There is a high prevalence of gestational diabetes (GD) in South Africa, which is continually growing. South African women with GD are not effectively managed or educated about selfcare, do not self-monitor frequently enough and, therefore, often succumb to various GD induced complications. The ineffective management of GD is largely due to financial and time constraints caused by the regularly required outpatient services. On the other hand, healthcare professionals do not monitor their patients frequently enough because of accessibility issues, which means they cannot intervene timeously to prevent diabetes complications. The aim of this project was to develop a mobile health (mHealth) platform for GD self-management and for remote monitoring to improve the GD cycle of care in South Africa. The objectives were to assess the current GD management practices in South Africa, to assess the existing mHealth solutions for GD and to design, develop and test a GD mHealth platform. The existing GD management practices and current GD mHealth solutions were investigated. The results of the investigation informed the design of low-fidelity and high-fidelity mock-ups of the platform. The high-fidelity mock-up underwent usability testing and the insights gained were used to develop a working prototype of the new mHealth platform, which was then ready for in-lab testing. It was found that GD had a prevalence of up to 25% in parts of South Africa. Over 70% of patients in both private and public healthcare sectors did not meet their diabetic goals, which directly correlated with diabetes induced complications. However, previous research found that using mHealth as an intervention caused a statistically significant decrease of 0.38 mmol/L (95% confidence interval (CI) 0.52 mmol/L to 0.23 mmol/L) in overall blood glucose levels during pregnancy when compared to a control group. There was a higher probability of vaginal deliveries in the intervention group than in the control group (risk ratio = 1.18). It was less likely for new-borns from the intervention group to be diagnosed with hypoglycaemia than new-borns from the control group (risk ratio = 0.67). Based on the research and usability studies conducted, an alpha version of the GD mHealth platform was developed, including a mobile app used to track the patient’s blood glucose levels via a Bluetooth-enabled glucose meter. The food intake, exercise and weight gain during pregnancy were manually captured by the patient. The app reminded the patient to take medication, measure glucose levels and attend appointments. A GD educational component was available for the patient throughout the pregnancy. The platform included a web app which allowed healthcare professionals to remotely monitor and communicate with their patients so that they could analyse trends in the data and intervene when necessary. The testing done on the prototype resulted in positive feedback with 60% of participants saying that they would use the GooDMoM mobile app to manage their GD and 70% of participants saying that they would use the GooDMoM web app to manage their patients with GD. This put the platform in a good position for beta development. The solution has the potential to benefit patients both financially and timewise, by reducing the frequency of hospital visits required. It also has the potential to positively impact the healthcare professionals by reducing the tediousness of their workload and allowing for remote monitoring of patients. The platform can, thus, optimise the GD management process in South Africa and worldwide.

No description available.

Over 220 million people worldwide are diagnosed with diabetes and rising prevalence is reported in nearly all surveyed populations. Accordingly, the percentage of pregnancies affected by pre-existing type 1 or 2 diabetes or by diabetes that develops during pregnancy, called gestational diabetes mellitus (GDM), is also on the rise. Today, approximately 8% of all pregnancies are complicated by diabetes. Diabetes alters drug disposition mechanisms in non-pregnant subjects but the impact of diabetes on drug disposition in pregnancy has not been properly evaluated. Atypical drug disposition in pregnancy has implications for maternal and fetal health. Because liver tissue from pregnant women is not readily available, this thesis investigated drug disposition mechanisms primarily in a rat model of experimental GDM. This model consisted of administering streptozotocin, a diabetogenic toxin, to pregnant rats on gestational day 6. One key finding was that elevated circulating lipids in GDM rats competed with drugs (e.g., glyburide and saquinavir) for plasma protein binding so as to increase free drug concentrations. Another key finding was that important hepatic drug efflux transporters (e.g., Mdr1a/b) and metabolic enzymes (e.g., Cyp3a2 and Ugt1a1) were upregulated in GDM as a consequence of, most likely, enhanced nuclear receptor activity (e.g., pregnane X receptor upregulation). Upregulation of hepatic drug efflux transporters and metabolic enzymes, coupled with larger unbound drug fractions, would be expected to increase the hepatic clearance of many drugs. Consistent with this, in GDM, maternal and fetal exposure to the Mdr1 and Cyp3a2 substrate lopinavir was substantially lower than controls post-administration and data supporting enhanced lopinavir metabolite formation were obtained. Placental drug efflux transporters were also examined in this lopinavir study. Elevated placental Mdr1b and Bcrp expression was observed in GDM, which was associated with decreased fetal exposure to lopinavir (even after correcting for maternal unbound concentrations). Taken together, this thesis demonstrates that experimental GDM can significantly impact drug disposition by altering key drug disposition mechanisms. If confirmed in humans, this drug-disease interaction would need to be considered when atypical therapeutic outcomes occur in diabetic pregnancies. Data from experiments with human placentas, obtained from pregnancies complicated by insulin-managed diabetes, is included/discussed.

Over 220 million people worldwide are diagnosed with diabetes and rising prevalence is reported in nearly all surveyed populations. Accordingly, the percentage of pregnancies affected by pre-existing type 1 or 2 diabetes or by diabetes that develops during pregnancy, called gestational diabetes mellitus (GDM), is also on the rise. Today, approximately 8% of all pregnancies are complicated by diabetes. Diabetes alters drug disposition mechanisms in non-pregnant subjects but the impact of diabetes on drug disposition in pregnancy has not been properly evaluated. Atypical drug disposition in pregnancy has implications for maternal and fetal health. Because liver tissue from pregnant women is not readily available, this thesis investigated drug disposition mechanisms primarily in a rat model of experimental GDM. This model consisted of administering streptozotocin, a diabetogenic toxin, to pregnant rats on gestational day 6. One key finding was that elevated circulating lipids in GDM rats competed with drugs (e.g., glyburide and saquinavir) for plasma protein binding so as to increase free drug concentrations. Another key finding was that important hepatic drug efflux transporters (e.g., Mdr1a/b) and metabolic enzymes (e.g., Cyp3a2 and Ugt1a1) were upregulated in GDM as a consequence of, most likely, enhanced nuclear receptor activity (e.g., pregnane X receptor upregulation). Upregulation of hepatic drug efflux transporters and metabolic enzymes, coupled with larger unbound drug fractions, would be expected to increase the hepatic clearance of many drugs. Consistent with this, in GDM, maternal and fetal exposure to the Mdr1 and Cyp3a2 substrate lopinavir was substantially lower than controls post-administration and data supporting enhanced lopinavir metabolite formation were obtained. Placental drug efflux transporters were also examined in this lopinavir study. Elevated placental Mdr1b and Bcrp expression was observed in GDM, which was associated with decreased fetal exposure to lopinavir (even after correcting for maternal unbound concentrations). Taken together, this thesis demonstrates that experimental GDM can significantly impact drug disposition by altering key drug disposition mechanisms. If confirmed in humans, this drug-disease interaction would need to be considered when atypical therapeutic outcomes occur in diabetic pregnancies. Data from experiments with human placentas, obtained from pregnancies complicated by insulin-managed diabetes, is included/discussed.

Gestational Diabetes (GDM) is considered a high-risk pregnancy. Nutrition management plays a critical role in GDM management. How women with GDM make food choice decisions and how they follow dietary advice have not been fully investigated especially how stress and anxiety during a GDM pregnancy influence dietary management. This study used a mixed methods approach. Qualitative and quantitative data were collected concurrently and analysed together to answer research questions on factors that affected women with GDM at 26-38 gestational weeks in making food choice decisions, the stress and anxiety that they experienced, and the barriers that they encountered when following dietary advice. The results showed: 1. Despite of the dietary recommendations from the healthcare professionals, food choice decisions were still strongly influenced by individual factors such as personal food preference, cravings, and hunger. Women sought information from different sources to adapt to the dietary changes, especially when the health services information provided was too general, and when some of the dietary advice conflicted with their eating habits. Difficulties in dealing with cravings, food portion size, hunger, and eating out led to a sense of decreased control and to stress and frustration. 2. The GDM diagnosis triggered stress in some women. Women who were on insulin were more likely to experience dietary management related stress compared to the ones on diet treatment only. Anxiety was explained as the fear of the macrosomia and labor complications. These kinds of fear could be aggravated by abnormal blood glucose readings and hence triggered some emotional breakdown and coping actions. 3. Underlying beliefs such as behavioural, normative, and self-efficacy beliefs can produce barriers to following dietary advice. Other factors such as environmental constraints and lack of knowledge added more challenges to following dietary advice. Quick adaptation to dietary management in a short time period was not easy for women with first time diagnosed GDM and created emotional distress, often leading to unhealthy dietary coping strategies. The above results concluded that women with first time diagnosed GDM faced challenges of quick adaptation of dietary behavioral changes in a limited time frame. These challenges were rooted in the expected health behavior changes that are often in conflict with the individual’s behavioral, normative, and self-efficacy beliefs. Stress and anxiety generated in the process of GDM management sometimes led to altered dietary behaviors to cope with blood glucose control.

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy that affects 1-14% of all pregnancies. If not properly managed, GDM can be a devastating disease, leading to birth complications such as shoulder dystocia and neonatal hypoglycemia. GDM has many long-term implications as well, such as increased risk of obesity and type 2 diabetes mellitus (T2DM) in both the mother and the offspring. Additionally, women with a history of GDM are at increased risk of recurrent GDM in a subsequent pregnancy and multiple episodes of GDM further increases a woman’s risk for these short and long-term consequences. For this reason, a diagnosis of GDM provides an opportunity to target GDM and T2DM risk factors to prevent recurrence of GDM and halt the diabetes disease course. Research has shown that diet and physical activity interventions provided after a pregnancy complicated by GDM can delay or prevent the onset of T2DM yet literature on prevention of recurrent GDM is lacking. This thesis will propose a new intervention applied to the inter-pregnancy interval (IPI), designed to reduce incidence of recurrent GDM. The study will examine the effect of a diet and physical activity intervention for women with a recent pregnancy complicated by GDM on recurrence in a subsequent pregnancy and weight gain in the IPI. We hypothesize that our intervention will reduce incidence of GDM recurrence compared to the control group and that women in the intervention group will lose more weight compared to women in the control group. The results of this study will provide a background for further study on the prevention of GDM recurrence with the hope that prevention of recurrent GDM will prevent the short and long-term sequela of GDM.

Gestational diabetes mellitus can have devastating effects in the health of the mother and child. While pregnancy rates are decreasing, prevalence of GDM is increasing, and it is estimated that up to 9% of pregnancies are complicated by diabetes in the United States. Traditional treatment and monitoring of gestational diabetes mellitus relies on patient’s compliance to document glycemic levels. This proposed study will evaluate the effectiveness of telemedicine using a wireless glucose meter that transmits information to the providers in real time. The prospective open cohort randomized clinical trial will take place in medical centers around Boston. Two hundred participants diagnosed with gestational diabetes will be recruited over a period of 24 months from these centers and randomly placed into two groups. One group will follow traditional treatment, and the intervention group will be asked to use iGlucose meter system. Glycemic levels and frequency of prenatal visits will be evaluated and analyzed. If telemedicine proves to be efficacious in treating GDM, this would give providers a new treatment plan to consider to effectively manage blood glucose levels and reduce poor perinatal outcomes related to gestational diabetes mellitus.

This literature-based thesis aimed to evaluate the relationship between gestational diabetes mellitus (GDM) and the Latinx community. The Latinx community is one of the groups most affected by GDM in the United States of America. Latinx patients have higher prepregnancy body mass index (BMI) and excessive gestational weight gain (GWG), the two main risk factors for developing GDM. The occurrence of GDM increases the risk for adverse pregnancy outcomes and early onset type II diabetes mellitus (T2DM) postpartum. For the fetus, GDM increases the risk of hypoglycemia and hyperinsulinemia, both of which can affect the long-term metabolic health. Current treatments of GDM in Latinx patients focus on lifestyle intervention through diet and exercise, an action that proves to be effective in this population. Enhanced GDM care that includes pregnancy health education in a group setting significantly improves birth outcomes. Advanced screening utilizing biomarkers and more accessible diagnostic tools is recommended for improving GDM treatment in Latinx patients. Finally, pregnancy studies on GDM should adequately represent the Latinx population among participants. Although this thesis analyzed GDM in the Latinx community and offered solutions for the disproportionate adverse pregnancy outcomes, these results may also be applicable to other racially and ethnically diverse populations.

O Diabetes mellitus gestacional (DMG) é uma séria condição que afeta muitas gestantes e traz muitos riscos tanto para a gestante, como para o feto. A recomendação é que se faça o rastreamento com teste oral de tolerância à glicose (TOTG) entre 24 e 28 semanas de gestação. O objetivo desse estudo é determinar a utilidade do teste de hemoglobina glicada (A1c) como teste diagnóstico de DMG, comparado com os critérios baseados na medida de glicemia. Métodos: este é um estudo de acurácia de teste diagnóstico. Nós avaliamos o metabolismo dos carboidratos através dos testes de TOTG e A1c em mulheres grávidas brasileiras atendidas nas visitas de pré-natal do Hospital de Clínicas de Porto Alegre (HCPA). Além dos testes de TOTG e A1c, foi analisada a história clínica das pacientes. O DMG foi definido de acordo com critério da American Diabetes Association (ADA) - um ou mais pontos alterados, glicemia de jejum, 1h ou 2h com concentrações de glicose plasmática ≥5.1, 10.0, ou 8.5 mmol/L, respectivamente-, ou de acordo com os critérios da Organização Mundial da Saúde (OMS) - glicemia de jejum ou 2h com concentrações de glicose plasmática ≥7.0mmol/L ou ≥7.8mmol/L, respectivamente. Presença de anemia, hemoglobinas variantes e doença renal crônica foram excluídas. Para avaliar o desempenho do teste de A1c foi utilizada a curva ROC (receiver operating characteristic curve). Resultados: um total de 262 mulheres grávidas (média de idade de 30 anos, média de idade gestacional de 26 semanas) foram avaliadas e 82 (31,3%) tiveram diagnóstico positivo (40 pelo critério da ADA e 42 pelo critério da OMS). Baseado na análise da curva ROC, considerando os critérios da ADA e OMS juntos e o TOTG como teste de referência, o ponto de corte para obter o melhor equilíbrio entre sensibilidade e especificidade (diagonal 100% a 100%) foi o valor de A1c de 31mmol/mol (5,3%). A sensibilidade e especificidade para este ponto de corte foi de 69,9% e 65,9%, respectivamente. Os pontos de corte de 40 mmol/mol (5.8%), 41 mmol⁄mol (5.9%) e 42 mmol⁄mol (6.0%) representaram especificidades de 96,1%, 96,6% e 98,3%, respectivamente. Conclusões: o teste de A1c apresenta baixa sensibilidade e alta especificidade para o diagnóstico de DMG, quando comparado com o critério tradicional. Nossos resultados mostraram que 39% dos casos de DMG foram diagnosticados usando o ponto de corte de A1c≥ 40 mmol/mol (5.8%). O teste de A1c, sozinho ou em combinação com o TOTG, talvez seja bastante útil no diagnóstico de DMG. / BACKGROUND: Gestational diabetes mellitus (GDM) is a potentially serious condition that affects many pregnancies and it carries risk for the mother and neonate. The current recommendation is to perform screening before 24 - 28 weeks of gestation by an oral glucose tolerance test (OGTT). The aim of this study is to determine the usefulness of glycated hemoglobin (A1c) as a diagnostic tool for GDM compared with the traditional criteria based on glycemia measurements. METHODS: This is a study of diagnostic test accuracy. We evaluated the status of carbohydrate metabolism by performing OGTT and A1c in Brazilian pregnant women attending prenatal visits at Hospital de Clínicas de Porto Alegre (HCPA). A1c, OGTT, and clinical history were analyzed. GDM was defined according to the American Diabetes Association (ADA) criteria (one or more fasting, 1-h, or 2-h plasma glucose concentrations ≥5.1, 10.0, or 8.5 mmol/L; respectively) or World Health Organization (WHO) criteria (fasting or 2-h plasma glucose ≥7.0mmol/L or ≥7.8mmol/L, respectively). Presence of anemia, variant hemoglobins and chronic renal disease were excluded. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic performance of A1c. RESULTS: A total of 262 pregnant women (mean age 30 years, mean gestational duration 26 weeks) were enrolled and 82 (31.3%) were diagnosed with diabetes (40 by ADA criteria and 42 by WHO criteria). Based on ROC curve analysis, and considering OGTT as the reference criterion, the cut-off point obtained by the point with the best equilibrium between sensitivity and specificity (100%-to-100% diagonal) was A1c value of 31 mmol⁄mol (5.3%). The sensitivity and specificity for this cut-off 27 point were 69.9 % and 65.9 %, respectively. The cut-off points of A1c of 40 mmol/mol (5.8%), 41 mmol⁄mol (5.9%) and 42 mmol⁄mol (6.0%) presented specificities of 96,1%, 96,6% and 98,3%, respectively. CONCLUSIONS: A1c test presented low sensitivity and very high specificity for GDM diagnosis when compared with traditional criteria. Our results show that 39% of GDM cases would be diagnosed by using the cut-off point A1c≥ 40 mmol/mol (5.8%) alone. A1c test, alone or in combination with OGTT, may be a very useful diagnostic tool in GDM.

No description available.