Gestational diabetes mellitus and adverse maternal and perinatal outcomes in twin and singleton pregnancies: a systematic review and meta-analysis

ObjectiveThis study aimed to assess the risk of adverse maternal and perinatal complications between twin and singleton pregnancies affected by gestational diabetes mellitus and the respective group without gestational diabetes mellitus (controls).Data SourcesA literature search was performed using MEDLINE, Embase, and Cochrane from January 1980 to May 2023.Study Eligibility CriteriaObservational studies reporting maternal and perinatal outcomes in singleton and/or twin pregnancies with gestational diabetes mellitus vs controls were included.MethodsThis was a systematic review and meta-analysis. Pooled estimate risk ratios with 95% confidence intervals were generated to determine the likelihood of adverse pregnancy outcomes between twin and singleton pregnancies with and without gestational diabetes mellitus. Heterogeneity among studies was evaluated in the model and expressed using the I2 statistic. A P value of <.05 was considered statistically significant. The meta-analyses were performed using Review Manager (RevMan Web). Version 5.4. The Cochrane Collaboration, 2020. Meta-regression was used to compare relative risks between singleton and twin pregnancies. The addition of multiple covariates into the models was used to address the lack of adjustments.ResultsOverall, 85 studies in singleton pregnancies and 27 in twin pregnancies were included. In singleton pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.85; 95% confidence interval, 1.69–2.01), induction of labor (relative risk, 1.36; 95% confidence interval, 1.05–1.77), cesarean delivery (relative risk, 1.31; 95% confidence interval, 1.24–1.38), large-for-gestational-age neonate (relative risk, 1.61; 95% confidence interval, 1.46–1.77), preterm birth (relative risk, 1.36; 95% confidence interval, 1.27–1.46), and admission to the neonatal intensive care unit (relative risk, 1.43; 95% confidence interval, 1.38–1.49). In twin pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.69; 95% confidence interval, 1.51–1.90), cesarean delivery (relative risk, 1.10; 95% confidence interval, 1.06–1.13), large-for-gestational-age neonate (relative risk, 1.29; 95% confidence interval, 1.03–1.60), preterm birth (relative risk, 1.19; 95% confidence interval, 1.07–1.32), and admission to the neonatal intensive care unit (relative risk, 1.20; 95% confidence interval, 1.09–1.32) and reduced risks of small-for-gestational-age neonate (relative risk, 0.89; 95% confidence interval, 0.81–0.97) and neonatal death (relative risk, 0.50; 95% confidence interval, 0.39–0.65). When comparing relative risks in singleton vs twin pregnancies, there was sufficient evidence to suggest that twin pregnancies have a lower relative risk of cesarean delivery (P=.003), have sufficient adjustment for confounders, and have lower relative risks of admission to the neonatal intensive care unit (P=.005), stillbirths (P=.002), and neonatal death (P=.001) than singleton pregnancies.ConclusionIn both singleton and twin pregnancies, gestational diabetes mellitus was associated with an increased risk of adverse maternal and perinatal outcomes. In twin pregnancies, gestational diabetes mellitus may have a milder effect on some adverse perinatal outcomes and may be associated with a lower risk of neonatal death. This study aimed to assess the risk of adverse maternal and perinatal complications between twin and singleton pregnancies affected by gestational diabetes mellitus and the respective group without gestational diabetes mellitus (controls). A literature search was performed using MEDLINE, Embase, and Cochrane from January 1980 to May 2023. Observational studies reporting maternal and perinatal outcomes in singleton and/or twin pregnancies with gestational diabetes mellitus vs controls were included. This was a systematic review and meta-analysis. Pooled estimate risk ratios with 95% confidence intervals were generated to determine the likelihood of adverse pregnancy outcomes between twin and singleton pregnancies with and without gestational diabetes mellitus. Heterogeneity among studies was evaluated in the model and expressed using the I2 statistic. A P value of <.05 was considered statistically significant. The meta-analyses were performed using Review Manager (RevMan Web). Version 5.4. The Cochrane Collaboration, 2020. Meta-regression was used to compare relative risks between singleton and twin pregnancies. The addition of multiple covariates into the models was used to address the lack of adjustments. Overall, 85 studies in singleton pregnancies and 27 in twin pregnancies were included. In singleton pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.85; 95% confidence interval, 1.69–2.01), induction of labor (relative risk, 1.36; 95% confidence interval, 1.05–1.77), cesarean delivery (relative risk, 1.31; 95% confidence interval, 1.24–1.38), large-for-gestational-age neonate (relative risk, 1.61; 95% confidence interval, 1.46–1.77), preterm birth (relative risk, 1.36; 95% confidence interval, 1.27–1.46), and admission to the neonatal intensive care unit (relative risk, 1.43; 95% confidence interval, 1.38–1.49). In twin pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.69; 95% confidence interval, 1.51–1.90), cesarean delivery (relative risk, 1.10; 95% confidence interval, 1.06–1.13), large-for-gestational-age neonate (relative risk, 1.29; 95% confidence interval, 1.03–1.60), preterm birth (relative risk, 1.19; 95% confidence interval, 1.07–1.32), and admission to the neonatal intensive care unit (relative risk, 1.20; 95% confidence interval, 1.09–1.32) and reduced risks of small-for-gestational-age neonate (relative risk, 0.89; 95% confidence interval, 0.81–0.97) and neonatal death (relative risk, 0.50; 95% confidence interval, 0.39–0.65). When comparing relative risks in singleton vs twin pregnancies, there was sufficient evidence to suggest that twin pregnancies have a lower relative risk of cesarean delivery (P=.003), have sufficient adjustment for confounders, and have lower relative risks of admission to the neonatal intensive care unit (P=.005), stillbirths (P=.002), and neonatal death (P=.001) than singleton pregnancies. In both singleton and twin pregnancies, gestational diabetes mellitus was associated with an increased risk of adverse maternal and perinatal outcomes. In twin pregnancies, gestational diabetes mellitus may have a milder effect on some adverse perinatal outcomes and may be associated with a lower risk of neonatal death.