Obstetrics and gynecology最新文献

Insulin is preferred as the first-line agent for glucose management of gestational diabetes mellitus and type 2 diabetes in pregnancy when nutritional and lifestyle modifications are unable to achieve pregnancy-specific glucose targets. Individual heterogeneity in defects of insulin secretion or sensitivity in liver and muscle, unique genetic influences on pregnancy glycemic regulation, and variable cultural and lifestyle behaviors that affect meal, activity, sleep, and occupational schedules necessitate a personalized approach to insulin regimens. Newer insulin preparations have been developed to mimic the physiologic release of endogenous insulin, maintaining appropriate basal levels to cover hepatic gluconeogenesis and simulate the rapid, meal-related, bolus rise of insulin. Such physiologic basal-bolus dosing of insulin can be administered safely, achieving tighter glycemic control while reducing episodes of hypoglycemia. Insulin initiation and titration require understanding the pharmacodynamics of different insulin preparations in addition to a patient's glycemic profiles, effect of variable nutritional intake and mealtimes, physical activity, stress, timing of sleep cycles, and cultural habits. Educating and empowering patients to learn how their glucose responds to insulin, portion and content of meals, and physical activity can increase personal engagement in therapy, flexibility in eating patterns, and improved glycemic control. This Clinical Expert Series article is focused on optimizing insulin management (initiation, dosing, and titration) of gestational and type 2 diabetes in pregnancy.

Objective: To identify individual- and community-level factors that predict the odds of multigravid Black women having consecutive pregnancies without adverse pregnancy outcomes.

Methods: We conducted a secondary analysis of 515 multigravid Black women from a longitudinal observational study (2017-2019). We assessed the presence of adverse pregnancy outcomes (hypertensive disorders, gestational diabetes, preterm birth, fetal growth restriction, placental abruption, and pregnancy loss) for the index and prior pregnancies. We examined U.S. Census data, medical records, and surveys across multiple socioecologic domains: personal, behavioral, socioeconomic, and policy. We estimated adjusted odds ratios (aORs) and 95% CIs for the association between individual- and community-level factors and consecutive healthy pregnancies using hierarchical logistic regression models adjusted for maternal age, body mass index (BMI), gravidity, interpregnancy interval, and median household income.

Results: Among 515 multigravid Black women (age 27±5 years, BMI 31.4±8.9, gravidity 4±2), 38.4% had consecutive healthy pregnancies without adverse pregnancy outcomes. Individual-level factors associated with consecutive healthy pregnancies included normal glucose tolerance (aOR 3.9, 95% CI, 1.2-12.1); employment (aOR 1.9, 95% CI, 1.2-2.9); living in communities with favorable health indicators for diabetes, hypertension, and physical activity; and household income of $50,000 per year or more (aOR 3.5, 95% CI, 1.4-8.7). When individual and community factors were modeled together, only income and employment at the individual and community levels remained significant.

Conclusion: Individual and community income and employment are associated with consecutive healthy pregnancies in a cohort of Black patients, emphasizing the need for comprehensive, multilevel systems interventions to reduce adverse pregnancy outcomes for Black women.

Objective: To evaluate the association between continuous glucose monitoring in pregnant people with type 2 diabetes and perinatal outcomes.

Methods: This was a retrospective cohort study of pregnant people with type 2 diabetes who received prenatal care and delivered singleton, nonanomalous neonates at a single academic tertiary care center from November 1, 2019, to February 28, 2023. The primary outcome was a composite of neonatal morbidity, including hypoglycemia, hyperbilirubinemia, shoulder dystocia, large for gestational age at birth, preterm birth, neonatal intensive care unit (NICU) admission, or perinatal death. Demographics and outcomes were compared by type of monitoring (continuous glucose monitoring vs intermittent self-monitoring of blood glucose), and multivariable logistic regression estimated the association between continuous glucose monitoring use and perinatal outcomes.

Results: Of 360 pregnant people who met the inclusion criteria, 82 (22.7%) used continuous glucose monitoring. The mean gestational age at continuous glucose monitoring initiation was 21.3±6.4 weeks. The use of continuous glucose monitoring was associated with lower odds of the primary composite neonatal morbidity (65.9% continuous glucose monitoring vs 77.0% self-monitoring of blood glucose, adjusted odds ratio [aOR] 0.48, 95% CI, 0.24-0.94). Continuous glucose monitoring use was also associated with lower odds of preterm birth (13.4% vs 25.2%, aOR 0.48, 95% CI, 0.25-0.93) and NICU admission (33.8% vs 47.6%, aOR 0.36, 95% CI, 0.16-0.81).

Conclusion: In pregnant people with type 2 diabetes, continuous glucose monitoring use was associated with less neonatal morbidity, fewer preterm births, and fewer NICU admissions.

Objective: To examine long-term diabetes risk after preterm delivery or hypertensive disorders of pregnancy in a large population-based cohort.

Methods: This retrospective cohort study included all women with a singleton delivery in Sweden during 1973-2015 and no preexisting diabetes mellitus. Participants were followed up for development of type 2 diabetes identified from nationwide outpatient and inpatient diagnoses through 2018. Cox regression was used to compute hazard ratios (HRs) for the association between preterm delivery or hypertensive disorders of pregnancy and type 2 diabetes with adjustment for gestational diabetes and other maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic or environmental) factors.

Results: Overall, 2,184,417 women were included. Within 10 years after delivery, adjusted HRs for type 2 diabetes associated with specific pregnancy outcomes were as follows: any preterm delivery (before 37 weeks of gestation), 1.96 (95% CI, 1.83-2.09); extremely preterm delivery (22-27 weeks), 2.53 (95% CI, 2.03-3.16); and hypertensive disorders of pregnancy, 1.52 (95% CI, 1.43-1.63). All HRs remained significantly elevated (1.1-1.7-fold) 30-46 years after delivery. These findings were largely unexplained by shared familial factors.

Conclusion: In this large national cohort, preterm delivery and hypertensive disorders of pregnancy were associated with increased risk for type 2 diabetes up to 46 years later. Women with these pregnancy complications are candidates for early preventive actions and long-term monitoring for type 2 diabetes.