Gestational diabetes drugs and perinatal outcomes in underserved populations

项目摘要/摘要 妊娠期糖尿病(GDM)的特征是母体高血糖导致胎儿过度生长。 及相关并发症：胎龄过大(LGA)、新生儿低血糖、肩难产、 产伤和剖腹产。而胰岛素一直是维持健康的传统药物干预手段 在患有妊娠期糖尿病的女性中，胰岛素的使用存在许多障碍。胰岛素治疗经常 需要转介到专业提供商，接受管理培训，并每天多次注射-所有因素 这可能会阻碍有效利用，特别是对来自种族/族裔少数群体的妇女或生活在农村地区的妇女。 诊断和治疗妊娠期糖尿病的差异可能会对公共卫生产生重大影响；非白人女性 被诊断为妊娠期糖尿病的可能性是白人女性的两倍多，黑人女性 与白人妇女相比，妊娠期糖尿病相关妊娠和新生儿并发症的风险更高。更新的 口服降糖药，如二甲双胍，可能是安全有效的胰岛素替代品，这些药物 在少数群体或资源有限的人群中更广泛地获得和接受。美国理工学院 产科医生和妇科医生以及母胎医学学会继续就 妊娠期糖尿病的最佳药物治疗。此外，到目前为止，很少有研究研究患者 社会人口因素--特别是种族/民族、农村居住地和社会经济地位--影响 降糖药物选择与围产儿结局的关系。尽管 GDM的管理最好是通过适当的随机临床试验来提供信息， 令人感兴趣的药物已经上市，不太可能进行新的试验。我们的多学科团队 母胎医学、卫生政策、药物流行病学、生物统计学和计算机方面的专家 科学已经证明成功地合作调查了怀孕期间和 产后时期。我们提出了一项精心设计的观察性队列研究，使用了一项全面的 相关记录的研究平台，包括TN医疗补助申请、出生证明和所有人的登记 以医院为基础的TN会诊，将侧重于相关的临床结果，并纳入 现实世界环境的实际复杂性。我们的建议旨在测试二甲双胍在治疗中的假设 患有妊娠期糖尿病的妇女与不良新生儿(目标1)和母亲(目标2)的风险较低相关 与格列本脲或胰岛素比较的结果，特别是在来自社会人口少数群体的妇女中 组。关键的新生儿结局包括胎龄过大、新生儿低血糖和新生儿重症监护室 入院和关键的孕产妇结局包括剖腹产，新的妊娠高血压疾病， 三度和四度会阴撕裂伤。

PROJECT SUMMARY/ABSTRACT Gestational diabetes mellitus (GDM) is characterized by maternal hyperglycemia leading to fetal overgrowth and associated complications: large for gestational age (LGA), neonatal hypoglycemia, shoulder dystocia, birth injury, and cesarean birth. While insulin has been the traditional pharmacologic intervention to maintain euglycemia among women with GDM, there are numerous barriers to insulin use. Insulin therapy often requires referral to specialized providers, training on administration, and multiple daily injections – all factors that may deter effective utilization, particularly in women from racial/ethnic minorities or living in rural areas. Disparities in diagnosis and treatment of GDM may have large public health implications; non-white women are more than twice as likely to be diagnosed with GDM compared to white women, and black women have higher risks for GDM-associated pregnancy and neonatal complications compared to white women. Newer oral hypoglycemic agents, such as metformin, may be safe and effective alternatives to insulin that are more widely accessible and acceptable in minority or resource-limited populations. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine continue to disagree about the optimal pharmacological treatment for GDM. Furthermore, to date, few studies have examined how patient sociodemographic factors - especially race/ethnicity, rural residence, and socioeconomic status - impact the relationship between hypoglycemic medication selection and perinatal outcomes. Although the management of GDM ideally would be informed by properly powered randomized clinical trials, the medications of interest are already on the market and new trials are unlikely. Our multidisciplinary team of experts in maternal-fetal medicine, health policy, pharmacoepidemiology, biostatistics, and computer sciences have demonstrated successful collaboration to investigate medication use during pregnancy and the postpartum period. We propose a carefully designed observational cohort study using a comprehensive research platform of linked records including TN Medicaid claims, birth certificates and a registry of all hospital-based encounters in TN, which will focus on relevant clinical outcomes and incorporate the practical complexities of real-world settings. Our proposal aims to test the hypotheses that metformin use in women with GDM is associated with a lower risk of adverse neonatal (Aim 1) and maternal (Aim 2) outcomes compared to glyburide or insulin, especially among women from sociodemographic minority groups. Key neonatal outcomes include large for gestational age, neonatal hypoglycemia, and NICU admission and key maternal outcomes include cesarean birth, new hypertensive disorders of pregnancy, and third- and fourth-degree perineal lacerations.