Original articleHeterogeneity of pregnancy outcomes and risk of LGA neonates in Caucasian females according to IADPSG criteria for gestational diabetes mellitusHétérogénéité du pronostic maternel et fœtal au cours du diabète gestationnel en fonction des critères du Groupe international d’étude diabète et grossesse (IADPSG)
Introduction
Gestational diabetes mellitus (GDM) represents a healthcare burden that is expected to rise as the frequency of obesity increases worldwide [1], [2]. This means that GDM is the subject of considerable clinical interest. The International Association of Diabetes and Pregnancy Study Group (IADPSG) has recently revisited the criteria for diagnosis [3] established more than 40 years ago [4]. Beyond the utility for detecting women at high risk of developing diabetes in later life, current strategies of GDM screening [5] were defined to improve pregnancy outcomes and reduce fetal complications. GDM and maternal obesity are independently associated with adverse effects [1]. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study demonstrated a positive linear relationship between glucose values and adverse perinatal outcomes, and argued for new screening values that would better identify pregnancies at risk of perinatal complications [6], [7]. One characteristic of the new IADPSG criteria is that only one single value above defined fasting or post-load glucose thresholds is now sufficient for a diagnosis of GDM.
However, the metabolic roots underlying impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) with elevated 1- or 2-h oral glucose tolerance test (OGTT) plasma glucose levels are different. Isolated IFG is a common feature of insulin resistance [8], while subjects with isolated IGT exhibit more severe deficits in beta-cell function with defects in early- and late-phases of insulin secretion [9]. Given the different physiological bases of IFG and IGT, differences in pregnancy outcomes and fetal complications are to be expected. Delivery of infants large for gestational age (LGA) in terms of body weight is the most common complication of GDM, and is linearly related to maternal plasma glucose levels [6]. Birth weight above the 90th percentile for gestational age is associated with serious birth complications, including neonatal hyperinsulinaemia and adiposity resulting from insulin resistance during fetal life [10], and later health risks with a greater prevalence of the metabolic syndrome in childhood [11]. In a recent meta-analysis of several interventional trials [12], it was reported that the detection and treatment of mild GDM was associated with reductions in birth weight. Thus, an important rationale for GDM screening is to identify women at higher risk of LGA neonates to allow intensive targeted interventions. It was also hypothesized that women screened according to the IADPSG criteria for GDM were heterogeneous from a metabolic point of view, thereby resulting in different possible outcomes. The present study was performed to determine whether the type of glucose abnormalities in GDM presages maternal and fetal outcomes.
Section snippets
Participants
All pregnant women at a single institution were eligible to participate unless they had one or more of the following exclusion criteria: age < 18 years; type 1 or type 2 diabetes mellitus before pregnancy; gestational age > 32 weeks; and multiple pregnancies. The study cohort was initially selected to determine the predictive value of proinflammatory cytokines during GDM, as diagnosed by World Health Organization (WHO) criteria, for maternal and fetal outcomes. The local Institutional Review Board
Demographic and anthropometric characteristics
The demographics of the study population are shown in Table 1. Women in the GDM group (n = 55) had comparable age, personal history of GDM, history of type 2 diabetes in first-degree relatives and smoking status to those of the control group (n = 20). Women in the IFG group (isolated IFG or combined with IGT) had a higher prevalence of multiparity compared with the IGT group (P < 0.05). In addition, women in the IFG group had significantly higher antepartum weights than either the IGT group (BMI 30.1 ±
Discussion
Pregnant women with IADPSG criteria for GDM are heterogeneous in their underlying metabolic alterations and thus have potentially different fetal outcomes. Indeed, it was observed that our GDM women with IFG were heavier and fatter, and had greater fasting insulin levels and hepatic insulin resistance compared with GDM women with normal fasting glucose. Our study also demonstrated that GDM women with IFG were at higher risk of delivering LGA neonates than were GDM women with normal fasting
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
We thank Dr D. Maucort-Boulch from the biostatistics department of Hospices Civils de Lyon for statistical advice.
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