Glycemic Control Trajectories and Risk of Perinatal Complications Among Individuals With Gestational Diabetes

Abstract

ImportanceGlycemic control is the cornerstone of gestational diabetes management. Glycemic control trajectories account for differences in longitudinal patterns throughout pregnancy; however, studies on glycemic control trajectories are scarce.ObjectiveTo examine whether glycemic control trajectories from gestational diabetes diagnosis to delivery were associated with differential risk of perinatal complications.Design, Setting, and ParticipantsThis population-based cohort study included individuals with gestational diabetes with longitudinal electronic health record data from preconception to delivery who received prenatal care at Kaiser Permanente Northern California (KPNC) and were enrolled in KPNC’s telemedicine-based gestational diabetes care program between January 2007 and December 2017. Data analysis was conducted from September 2021 to January 2022.ExposuresGlycemic control trajectories were derived using latent class modeling based on the American Diabetes Association’s recommended self-monitoring of blood glucose measurements. Optimal glycemic control was defined as at least 80% of all measurements meeting the targets at KPNC clinical settings.Main Outcomes and MeasuresMultivariable Poisson regression models were used to estimate the associations of glycemic control trajectories with cesarean delivery, preterm birth, shoulder dystocia, large- and small-for-gestational-age, and neonatal intensive care unit admission and stay of 7 days or longer.ResultsAmong a total of 26 774 individuals (mean [SD] age, 32.9 [5.0] years; 11 196 Asian or Pacific Islander individuals [41.8%], 1083 Black individuals [4.0%], 7500 Hispanic individuals [28.0%], and 6049 White individuals [22.6%]), 4 glycemic control trajectories were identified: stably optimal (10 528 individuals [39.3%]), rapidly improving to optimal (9151 individuals [34.2%]), slowly improving to near-optimal (4161 individuals [15.5%]), and slowly improving to suboptimal (2934 individuals [11.0%]). In multivariable models with the rapidly improving to optimal trajectory group as the reference group, glycemic control trajectories were associated with perinatal complications with a gradient across stably optimal to slowly improving to suboptimal. For individuals in the stably optimal trajectory group, there were lower risks of cesarean delivery (adjusted relative risk [aRR], 0.93 [95% CI, 0.89-0.96]), shoulder dystocia (aRR, 0.75 [95% CI, 0.61-0.92]), large-for-gestational age (aRR, 0.74 [95% CI, 0.69-0.80]), and neonatal intensive care unit admission (aRR, 0.90 [95% CI, 0.83-0.97]), while for patients in the slowly improving to suboptimal glycemic control trajectory group, risks were higher for cesarean delivery (aRR, 1.18 [95% CI, 1.12-1.24]; (P for trend < .001), shoulder dystocia (aRR, 1.41 [95% CI, 1.12-1.78]; P for trend < .001), large-for-gestational-age (aRR, 1.42 [95% CI, 1.31-1.53]; P for trend < .001), and neonatal intensive care unit admission (aRR, 1.33 [95% CI, 1.20-1.47]; P for trend < .001). The risk of small-for-gestational-age was higher in patients in the stably optimal group (aRR, 1.10 [95% CI, 1.02-1.20]) and lower in the slowly improving to suboptimal group (aRR, 0.63 [95% CI, 0.53-0.75]).Conclusions and RelevanceThese findings suggest that slowly improving to near-optimal and slowly improving to suboptimal glycemic control trajectories were associated with increased risk of perinatal complications. Future interventions should help individuals achieve glycemic control early after gestational diabetes diagnosis and throughout pregnancy to decrease the risk of perinatal complications.

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“…Daly et al ( 9 ) conducted a retrospective cohort study and showed that pregnant women with GDM have a significantly higher risk of developing hypertension and T2DM than pregnant women with normal blood sugar levels. Second, as the mother’s blood sugar levels increase, the chances of adverse pregnancy outcomes such as hypoglycemia, macrosomia, and intrauterine distress also increase ( 10 , 11 ). A study from Finland also showed that the offspring of patients with GDM have a higher risk of congenital malformations ( 12 ).…”

Adverse perinatal outcomes in gestational diabetes mellitus with and without SARS-CoV-2 infection during pregnancy: results from two nationwide registries in Germany

“…Associations of increasing glucose levels from OGTT with adverse perinatal outcomes are well known from pregnant women with GDM without treatment 5. In general, the risks of perinatal complications in treated women with GDM are associated with trajectories of glycemic control, depending on, for example, (1) how fast glucose control can be improved, (2) how long optimal control is maintained between GDM diagnosis and birth,33 and (3) the used glycemic targets 34…”

Comparison of the clinical characteristics, glycemic control, and pregnancy outcomes between women with gestational diabetes mellitus in waves I and III of the COVID-19 pandemic: a reference center report

“…Diabetes with predominant GDM is the most common disease com-plicating pregnancy, as it affects more than 10% of pregnant women worldwide and, most importantly, increases the risk of unfavorable pregnancy outcomes. Effective glycemic control during pregnancy complicated by GDM is essential to improve maternal and neonatal outcomes [4]. Two essential components of diabetes care during the COVID-19 pandemic and its accompanying social isolation measures were proper education of newly diagnosed pregnant women with GDM and immediate introduction of appropriate www.…”