In 2010, the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) panel published consensus-based recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Cognizant that milder degrees of hyperglycemia would also be detected by early pregnancy testing, the IADPSG recommended that fasting plasma glucose (FPG) in the range of 5.1-6.9 mmol/l should be considered diagnostic of early Gestational Diabetes Mellitus (GDM) even if the level of proof for this recommendation is very low regarding to prognosis. This threshold was extrapolated from the FPG value used between 24 and 28 weeks. In France, a FPG is proposed at the first prenatal visit for women with risk factors of GDM. Early GDM is diagnosed if FPG is ≥ 5.1 mmol/l, leading to an intensive metabolic management. Data have shown that GDM prevalence increased rapidly from 5.9% in 2009 to 9.3% in 2014. 26.9% of women with hyperglycemia during their pregnancy but without known diabetes are treated before 22 weeks' gestation (WG). More recent data from Italy and China, where IADPSG diagnosis criteria were applied, have strongly challenged this recommendation, and showed that early FPG ≥ 5.1mmo/L is poorly predictive of later GDM. No prior studies have demonstrated benefits to early screening and management. In 2016, the IADPSG members have suggested that the use of the FPG threshold ≥5.1 mmol/l for the identification of GDM in early pregnancy is not justified by current evidence
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
2,010
late management strategy of GDM defined as no intervention until GDM screening at 24-28 weeks. Between 24-28 weeks gestation, a 75-g OGTT will be done
early management of GDM defined as intensive metabolic treatment. Intensive treatment involved the following multidisciplinary approach: lifestyle defined by diet and exercise intervention according to the French guidelines
CH ARRAS
Arras, France
RECRUITINGHopital Estaing - Chu63 - Clermont Ferrand
Clermont-Ferrand, France
RECRUITINGHop Claude Huriez Chu Lille
Lille, France
RECRUITINGHopital Saint Vincent - Saint Antoine - Lille
Lille, France
RECRUITINGChu Nimes Caremeau - Nimes 9
Nîmes, France
RECRUITINGHopital Haut-Leveque - Chu - Pessac
Pessac, France
RECRUITINGCh Rene Dubos - Pontoise
Pontoise, France
RECRUITINGChu Site Sud (Saint Pierre) - St Pierre
Saint-Pierre, France
RECRUITINGCsapa / Hus / Hopital Civil - Strasbourg
Strasbourg, France
RECRUITINGHopital de Rangueil Chu Toulouse
Toulouse, France
RECRUITINGThe occurrence of materno-fetal complications
Composite endpoint defined by Large for Gestational Age (LGA) (defined by birth weight ≥90th percentile, adjusted for gestational age, sex, maternal BMI, parity, ethnicity) and/or neonatal hypoglycemia and/or shoulder dystocia and/or birth traumatisms
Time frame: at delivery
Correlation between composite endpoint (defined in the outcome 1) and the 5 risk factors of GDM
Correlation between composite endpoint (defined in the outcome 1) and the 5 risk factors of GDM (age more or equal to 35 years, BMI more or equal to 25 kg/m2, familial history of diabetes, personal history of GDM, personal history of macrosomia)
Time frame: at delivery
Need for insulin during pregnancy
After at least 10 days of dietary and lifestyles measures, if the target are not achieved, women will receive insulin therapy. fastin glucose target \<5.1 mmol/ and/or a 2 hour post prandial capillary glucose \< 6.6 mmol/l at each 10 days a contact with the diabetologist or the nurses for the transmission of the capillary glycaemia either by phone or by the platform 'myDiabby"
Time frame: at each 10 days until delivery
Metabolic data: Fasting plasma glucose
Change of value of fasting plasma glucose
Time frame: at inclusion (because <20 weeks') and an average at 24 28 weeks of gestation
Metabolic data: HbA1c
Change of value of HbA1c
Time frame: at inclusion (because <20 weeks') and an average at 24 28 weeks of gestation
Oral Glucose Tolerance Test (OGTT)
Time frame: an average at 24 28 weeks of gestation
Percent of GDM women in the late GDM management group according to the IADPSG criteria.
IADPSG criteria(fasting glucose more or equal to 5.1 mmol/l and/or 1h more or equal to 10.0 mmol/l and /or 2h more or equal to 8.5 mmol/l
Time frame: an average at 24 28 weeks of gestation
Number of complications in each subgroup of the late GDM management group
Maternal and neonatal complication
Time frame: at delivery
Neonatal anthropometric parameters
Weight (kilograms), height in centimeters will be combined to report body mass index (kg/m2) at 6 weeks after delivery. GDM+ children, body mass index (BMI) z score, , waist circumference, Height was measured to the nearest 0.1 centimeter using a stadiometer, weight was measured to the nearest 0.1 kilogram using a calibrated balance (Tanita BC-418) and BMI was calculated (kg/m2). Children's BMI z-score was calculated using World Health Organization Anthroplus software (version 1.0.4, WHO, Geneva, Switzerland, 2009) and compared between birth and 6 weeks after delivery.
Time frame: 6 weeks after delivery
Maternal plasma metabolic parameters
Several biochemical parameters will be measured in maternal plasma both at inclusion and delivery such as (fasting) glucose (mM) using colorimetric detection kit, (fasting) plasma insulin (pM), and glycated hemoglobin (HbA1c) (%) using specific enzyme-linked immunosorbent assay (ELISA) kits. Glucose and insulin levels will be combined to report the HOMA-IR index, calculated as follows: Fasting insulin (pmol/L)/6.945) x fasting glucose (mmol/L))/22.5. Triglycerides (mM) and LDL- and HDL-cholesterol (mM) will be measured in maternal plasma between inclusion and delivery and determined simultaneously on Erba XL670 system. Exploratory analyses will be performed in maternal blood at inclusion and at delivery, using liquid-chromatography-high resolution combined with mass spectrometry in tandem in order to characterize the maternal metabolomic, lipidomic patterns as reflects of maternal metabolic status. Each variable will be expressed as %.
Time frame: at 6 weeks after delivery
Cord blood metabolic parameters
Glucose (mM) will be measured in cord blood using colorimetric detection kit, and insulin (pM), and glycated hemoglobin (HbA1c) (%) using specific enzyme-linked immunosorbent assay (ELISA) kits. Exploratory analyses will be performed in cord blood plasma, using liquid-chromatography-high resolution combined with mass spectrometry in tandem in order to characterize the umbilical cord blood metabolomic, lipidomic patterns as reflects of neonatal metabolic status in order to characterize the new-born metabolic status. Each variable will be expressed as %.
Time frame: 6 weeks after delivery
Fecal microbiota composition and diversity in early and late GDM management group compared to euglycaemic group and, for the early and late GDM groups, analyzed according to GDM management of their own mothers and in regard of colostrum microbiota
Fecal microbiota in infant feces collected will be analyzed following the French Gut workflow pipeline (https://hal.inrae.fr/hal-04707112v1) combining a large-scale longitudinal dataset of fecal microbiota limited to taxonomic composition of bacteria from 16S rRNA gene sequencing and high-throughput shotgun metagenomics with MetaGenoPolis facilities (https://mgps.eu/) that describe the microbiome at the functional level. A similar workflow will be used for analyze microbiota from colostrum. The shotgun sequencing data (expressed in % relative abundance and alpha-diversity using Shannon and Simpson indexes) together with the metadata provided (maternal GDM management, colostrum composition) using innovative statistical tools as path modelling approaches (tools specifically developed in the ANR GDM-MILK program a funder of this ancillary study GDM-MILK) will enable to evaluate both early and late GDM-management and colostrum microbiota impact on infant fecal microbiota.
Time frame: at 6 weeks after delivery
Breast milk composition (nutrients and bacterial community) in early and late GDM management group compared to euglycaemic group
Time frame: at 6 weeks after delivery
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