, RR 1.3 [95% confidence interval (CI) 0.9, 1.8], aRR 1.2 [95% CI 0.8, 1.7]). Women with abnormal screening, however, were at greater risk for spontaneous preterm delivery in unadjusted and adjusted analysis (8.9% vs. 4.5%; RR 2.0 [95% CI 1.2, 3.2], aRR 1.8 [95% CI 1.1, 2.9]). CONCLUSIONS: There was no difference in risk of overall preterm delivery in women with abnormal compared with normal cervical cancer screening tests. Our data suggest, however, that abnormal screening in pregnancy may be associated with spontaneous preterm delivery.

Population health: modest glycaemic improvements in a pregnant cohort with mild glucose intolerance decreased adverse outcomes.

BACKGROUND: Adverse perinatal outcomes are common with pregnancy-related mild glucose intolerance. The perinatal impact of improving this population's health, instead of individual health, has not been quantified. METHODS: We estimated this impact among women with mild glucose intolerance, delivered at The University of North Carolina Women's Hospital from April 1996 to May 2010. We compared observed with predicted risks of perinatal outcomes after simulating a cohort with a one standard deviation decrease in each glucose value. We estimated absolute and adjusted risks, relative risks, and risk differences with Poisson regression and bootstrapped 95% confidence intervals [CI]. RESULTS: Among 3217 women, mean (SD) 1-h screening result was 157 (16) mg/dL; 3-h diagnostic results were 81 (10), 154 (28), 130 (25), and 104 (26) mg/dL for fasting, 1-h, 2-h, and 3-h, respectively. Compared with observed, predicted risks decreased for preeclampsia (9.1% vs. 6.6%, risk ratio [RR] 0.73 [95% CI 0.60, 0.88]), caesarean delivery (30.1% vs. 26.4%, RR 0.88 [95% CI 0.81, 0.96]), preterm birth (13.0% vs. 9.8%, RR 0.75 [95% CI 0.64, 0.87]), birthweight >4000 g (13.4% vs. 10.5%, RR 0.78 [95% CI 0.67, 0.90]), and shoulder dystocia (3.5% vs. 2.2%, RR 0.61 [95% CI 0.46, 0.83]). CONCLUSIONS: Modestly improved population distribution of glucose tolerance in pregnancies affected by mild glucose intolerance translated to meaningful improvements in perinatal outcomes.

Oral agents for the management of gestational diabetes.

In gestational diabetes (GDM), achieving euglycemia through treatment decreases the risk of adverse outcomes associated with hyperglycemia. Treatment starts with diet and nutritional counseling; however, up to 50% of women will require pharmacologic therapy to meet glucose goals. Although insulin remains the only Federal Drug Administration-approved agent to treat GDM, oral hypoglycemic agents are an attractive and increasingly common alternative. Research suggests that glyburide and metformin can each effectively manage hyperglycemia in pregnancy. This review highlights research on efficacy, safety, and advantages versus disadvantages of each. We offer management and counseling strategies for clinicians caring for patients with GDM.

Severe preeclampsia and maternal self-report of oral health, hygiene, and dental care.

BACKGROUND: Maternal periodontal disease diagnosed by a detailed oral health examination is associated with preeclampsia. Our objective was to measure the association between maternal self-report of oral symptoms/problems, oral hygiene practices, and/or dental service use before or during pregnancy and severe preeclampsia. METHODS: A written questionnaire was administered to pregnant females at the time of prenatal ultrasound and outcomes were ascertained by chart abstraction. The χ(2) test compared maternal oral symptoms/problems, hygiene practices, and dental service use between females with severe preeclampsia versus normotensive females. Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for severe preeclampsia. RESULTS: A total of 48 (10%) of 470 females reported ≥2 oral symptoms/problems in the 6 months before pregnancy and 77 (16%) since pregnancy. Fifty-one (11%) reported previous periodontal treatment. Twenty-eight (6%) of 470 developed severe preeclampsia. Females with a history of periodontal treatment were more likely to develop severe preeclampsia (aOR = 3.71; 95% CI = 1.40 to 9.83) than females without a history of periodontal treatment. Self-reported oral health symptoms/problems, oral hygiene practices, or dental service use before or during pregnancy were not associated with severe preeclampsia when considered in the context of other maternal risk factors. CONCLUSION: Maternal self-report of previous periodontal treatment before pregnancy is associated with severe preeclampsia.

Perinatal outcomes in Hispanic and non-Hispanic white women with mild gestational diabetes.

OBJECTIVE: To compare perinatal outcomes between self-identified Hispanic and non-Hispanic white women with mild gestational diabetes mellitus (GDM) or glucose intolerance. METHODS: In a secondary analysis of a mild GDM treatment trial, we compared perinatal outcomes by race and ethnicity for 767 women with glucose intolerance (abnormal 50-g 1-hour screen, normal 100-g 3-hour oral glucose tolerance test), 371 women with mild GDM assigned to usual prenatal care, and 397 women with mild GDM assigned to treatment. Outcomes included: composite adverse perinatal outcome (neonatal death, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, stillbirth, birth trauma), gestational age at delivery, birth weight, and hypertensive disorders of pregnancy. Adjusted regression models included: 100-g 3-hour oral glucose tolerance test results, parity, gestational age, body mass index, maternal age at enrollment, and current tobacco use. RESULTS: The sample of 1,535 women was 68.3% Hispanic and 31.7% non-Hispanic white. Among women with glucose intolerance, Hispanic women had more frequent composite outcome (37% compared with 27%, adjusted odds ratio [OR] 1.62, 95% confidence interval [CI] 1.10-2.37) with more neonatal elevated C-cord peptide (19% compared with 13%, adjusted OR 1.79, 95% CI 1.04-3.08) and neonatal hypoglycemia (21% compared with 13%, adjusted OR 2.04, 95% CI 1.18-3.53). Among women with untreated mild GDM, outcomes were similar by race and ethnicity. Among Hispanic women with treated mild GDM, composite outcome was similar to non-Hispanic white women (35% compared with 25%, adjusted OR 1.62, 95% CI 0.92-2.86), but Hispanic neonates had more frequent hyperinsulinemia (21% compared with 10%, adjusted OR 2.96, 95% CI 1.33-6.60). CONCLUSION: Individual components of some neonatal outcomes were more frequent in Hispanic neonates, but most perinatal outcomes were similar between Hispanic and non-Hispanic ethnic groups. LEVEL OF EVIDENCE: II.

Racial disparities in perinatal outcomes among women with gestational diabetes.

BACKGROUND: We sought to evaluate perinatal outcomes by race/ethnicity among women with gestational diabetes mellitus (GDM). METHODS: We conducted a 14-year retrospective cohort study of women with GDM. Selected perinatal outcomes were examined. Unadjusted and adjusted prevalence ratios (PR, aPR) of perinatal outcomes, comparing Hispanic and African American women with Caucasian women, were calculated. RESULTS: Hispanics comprised 54% of the 1018 woman cohort. Half received medical management of GDM (52%), more than African Americans (45%) or Caucasians (39%)(p<0.05). Compared with Caucasians, Hispanics had fewer deliveries <37 weeks (aPR 0.58, 95% confidence interval [CI] 0.42-0.81), less gestational hypertension (aPR 0.43, 95% CI 0.22-0.83), larger median birth weight infants (3453 g vs 3291 g, p<0.05), and greater risk of shoulder dystocia (aPR 3.52, 95% CI 1.30-9.50). Hispanic women had fewer adverse outcomes overall compared with Caucasian or African American women. CONCLUSIONS: We report differences between Hispanic and Caucasian women with GDM. Treatment to achieve glycemic control and reduce adverse outcomes may differ by race/ethnicity.

National Diabetes Data Group vs Carpenter-Coustan criteria to diagnose gestational diabetes.

OBJECTIVE: The objective of the study was to compare perinatal outcomes among women diagnosed with gestational diabetes by the National Diabetes Data Group (NDDG) criteria with women meeting only Carpenter-Coustan criteria. STUDY DESIGN: This was a 14 year retrospective cohort. Women who screened positive with 1 hour glucose load 140 mg/dL or greater underwent a diagnostic 3 hour oral glucose tolerance test. We report adjusted prevalence ratios (aPRs) of perinatal outcome risk. RESULTS: Of the 4659 screen-positive women with diagnostic testing, 1082 (3.3%, of 33,179) met NDDG criteria; 1542 (4.6%, of 33,179), or 460 more, met Carpenter-Coustan criteria. These 460 untreated women had greater risk of preeclampsia than women diagnosed by NDDG criteria (aPR, 1.70; 95% confidence interval [CI], 1.23-2.35). They had a greater risk of cesarean delivery (aPR, 1.16; 95% CI, 1.04-1.30) and infants greater than 4000 g (aPR, 1.25; 95% CI, 1.01-1.56) than women not meeting either diagnostic criteria. CONCLUSION: The 42.5% additional women diagnosed only by Carpenter-Coustan criteria are at greater risk for some adverse outcomes. Cost-effectiveness of a change remains to be determined.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae and repeat infection among pregnant urban adolescents.

BACKGROUND: Negative maternal and fetal consequences associated with Chlamydia trachomatis and Neisseria gonorrhoeae during pregnancy make diagnosis essential. The Centers for Disease Control and Prevention recommend routine screening for sexually transmitted infections at the first prenatal visit, and third trimester repeat screening, specifically for C. trachomatis, is recommended for women under age 25 or at increased infection risk. The effect of repeat screening on diagnosis during pregnancy is not well documented among adolescents. METHODS: A prospective cohort of 125 pregnant adolescents with at least one prenatal screening for C. trachomatis and N. gonorrhoeae was analyzed. All participants received prenatal care and delivered at one urban teaching hospital in Washington, DC. Screening results were documented for both sexually transmitted infections. Descriptive and univariate analyses were performed to describe disease prevalence. RESULTS: Of pregnant adolescents, 31% were diagnosed with either C. trachomatis or N. gonorrhoeae infection during pregnancy. Of the 75% (95/125) of patients who had more than one screening test, 11% (10/95) had a reinfection, and 7% (7/95) had a new infection on repeat testing. Nine percent (9/95) had recurrent C. trachomatis, whereas 4% (4/95) had a new diagnosis. Three percent (3/95) had recurrent N. gonorrhoeae, whereas 4% (4/95) had a new diagnosis. Some experienced coinfection at either initial or repeat testing. CONCLUSIONS: Screening for C. trachomatis and N. gonorrhoeae is recommended during pregnancy. In this sample of pregnant adolescents, the overall high incidence and recurrence of C. trachomatis and N. gonorrhoeae support Centers for Disease Control and Prevention screening and rescreening recommendations, regardless of initial test results.

Use of the Copper T380A intrauterine device by adolescent mothers: continuation and method failure.

STUDY OBJECTIVE: This report contributes to limited empirical data regarding use of the Copper T380A intrauterine device among adolescent mothers. DESIGN: We conducted a retrospective case series of adolescent mothers aged 15 to 21 years whose index delivery occurred before age 18 and met study inclusion criteria. SETTING: All adolescent mothers received obstetrics and gynecology care at one urban clinical site in Washington, DC. PARTICIPANTS: All participated in a teen secondary pregnancy prevention program from April 2002 to November 2008 and used the Copper T380A intrauterine device. MAIN OUTCOME MEASURES: We abstracted data to evaluate intrauterine device utilization, expulsion, removal, and pregnancy diagnosis. RESULTS: Thirty-nine adolescent mothers met inclusion criteria. Six patients had partial or complete expulsion (15%; 95% CI, 6-29), and 10 requested removal (26%; 95% CI, 14-41) within 24 months of placement. Four users (10%; 95% CI, 3-23) became pregnant. Three had an intrauterine device in place at time of conception, while one became pregnant due to unrecognized device expulsion. CONCLUSIONS: In this case series, many adolescent mothers discontinued Copper T380A use within two years of placement. The numbers of patients were too limited to provide stable estimates of contraceptive effectiveness. Larger comparative studies will further evaluate both effectiveness and acceptability of this device among teen mothers.

Chlamydia trachomatis Infection in minority adolescent women: a public health challenge.

UNLABELLED: Chlamydia trachomatis is the most common bacterial sexually transmitted infection in the United States. This disease disproportionately affects adolescent minority women, and untreated infection can lead to lasting reproductive tract morbidity. Recommendations for primary prevention include patient counseling to decrease risky behavior and increase barrier protection use; secondary prevention recommendations include screening and treatment of affected individuals and their sexual partners, barrier contraception use, as well as counseling to decrease behaviors that lead to reinfection. Despite these strategies, both incidence and prevalence of Chlamydia have continued to escalate in this population. Interventions to decrease chlamydial infection should encompass all facets of primary and secondary prevention as well as address the fundamental barrier to prevention-lack of perception of risk in this young age group. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this educational activity, the obstetrician/gynecologist should be better able to identify current screening guidelines to test for chlamydial infection in sexually active adolescents; obtain more thorough sexual histories, and understand dynamics of disproportionate disease burden in minority teens; recognize and act to decrease the high risk of reinfection in this patient population; and employ novel methods to increase STI screening.