Vincent W. Wong

OBJECTIVE: To investigate associations between polyendocrine metabolic ovarian syndrome (PMOS) and maternal and neonatal outcomes and explore interactions with BMI and ethnicity. RESEARCH DESIGN AND METHODS: This was a prospective nested cohort study of pregnant women with risk factors for hyperglycemia enrolled in an international, multicenter, randomized controlled trial of gestational diabetes mellitus (GDM) treatment. We compared baseline and pregnancy characteristics, evaluated adverse maternal and neonatal outcomes by PMOS status, and used multivariable regression models to evaluate factors (maternal age, baseline BMI, ethnicity, parity, smoking, and level of education) that independently affected maternal and neonatal outcomes. RESULTS: Of 3,645 participants, PMOS prevalence was 17.1% (95% CI 15.9, 18.3). At booking visits, women with PMOS (vs. without) were younger (30.6 ± 4.7 vs. 31.3 ± 5.2 years; P < 0.001) and had higher median (interquartile range) BMI at baseline (29.8 [25.1–35.7] vs. 28.1 [24.1–33.9] kg/m2; P < 0.001), and more were primigravid (30.2% [n = 188] vs. 25.7% [n = 778]; P = 0.022). There were positive associations between PMOS and early GDM, with an adjusted odds ratio (aOR) of 1.37 (95% CI 1.10, 1.72), a composite of adverse neonatal outcomes (aOR 1.28 [95% CI 1.04, 1.58]), admission to a neonatal special care nursery or neonatal intensive care unit (aOR 1.32 [95% CI 1.05–1.65]), and negative associations between PMOS and gestational age at birth (−1.60 days [95% CI −2.82, −0.39]) and birth length (−0.33 cm [95% CI −0.61, −0.04]). No interactions were found with baseline BMI and ethnicity. CONCLUSIONS: PMOS was associated with higher odds of early GDM, and neonatal outcomes were poorer on adjusted analyses, highlighting independent pregnancy risks in PMOS and the need to identify, monitor, and treat women with PMOS to mitigate risks of adverse pregnancy outcomes.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are now a cornerstone anti-hyperglycaemic therapy for people with type 2 diabetes mellitus, especially with concurrent cardiovascular and/or kidney disease. Diabetic ketoacidosis, including euglycemic diabetic ketoacidosis, is an uncommon but serious adverse effect associated with SGLT2i use. Commonly reported risk factors include surgical stress, infection, fasting, dehydration and non-adherence with diabetes treatment; diabetic ketoacidosis is also more common in acute care settings. The objectives of this study are to detail the acute care and diabetes profiles of people who experienced SGLT2i-associated diabetic ketoacidosis during their hospitalisation, and to detail the DKA event. SGTL2i-DKA is also compared to concurrent inpatients with T2D taking SGLT2is but who did not experience DKA. Methods: A pragmatically driven part retrospective and part prospective electronic medical record audit was conducted recording patient demographics, diabetes history, admission parameters and hospital stay characteristics cases of SGLT2i-associated diabetic ketoacidosis referred to the Inpatient Diabetes team at an Australian quaternary hospital across 18-months. This patient cohort was compared to that of all inpatients prescribed with SGLT2i, but did not develop diabetic ketoacidosis, admitted at the same hospital during an overlapping 12-month period. Results: Thirty-five patients (54.3% male, aged 65.4±12.9 years) with SGLT2i-associated diabetic ketoacidosis were analysed. Almost 90% were admitted via emergency department. Lowest pH was 7.08 ± 1.20. Average blood glucose levels indicated hyperglycaemia (initial: 16.8 ± 12.0 mmol/L; peak: 19.5 ± 11.9 mmol/L). Mean time from detection to resolution of DKA was 12.4 hours. No deaths were reported. Patients with diabetic ketoacidosis had poorer glycaemic control than those without (HbA1c: 9.4 ± 2.3% vs 8.4 ± 2.7%, P = 0.013). Sepsis (P = 0.012) and surgery (P < 0.001) were identified as precipitating risk factors for SGLT2i-associatd DKA. Conclusion: SGLT2i-associated DKA was observed in inpatients with poorer glycaemic control and was more prevalent among emergency admissions who experienced sepsis or who underwent surgery. Although accompanied by moderate to severe acidosis, all episodes were treated promptly, and no deaths were reported.

Carbohydrate intake (CI) has the largest impact on the short-term glycaemia of all nutrients, yet optimal CI management in gestational diabetes remains unclear. Objective: To examine CI behaviours in individuals with recently diagnosed gestational diabetes and their association with self-monitored blood glucose. Methods: Data from 97 individuals were collected using food and blood glucose diaries. CI (including amounts, types, and timing) was manually assessed using 15 g servings over 5–8 days, while a 3-day computerised analysis examined a broader intake of macro- and micronutrients. Results: Elevated fasting glycaemia (EFG) was associated with lower total CI (Mdn 10.8 vs. 12.5 servings/day, p = 0.006), missed meals (Mdn 1.4 vs. 0.0/week, p = 0.007), missed snacks (Mdn 10.5 vs. 7.5/week, p = 0.038), low-carbohydrate meals (p = 0.004), and a higher proportion of energy intake from fat (Mdn 35% vs. 33%, p = 0.047), as compared with in-target fasting glycaemia. In contrast, elevated postprandial glycaemia (EPG) was not significantly associated with total CI, low-carbohydrate meals (p = 0.026; Mdn 0.9 vs. 0.0 dinner meals/week, p = 0.023); and a lower intake of energy (Mdn 7650 kJ vs. 9070 kJ/day, p = 0.031), protein (Mdn 91 g vs. 109 g/day, p = 0.015), fat (Mdn 61 g vs. 84 g/day, p = 0.003), and multiple micronutrients (p <0.05), as compared with in-target postprandial glycaemia. Conclusions: CI profiles differed for individuals with EFG, as compared with EPG, emphasising the need for dietary guidelines tailored for gestational diabetes subtypes. Further interventional studies are needed to explore these findings, particularly the associations between EFG and low CI behaviours.

Background: The optimal application of medical nutrition therapy (MNT) in treating gestational diabetes remains uncertain. MNT involves individualised nutrition assessment and counselling, which is labour-intensive and is not the sole type of intervention offered by clinical dietitians. Objective: To determine whether pregnancy outcomes differed for individuals with gestational diabetes who were offered MNT on a risk-prioritised (RP) versus universal basis. Methods: Observational data from two cohorts of individuals who were offered MNT only if they met the high-risk criteria following general group-based dietary education (RP1, n = 369; RP2, n = 446) were compared with a baseline cohort who were universally offered at least one MNT consultation (UM, n = 649). The RP1 cohort were seen during community-wide COVID-19 restrictions in 2021, while RP2 were seen after restrictions had lifted in 2022. Furthermore, the RP approach primarily utilised telemedicine, while the UM approach was delivered in person. Results: MNT consultations halved under the RP approach (59 vs. 119 sessions per 100 diagnoses for RP2 vs. UM) and saved more than 20 h of dietitian time per 100 diagnoses (95 vs. 73 h for RP2 vs. UM). No significant increases were observed (p < 0.05) for any pregnancy outcomes in the RP cohorts compared with the UM cohort, including usage of diabetes medications, maternal weight gain below and above target, early deliveries, induced deliveries, emergency caesarean sections, large- and small-for-gestational-age (SGA) infants, infant macrosomia, neonatal hypoglycaemia and neonatal intensive care admissions. The use of both basal insulin (27% vs. 33%, OR 0.62, 95% CI 0.46 to 0.84) and metformin (6% vs. 10%, OR 0.52, 95% CI 0.31 to 0.88) was lower in the RP1 cohort during pandemic restrictions compared with the UM cohort; however, these differences were not retained in the RP2 cohort. Additionally, there were fewer SGA infants under the RP approach, particularly for the RP2 cohort (6% vs. 11% for RP2 vs. UM, OR 0.55, 95% CI 0.34 to 0.89). Conclusions: Risk-prioritised MNT was a more efficient dietetic service approach to gestational diabetes than the universal MNT model, with comparable pregnancy outcomes. Similar approaches may represent a strategic way to address sustainable health service planning amidst the rising global prevalence of this condition. However, further research is needed to investigate consumer perspectives, wider service impacts and post-partum maternal and child health outcomes.

OBJECTIVE: We evaluated associations between early-pregnancy oral glucose tolerance test (OGTT) glucose and complications in the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) cohort to inform prognostic OGTT thresholds. RESEARCH DESIGN AND METHODS: Individuals with risk factors for hyperglycemia were recruited for an international, multicenter, randomized controlled gestational diabetes mellitus (GDM) (World Health Organization 2013 criteria) treatment trial. A 2-h 75-g OGTT was performed at <20 weeks’ gestation. Individuals with early treated hyperglycemia in pregnancy were excluded from the primary analysis. Early OGTT glucose concentrations were analyzed continuously and in glycemic categories (normal, low band, and high band). RESULTS: Overall, 3,645 individuals had an OGTT at (mean ± SD) 15.6 ± 2.5 weeks. For each 1-SD increase in fasting, 1-h, and 2-h glucose values, there were continuous positive associations with late GDM: adjusted odds ratio (aOR) 2.04 (95% CI 1.82–2.27), 3.05 (2.72–3.43), and 2.21 (1.99–2.45), respectively. There were continuous positive associations between 1-h and 2-h glucose and the perinatal composite (birth <37 + 0 weeks, birth trauma, birth weight ≥4,500 g, respiratory distress, phototherapy requirement, stillbirth/neonatal death, and shoulder dystocia), with aOR 1.15 (95% CI 1.04–1.26) and 1.14 (1.04–1.25), respectively, and with large-for-gestational-age offspring, with aOR 1.18 (1.06–1.31) and 1.26 (1.01–1.25), respectively. Significant associations were also observed between 1-h glucose and cesarean section and between fasting and 2-h glucose and neonatal hypoglycemia. In categorical analysis, only the high-band 1-h glucose (≥10.6 mmol/L [191 mg/dL]) predicted the perinatal composite. CONCLUSIONS: There is a continuous positive association between early-pregnancy OGTT glucose and complications. In individuals with hyperglycemia risk factors, only the high-glycemic-band 1-h glucose corresponded to increased risk of major perinatal complications.

OBJECTIVE: To compare pregnancy outcomes among women with a normal oral glucose tolerance test (OGTT) before 20 weeks’ gestation (early) and at 24–28 weeks’ gestation (late) (no gestational diabetes mellitus, or No-GDM), those with early GDM randomized to observation with a subsequent normal OGTT (GDM-Regression), and those with GDM on both occasions (GDM-Maintained). RESEARCH DESIGN AND METHODS: Women at <20 weeks’ gestation with GDM risk factors who were recruited for a randomized controlled early GDM treatment trial were included. Women with treated early GDM and late GDM (according to the World Health Organization’s 2013 criteria) were excluded from this analysis. Logistic regression compared pregnancy outcomes. RESULTS: GDM-Regression (n = 121) group risk factor profiles and OGTT results generally fell between the No-GDM (n = 2,218) and GDM-Maintained (n = 254) groups, with adjusted incidences of pregnancy complications similar between the GDM-Regression and No-GDM groups. CONCLUSIONS: Women with early GDM but normal OGTT at 24–28 weeks’ gestation had pregnancy outcomes that were similar to those of individuals without GDM. Identifying early GDM likely to regress would allow treatment to be avoided.

Canaan Negash Seifu, Jincy Immanuel, William M. Hague, Helena Teede, N. Wah Cheung, Emily J. Hibbert, Christopher J. Nolan, Michael J. Peek, Vincent W. Wong, Je