Is there a value for probiotic supplements in gestational diabetes mellitus? A randomized clinical trial Nonpharmacological interventions to prevent type 2 diabetes in women diagnosed with gestational diabetes mellitus: a systematic overview Effects of a Multispecies Probiotic Mixture on Glycemic Control and Inflammatory Status in Women with Gestational Diabetes: A Randomized Controlled Clinical Trial Early pregnancy probiotic supplementation with Lactobacillus rhamnosus HN001 may reduce the prevalence of gestational diabetes mellitus: a randomised controlled trial Probiotics for the Prevention of Gestational Diabetes Mellitus in Overweight and Obese Women: Findings From the SPRING Double-Blind Randomized Controlled Trial Gestational diabetes risk factors and long-term consequences for both mother and offspring: a literature review Impact of maternal probiotic-supplemented dietary counselling on pregnancy outcome and prenatal and postnatal growth: a double-blind, placebo-controlled study. The effects of probiotic supplementation on biomarkers of inflammation, oxidative stress and pregnancy outcomes in gestational diabetes Effects of probiotic supplementation on glycaemic control and lipid profiles in gestational diabetes: A randomized, double-blind, placebo-controlled trial. Metformin compared with insulin in the management of gestational diabetes mellitus: a randomized clinical trial. Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Atlantic Diabetes in Pregnancy (DIP): the prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria Can a Low–Glycemic Index Diet Reduce the Need for Insulin in Gestational Diabetes Mellitus? Postpartum Diabetes Screening in Women With a History of Gestational Diabetes Effect of low glycemic load diet with and without wheat bran on glucose control in gestational diabetes mellitus: A randomized trial
Background Although several studies have found probiotics encouraging in prevention of gestational diabetes mellitus ( GDM ) , the evidence for the use of probiotics in diagnosed GDM is largely limited . The aim of this study was to assess the effect of a probiotic supplement capsule containing four bacterial strains on glucose metabolism indices and weight changes in women with newly diagnosed GDM . Methods Sixty-four pregnant women with GDM were enrolled into a double-blind placebo-controlled r and omized clinical trial . They were r and omly assigned to receive either a probiotic or placebo capsule along with dietary advice for eight consecutive weeks . The trend of weight gain along with glucose metabolism indices was assayed . Results During the first 6 weeks of the study , the weight gain trend was similar between the groups . However , in the last 2 weeks of the study , the weight gain in the probiotic group was significantly lower than in the placebo group ( p < 0.05 ) . Fasting blood sugar ( FBS ) decreased in both intervention ( from 103.7 to 88.4 mg/dl ) and control ( from 100.9 to 93.6 mg/dl ) groups significantly , and the decrease in the probiotic group was significantly higher than in the placebo group ( p < 0.05 ) . Insulin resistance index in the probiotic group had 6.74 % reduction over the study period ( p < 0.05 ) . In the placebo group , however , there was an increase in insulin resistance index ( 6.45 % ) , but the observed change in insulin resistance was not statistically significant . Insulin sensitivity index was increased in both groups . The post-intervention insulin sensitivity index in the probiotic group was not significantly different from placebo when adjusted for the baseline levels . Conclusions The probiotic supplement appeared to affect glucose metabolism and weight gain among pregnant women with GDM . This needs to be confirmed in other setting s before a therapeutic value could be approved This systematic overview summarizes the relevant evidence from multiple systematic review s of the benefits of nonpharmacological interventions for preventing  type 2 diabetes mellitus ( T2MD ) in women diagnosed with gestational diabetes mellitus ( GDM ) . A comprehensive search using the Cochrane Library , CINAHL , EMBASE and MEDLINE via Ovid SP , and PubMed data bases was completed on 18 November 2015 . Any systematic review s that evaluated r and omized controlled trials ( RCTs ) with defined nonpharmacological interventions for preventing T2DM in women diagnosed with GDM were eligible for inclusion . The authors independently performed critical appraisal s and quality assessment s of the included review s using the AMSTAR tool , and extracted data were converted to coherent values for tabular summarization . Six eligible review s of diet and /or exercise , breastfeeding , and reminder interventions were identified ; however , the method ologies of the review s varied greatly , and the majority of the evidence suggested unclear bias . We found inconsistent reporting on the rates at which diet and exercise interventions reduced the risk of T2DM progression , but these interventions were found to be effective at reducing glycemic load . Combined diet , exercise , and breastfeeding interventions proved to be effective at returning women to their postpartum weight . Neither diet alone nor exercise alone proved to be effective at lowering the risk of T2DM . Overall , there was no robust evidence to support the hypothesis that nonpharmacological interventions are effective at lowering the risk of T2DM in women diagnosed with GDM , and there was no consistent evidence showing that these interventions improved the predictor outcomes of T2DM , such as glycemic load or anthropometric changes Objective . This trial aims to examine the effects of a Probiotic Mixture ( VSL#3 ) on glycemic status and inflammatory markers , in women with GDM . Material s and Methods . Over a period of 8 weeks , 82 women with gestational diabetes were r and omly assigned to either an intervention group ( n = 41 ) which were given VSL#3 capsule or to a control group which were given placebo capsule ( n = 41 ) . Fasting plasma glucose , homeostatic model assessment of insulin resistance , glycosylated hemoglobin , high-sensitivity C-reactive protein , tumor necrosis factor-α , interleukin-6 , Interferon gamma , and interleukin-10 were measured before and after the intervention . Results . After 8 wk of supplementation FPG , HbA1c , HOMA-IR , and insulin levels remained unchanged in the probiotic and placebo groups . The comparison between the two groups showed no significant differences with FPG and HbA1c , but there were significant differences in insulin levels and HOMA-IR ( 16.6 ± 5.9 ; 3.7 ± 1.5 , resp . ) . Unlike the levels of IFN-g ( 19.21 ± 16.6 ) , there was a significant decrease in levels of IL-6 ( 3.81 ± 0.7 ) , TNF-α ( 3.10 ± 1.1 ) , and hs-CRP ( 4927.4 ± 924.6 ) . No significant increase was observed in IL-10 ( 3.11 ± 5.7 ) in the intervention group as compared with the control group . Conclusions . In women with GDM , supplementation with probiotics ( VSL#3 ) may help to modulate some inflammatory markers and may have benefits on glycemic control The study aims to assess whether supplementation with the probiotic Lactobacillus rhamnosus HN001 ( HN001 ) can reduce the  prevalence of gestational diabetes mellitus ( GDM ) . A double-blind , r and omised , placebo-controlled parallel trial was conducted in New Zeal and ( NZ ) ( Wellington and Auckl and ) . Pregnant women with a personal or partner history of atopic disease were r and omised at 14–16 weeks ’ gestation to receive HN001 ( 6 × 109 colony-forming units ) ( n 212 ) or placebo ( n 211 ) daily . GDM at 24–30 weeks was assessed using the definition of the International Association of Diabetes and Pregnancy Study Groups ( IADPSG ) ( fasting plasma glucose ≥5·1 mmol/l , or 1 h post 75 g glucose level at ≥10 mmol/l or at 2 h ≥8·5 mmol/l ) and NZ definition ( fasting plasma glucose ≥5·5 mmol/l or 2 h post 75 g glucose at ≥9 mmol/l ) . All analyses were intention-to-treat . A total of 184 ( 87 % ) women took HN001 and 189 ( 90 % ) women took placebo .  There was a trend towards lower relative rates ( RR ) of GDM ( IADPSG definition ) in the HN001 group , 0·59 ( 95 % CI 0·32 , 1·08 ) ( P=0·08 ) . HN001 was associated with lower rates of GDM in women aged ≥35 years ( RR 0·31 ; 95 % CI 0·12 , 0·81 , P=0·009 ) and women with a history of GDM ( RR 0·00 ; 95 % CI 0·00 , 0·66 , P=0·004 ) . These rates did not differ significantly from those of women without these characteristics . Using the NZ definition , GDM prevalence was significantly lower in the HN001 group , 2·1 % ( 95 % CI 0·6 , 5·2 ) , v. 6·5 % ( 95 % CI 3·5 , 10·9 ) in the placebo group ( P=0·03 ) . HN001 supplementation from 14 to 16 weeks ’ gestation may reduce GDM prevalence , particularly among older women and those with previous GDM OBJECTIVE Given the role of gut microbiota in regulating metabolism , probiotics administered during pregnancy might prevent gestational diabetes mellitus ( GDM ) . This question has not previously been studied in high-risk overweight and obese pregnant women . We aim ed to determine whether probiotics ( Lactobacillus rhamnosus and Bifidobacterium animalis subspecies lactis ) administered from the second trimester in overweight and obese women prevent GDM as assessed by an oral glucose tolerance test ( OGTT ) at 28 weeks ’ gestation . Secondary outcomes included maternal and neonatal complications , maternal blood pressure and BMI , and infant body composition . RESEARCH DESIGN AND METHODS This was a double-blind r and omized controlled trial of probiotic versus placebo in overweight and obese pregnant women in Brisbane , Australia . RESULTS The study was completed in 411 women .  GDM occurred in 12.3 % ( 25 of 204 ) in the placebo arm and 18.4 % ( 38 of 207 ) in the probiotics arm ( P = 0.10 ) . At OGTT , mean fasting glucose was higher in women r and omized to probiotics ( 79.3 mg/dL ) compared with placebo ( 77.5 mg/dL ) ( P = 0.049 ) . One- and two-hour glucose measures were similar . Preeclampsia occurred in 9.2 % of women r and omized to probiotics compared with 4.9 % in the placebo arm ( P = 0.09 ) . Excessive weight gain occurred in 32.5 % of women in the probiotics arm ( 55 of 169 ) compared with 46 % in the placebo arm ( 81 of 176 ) ( P = 0.01 ) . Rates of small for gestational age ( < 10th percentile ) were 2.4 % in the probiotics arm ( 5 of 205 ) and 6.5 % in the placebo arm ( 13 of 199 ) ( P = 0.042 ) . There were no differences in other secondary outcomes . CONCLUSIONS The probiotics used in this study did not prevent GDM in overweight and obese pregnant women ABSTRACT Introduction : Established risk factors for gestational diabetes mellitus ( GDM ) include ethnicity , obesity , and family history of diabetes . Untreated GDM patients have higher rates of maternal and perinatal morbidity . GDM is an independent risk factor for future longer-term risk of type 2 diabetes mellitus ( T2DM ) , metabolic syndrome , cardiovascular morbidity , malignancies , ophthalmic , psychiatric , and renal disease in the mother . Offspring risk long-term adverse health outcomes , including T2DM , subsequent obesity , impacted neurodevelopmental outcome , increased neuropsychiatric morbidity , and ophthalmic disease . Areas covered : We critically review data from retrospective , prospect i ve , and meta- analysis studies pertaining to established GDM risk factors , complications during pregnancy and birth ( both mother and offspring ) , and long-term consequences ( both mother and offspring ) . Expert commentary : Many of the adverse consequences of GDM might be avoided with proper management and treatment . Patients belonging to high-risk ethnic groups , and /or with body mass index ≥ 25 kg/m2 , and /or known history of diabetes in first-degree relatives may benefit from universal screening and diagnostic criteria proposed by the International Association of Diabetes and Pregnancy Study Group ( IADPSG ) . The IADPSG one-step method has several advantages , including simplicity of execution , greater patient-friendliness , and higher diagnostic accuracy . Additionally , evidence suggests that the recent increased popularity of bariatric surgery will help to decrease GDM rates over next 5 years . Similarly , metformin may be useful for treating and preventing obstetrical complications in confirmed GDM patients The perinatal nutritional environment impacts upon the health and well-being of mother and child also in the long term . The aim of the present study was to determine the safety and efficacy of perinatal probiotic-supplemented dietary counselling by evaluating pregnancy outcome and fetal and infant growth during the 24 months ' follow-up . Altogether , 256 women were r and omised at their first trimester of pregnancy into a control and a dietary intervention group . The intervention group received intensive dietary counselling provided by a nutritionist and were further r and omised , double-blind to receive probiotics ( Lactobacillus rhamnosus GG and Bifidobacterium lactis Bb12 ; diet/probiotics ) or placebo ( diet/placebo ) . Firstly , probiotic intervention reduced the frequency of gestational diabetes mellitus ( GDM ) ; 13 % ( diet/probiotics ) v. 36 % ( diet/placebo ) and 34 % ( control ) ; P = 0.003 . Secondly , the safety of this approach was attested by normal duration of pregnancies with no adverse events in mothers or children . No significant differences in prenatal or postnatal growth rates among the study groups were detected . Thirdly , distinctive effects of the two interventions were detected ; probiotic intervention reduced the risk of GDM and dietary intervention diminished the risk of larger birth size in affected cases ; P = 0.035 for birth weight and P = 0.028 for birth length . The results of the present study show that probiotic-supplemented perinatal dietary counselling could be a safe and cost-effective tool in addressing the metabolic epidemic . In view of the fact that birth size is a risk marker for later obesity , the present results are of significance for public health in demonstrating that this risk is modifiable Abstract Objective : This study was design ed to evaluate the effects of probiotic supplementation on biomarkers of inflammation , oxidative stress and pregnancy outcomes  among subjects with gestational diabetes ( GDM ) . Methods : This r and omized , double-blind , placebo-controlled clinical trial was done among 60 subjects with GDM who were not on oral hypoglycemic agents . Patients were r and omly allocated to intake either probiotic capsule containing Lactobacillus acidophilus , Lactobacillus casei and Bifidobacterium bifidum ( 2 × 109 CFU/g each ) ( n = 30 ) or placebo ( n = 30 ) for six weeks . Results : Compared with the placebo , probiotic supplementation result ed in significant decreases in fasting plasma glucose ( FPG ) ( −5.3 ± 6.7 vs. + 0.03 ± 9.0 mg/dL , p = .01 ) , serum high-sensitivity C-reactive protein ( hs-CRP ) ( −2.2 ± 2.7 vs. + 0.5 ± 2.4 μg/mL , p < .001 ) , plasma malondialdehyde ( MDA ) concentrations ( −0.1 ± 0.8 vs. + 0.5 ± 1.5 μmol/L , p = .03 ) and MDA/TAC ratio ( −0.0003 ± 0.0008 vs. + 0.0009 ± 0.002 , p = .004 ) , and a significant increase in total antioxidant capacity ( TAC ) levels ( + 65.4 ± 103.3 vs. −37.2 ± 143.7 mmol/L , p = .002 ) . Probiotic supplementation did not affect pregnancy outcomes . Conclusions : Overall , probiotic supplementation among women with GDM for six weeks had beneficial effects on FPG , serum hs-CRP , plasma TAC , MDA and oxidative stress index , but did not affect pregnancy outcomes BACKGROUND To our knowledge , data on the effects of probiotic supplementation on glycaemic control and lipid concentrations in patients with gestational diabetes mellitus ( GDM ) are scarce . AIM The aim of the present study was to determine the effects of probiotic supplementation on glycaemic control and lipid profiles in GDM patients . METHODS Sixty pregnant women with GDM , primigravida and aged 18 - 40years , were divided into two groups to receive either probiotic capsules ( n=30 ) or a matching placebo ( n=30 ) in this r and omized double-blind , placebo-controlled trial . The patients in the probiotic group took a daily capsule that contained three viable freeze-dried strains : Lactobacillus acidophilus ( 2 × 10(9)CFU/g ) , L. casei ( 2 × 10(9)CFU/g ) and Bifidobacterium bifidum ( 2 × 10(9)CFU/g ) for 6weeks . The placebo group took capsules filled with cellulose for the same time period . Fasting blood sample s were taken at the beginning and end of the study to quantify the relevant markers . RESULTS After 6weeks of intervention , probiotic supplementation vs a placebo result ed in significant decreases in fasting plasma glucose ( -9.2±9.2mg/dL vs + 1.1±12.2mg/dL , P<0.001 ) , serum insulin levels ( -0.8±3.1μIU/mL vs + 4.5±10.6μIU/mL , P=0.01 ) , homoeostasis model assessment ( HOMA ) for insulin resistance ( -0.4±0.9 vs + 1.1±2.5 , P=0.003 ) and HOMA for β-cell function ( + 1.1±9.8 vs + 18.0±42.5 , P=0.03 ) , and a significant increase in the quantitative insulin sensitivity check index ( + 0.007±0.01 vs -0.01±0.02 , P=0.007 ) . In addition , significant decreases in serum triglycerides ( -1.6±59.4mg/dL vs + 27.1±37.9mg/dL , P=0.03 ) and VLDL cholesterol concentrations ( -0.3±11.9mg/dL vs + 5.4±7.6mg/dL , P=0.03 ) were seen following supplementation with the probiotics compared with the placebo . However , no significant changes in other lipid profiles were seen with the intervention . CONCLUSION Overall , the results of our study have demonstrated that taking probiotic supplements for 6weeks in patients with GDM had beneficial effects on glycaemic control , triglycerides and VLDL cholesterol concentrations , although there was no effect on other lipid profiles AIMS To evaluate the effect of metformin and insulin in glycemic control and compare pregnancy outcome in women with gestational diabetes mellitus ( GDM ) . METHODS This r and omized controlled trial was conducted in GDM women with singleton pregnancy and gestational age between 20 and 34 weeks who did not achieve glycemic control on diet were assigned r and omly to receive either metformin ( n=80 ) or insulin ( n=80 ) . The primary outcomes were maternal glycemic control and birth weight . The secondary outcomes were neonatal and obstetric complications . RESULTS Two groups were comparable regarding the maternal characteristics . Two groups were similar in mean FBS ( P=0.68 ) and postpr and ial measurements ( P=0.87 ) throughout GDM treatment . The neonates of metformin group had less rate of birth weight centile > 90 than insulin group ( RR : 0.5 , 95 % CI : 0.3 - 0.9 , P=0.012 ) . Maternal weight gain was reduced in the metformin group ( P<0.001 ) . Two groups were comparable according to neonatal and obstetric complications ( P>0.05 ) . In metformin group 14 % of women needed to supplemental insulin to achieve euglycemia . CONCLUSION Metformin is an effective and safe alternative treatment to insulin for women with GDM . This study does not show significant risk of maternal or neonatal adverse outcome with the use of metformin The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus ( GDM ) with a focus on 1 ) early pregnancy diagnosis and treatment and 2 ) pharmacologic treatment strategies . This article summarizes the proceedings of the workshop . In early pregnancy , the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined , and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated . Despite many small r and omized controlled trials of glucose-lowering medication treatment in GDM , our underst and ing of medication management of GDM is incomplete as evidence d by discrepancies among professional society treatment guidelines . The comparative effectiveness of insulin , metformin , and glyburide remains uncertain , particularly with respect to long-term outcomes . Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches . Further research on these topics is likely to improve our underst and ing of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children Aims /hypothesisNew diagnostic criteria for gestational diabetes mellitus ( GDM ) have recently been published . We wished to evaluate what impact these new criteria would have on GDM prevalence and outcomes in a predominantly European population . Methods The Atlantic Diabetes In Pregnancy ( DIP ) programme performed screening for GDM in 5,500 women with an oral glucose tolerance test at 24–28 weeks . GDM was defined according to the new International Association of Diabetes and Pregnancy Study Groups ( IADPSG ) criteria and compared with previous WHO criteria ; maternal and neonatal adverse outcomes were prospect ively recorded . Results Of the participants , 12.4 % and 9.4 % were diagnosed with GDM using IADPSG and WHO criteria , respectively . IADPSG GDM pregnancies were associated with a statistically significant increased incidence of adverse maternal outcomes ( gestational hypertension , polyhydramnios and Caesarean section ) and neonatal outcomes ( prematurity , large for gestational age , neonatal unit admission , neonatal hypoglycaemia and respiratory distress ) . The odds ratio for the development of these adverse outcomes remained significant after adjustment for maternal age , body mass index and non-European ethnicity . Those women who were classified as having normal glucose tolerance by WHO criteria but as having GDM by IADPSG criteria also had significant adverse pregnancy outcomes . Conclusions /interpretationGDM prevalence is higher when using newer IADPSG , compared with WHO , criteria , and these women and their offspring experience significant adverse pregnancy outcomes . Higher rates of GDM pose a challenge to healthcare systems , but improved screening provides an opportunity to attempt to reduce the associated morbidity for mother and child OBJECTIVE A low – glycemic index diet is effective as a treatment for individuals with diabetes and has been shown to improve pregnancy outcomes when used from the first trimester . A low – glycemic index diet is commonly advised as treatment for women with gestational diabetes mellitus ( GDM ) . However , the efficacy of this advice and associated pregnancy outcomes have not been systematic ally examined . The purpose of this study was to determine whether prescribing a low – glycemic index diet for women with GDM could reduce the number of women requiring insulin without compromise of pregnancy outcomes . RESEARCH DESIGN AND METHODS All women with GDM seen over a 12-month period were considered for inclusion in the study . Women ( n = 63 ) were r and omly assigned to receive either a low – glycemic index diet or a conventional high-fiber ( and higher glycemic index ) diet . RESULTS Of the 31 women r and omly assigned to a low – glycemic index diet , 9 ( 29 % ) required insulin . Of the women r and omly assigned to a higher – glycemic index diet , a significantly higher proportion , 19 of 32 ( 59 % ) , met the criteria to commence insulin treatment ( P = 0.023 ) . However , 9 of these 19 women were able to avoid insulin use by changing to a low – glycemic index diet . Key obstetric and fetal outcomes were not significantly different . CONCLUSIONS Using a low – glycemic index diet for women with GDM effectively halved the number needing to use insulin , with no compromise of obstetric or fetal outcomes OBJECTIVE : Women with a history of gestational diabetes mellitus ( GDM ) are at high risk for developing type 2 diabetes ( diabetes mellitus , DM ) . The American Diabetes Association recommends regular postpartum diabetes screening for women with a history of GDM , but the American College of Obstetricians and Gynecologists ( ACOG ) is not as directive . We sought to examine postpartum glycemic testing in women diagnosed with GDM . METHODS : We conducted an observational cohort study of women diagnosed with GDM at one of two large academic medical centers between 2000 and 2001 . Kaplan-Meier estimates of the time from delivery to the first postpartum DM screening tests were determined , and predictors of postpartum DM screening were examined using Cox proportional hazards testing . RESULTS : Only 37 % of eligible women underwent the postpartum diabetes screening tests recommended by the American Diabetes Association ( fasting glucose or oral glucose tolerance test [ OGTT ] ) , with a median time from delivery to the first such testing of 428 days . By comparison , 94 % of women underwent postpartum cervical cancer screening  using a Papanicolaou ( Pap ) test , with a median time from delivery to Pap testing of 49 days . Even when r and om glucose testing was included in a broad definition of postpartum DM screening ( r and om or fasting glucose , glycosylated hemoglobin , or OGTT ) , only two thirds of women ( 67 % ) received a postpartum glycemic assessment . CONCLUSION : In the population studied , only 37 % of women with a history of GDM were screened for postpartum DM according to guidelines published by the American Diabetes Association . Efforts to improve postpartum DM screening in this high-risk group are warranted . LEVEL OF EVIDENCE : Background : A low-glycemic index diet is effective in blood glucose control of diabetic subjects , reduces insulin requirement in women with gestation diabetes mellitus ( GDM ) and improves pregnancy outcomes when used from beginning of the second trimester . However there are limited reports to examine the effect of low glycemic load ( LGL ) diet and fiber on blood glucose control and insulin requirement of women with GDM . Therefore , the aim of this study was to examine the effect of low glycemic load diet with and without fiber on reducing the number of women with GDM requiring insulin . Material s and Methods : All GDM women ( n = 31 ) were r and omly allocated to consume either a LGL diet with Fiber or LGL diet . Results : We found that 7 ( 38.9 % ) of 18 women with GDM in Fiber group and 10 ( 76.9 % ) in “ Without Fiber ” group required insulin treatment . Conclusion : The LGL diet with added fiber for women with GDM dramatically reduced the number needing for insulin treatment
Conclusion Probiotic supplementation seemed to be able to reduce the risk of a newborn 's hyperbilirubinemia and improve glycemic control , blood lipid profiles and inflammation and oxidative stress in pregnant women with GDM .
Background Previous studies showed that probiotics could improve glycemic control and attenuate some of the adverse effects of type 2 diabetes .
However , whether the effects are generalizable to gestational diabetes mellitus ( GDM ) remains uncertain .
Objective We conducted a systematic review and meta- analysis to evaluate the effects of probiotic supplement in GDM .