Continuous Glucose Monitoring-Derived Differences in Pregnancies With and Without Adverse Perinatal Outcomes.

OBJECTIVE: To evaluate whether continuous glucose monitoring (CGM)-derived glycemic patterns observed throughout pregnancy were associated with adverse perinatal outcomes, specifically fetal growth disorders and hypertensive disorders of pregnancy (HDP). METHODS: We conducted a prospective observational study of individuals with viable singleton pregnancies and screening hemoglobin A1c levels less than 6.5%. Those with preexisting diabetes were excluded. Enrollment occurred at the earliest gestational age before 17 weeks. Participants wore blinded continuous glucose monitors consecutively as willing until delivery. Those with at least 14 days of CGM data were included in analysis. Rates of large-for-gestational-age (LGA) neonates, small-for-gestational age (SGA) neonates, and HDP were assessed. Continuous glucose monitoring-derived glycemic metrics were calculated, including mean glucose level and percent time above and below thresholds. Two-sample t tests were used to compare glycemic metrics between participants with and without adverse perinatal outcomes. RESULTS: Of 937 participants enrolled, 760 met inclusion criteria. Those delivering LGA neonates or who were diagnosed with HDP had higher mean glucose levels (102±9 vs 100±8, P=.01 and 103±8 vs 99±8, P<.001) and spent more time above 120 mg/dL (median 16% vs 12%, P=.006, and 16% vs 12%, P<.001, respectively) and above 140 mg/dL (median 3.9% vs 2.8%, P=.006, and 3.5% vs 2.8%, P<.001, respectively) throughout gestation than those without these outcomes. These findings were present regardless of gestational diabetes mellitus status. Participants with SGA neonates had lower mean glucose levels (97±7 vs 101±8, P=.01) and spent less time above 140 mg/dL (median 1.6% vs 2.3%, P=.01) and more time below 63 mg/dL (median 3.0% vs 2.3%, P=.02) than those without SGA neonates. CONCLUSION: Individuals with LGA neonates or HDP exhibit a slightly higher mean glucose levels and spend more time hyperglycemic in early pregnancy than those who do not experience these outcomes.

Continuous Glucose Monitoring for Diabetes Management During Pregnancy: Evidence, Practical Tips, and Common Pitfalls.

Continuous glucose monitoring (CGM) has the potential to revolutionize diabetes management during pregnancy by providing detailed and real-time data to patients and clinicians, overcoming many of the limitations of self-monitoring of blood glucose. Although there are limited data on the role of CGM to improve pregnancy outcomes in patients with type 2 diabetes or gestational diabetes, CGM has been shown to reduce pregnancy complications in patients with type 1 diabetes. Despite the limited data in some populations, given its ease of use and recent U.S. Food and Drug Administration approval with expanding insurance coverage, CGM has gained widespread popularity among pregnant patients with all types of diabetes. It is critical for obstetric clinicians to understand how CGM can be successfully integrated into clinical practice. We present a practical, step-wise approach to CGM data interpretation that can be incorporated into diabetes management during pregnancy and common CGM pitfalls and solutions. Although technology will continue to advance with newer-generation CGM devices and diabetes technology such as automated insulin delivery (not covered here), these key principles form a basic foundation for understanding CGM technology and its utility for pregnant people.

Continuous Glucose Monitoring Prediction of Gestational Diabetes Mellitus and Perinatal Complications.

Objective: To assess the performance of continuous glucose monitoring (CGM)-measured glycemic metrics in predicting development of gestational diabetes mellitus (GDM) and select perinatal complications. Research Methods: In a prospective observational study, CGM data were collected from 760 pregnant females throughout gestation after study enrollment. GDM was diagnosed using the oral glucose tolerance test (OGTT) at 24-34 weeks of gestation. Predictive models were built using logistic and elastic net regression. Predictive performance was assessed by the area under the receiver-operating characteristic (AUROC) curve. Results: The AUROCs of using second trimester percent time >140 mg/dL (TA140) and week 13-14 TA140 in predicting GDM were 0.81 and 0.74, respectively. The AUROCs for predicting large-for-gestational-age (LGA) births and hypertensive disorders of pregnancy (HDP) using second trimester TA140 were both 0.58. When matching the specificity of OGTT, a model using TA140 in weeks 13-14 achieved similar sensitivity to OGTT in predicting HDP (13% vs. 10%, respectively) and LGA (6% for both methods). Elastic net also demonstrated similar AUROC and diagnostic performance with no meaningful improvement by using multiple predictors. Conclusion: CGM-measured hyperglycemic metrics such as TA140 predicted GDM with high AUROCs as early as 13-14 weeks of gestation. These metrics were also similar statistically to the OGTT at 24-34 weeks in predicting perinatal complications, although sensitivity was low for both. CGM could potentially be used as an early screening tool for elevated hyperglycemia during gestation, which could be used in addition to or instead of the OGTT.

Continuous Glucose Monitoring Profiles in Pregnancies With and Without Gestational Diabetes Mellitus.

OBJECTIVE: To determine whether continuous glucose monitoring (CGM)-derived glycemic patterns can characterize pregnancies with gestational diabetes mellitus (GDM) as diagnosed by standard oral glucose tolerance test at 24-28 weeks' gestation compared with those without GDM. RESEARCH DESIGN AND METHODS: The analysis includes 768 individuals enrolled from two sites prior to 17 weeks' gestation between June 2020 and December 2021 in a prospective observational study. Participants wore blinded Dexcom G6 CGMs throughout gestation. Main outcome of interest was a diagnosis of GDM by oral glucose tolerance test (OGTT). Glycemic levels in participants with GDM versus without GDM were characterized using CGM-measured glycemic metrics. RESULTS: Participants with GDM (n = 58 [8%]) had higher mean glucose (109 ± 13 vs. 100 ± 8 mg/dL [6.0 ± 0.7 vs. 5.6 ± 0.4 mmol/L], P < 0.001), greater glucose SD (23 ± 4 vs. 19 ± 3 mg/dL [1.3 ± 0.2 vs. 1.1 ± 0.2 mmol/L], P < 0.001), less time in range 63-120 mg/dL (3.5-6.7 mmol/L) (70% ± 17% vs. 84% ± 8%, P < 0.001), greater percent time >120 mg/dL (>6.7 mmol/L) (median 23% vs. 12%, P < 0.001), and greater percent time >140 mg/dL (>7.8 mmol/L) (median 7.4% vs. 2.7%, P < 0.001) than those without GDM throughout gestation prior to OGTT. Median percent time >120 mg/dL (>6.7 mmol/L) and time >140 mg/dL (>7.8 mmol/L) were higher as early as 13-14 weeks of gestation (32% vs. 14%, P < 0.001, and 5.2% vs. 2.0%, P < 0.001, respectively) and persisted during the entire study period prior to OGTT. CONCLUSIONS: Prior to OGTT at 24-34 weeks' gestation, pregnant individuals who develop GDM have higher CGM-measured glucose levels and more hyperglycemia compared with those who do not develop GDM.

Glucose levels measured with continuous glucose monitoring in uncomplicated pregnancies.

INTRODUCTION: To characterize glucose levels during uncomplicated pregnancies, defined as pregnancy with a hemoglobin A1c <5.7% (<39 mmol/mol) in early pregnancy, and without a large-for-gestational-age birth, hypertensive disorders of pregnancy, or gestational diabetes mellitus (ie, abnormal oral glucose tolerance test). RESEARCH DESIGN AND METHODS: Two sites enrolled 937 pregnant individuals aged 18 years and older prior to reaching 17 gestational weeks; 413 had an uncomplicated pregnancy (mean±SD body mass index (BMI) of 25.3±5.0 kg/m2) and wore Dexcom G6 continuous glucose monitoring (CGM) devices throughout the observed gestational period. Mealtimes were voluntarily recorded. Glycemic levels during gestation were characterized using CGM-measured glycemic metrics. RESULTS: Participants wore CGM for a median of 123 days each. Glucose levels were nearly stable throughout all three trimesters in uncomplicated pregnancies. Overall mean±SD glucose during gestation was 98±7 mg/dL (5.4±0.4 mmol/L), median per cent time 63-120 mg/dL (3.5-6.7 mmol/L) was 86% (IQR: 82-89%), median per cent time <63 mg/dL (3.5 mmol/L) was 1.8%, median per cent time >120 mg/dL (6.7 mmol/L) was 11%, and median per cent time >140 mg/dL (7.8 mmol/L) was 2.5%. Mean post-prandial peak glucose was 126±22 mg/dL (7.0±1.2 mmol/L), and mean post-prandial glycemic excursion was 36±22 mg/dL (2.0±1.2 mmol/L). Higher mean glucose levels were low to moderately associated with pregnant individuals with higher BMIs (103±6 mg/dL (5.7±0.3 mmol/L) for BMI ≥30.0 kg/m2 vs 96±7 mg/dL (5.3±0.4 mmol/L) for BMI 18.5-<25 kg/m2, r=0.35). CONCLUSIONS: Mean glucose levels and time 63-120 mg/dL (3.5-6.7 mmol/L) remained nearly stable throughout pregnancy and values above 140 mg/dL (7.8 mmol/L) were rare. Mean glucose levels in pregnancy trend higher as BMI increases into the overweight/obesity range. The glycemic metrics reported during uncomplicated pregnancies represent treatment targets for pregnant individuals.

Continuous Glucose Monitoring Metrics for Pregnancies Complicated by Diabetes: Critical Appraisal of Current Evidence.

Ascertaining the utility of continuous glucose monitoring (CGM) in pregnancy complicated by diabetes is a rapidly evolving area, as the prevalence of type 1 diabetes (T1D), type 2 diabetes (T2D), and gestational diabetes mellitus (GDM) escalates. The seminal randomized controlled trial (RCT) evaluating CGM use added to standard care in pregnancy in T1D demonstrated significant improvements in maternal glycemia and neonatal health outcomes. Current clinical guidance recommends targets for percentage time in range (TIR), time above range (TAR), and time below range (TBR) during pregnancy complicated by T1D that are widely used in clinical practice. However, the superiority of CGM over blood glucose monitoring (BGM) is still questioned in both T2D and GDM, and whether glucose targets should be different than in T1D is unknown. Questions requiring additional research include which CGM metrics are superior in predicting clinical outcomes, how should pregnancy-specific CGM targets be defined, whether CGM targets should differ according to gestational age, and if CGM metrics during pregnancy should be similar across all types of diabetes. Limiting the potential for CGM to improve pregnancy outcomes may be our inability to maintain TIR > 70% throughout gestation, a goal achieved in the minority of patients studied. Adverse pregnancy outcomes remain high in women with T1D and T2D in pregnancy despite CGM technology, and this review explores the potential reasons and questions yet to be investigated.

Mental Bandwidth is Associated with HIV and Viral Suppression Among Low-Income Women in Philadelphia.

Behavioral economics research suggests poverty may influence behavior by reducing mental bandwidth, increasing future discounting, and increasing risk aversion. It is plausible that these decision-making processes are further impaired in the context of HIV or pregnancy. In this cross-sectional study of 86 low-income women in Philadelphia, multivariable models showed that HIV was associated with decreased mental bandwidth (one of two measures) and lower risk aversion. Pregnancy was not associated with any decision-making factors. Viral suppression was associated with greater mental bandwidth (one of two measures), and antenatal care engagement with lower future discounting. Anti-poverty interventions may be particularly beneficial to improve health behaviors in the context of HIV.

Effects of Implementing a Routine Postpartum Fasting Blood Glucose on the Completion of the Gold Standard 2-Hour Oral Glucose Tolerance Test in Gestational Diabetics.

OBJECTIVE: Rates of completion of the gold standard 2-hour oral glucose tolerance test (OGTT) for impaired glucose intolerance postpartum in patients with gestational diabetes mellitus (GDM) are consistently less than 50%. Screening tests performed prior to hospital discharge, including fasting blood glucose (FBG) to detect persistent hyperglycemia, have been investigated. We lack evidence, however, on whether implementation of routine postpartum FBG impacts the likelihood of obtaining the routine 2-hour OGTT. We sought to retrospectively compare the rates of completion of the 2-hour OGTT pre- and postimplementation of a routine FBG screen. STUDY DESIGN: We performed a single-center retrospective cohort study comparing the completion of the 2-hour OGTT pre- and postimplementation of a routine FBG screen. Our primary outcome was the completion of the postpartum OGTT. Bivariate analyses assessed associations between demographic and preinduction clinical characteristics by pre- and post-implementation groups, as well as OGTT completion. Multivariable logistic regression was used to control for possible confounders. A sensitivity analysis was performed to account for the overlap with the coronavirus disease 2019pandemic. RESULTS: In total, 468 patients met the inclusion and exclusion criteria. In our post-intervention group, 64% of patients completed a postpartum FBG. For our primary outcome, completion of the 2-hour OGTT significantly decreased in our postintervention group from 37.1 to 25.9% (p = 0.009), adjusted odds ratio (aOR): 0.62, confidence interval (CI): 0.41-0.92. This difference was no longer statistically significant when excluding patients during the pandemic, from 40.3 to 33.1% (p = 0.228), aOR: 0.76, CI: 0.455-1.27. CONCLUSION: Implementation of a routine FBG was associated with a negative impact on patients completing a 2-hour OGTT. The difference was no longer significant when excluding patients who would have obtained the OGTT during the pandemic, which may have been due to the smaller cohort. Future work should investigate patient perceptions of the FBG and its impact on their decision-making around the OGTT. KEY POINTS: · Screening for postpartum glucose intolerance is imperative for gestational diabetics.. · A fasting blood glucose is recommended as a postpartum screen for hyperglycemia in GDM patients.. · Implementation of an FBG was associated with a decrease in completion of the gold standard OGTT..

Feasibility and Acceptability of Home-Delivered Medically Tailored Meals for Treatment of Diabetes in Pregnancy.

BACKGROUND: Diabetes complicates ≤7% of pregnancies in the United States. Although medical nutrition therapy is the mainstay of diabetes treatment, many barriers exist to the successful implementation of dietary modifications. Home-delivered medically tailored meals (MTMs) are promising to overcome such barriers. OBJECTIVE: The objective of this study was to evaluate the feasibility and acceptability of home-delivered MTM in pregnant patients with diabetes. METHODS: We performed a prospective cohort study of home-delivered MTM for pregnant patients with diabetes using a mixed-methods approach. Participants <35 wk of gestation at the time of enrollment received weekly home delivery of diabetes-specific meals. Qualitative semistructured interviews were conducted to gain insight into participants' experience. Diabetes self-efficacy was assessed pre- and postintervention using the Diabetes Self-Efficacy Scale and 2-Item Diabetes Distress Screening Scale. The difference in mean scores was compared using t-tests with P value of <0.05 considered significant. Feasibility and acceptability were evaluated through participants' attitude toward MTM in qualitative interviews and indirectly evaluated through diabetes self-efficacy surveys. RESULTS: Twenty pregnant people with diabetes who received home-delivered MTM during pregnancy were interviewed postpartum. Participants found this program convenient for various reasons, including reduced time for grocery shopping and preparing meals. Participants were satisfied with meals, citing a positive impact on diabetes management, accessibility of healthy foods, reduced stress with meal planning, and greater perceived control of blood glucose. Most participants shared meals with their families or received specific meals for their dependents, which was positively received. Reduced financial and mental stress was also widely reported. Diabetes self-efficacy was significantly improved postintervention with MTM. CONCLUSION: Home-delivered MTM is feasible and acceptable in pregnant patients with diabetes and may improve diabetes self-efficacy. Individual experiences offered insight into various barriers overcome by using this service. Home-delivered MTM may help ensure an accessible, healthy diet for pregnant patients with diabetes.

Metformin Plus Insulin for Preexisting Diabetes or Gestational Diabetes in Early Pregnancy: The MOMPOD Randomized Clinical Trial.

Importance: Insulin is recommended for pregnant persons with preexisting type 2 diabetes or diabetes diagnosed early in pregnancy. The addition of metformin to insulin may improve neonatal outcomes. Objective: To estimate the effect of metformin added to insulin for preexisting type 2 or diabetes diagnosed early in pregnancy on a composite adverse neonatal outcome. Design, Setting, and Participants: This randomized clinical trial in 17 US centers enrolled pregnant adults aged 18 to 45 years with preexisting type 2 diabetes or diabetes diagnosed prior to 23 weeks' gestation between April 2019 and November 2021. Each participant was treated with insulin and was assigned to add either metformin or placebo. Follow-up was completed in May 2022. Intervention: Metformin 1000 mg or placebo orally twice per day from enrollment (11 weeks -<23 weeks) through delivery. Main Outcome and Measures: The primary outcome was a composite of neonatal complications including perinatal death, preterm birth, large or small for gestational age, and hyperbilirubinemia requiring phototherapy. Prespecified secondary outcomes included maternal hypoglycemia and neonatal fat mass at birth, and prespecified subgroup analyses by maternal body mass index less than 30 vs 30 or greater and those with preexisting vs diabetes early in pregnancy. Results: Of the 831 participants randomized, 794 took at least 1 dose of the study agent and were included in the primary analysis (397 in the placebo group and 397 in the metformin group). Participants' mean (SD) age was 32.9 (5.6) years; 234 (29%) were Black, and 412 (52%) were Hispanic. The composite adverse neonatal outcome occurred in 280 (71%) of the metformin group and in 292 (74%) of the placebo group (adjusted odds ratio, 0.86 [95% CI 0.63-1.19]). The most commonly occurring events in the primary outcome in both groups were preterm birth, neonatal hypoglycemia, and delivery of a large-for-gestational-age infant. The study was halted at 75% accrual for futility in detecting a significant difference in the primary outcome. Prespecified secondary outcomes and subgroup analyses were similar between groups. Of individual components of the composite adverse neonatal outcome, metformin-exposed neonates had lower odds to be large for gestational age (adjusted odds ratio, 0.63 [95% CI, 0.46-0.86]) when compared with the placebo group. Conclusions and Relevance: Using metformin plus insulin to treat preexisting type 2 or gestational diabetes diagnosed early in pregnancy did not reduce a composite neonatal adverse outcome. The effect of reduction in odds of a large-for-gestational-age infant observed after adding metformin to insulin warrants further investigation. Trial Registration: ClinicalTrials.gov Identifier: NCT02932475.

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance.

OBJECTIVE: There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN: This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS: Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION: Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Elevated HbA1c on universal prenatal screening is associated with decreased postpartum weight retention.

OBJECTIVE: To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes. METHODS: This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016-2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7-6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c. RESULTS: 2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant (B = -0.86, p < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines. CONCLUSION: Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Text Message-Based Breastfeeding Support Compared With Usual Care: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether a postpartum text message-based communication platform improves breastfeeding rates. METHODS: In a randomized controlled trial, a control group receiving weekly text messages inquiring about infant feeding method was compared with an intervention group receiving educational text messages and personalized, text message-based breastfeeding support. The primary outcome was breastfeeding exclusivity at 6 weeks postpartum. Secondary outcomes included any breastfeeding and formula supplementation at 6 weeks postpartum. A sample size of 190 was planned to achieve 80% power to detect a 50% change in breastfeeding exclusivity from 40% baseline, with a two-sided alpha of 5%. Race was noted to be an effect modifier; therefore, results are presented overall and stratified by self-reported Black race compared with non-Black race. RESULTS: From January 2020 to January 2021, 300 patients were enrolled and 216 were randomized as follows: 110 to control and 106 to intervention. In the cohort, 52.8% were Black, 45.4% had public insurance, and 46.3% were nulliparous. There were no differences in demographic, delivery, or postpartum characteristics between groups. Among the 185 patients (85.6%) with data available for the primary outcome, there was no difference in breastfeeding exclusivity by treatment group (intervention 48.4% vs usual care 41.3%, P =.33). When stratified by race, Black patients in the intervention arm had 2.6 times higher odds of exclusively breastfeeding at 6 weeks postpartum compared with Black patients in the control arm (39.5% vs 20.0%, odds ratio 2.62, 95% CI 1.04-6.59). Enrollment in the intervention arm decreased the Black-non-Black disparity in the primary outcome (20.0% vs 66.7%, P <.001in usual care arm vs 39.5% vs 56.0%, P =.11 in intervention arm). There were no differences in other secondary outcomes. CONCLUSION: A text message-based communication platform was not associated with breastfeeding exclusivity at 6 weeks postpartum compared with usual care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04108533.

Increased Protein with Decreased Carbohydrate Intake Reduces Postprandial Blood Glucose Levels in Women with Gestational Diabetes: The iPRO Study.

Introduction: There is an urgent need to establish an evidence base for recommendations regarding proportions of macronutrients for optimized nutritional management of gestational diabetes mellitus (GDM). Our study compared isocaloric diets in women with GDM that differed in protein and carbohydrate content with fats held constant. We hypothesized that the glucose area under the curve (AUC) would be lower with the higher protein/lower carbohydrate diet. Research Design and Methods: This study used a random order crossover design within a controlled research unit environment. Nineteen women were randomized to treatment, with 12 participants completing both arms of the study. Blood sampling occurred preprandially and at t = 30, 60, 120, and 180" relative to meals. Inclusion criteria were confirmed diet-controlled GDMA1, singleton gestation, and with no pre-existing medical comorbidities. Mean gestational age at entrance to study = 32 (±1.76) weeks. Mean prepregnant body mass index of participants = 28.7 (±5.3) kg/m2 Participants were randomly assigned initially to either an increased protein/low carbohydrate (iPRO30%/CHO35%) diet or a lower protein/higher carbohydrate (LPRO15%/CHO50%) diet for a 36 hour inpatient stay on the research unit. All meals and snacks were prepared in a metabolic kitchen. After a 3-7 day washout period, participants were randomized to the opposite treatment. Results: On day 2 (with confirmed overnight fasting), the average 3-hour pre- through postprandial glucose AUC was lower in iPRO30%/CHO35% treatment arm (17395.20 ± 2493.47 vs. 19172.47 ± 3484.31, p = 0.01). Conclusion: This study is the first to demonstrate that a higher protein, lower carbohydrate meal, especially at breakfast, can result in lower postprandial blood glucose values in women with gestational diabetes. A lack of statistically significant differences at other collection time points could have been due to several factors, but most likely due to small sample size. Longer term outcomes of a higher protein diet, including maternal glycemic control, nitrogen balance, and impact on fetal growth outcomes, are needed.

Adverse Pregnancy Outcomes in Nondiabetic Patients with an Elevated Early Pregnancy HbA1c.

OBJECTIVE: This study aimed to evaluate the impact of elevated early hemoglobin A1c (HbA1c) values on perinatal outcomes in patients without a diagnosis of diabetes or gestational diabetes. STUDY DESIGN: This is a retrospective study of patients with a singleton pregnancy who underwent universal HbA1c screening in early pregnancy at an urban tertiary care center between December 1, 2016, and December 31, 2018. Patients with pregestational diabetes mellitus (DM) and gestational DM (GDM) were excluded from analysis. The exposure of interest was HbA1c of 5.7 to 6.4% as measured on routine prenatal bloodwork at or during 16 weeks' gestation. The following pregnancy outcomes were assessed: preterm delivery <37 weeks, hypertensive disorders of pregnancy, shoulder dystocia, macrosomia (birth weight >4,000 g), small or large for gestational age neonate, operative vaginal delivery, third- or fourth-degree lacerations, cesarean delivery, neonatal intensive care unit (NICU) admission, neonatal hypoglycemia, and neonatal hyperbilirubinemia. Multivariable regression was performed to assess the relationship between HbA1c and selected adverse outcomes while controlling for potential confounders RESULTS: Of the 2,621 patients who met inclusion criteria, 334 (12.7%) had an elevated HbA1c of 5.7 to 6.4%. Patients with an elevated HbA1c were more likely to be older, Black, multiparous, publically insured, obese, or have chronic hypertension than patients with normal HbA1c values. In the unadjusted analysis, patients with an elevated HbA1c were less likely to deliver at term (84.7 vs. 92.4%, p = 0.006), but more likely to undergo cesarean section (32.8 vs. 27.6%, p = 0.038), develop hypertensive disorders of pregnancy (31.9 vs. 23.2%, p = 0.001), or deliver a macrosomic infant (10.5 vs. 6.8%, p = 0.016) than those with a normal A1c. After adjusting for race, body mass index, insurance status, nulliparity, and age, however, only the relationship between HbA1c and spontaneous preterm birth remained significant (adjusted odds ratio [aOR] = 1.76, 95% confidence interval [CI]: 1.01-3.07). CONCLUSION: In our urban population, an elevated early HbA1c was associated with spontaneous preterm birth in nondiabetic patients KEY POINTS: · In nondiabetic patients, early pregnancy HbA1c was associated with selected adverse outcomes.. · Rates of preterm birth, pregnancy-induced hypertension, cesarean section, and macrosomia were higher in patients with an elevated HbA1c.. · The relationship between early pregnancy HbA1c and spontaneous preterm birth remained significant after adjustment..

Universal HbA1c screening and gestational diabetes: a comparison with clinical risk factors.

BACKGROUND: Screening strategies for gestational diabetes mellitus (GDM), particularly early GDM, have traditionally relied upon the use of clinical risk factors (CRFs). Although commonly used in nonpregnant patients, HbA1c screening is not widely used despite reports of abnormal HbA1c values being predictive of GDM development. The aims of this study are to assess the utility of universal HbA1c screening in predicting GDM and to compare universal screening to targeted CRF-based screening for the diagnosis of GDM. STUDY DESIGN: This is a retrospective cohort study of patients undergoing universal HbA1c screening at ≤16 completed weeks gestation with a singleton pregnancy between December 2016 and April 2018 at a single urban tertiary care center. Patients with preexisting diabetes (HbA1c ≥6.5%) or patients who did not have glucose tolerance testing were excluded. Patients with HbA1c 5.7-6.4% underwent early two-step GDM screening. Positive screens were diagnosed with early GDM. Normal early screeners underwent repeat 3rd trimester screening. Clinical risk factors for early GDM screening at our institution prior to universal screening were history of GDM, body mass index (BMI) ≥40 kg/m2, prior macrosomia (birth weight ≥4000 g) or stillbirth, and polycystic ovary syndrome. Multivariable regression was performed to assess the relationship between HbA1c and GDM. The predictive ability of universal HbA1c screening compared to that of CRFs was evaluated by testing for differences in the area under the curve (AUC) of receiver operating curves (ROCs). RESULTS: One thousand nine hundred and fifteen patients met inclusion criteria. Two hundred and thirty-one (12.1%) patients had an elevated HbA1c ≥5.7%. Patients with elevated HbA1c were more likely to be older, Black, or obese compared with patients with normal HbA1c values. After adjusting for Black race, BMI, age, and public insurance, the odds of GDM development are 3.50 (95%CI 2.26-5.39) times higher among patients with HbA1c ≥5.7% compared to those with a normal HbA1c. Clinical risk factors for early glucose screening were present in 33% of patients with an elevated HbA1c. The AUC of CRF screening and HbA1c ≥5.7% was 0.72 and 0.75, respectively (p= .07), after controlling for Black race, BMI, maternal age, and insurance. CONCLUSIONS: An elevated HbA1c is associated with an increased risk of GDM. Universal HbA1c screening performs as favorably as CRF based screening for the prediction of GDM.

Screening Echocardiogram in High-Risk Women with Class III Obesity to Predict the Risk of Preeclampsia.

OBJECTIVE: Women with obesity and other comorbidities such as hypertension and diabetes are at an increased risk of preeclampsia and perinatal morbidity. This study evaluates whether screening echocardiogram can identify women with obesity at a higher risk of preeclampsia. METHODS: We conducted a retrospective cohort study of women with class III obesity (body mass index [BMI] ≥40 kg/m2) and one or more medical comorbidities associated with an increased risk of preeclampsia (such as diabetes, hypertension, and rheumatologic disease) undergoing screening echocardiogram. Abnormal findings were defined as the presence of one or more of the following: diastolic dysfunction, ejection fraction of ≤45%, or cardiac chamber enlargement or hypertrophy. Multivariable logistic regression was used to estimate the odds ratio (OR) of gestational hypertension/mild preeclampsia, severe preeclampsia, and any preterm delivery <37 weeks associated with abnormal echocardiographic findings when controlling for potential confounders. RESULTS: Of 267 eligible women, 174 (64%) underwent screening echocardiograms. Sixty-nine women (40%) had abnormal echocardiograms. Maternal clinical characteristics were similar between women with normal echocardiographic findings and women with abnormal findings. Women with abnormal echocardiograms were more likely to have chronic hypertension (78 vs. 62%, p = 0.04) and a history of preeclampsia (27 vs. 10%, p = 0.02). After controlling for confounders, women with abnormal echocardiogram were at an increased risk of hypertensive disorders of pregnancy, OR 6.80 (95% confidence interval [CI] 3.32-13.93, p = 0.01), and in particular severe preeclampsia, OR 8.77 (95% CI 3.90-19.74, p = 0.01). CONCLUSION: Among pregnant women with class III obesity and medical comorbidities, screening echocardiogram may help identify a subset of women at the highest risk of developing preeclampsia. KEY POINTS: · Women with obesity and comorbid conditions are at a high risk of abnormal echocardiogram.. · Women with obesity, medical comorbid conditions, and abnormal echo are at a high risk of preeclampsia.. · Screening echocardiogram can help identify obese women at the highest risk of severe preeclampsia..

Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol.

OBJECTIVE: We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. STUDY DESIGN: This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m2) and nonobese (<30 kg/m2) women. Indication for cesarean was also evaluated. RESULTS: A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol. CONCLUSION: Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. KEY POINTS: · Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction..

Pregnant and hungry: addressing food insecurity in pregnant women during the COVID-19 pandemic in the United States.

Food insecurity is a major social determinant of health affecting more than 10% of Americans. Social determinants of health are increasingly recognized as a driving force of health inequities. It is well established that food insecurity leads to adverse health outcomes outside of pregnancy, such as obesity, hypertension, diabetes mellitus, and mental health problems. However, limited data exist about the impact of food insecurity during pregnancy on maternal and neonatal outcomes. Food insecurity and other social determinants of health are rarely addressed as part of routine obstetrical care. The COVID-19 pandemic has only exacerbated the crisis of food insecurity across the country, disproportionally affecting women and racial and ethnic minorities. Women's health providers should implement universal screening for maternal food insecurity and offer resources to women struggling to feed themselves and their families. Reducing maternal health inequities in the United States involves recognizing and addressing food insecurity, along with other social determinants of health, and advocating for public policies that support and protect all women's right to healthy food during pregnancy.

A Pragmatic Approach to the Treatment of Women With Type 2 Diabetes in Pregnancy.

Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care.