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In Gestational Diabetes, Quicker Time to Goal Associated with Improved Perinatal Outcomes

Mothers with gestational diabetes experienced a lower rate of adverse perinatal outcomes if they achieved glycemic control within the first 8 weeks of diagnosis, according to the results of a new study.

A population-based cohort study of more than 26,000 individuals with gestational diabetes, results indicate those with optimal glucose control and those who improved to optimal control within the first 8 weeks of diagnosis had a lower risk of cesarean delivery, shoulder dystocia, large-for-gestational-age, and neonatal intensive care unit admission than their counterparts with suboptimal control trajectories.

“Glycemic control is a cornerstone of gestational diabetes management, so it’s important to learn in detail about the trajectory of control between diagnosis and delivery,” said lead investigator Yeyi Zhu, PhD, a research scientist with the Kaiser Permanente Division of Research, in a statement from Kaiser Permanente. “This study goes beyond identifying whether a patient has control of their blood sugar and offers insights into the role of timing of glycemic control.”

As the community has developed a greater understanding of glycemic control and outcomes with diabetes mellitus, the impact of suboptimal glycemic control among women with gestational diabetes has become a major research focus. With this in mind, Zhu and a team of colleagues from Kaiser Permanente designed the current research endeavor as a population-based cohort study with the intent of assessing the impact of glycemic control and time to control on risk of perinatal complications.

For their study cohort, investigators used data from women enrolled in a Kaiser Permanente Northern California Regional Perinatal Service Center (RSPC) telehealth program for people with gestational diabetes between January 2007 and December 2017. As part of their participation in an RSPC program, individuals were offered standardized telephone counseling on diet, physical activity, glucose monitoring, and medications to improve glycemic control. Additionally, all participants were asked to closely self-monitor blood glucose levels 4 times per day.

Using the information obtained from the study cohort investigators developed 4 distinct glycemic control trajectories. These were defined as stably optimal glycemic control, rapidly improving to optimal glycemic control, slowly improve to near-optimal glycemic control, and slowly improving to suboptimal glycemic control. Investigators noted optimal glycemic control was defined as meeting targets in at least 80% of study measurements. Rapidly improving to optimal glycemic control trajectory was defined as reaching optimal control by 8 weeks after diagnosis and painting it through the last 2 weeks prior to delivery.

Overall, 26,774 were identified for inclusion. This cohort had a mean age of 32.9 (SD, 5.0) years, 41.8% identified Asian or Pacific Islander, 28.0% identified as Hispanic, 22.6% identified as non-Hispanic White, and 4.0% identified as non-Hispanic Black. Regarding glycemic trajectories for the cohort, 39.3% had stably optimal glycemic control, 34.2% had rapidly improving to optimal trajectory glycemic control, 15.5% had slowly improving to near-optimal glycemic control, and 11.0% had slowly improving to suboptimal glycemic control.

The primary outcomes of interest, which were assessed using multivariable Poisson regression models, were 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.

Upon analysis, results pointed to a gradient of increasing risk for most outcomes across the trajectories. Compared to those in the rapidly improving to optimal glycemic control group, those in the stably optimal group had 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]). An increased risk of 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) was observed for Those with slowly improving to suboptimal glycemic control trajectory compared to those with rapidly improving to optimal trajectory.

Investigators noted an increased risk was observed for risk of small-for-gestational-age among those in the stably optimal group (aRR, 1.10 [95% CI, 1.02-1.20]) while a decreased risk was observed for the slowly improving to suboptimal group (aRR, 0.63 [95% CI, 0.53-0.75]) when compared to their counterparts in the rapidly improving to optimal glycemic control group.

“Managing one’s blood sugars in pregnancy can be difficult, and we give patients personalized care from very knowledgeable, caring staff members,” said study investigator Mara Greenberg, MD, a maternal-fetal medicine specialist with The Permanente Medical Group, in the aforementioned statement. “This study shows great outcomes for the majority of our patients and we’re very proud of that.”

This study, “Glycemic Control Trajectories and Risk of Perinatal Complications Among Individuals With Gestational Diabetes,” was published in JAMA Network Open.