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

Abstract

Importance: Glycemic 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.

Objective: To examine whether glycemic control trajectories from gestational diabetes diagnosis to delivery were associated with differential risk of perinatal complications.

Design, setting, and participants: This 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.

Exposures: Glycemic 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 measures: Multivariable 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.

Results: Among 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 relevance: These 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.

Figure 1.. Study Participant Flowchart

GDM, gestational diabetes; KPNC, Kaiser Permanente Northern California; RPSC, Regional Perinatal Service Center.

Figure 2.. Glycemic Control Trajectories Between Gestational Diabetes Diagnosis and Delivery

Trajectories T1-T4 were derived using serial self-monitored blood glucose measurements between gestational diabetes diagnosis and delivery. Optimal glycemic control was defined as at least 80% of all self-monitored blood glucose measurements meeting the targets recommended by the American Diabetes Association guidelines and implemented at Kaiser Permanente Northern California. T1 indicates stably optimal (10 528 individuals [39.3%]); T2, rapidly improving to optimal (9151 individuals [34.2%]); T3, slowly improving to near-optimal (4161 individuals [15.5%]); and T4, slowly improving to suboptimal (2934 individuals [11.0%]).

Figure 3.. Associations of Glycemic Control Trajectories With Perinatal Complications

Data are presented as adjusted relative risk (95% confidence interval) calculated using Poisson regression models with robust SEs. P-for-trend was calculated using the Poisson trend test. Model adjusted for age at delivery, race and ethnicity, neighborhood poverty level, Medicare or Medicaid during pregnancy, multiparity, prepregnancy body mass index, smoking and alcohol during pregnancy, higher oral glucose tolerance test levels, early gestational diabetes diagnosis, RPSC program engagement, and frequency of self-monitoring of blood glucose measurements. aRR indicates adjusted relative risk; AGA, appropriate-for-gestational age; LGA, large-for-gestational age; NICU, neonatal intensive care unit; SGA, small-for-gestational age; T1, stably optimal (10 528 individuals [39.3%]); T2, rapidly improving to optimal (9151 individuals [34.2%]); T3, slowly improving to near-optimal (4161 individuals [15.5%]); and T4, slowly improving to suboptimal (2934 individuals [11.0%]). ^aFalse discovery rate–corrected P < .05. ^bAGA, LGA, and SGA birthweight categories were derived using sex and gestational age-specific percentiles calculated using a 2017 US reference population.