diabetes research and clinical practice
1 4 1 ( 2 0 1 8 ) 8 8 –9 7
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journa l home page: www.e lse vier.com/locate/diabres
Gestational weight gain and weight loss among women with gestational diabetes mellitus Daphna Komem a, Lina Salman a,b, Eyal Krispin a,b, Nissim Arbib b,c, Ron Bardin a,b, Arnon Wiznitzer a,b, Eran Hadar a,b,* a
Helen Schneider’s Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel c Department of Obstetrics & Gynecology, Meir Medical Center, Kfar Saba, Israel b
A R T I C L E I N F O
A B S T R A C T
Article history:
Aims: To assess the association of gestational weight gain or loss with adverse pregnancy
Received 1 February 2018
outcome among women with gestational diabetes mellitus (GDM).
Received in revised form
Methods: Retrospective study of all women diagnosed with GDM, from July 2012 to Decem-
4 April 2018
ber 2016, stratified by gestational weight change according to the institute of medicine rec-
Accepted 17 April 2018
ommendations. Primary maternal outcome was glycemic control and primary neonatal
Available online 22 April 2018
outcome was large or small for gestational age (LGA or SGA). Results: 451 women were enrolled. Total weight change was associated with poor glycemic
Keywords: Weight
control, cesarean delivery, polyhydramnios, higher birthweight (when above recommendations), oligohydramnios and SGA (when below recommendations). GDM-related weight change was associated with polyhydramnios, cesarean delivery, higher birthweight (when
Gain
above recommendations) and lower incidence of hypertensive disorders (when below rec-
Loss Gestational Diabetes
ommendations). Adjusted odds ratio for poor glucose control among those with total weight gain above recommendations was 2.194 (95% CI 1.214–3.961) vs. those within-; and 1.048 (95% CI 0.611–1.799) vs. those who gained below- recommendations. The rate of SGA or LGA was not different for those gaining below or above vs. within recommendations. Conclusion: Gestational weight gain is an important predictor of glycemic control and adverse pregnancy outcome among women with GDM – both overall and GDM-related. Ó 2018 Elsevier B.V. All rights reserved.
1.
Introduction
Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance commencing during pregnancy, short of overt diabetes, either Type 2 or rarely Type 1 diabetes [1]. Women diagnosed with GDM, as their fetuses and infants, are at risk for adverse outcome, including excessive
growth, birth injuries, respiratory complications, hypoglycemia, hyperbilirubinemia; as well as long-term obesity and diabetes. In order to prevent such complications, appropriate care is achieved primarily by tight glycemic control through lifestyle modifications – diet and exercise; and pharmacological interventions if glucose thresholds are unmet [2–4].
* Corresponding author at: Helen Schneider Hospital for Women, Rabin Medical Center, 39 Zabotinski Street, Petach-Tikva 49100, Israel. E-mail address:
[email protected] (E. Hadar). https://doi.org/10.1016/j.diabres.2018.04.034 0168-8227/Ó 2018 Elsevier B.V. All rights reserved.
diabetes research and clinical practice
Adequate gestational weight gain (GWG) is a significant antenatal factor to avoid pregnancy complications. In 2009, the American institute of medicine (IOM) published revised guidelines for GWG, stratified according to pre-pregnancy body mass index (BMI) [5]. These recommendations did not specifically refer to GWG amid high risk pregnancies, thus it is unclear whether they are applicable for those complicated by GDM. It is well established that excessive GWG, beyond IOM recommendations, is associated with increased risk for GDM related complications [6–17]; including: poor glycemic control, excessive fetal growth, cesarean delivery, hypertensive disorders and prematurity. However, it is debatable whether, and to what extent, weight gain below IOM recommendation or even weight loss has a beneficial or unfavorable effect on pregnancy outcome among women with GDM [11–17]. The question remains whether more stringent recommendations for weight gain may improve diabetes related adverse outcome, possibly by reducing the synergistic effect of diabetes, obesity and excessive weight gain. Even less is known about weight loss for women with GDM and the relative contribution of weight gain prior and after the diagnosis of GDM. Therefore, the objective of our study was to investigate the association of gestational weight change, gain or loss, with maternal and neonatal outcome among women with GDM. We aimed to consider all BMI subclasses and to analyze both total weight change – from conception to delivery, and GDMrelated weight change – from GDM diagnosis to delivery.
2.
considered screen positive and were followed by a diagnostic 100 g, 3-h, oral glucose tolerance test (OGTT), performed after overnight fasting. GDM diagnosis was made if two or more of the glucose measurements exceed the established thresholds according to Carpenter and Coustan’s criteria – fasting glucose >95 mg/dL; 1-h > 180 mg/dL; 2-h > 155 mg/dL; 3-h > 140 mg/dL [19]. Management of women diagnosed with GDM was done by our multidisciplinary team, led by maternal-fetal specialists. This included lifestyle education for an appropriate diet and exercise, by a nurse educator and certified dietician. For those not meeting plasma glucose thresholds (fasting < 90 mg/dl, 1-h post prandial < 140 mg/dl, 2-h post prandial < 120mgd/dl and pre-prandial < 95md/dl) within 1–2 weeks of diet adherence, pharmacological treatment was initiated, by either Glyburide or Insulin, at the discretion of the treating physician. Antenatal care, including surveillance for glucose control, maternal weight and fetal growth was completed during routine follow up visits every 1–4 weeks. For those with excessive weight gain, an additional dietician appointment was set. Self-monitoring of blood glucose was achieved by glucometers and women were instructed to perform 6 daily measurements, at fasting, pre- and post- prandial. Level of glycemic control was evaluated by the treating physician, according to the following thresholds: 90 mg/dL at fasting, 100 mg/dl pre-prandial and 120 mg/dL 2-h postprandial or 140 mg/dl 1-h postprandial. If glucose threshold were met at more than 80% of measurement then glucose control was considered to be good glycemic control.
2.3.
Study population
Eligibility criteria for study participation included all women with singleton gestation, diagnosed with GDM and for whom the diagnosis, follow-up, treatment and delivery, all took place at the maternal-fetal clinics and delivery ward in Rabin medical center; with known height and weight within 3 weeks of 3 pre-defined time points – at conception, at GDM diagnosis and at delivery. Exclusion criteria included multifetal gestation, known genetic or anatomic fetal abnormalities, pre-gestational diabetes or suspected type 2 diabetes diagnosed during pregnancy, lack of any 1 of the 3 wt measurement and unavailable data on pregnancy outcome.
2.2.
89
Materials and methods
This was a retrospective cohort study of all women diagnosed with GDM at a single, tertiary, university-affiliated, medical center, from July 2012 to December 2016. The study was approved by the local Institutional review board, informed consent was waived due to the retrospective design of the study.
2.1.
1 4 1 ( 2 0 1 8 ) 8 8 –9 7
GDM diagnosis and management
GDM was diagnosed according to the two-step approach [18]. Shortly, universal screening was done by a 50 g, 1-h, glucose challenge test (GCT), between 24 and 28 gestational weeks. Serum glucose levels of more than 140 mg/dL were
Data collection
Data were extracted from maternal and neonatal medical records, maternal-fetal clinic visitations charts and delivery ward maternal-neonatal birth records. Collected data for each participant included maternal age, comorbidities, gravidity, parity, height and weight. Maternal weight was collected at 3 time points – prior conception, during pregnancy at the time of GDM diagnosis and prior to delivery. All weight measurements were considered valid for collection if they were available within 3 weeks of the relevant time point. Pre-pregnancy BMI was calculated and categorized into underweight (
