Diabetes, Gestational

The guidelines for weight gain during pregnancy in obese women have long been questioned. New research supports the idea of lowering or removing the current recommendation of a weight gain of at least 5 kg. The guidelines for weight gain during pregnancy in obese women have long been questioned. New research from Karolinska Institutet supports the idea of lowering or removing the current recommendation of a weight gain of at least 5 kg. The results are published in The Lancet. International guidelines from the US Institute of Medicine (IOM) state that women with obesity should gain a total of 5 to 9 kg during pregnancy, compared to 11.5 to 16 kg for normal-weight women. The guidelines have long been questioned, but there has been no evidence to warrant a re-examination. A new study from Karolinska Institutet in Sweden now shows that there are no increased health risks for either the mother or the child with weight gain below current guidelines for women with obesity class 1 and 2 (BMI of 30-34.9 and 35-39.9 respectively). On the contrary, for women with obesity class 3 (BMI over 40), weight gain below current guidelines might even be beneficial for those with class 3 obesity. The study supports previous calls to either lower or remove the current recommended lower limit of a weight gain of at least 5 kg, according to Kari Johansson, docent at the Department of Medicine, Solna. "We hope that our research can inform a re-examination of national and international guidelines on weight gain during pregnancy," she says. The study is based on electronic medical records and registry data for 15,760 women with obesity in Stockholm and Gotland (the so-called Stockholm Gotland Perinatal Cohort). 11,667 of the women in the study had obesity class 1, 3,160 had obesity class 2 and 933 had obesity class 3. The study included singleton pregnancies that delivered between 2008 and 2015. The women were followed for a median of eight years after delivery. Ten known adverse outcomes associated with weight gain during pregnancy were studied: pre-eclampsia, gestational diabetes, excess postpartum weight retention, maternal cardiometabolic disease, unplanned caesarean delivery, preterm birth, large for gestational age and small for gestational age at birth, stillbirth and infant death. These adverse outcomes were assigned weights according to their severity and combined into an adverse composite outcome. Overall, the study shows no increased risks of the adverse composite outcome with weight gain below current IOM guidelines in women with obesity classes 1 and 2. For women with obesity class 3, on the contrary, weight gain values below the guidelines or weight loss were associated with reduced risk of the adverse composite outcome. For example, an absence of weight gain (i.e. 0kg) was associated with a risk reduction of about 20 per cent. "Based on this, we have concluded that weight gain below current recommendations is likely safe in pregnancies with obesity, and might even be beneficial for those with class 3 obesity," says Kari Johansson. The results also indicate that there is a need for specific recommendations for women with class 3 obesity. "Unlike today, this group could receive separate recommendations," says Kari Johansson. The researchers will now proceed with similar studies on overweight, normal weight and underweight women. The study was conducted in collaboration with the University of British Columbia, Canada, the University of Pittsburgh, USA, and the University of California, USA. Funders were Karolinska Institutet Research Grants and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Kari Johansson and co-authors Lisa Bodnar and Jennifer Hutcheon are part of a WHO initiative for global standards for weight gain during pregnancy. However, the views expressed in the study do not reflect the views of the WHO. Olof Stephansson is co-founder and co-owner of a Swedish pregnancy app, One Million Babies. No other conflicts of interest are reported.

Researchers analyzed 52 studies involving more than 4 million pregnancies across 22 countries to investigate the health impacts of miscarriage, abortion and recurrent pregnancy loss (more than two miscarriages in succession) on subsequent pregnancies. The study found different health risks for each group. New Curtin University research has revealed a link between miscarriage and the increased risk of developing complications of gestational diabetes and high blood pressure-related disorders in later pregnancies. Researchers from the Curtin School of Population Health analysed 52 studies involving more than 4 million pregnancies across 22 countries to investigate the health impacts of miscarriage, abortion and recurrent pregnancy loss (more than two miscarriages in succession) on subsequent pregnancies. The study found different health risks for each group. People who had experienced a miscarriage were 44 per cent more likely to develop gestational diabetes during later pregnancies but only 6 per cent more likely to develop high blood pressure in subsequent pregnancies. Conversely, people who had experienced recurrent pregnancy loss showed no increased risk of gestational diabetes but were 37 per cent more likely to develop pre-eclampsia, a potentially dangerous complication characterised by high blood pressure, in later pregnancies. There was no evidence linking abortion to diabetic or hypertensive related issues, either during or outside of pregnancy. Lead study author Dr Jennifer Dunne said establishing the links between pregnancy loss, diabetes and high blood pressure could have a far reaching impact. "Miscarriages occur in 15-25 per cent of all pregnancies -- which is around 23 million per year, globally," Dr Dunne said. "Gestational diabetes and high blood pressure disorders in pregnancy can cause a variety of significant health problems; understanding the relationship between pregnancy loss and later pregnancy complications could reveal new ways to mitigate risks or possibly prevent these conditions from progressing. "Further research into the biological links between pregnancy loss and later health issues might reveal new targets for developing treatments." Dr Dunne said the study added to what was already known about pregnancy complications and health later in life, even beyond pregnancy. "Knowing miscarriage can lead to these pregnancy complications later on is important, as these conditions during pregnancy have previously been linked to a higher risk of people developing heart disease later in life," Dr Dunne said. "By shedding light on the long-term health effects of miscarriages and repeated pregnancy losses, this study paves the way for improved healthcare strategies, research, and support for those affected -- hopefully enhancing the outcomes for parents and babies in future pregnancies."

One way Northern Health, a major provider in Melbourne's north, is creating value for its patients and community, is by enabling its clinicians to offer virtual options. THE PROBLEM It began during the pandemic. As with the rest of the industry, the organisation too had to accelerate its digital transformation by embracing digital tools for delivering remote care. However, they had to make do with little technologies available to them back then. "Systems were clunky, there was little or limited integration of our systems and poor interoperability," recalled Dr Katharine See, chief health outcomes officer and director of Respiratory Medicine at Northern Health. Once the dust settled, they realised that they could never go back to the way things were before. Northern Health is now receiving over 114,000 admissions each year; its emergency department alone treats over 111,000 patients annually with the auxiliary Victorian Virtual Emergency Department now attending to calls from more than 103,000 patients. "Much of our care reverted to a traditional face-to-face model following the relaxation of COVID restrictions. Given our rapidly growing population, we recognised the need to do things fundamentally differently." Dr Katharine See, Chief Health Outcomes Officer, Director of Respiratory Medicine, Northern Health Indeed, the rising demand for health services due to an ageing population, along with the expected increase in chronic disease cases and persistent issues in accessing primary care, necessitates changing the way care is delivered – particularly one that leverages digital technology, according to Uri Bettesh, CEO and founder of Israel and United States-based Datos Health. As a region, Australia/New Zealand pushes towards building a digitally-enabled healthcare system. "The crucial element for ANZ as we see it is the need to implement solutions to increasing workforce pressures with proven innovative models," Bettesh noted. Besides workforce solutions, enabling the real-time exchange of information between and among patients and care teams is also imperative to "prevent siloed care and support transitions of care which are so crucial in care continuity and health outcomes." PROPOSAL Taking a value-based approach to providing care, Northern Health started extending virtual options, first to its lung cancer patients. "As the lead for the Lung Tumour Stream, I regularly reviewed the findings from the Victorian Lung Cancer Registry report, which showed that we were performing well compared to other healthcare providers. However, relying solely on administrative data had limitations, leaving us without a definitive measure of whether we were meeting the outcomes that mattered most to our patients and community," Dr See shared. "We decided [that] we needed to develop a digital care pathway to measure what matters most to our patients to address this," she added . They eventually found success in that project. Recognising its benefits, it was a natural next step to digitise other patient pathways across the organisation – but it had to be through a single platform that could handle multiple use cases. In that single platform, Northern Health specifically looked for the following key requirements: flexible and easy to use; interoperability; automates workflows; expands clinical reach and drives clinical efficiency; reduces clinician burden; increases patient self-management and agency; and multilingual. The organisation found a partner in New York-headquartered Datos Health, which offers the Open Care platform for the delivery of hybrid care. From this implementation, the organisation hopes to achieve the following outcomes: improved equity and accessibility maximise return on investment by investing in secondary prevention (such as cardiac rehabilitation) increased activation and improved self-management MEETING THE CHALLENGE Datos offers a comprehensive open platform for customising care plans according to both clinicians' and patients' needs. Clinicians can either create their care plans from scratch or choose from over 200 templates that can be tweaked and adjusted by patient population, acuity levels, and devices, among other factors. Different departments of an organisation can also tailor their care plans based on system integrations, preferred use of AI, and device integrations. Open Care helps automate tasks by automatically sending instructions, education, and directed actions to patients, as well as reminders to take medication, complete questionnaires, or measure vitals via the companion mobile application CareApps. "Choosing an open solution for remote health monitoring ensures adaptability to our diverse community needs. By utilising a customisable cloud-based platform, we can enable our clinicians to track our patients longitudinally through the alerting system and understand who is at higher risk of deterioration. This allows us to effectively prioritise their care," Dr See explained. Together with Datos' Australian partner IKAO Health, Northern Health will integrate Open Care across various patient pathways, including cardiac rehabilitation, back pain, severe asthma and gestational diabetes. There is also a plan to expand it to its community healthcare programs. "We are planning to go live with four programs within the next three months with an additional 10 in the pipeline by year's end. We are currently in the process of finalising integrations," an IKAO Health representative disclosed. RESULTS Thus far, Northern Health staff have been "overwhelmingly positive" about the virtual care platform. The organisation even have a "long waiting list" of staff keen to implement it in their respective programs, Dr See mentioned. Reflecting on their take on value-based care by leveraging virtual tools, Dr See shared: "A virtual model of care positively impacts value-based care by enhancing access to healthcare through implementing new technology, empowering our patients to engage in their own healthcare, reducing costs associated with traditional in-person visits, utilising data analytics to support continuous quality improvement efforts for our models of care. By leveraging virtual care platforms, Northern Health can deliver more accessible, patient-centred, cost-effective, and high-quality care that aligns with the objectives of value-based care models, ultimately improving health outcomes and patient satisfaction while optimising resource utilisation. The transition from inpatient to community-based care focuses on shifting from reactive to proactive care, ultimately creating value for both patients and the healthcare system."