PAPPA and gestational diabetes: Although our post-hoc analysis showed that the pooled MD for PAPP-A MoMs were similar between studies reporting PAPP-A MoM levels for women who were diagnosed with GDM early in pregnancy and studies reporting on women who were diagnosed later in pregnancy, the significant reductions in first trimester PAPP-A among women with GDM compared to normoglycemic women suggest that this biomarker may be a useful indicator of the presence of glucose intolerance at the start of pregnancy [32, 37, 41].