Gestational Diabetes

Gestational Diabetes

What is gestational diabetes?
Important steps:

Meal plan
Frequent monitoring
Insulin administration and dosage adjustment
Hypoglycemia control and treatment
Exercise

About three to five percent of all pregnant women develop gestational diabetes during pregnancy. It is different from type 1 diabetes, in which the body produces no insulin and insulin must be injected, and from the more common type 2 diabetes. Patients with type 2 diabetes suffer from varying levels of insulin resistance and may control blood glucose levels through diet and exercise, with oral medication, or with insulin injections.

Gestational diabetes usually develops about midway through a pregnancy, at about 20 to 24 weeks, and is caused by the changes in hormones in your body during pregnancy. In addition to supplying your baby with nutrients and water from your circulation, the placenta produces a number of hormones vital to the pregnancy. Some of these have a blocking effect on insulin. As the placenta grows larger, the more hormones are produced, and the greater the insulin resistance becomes. In most women, the pancreas is able to make additional insulin to overcome this insulin resistance. When the pancreas makes all the insulin it can, and there still isn't enough to overcome the effect of the placenta's hormones, gestational diabetes results.

Any woman might develop gestational diabetes during pregnancy. Factors that have been identified as increasing the risk for gestational diabetes are obesity, a family history of diabetes, having given birth to a very large infant previously, having had a stillbirth or a child with a birth defect, or having too much amniotic fluid. Women older than 25 are at greater risk than younger ones.

Gestational diabetes usually clears up as soon as the baby is born, since when the placenta is removed, the hormones it was producing - which were causing the insulin resistance -- are also removed. Once again your insulin is permitted to work normally without resistance, and you should no longer have any problems with blood glucose levels.

Although this type of diabetes disappears when the baby is born, some women who have gestational diabetes go on to develop diabetes when they get older. Some studies have reported that almost 40 percent of women who have gestational diabetes will go on to develop type 2 diabetes. So, if you have gestational diabetes, you will need to be screened for type 2 diabetes every year.

One of the major concerns about diabetes in pregnancy is the harmful effect that high blood glucose levels can have on the developing baby. In women who don't have their blood glucose levels controlled at near normal levels during the first trimester, there is a higher incidence of miscarriage and birth defects. However, since gestational diabetes doesn't appear until well after that critical period, there is little likelihood of those types of problems in gestational diabetes.

Although most women with this condition are treated with diet, some may need insulin. Gestational diabetes can't be treated with pills because it is not known what effects those medications may have on the baby.

Your healthcare provider may recommend that you see a diabetes specialist, and you will need to take additional steps to control your blood glucose levels for the duration of your pregnancy. The following steps can help you achieve a smooth pregnancy and a healthy baby:

Following an appropriate meal plan
Frequent self-monitoring of blood glucose (SMBG)
Administering insulin injections and knowing how to adjust the doses depending on results of SMBG
Controlling/treating hypoglycemia
Adding or maintaining an appropriate level of physical activity

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Important steps to achieve a smooth pregnancy

1)	Following an appropriate meal plan
	Your eating patterns are especially important now, since you want to control blood glucose levels and also assure that both you and your baby are getting adequate nutrition during your pregnancy. Your doctor will provide you with a personalized meal plan as part of your diabetes self-management program. This plan will be geared toward helping you maintain normal blood glucose levels. It will incorporate these fundamental patterns that have been proven to help keep glucose under control in people with diabetes: Avoid sugar and foods high in sugar Emphasize complex carbohydrates, such as vegetables, cereal, grains, beans, peas, and other starchy foods Emphasize foods high in fiber Keep your diet low in fat Have bedtime snacks that include both protein and complex carbohydrate Related information Diet for diabetes Top of page
2)	Frequent self-monitoring of blood glucose (SMBG)
	The only way to tell if you are succeeding in controlling your blood glucose is to monitor your levels, and to do it frequently. This is called self-monitoring of blood glucose, or SMBG. Pregnant women are advised to monitor at least four times a day, and sometimes as often as 10 times a day. It requires a drop of your blood (from a fingerstick) and a home glucose monitor. Since your need for this will be temporary, inquire about renting the equipment from your local pharmacy or diabetes supplier. Your doctor and diabetes specialist will teach you about this important aspect of your self-management. Related information Glucose testing \| Monitoring devices Top of page
3)	Administering insulin injections and knowing how to adjust the doses depending on the results of SMBG
	If you are unable to control your glucose levels with diet and exercise, you may need to take insulin. Pregnant women cannot take oral anti-diabetes medications, since the safety of those medications during pregnancy has not been established. You should use only human insulin, since the use of insulin analogs has not been adequately tested in pregnant women. Your body's need for insulin is going to steadily increase throughout your pregnancy. Your insulin dose may have to be adjusted upward periodically; it may also have to be recalculated as you and your baby get bigger. Your doctor will be watching this area carefully and will want to see your SMBG results for guidance. In order to maintain tight control, you will need to know how to adjust your dosage depending on the results of your frequent monitoring. Again, your healthcare provider or pharmacist can help you master this process. Related information Insulin \| Insulin delivery device \| Latest development Top of page
4)	Controlling/treating hypoglycemia
	When people with diabetes undertake a program to achieve tight control of their blood glucose levels, they increase the risk of severe hypoglycemia, or low blood glucose. There is no evidence that hypoglycemia is a risk to the developing baby, but it can be a problem for you. Therefore, be sure to keep ready sources of carbohydrates with you at all times. It would also be a good idea for you, your family, and perhaps a close co-worker to learn how to administer glucagon injections in case of a hypoglycemic crisis. Related information Hypoglycemia \| Emergency products Top of page
5)	Adding or maintaining an appropriate level of physical activity
	A moderate exercise program will help maintain control of blood glucose levels while also making you feel better. It will help get you in shape for delivery, too. If you've already been exercising, you can probably continue it, although you should avoid sports or exercises where you might fall. Bicycling, jogging, and cross-country skiing are good exercises to continue during your pregnancy. If you aren't exercising regularly, now is a good time to start, but check with your doctor about your planned activity and start slowly. Vigorous walking is an excellent way to start. Even if you are having some problems during your pregnancy, light exercise such as leisurely walking is still a good idea. You'll need to plan your periods of activity along with your food intake and insulin injections. If you're on insulin, you'll need to take a few precautions: Be aware of the risk of hypoglycemia, and take a high-sugar snack along with you. It may be necessary to eat small snacks between meals. If you exercise right after a meal, have a snack after the exercise. If you exercise two hours or more after a meal, eat the snack before the exercise. One serving of fruit will maintain blood sugar for most short-term activities (about 30 minutes). One serving of fruit plus a serving of starch will be enough for activities that last longer (an hour or more). Don't reduce your insulin intake before exercising. Don't inject insulin into a part of the body that will be exercised; for example, if you'll be walking, avoid injecting into your leg. Related information Diabetes and exercise

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How much weight to gain?

Your doctor has already given you guidelines for gaining weight during your pregnancy. Caloric input and nutrition are especially important for you and your baby.

The "optimal" weight gain depends on your weight when you became pregnant. If your weight was in a good range for your body size, then a weight gain of 24 to 27 pounds is recommended. If you are 20 or more pounds above your desirable level, you should gain 24 pounds.

If you gain too much weight, the extra fat requires the body to produce more insulin to try to keep blood sugar levels normal. But if your body is incapable of producing more insulin, then your blood glucose levels will rise above acceptable levels.

Diabetes & pregnancy

1: Diabetes Care. 2003 Aug;26(8):2244-9.

Related Articles, Links

Adiponectin is present in cord blood but is unrelated to birth weight.

Lindsay RS, Walker JD, Havel PJ, Hamilton BA, Calder AA, Johnstone FD; Scottish Multicentre Study of Diabetes Pregnancy.

MedStar Research Institute, Washington Hospital Center, Washington, DC 20010, USA. robert.lindsay@medstar.net

OBJECTIVE: In adults, adiponectin is reduced in association with excess adiposity, type 2 diabetes, and hyperinsulinemia. We assessed whether adiponectin was 1) present in the fetal circulation, 2) altered in the fetal circulation in the presence of maternal diabetes, and 3) had relations to fetal cord blood insulin or adiposity. RESEARCH DESIGN AND METHODS: We assessed adiponectin in cord blood in a large cohort of singleton offspring of diabetic mothers (ODM; n = 134) and control mothers (n = 45). RESULTS: Adiponectin was present in cord blood and, in ODM, was higher in those delivered at later gestational ages (Spearman r = 0.18, P = 0.03). Adiponectin was slightly lower in ODM than control subjects (ODM 19.7 +/- 6.1 vs. control 21.8 +/- 5.3 micro g/ml; P = 0.04), although this difference could potentially reflect different gestational ages in the two groups (ODM 37.6 +/- 1.5 and control 40.1 +/- 1.1 weeks). In contrast to adults, adiponectin levels in the fetus were unrelated to the degree of adiposity, blood insulin, or leptin in either control subjects or ODM. CONCLUSIONS: Adiponectin is present in cord blood but does not show expected physiological relations with adiposity as observed in adults.

PMID: 12882843 [PubMed - in process]

: Hypertensive disorders of pregnancy in women with Type 1 and Type 2 diabetes.

Cundy T, Slee F, Gamble G, Neale L.

Department of Medicine, Faculty of Medicine & Health Sciences, University of Auckland and, Diabetes Pregnancy Clinic, National Women's Hospital, Auckland, New Zealand. t.cundy@auckland.ac.nz

AIMS: Hypertensive disorders in pregnancy are common in women with Type 1 diabetes and can be associated with adverse fetal outcomes, but little is known about hypertension in pregnancy in women with Type 2 diabetes. The aim of this study was to compare the incidence and outcomes of, and risk factors for, hypertension in pregnancy in women with Type 1 and Type 2 diabetes. METHODS: One hundred consecutive singleton pregnancies in women with Type 2 and 100 in women with Type 1 diabetes were studied. Hypertension in pregnancy was classified according to Australasian Society for the Study of Hypertension in Pregnancy guidelines. Outcomes of pregnancy examined included birth weight, rates of caesarean section, premature delivery and special care unit admission, and perinatal mortality. RESULTS: The overall incidence of hypertension in pregnancy was similar in Type 2 and Type 1 diabetes (41% vs. 45%), but the distribution of subtypes differed (P = 0.028). Women with Type 2 diabetes had more chronic hypertension (diagnosed at < 20 weeks gestation), but less preeclampsia than women with Type 1 diabetes. Hypertension in pregnancy was strongly associated with a number of adverse outcomes, but the impact of hypertension was significantly less for Type 2 diabetes than it was for Type 1 (premature delivery, P < 0.005; admission to Special Care Unit, P < 0.01; caesarean section, P = 0.05). This was, in part, because the frequency of adverse outcomes was greater in women with preeclampsia. Nulliparity, poor glycaemic control at presentation, and early pregnancy blood pressure and not smoking were risk factors for hypertension of similar magnitude in both types of diabetes. Significant effects of duration of diabetes and obesity were not seen in Type 2 subjects, but were in Type 1 (P < 0.01, P < 0.05, respectively). Early pregnancy albumin excretion rate was increased more frequently in Type 2 subjects than in Type 1 (P < 0.035), but was less strongly associated with the development of preeclampsia (P < 0.035). CONCLUSIONS: The incidence of hypertension in pregnancy is similar in Type 2 and Type 1 diabetes, but the different population characteristics are reflected in a significantly different pattern of types of hypertension. Hypertension has less impact on adverse outcomes in Type 2 diabetes. Some risk factors for hypertension also differ between Type 2 and Type 1 diabetes.

PMID: 12060060 [PubMed - indexed for MEDLINE]

3: Aust N Z J Obstet Gynaecol. 1999 Feb;39(1):99-102.

Related Articles, Links

Pregnancy in women with diabetes and ischaemic heart disease.

Bagg W, Henley PG, Macpherson P, Cundy TF.

Diabetes Pregnancy Clinic, National Women's Hospital, Auckland, New Zealand.

Publication Types:

Review
Review of Reported Cases

PMID: 10099760 [PubMed - indexed for MEDLINE]

4: Diabetes Care. 1998 Dec;21(12):2185-9.

Related Articles, Links

American Diabetes Association annual meeting, 1998. Type 1 diabetes; pregnancy and diabetes.

Bloomgarden ZT.

Division of Endocrinology, Mount Sinai School of Medicine, New York, New York, USA.

Publication Types:

Congresses

PMID: 9839114 [PubMed - indexed for MEDLINE]

: Incidence of gestational diabetes at Northdale Hospital, Pietermaritzburg.

Ranchod HA, Vaughan JE, Jarvis P.

Department of Obstetrics and Gynaecology, Northdale Hospital, Pietermaritzburg.

An incidence study for gestational diabetes was undertaken at Northdale Hospital, which serves a majority Indian and minority Coloured population in Pietermaritzburg. All patients presenting to the antenatal clinic were screened using a 75 g glucose load. If the 1-hour venous plasma glucose level was greater than or equal to 7.8 mmol/l an oral glucose tolerance test (OGTT) was performed. The screening procedure was repeated at 28 - 32 weeks gestation. The OGTT was done with a 75 g glucose load and patients were designated as having gestational diabetes if the 2-hour plasma glucose level was greater than or equal to 7.8 mmol/l. Subsequently, the patients were also evaluated by the 3rd trimester criteria of the Diabetes Pregnancy Study Group of the European Association for the Study of Diabetes (EASD): gestational diabetes being present if the fasting plasma glucose value was greater than or equal to 5.2 mmol/l and the 2-hour plasma glucose value was greater than or equal to 9.0 mmol/l after a 75 g glucose load. Between July 1987 and June 1988 1721 patients were seen. There were 4 pre-gestational diabetics. The remaining 1717 patients were screened for gestational diabetes. Forty-five patients had 2 OGTTs performed, while 251 patients had 1 OGTT in the 3rd trimester. Sixty-five patients had a 2-hour plasma glucose value of greater than or equal to 7.8 mmol/l on OGTT. Hence, the incidence of gestational diabetes using World Health Organisation criteria was 65/1717 (3.8%). Twenty-seven patients had 2-hour plasma glucose value of greater than or equal to 9 mmol/l on OGTT.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID: 2063235 [PubMed - indexed for MEDLINE]

: Management of diabetes mellitus complicating pregnancy.

Gabbe SG, Graves CR.

Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA

Diabetes mellitus complicates 3-5% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal morbidity. The availability of a variety of new insulins, the insulin pump, and self-monitoring of blood glucose have revolutionized the care of the pregnancy complicated by diabetes mellitus. However, challenges remain in caring for the pregnant patient with pregestational diabetes. Relatively few women receive preconceptional counseling, and major fetal malformations as a result of poor glucose control before and during the early weeks of gestation have emerged as the major cause of perinatal mortality. When the patient has diabetic vasculopathy, the obstetrician, maternal-fetal specialist, and/or endocrinologist and other members of the health care team must perform a challenging balancing act that promotes fetal health while minimizing maternal risk. As obesity increases in this country and our population becomes more diversified, the rate of gestational diabetes mellitus (GDM) will rise. Although there is controversy regarding which diagnostic standards to use for GDM, there is agreement that excellent blood glucose control, with diet and, when necessary, insulin will result in improved perinatal outcome. Finally, the goal of our educational programs should be not only to improve pregnancy outcome but also to promote healthy lifestyle changes for the mother that will last long after delivery.

PMID: 14551019 [PubMed - in process]

: Gestational diabetes mellitus and lesser degrees of pregnancy hyperglycemia: association with increased risk of spontaneous preterm birth.

Hedderson MM, Ferrara A, Sacks DA.

Division of Research at Kaiser Permanente, California, Oakland, USA

To investigate whether different degrees of maternal glucose intolerance are associated with the risk of spontaneous preterm birth.We performed a cohort study of 46,230 pregnancies screened by a 50-g, 1-hour oral glucose tolerance test between 24 and 28 gestation weeks at the Northern California Kaiser Permanente Medical Care Program. Spontaneous preterm birth was defined as an infant born at less than 37 gestation weeks with at least one of the following: spontaneous labor, preterm premature rupture of membranes, or incompetent cervix. Glucose tolerance status was categorized as normal screening (1-hour plasma glucose less than 140 mg/dL), abnormal screening (1-hour plasma glucose of at least 140 mg/dL with a normal diagnostic 100-g, 3-hour oral glucose tolerance test result), Carpenter-Coustan (plasma glucose measurements during the diagnostic oral glucose tolerance test met the thresholds but were lower than the National Diabetes Data Group thresholds), and gestational diabetes mellitus (GDM) by the National Diabetes Data Group criteria.One thousand nine hundred fifty-six spontaneous preterm births occurred. Age-adjusted incidences of spontaneous preterm birth were 4.0% in normal screening, 5.0% in abnormal screening, 6.7% in Carpenter-Coustan, and 6.7% in GDM. In a logistic regression model adjusted for age, race-ethnicity, preeclampsia-eclampsia-pregnancy-induced hypertension, chronic hypertension, polyhydramnios, and birth weight for gestational age, pregnancies with abnormal screening, Carpenter-Coustan, and GDM had a significantly higher risk of spontaneous preterm birth than pregnancies with normal screening (relative risk [95% confidence interval]: 1.23 [1.08, 1.41], 1.53 [1.16, 2.03], and 1.42 [1.15-1.77], respectively).The risk of spontaneous preterm birth increased with increasing levels of pregnancy glycemia. This association was independent of perinatal complications that could have triggered early delivery.

PMID: 14551018 [PubMed - in process]

: Allergy to insulin in a woman with gestational diabetes mellitus: transient efficiency of continuous subcutaneous insulin lispro infusion.

Durand-Gonzalez K, Guillausseau N, Anciaux M, Hentschel V, Gayno J.

Endocrinology department, Poissy-Saint Germain en Laye Hospital, France.

We report the case of a 31-year-old pregnant woman. She required insulin for the treatment of gestational diabetes from 27 weeks of amenorrhoea to delivery. An allergy to insulin was suspected because she presented with local symptoms at insulin injection sites and a decrease in efficiency of insulin. This diagnostic was confirmed by skin-prick tests. A treatment with subcutaneous continuous lispro insulin analogue infusion was initiated with an oral antihistaminic drug without local reaction. Seven weeks after the initiation of insulin pump, local reactions reappeared. The insulin analogue lispro is not always an alternative in insulin allergy. However, in the case we report, the lack of allergy during a few weeks allowed the birth of a normal infant.

PMID: 14526273 [PubMed - in process]

: [Diabetes mellitus]

[Article in Italian]

Bosi E.

Universit Vita-Salute San Raffaele, Istituto Scientifico Ospedale San Raffaele, Milano.

Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes is a serious health concern. The number of cases of diabetes mellitus is estimated to grow at a rate of 50% between 2000 and 2010. There are several types of diabetes: type 1 diabetes, type 2 diabetes, gestational diabetes, and other specific types of diabetes. Beta cell dysfunction plays a key role in the physiopathology of diabetes, even when insulin resistance, which is often present in several diabetes-related diseases, is considered among the causes of hyperglycemic type 2 diabetes. The prolonged hyperglycemia that is peculiar to all kind of diabetes has long term complications on several organs and systems. The diagnosis of diabetes is based on the evaluation of glucose plasma levels performed under fasting conditions or two hours after the oral ingestion of 75 grams of glucose. Currently, achieving and maintaining normal plasma levels of glucose are the aims of therapy for both type 1 and type 2 diabetes. Particularly, the therapy for type 1 diabetes is based on the administration of insulin, whereas that of type 2 diabetes changes over the time: diet and physical activity are the first treatments; oral hypoglycemic drugs are used as a second therapeutic step; and the administration of insulin is the last therapeutic option. The principal therapeutic innovation of the past ten years is represented by the tight and flexible control of glucose plasma level obtained by using the insulin analogues produced by recombinant DNA technology.

PMID: 14523905 [PubMed - in process]

: Pregnancy outcome in spontaneous twins versus twins who were conceived through in vitro fertilization.

Nassar AH, Usta IM, Rechdan JB, Harb TS, Adra AM, Abu-Musa AA.

Department of Obstetrics and Gynecology, American University of Beirut Medical Center Beirut, Lebanon.

OBJECTIVE: The purpose of this study was to compare maternal and neonatal complications in spontaneous versus in vitro fertilization twins. STUDY DESIGN: Twin gestations that were delivered from 1995 to 2000 were reviewed. Cases consisted of 56 in vitro fertilization twins, each of which was matched to two control mothers by age and parity. They were compared regarding various maternal and neonatal complications. RESULTS: In vitro fertilization twins were more likely to have preterm labor compared with control twins, with no difference in the incidences of pregnancy-induced hypertension, gestational diabetes mellitus, placenta previa, or preterm premature rupture of membranes between the two groups. The cesarean delivery rate was significantly higher in cases of twins who were conceived by in vitro fertilization (76.8% vs 58.0%, P=.026), despite a similar rate of elective cesarean delivery and the incidence of nonvertex twin A in both groups. The preterm delivery rate was significantly higher (67.9% vs 41.1%, P=.002) and the gestational age was significantly lower (35+/-3 weeks vs 36+/-3 weeks, P=.043) in cases compared with control subjects. Both twins were, on the average, 230 g lighter in the in vitro fertilization group compared with the control group. However, intrauterine growth restriction was more frequent in the control group (36.6% vs 25%, P=.044). There was a significantly higher incidence of admission to the neonatal intensive care unit, respiratory distress syndrome, a need for mechanical ventilation, and pneumothorax in cases compared with control subjects. CONCLUSION: When compared with spontaneous twins, in vitro fertilization twins are more likely to be delivered by cesarean delivery and to have a higher incidence of preterm birth and prematurity-related respiratory complications with a longer nursery stay.

PMID: 14520227 [PubMed - in process]

: Sonographic evaluation of fetal growth and body composition in women with different degrees of normal glucose metabolism.

Parretti E, Carignani L, Cioni R, Bartoli E, Borri P, La Torre P, Mecacci F, Martini E, Scarselli G, Mello G.

Department of Gynecology, Perinatology and Human Reproduction, University of Florence, Florence, Italy.

OBJECTIVE:-To investigate the maternal demographic and metabolic factors contributing to the growth of fetal lean and fat body mass in women whose degree of glucose intolerance is less than that defining gestational diabetes in comparison with women with normal glucose metabolism. RESEARCH DESIGN AND METHODS-Longitudinal sonographic examinations of 66 singleton fetuses without anomalies of nonobese mothers with abnormal oral glucose challenge test (GCT) results and without gestational diabetes (group 1) were compared with those of 123 singleton fetuses without anomalies of nonobese mothers with normal GCT values (group 2). Lean body mass measurements included head circumference, femur length, mid-upper arm, and mid-thigh central areas. Fat body mass measurements included the anterior abdominal wall thickness, the subscapular thickness, and the mid-upper arm and mid-thigh subcutaneous areas. All the women performed a 24-h glucose profile on the day preceding the ultrasound scan. Multivariate logistic regression analysis established best-fit equations for fetal sonographic measurements of fat and lean body mass. Independent variables included groups 1 and 2, maternal age, parity, prepregnancy BMI, gestational age, weight gain during pregnancy, fetal sex, and the following averaged 24-h profile maternal capillary blood glucose values: preprandial, 1-h postprandial, and 2-h postprandial. RESULTS:-No difference was found between the two groups with respect to fetal lean body mass parameters; the factors that contributed significantly and most frequently were gestational age and fetal sex (male). With respect to fetal fat body mass, all the measurements were significantly higher in group 1 than in group 2. In all instances, the significantly contributing factors were gestational age and maternal 1-h postprandial glucose values, whereas another frequent contributor was prepregnancy BMI. CONCLUSIONS:-Our study suggests the possibility of using sonographically determined fetal fat and lean mass measurements as indicators of body composition. The assessment of these parameters, achievable in a noninvasive and reproducible fashion in pregnancies complicated by glucose intolerance, might enable the real-time detection of fetal overgrowth and disproportion, thus opening the possibility of exploring interventions to limit fetal fat accretion, birth weight, and potential resulting morbidity.

PMID: 14514573 [PubMed - in process]

: Effect of modem transmission of blood glucose data on telephone consultation time, clinic work flow, and patient satisfaction for patients with gestational diabetes mellitus.

Kruger DF, White K, Galpern A, Mann K, Massirio A, McLellan M, Stevenson J.

Henry Ford Health System, Detroit, Michigan, USA. dkruger@diabetes.org

PURPOSE: To determine if modem transmission of blood glucose data by patients with gestational diabetes could provide faster communication of results, increased clinic work-flow efficiency, and equivalent accuracy. Participant and health care provider satisfaction with the technique was also assessed. DATA SOURCES: Participants were randomized to the modem group, which used the Acculink Modem to report blood glucose data, or to the control group, which used the telephone to report the data. Telephone consultation time, clinic visit time, and accuracy of data were measured. Participants and health care providers completed satisfaction questionnaires. CONCLUSIONS: No significant differences in telephone consultation time, clinic work-flow efficiency, or accuracy were found between the groups. However, both the modem group and clinic staff were highly satisfied with telemedicine transmission of blood glucose data. IMPLICATIONS FOR PRACTICE: Telemedicine is a convenient method for monitoring patients with gestational diabetes mellitus. As a result of this study, modem transmission was instituted in our clinic for insulin pump patients interested in using modem technology.

PMID: 14509102 [PubMed - in process]

: The impact of an insulin sensitizer, troglitazone, on glucose metabolism in African Americans at risk for type 2 diabetes mellitus: a placebo-controlled, 24-month randomized study.

Schuster D, Gaillard T, Rhinesmith S, Habash D, Osei K.

Department of Internal Medicine, The Ohio State University College of Medicine and Public Health, Columbus, USA.

African Americans (AA) have greater prevalence of type 2 diabetes mellitus (DM), and nondiabetic AA have demonstrated increased insulin resistance when compared with Caucasian Americans (CA). The objective of this study was to examine the impact of chronic use of an insulin sensitizer on glucose metabolism in normal glucose tolerant AA at risk for DM (previous gestational diabetes mellitus [GDM] or first-degree relative with DM). Forty-nine high-risk AA received 200 mg/d troglitazone (TRO) versus 81 age-, weight-, and body mass index (BMI)-matched high-risk AA who received placebo (PLA) for 24 months. Yearly anthropometric measurements, oral glucose tolerance test (OGTT) and frequently sampled intravenous glucose tolerance test (FSIVGTT) were performed. Biochemical parameters were monitored quarterly. There was no significant change in anthropometric measurements over 24 months in TRO versus PLA. There were no significant differences in serum glucose, insulin, or C-peptide incremental area under the curve (AUC) in TRO versus PLA at baseline or 24 months for OGTT and FSIVGTT. The insulin sensitivity (S(I)) for TRO and PLA increased from baseline to 24 months by 17% and 16%, respectively. The TRO demonstrated a 26% increase in insulin/glucose ratio versus 1% increase in the PLA at 24 months. The disposition index (DI) increased 33% from baseline in TRO versus 21% increase in PLA. Modest improvement in glucose metabolism was seen in TRO when compared with PLA. TRO was well tolerated without significant reported adverse events. Based on our current data, the treatment of normal glucose tolerant high-risk AA with thiazolidinedione (TZD) may be beneficial to "reset" and protect glucose metabolism by improving insulin responses. Because of the potential drug-related risks associated with use of TZD and the proven positive impact of diet and exercise in prevention of DM, studies of longer duration with examination of other potentially beneficial parameters, such as cardiovascular indices and inflammatory markers will be necessary to justify the cost in the nondiabetic population.

PMID: 14506629 [PubMed - in process]

: Diet plus insulin compared to diet alone in the treatment of gestational diabetes mellitus: a systematic review.

Giuffrida FM, Castro AA, Atallah AN, Dib SA.

Divis o de Endocrinologia e Metabolismo, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de S o Paulo, S o Paulo, SP, Brasil.

Fetuses of mothers with gestational diabetes mellitus are at increased risk to develop perinatal complications mainly due to macrosomia. However, in view of the marked heterogeneity of this disease, it seems difficult to set guidelines for diagnosis and treatment. This complicates the choice of assigning patients either to diet or to insulin therapy. Also of concern is how much benefit could be expected from insulin therapy in preventing fetal complications in these patients. In a systematic review of the literature assessing the efficacy of insulin in preventing macrosomia in fetuses of mothers with gestational diabetes, we found six randomized controlled trials comparing diet alone to diet plus insulin. The studies included a total of 1281 patients (644 in the diet plus insulin group and 637 in the diet group), with marked differences among trials concerning diagnostic criteria, randomization process and treatment goals. Meta-analysis of the data resulted in a risk difference of -0.098 (95%CI: -0.168 to -0.028), and a number-necessary-to-treat of 11 (95%CI: 6 to 36), which means that it is necessary to treat 11 patients with insulin to prevent one case of macrosomia. This indicates a potential benefit of insulin, but not significantly enough to set treatment guidelines. Because of the heterogeneous evidence available in the literature about this matter, we conclude that larger trials addressing the efficacy of these two therapeutic modalities in preventing macrosomia are warranted.

PMID: 14502360 [PubMed - in process]

: Improving the care of women with gestational diabetes.

Farrell M.

University of Scranton, Room 307 McGurrin Hall, Scranton, PA 18510, USA. farrellm1@scranton.edu

The article reviews gestational diabetes mellitus, including etiology, diagnostic and screening criteria, risk factors, and care of the affected woman. Gestational diabetes mellitus affects approximately 7% of all pregnant women, resulting in more than 200,000 cases each year, and is defined as glucose intolerance that begins or is first recognized during pregnancy. Women are considered at high risk for gestational diabetes if they are markedly obese, have a personal history of gestational diabetes, have a strong family history of diabetes, or have glycosuria. Risk assessment is essential in determining whether a woman should be screened or tested for gestational diabetes. Women who have had gestational diabetes should have comprehensive preconception care prior to a subsequent pregnancy to ascertain appropriate weight, nutrition, exercise, and signs of gestational diabetes.

PMID: 14501631 [PubMed - in process]

: Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation.

Armenti VT, Radomski JS, Moritz MJ, Gaughan WJ, Philips LZ, McGrory CH, Coscia LA; National Transplantation Pregnancy Registry.

Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

The NTPR maintains an ongoing database to study the outcomes of pregnancies in female transplant recipients as well as those pregnancies fathered by male transplant recipients. Recipients are entered into the database by completing. a single page questionnaire. There is steady follow-up of recipients and their offspring. While the majority of pregnancy outcomes have occurred in kidney recipients, data continue to accrue in the other types of organ recipients. KIDNEY: A small percentage of pregnancies in female kidney recipients are complicated by rejection with poorer outcomes with respect to both maternal graft function and their newborn. Other analyses this year focused on outcomes of recipients with systemic lupus erythematosus and those with multiple gestations. It was observed that recipients with systemic lupus erythematosus were able to maintain a pregnancy with outcomes that appear to be similar to other diagnoses. In an analysis of multiple gestations in female kidney recipients maintained on calcineurin inhibitors, no multiple gestations higher than triplets have been reported to the NTPR. Successful outcomes have been noted among these recipients. This does require continued surveillance, as there has been an increase in the number of multiple gestations in the general population with the use of adjunctive technologies. OTHER ORGANS: In analyzing outcomes in female liver recipients, no specific graft or newborn outcome differences have been noted when a comparison has been made between different caicineurin inhibitor regimens. Pregnancies in female pancreas-kidney recipients appear to be tolerated with respect to pancreas graft function with no diagnoses of gestational diabetes reported to the NTPR. Data continue to accrue among thoracic recipients. Poorer maternal survival postpartum in lung recipients may be related to higher risks inherent in this population and requires further experience and investigation. OTHER ISSUES: With the recent proliferation of newer immunosuppressive agents, a question that is raised is whether a regimen can be specifically designed with recipients of childbearing age in mind. Extensive data published on azathioprine and cyclosporine treated recipients suggests that while there is a pattern of prematurity among the newborn there has not been an increase in the incidence or pattern of specific malformations noted among the newborn. Less assurance can be given with newer agents such as sirolimus and MMF. Calcineurin inhibitor minimization or steroid withdrawal would require that other agents with less reproductive information be implemented. The unknown risk of teratogenicity must be balanced against the potential risk of rejection or graft dysfunction when deciding which agent to use during pregnancy. Through each of the organ recipient groups, there are sporadic cases of rejection, graft dysfunction, and graft deterioration. Birth defect patterns have not appeared to be specific to any specific regimen as yet. Two newborns with malformations have been noted among a limited series with MMF exposure, but other factors may also be at play. The use of MMF during pregnancy continues to be an unresolved issue in the transplant community. As yet, no one regimen has been identified as superior to another for use during pregnancy. Continued surveillance with the newer agents is necessary. Investigators have taken differing views regarding the safety of breastfeeding in the transplant recipient population, especially with regard to drug exposure to the infant. This issue remains unresolved and some transplant recipient mothers have chosen to breastfeed. Other factors for consideration are the potential long-term effects on offspring of transplant recipients. While there may not be specific structural defects noted at birth, more subtle effects on either immunologic or reproductive function may not manifest until later in life. Scott and his group in Utah have raised this issue with a case report and have initiated a study to focus on the next generation. The safety of pregnancy for parent and child remain the goals of the NTPR. Continued entries to the registry, especially in light of newer combinations of immunosuppressive agents, should assist in developing guidelines needed for management in this era of expanding immunosuppressive agents. All centers are encouraged to participate.

PMID: 12971441 [PubMed - in process]

: Insulin Regulation in AhR-Null Mice: Embryonic Cardiac Enlargement, Neonatal Macrosomia, and Altered Insulin Regulation and Response in Pregnant and Aging AhR-Null Females.

Thackaberry EA, Bedrick EJ, Goens MB, Danielson L, Lund AK, Gabaldon D, Smith SM, Walker MK.

Molecular and Environmental Toxicology Center, Department of Nutritional Sciences, University of Wisconsin, 1415 Linden Drive, Madison, WI 53706, USA.

The aryl hydrocarbon receptor (AhR) was originally characterized because of its high affinity binding of 2,3,7,8-tetrachlorodibenzo-p-dioxin. However, studies using AhR-null mice have demonstrated the importance of this protein in normal physiology and development. Here we demonstrate that AhR-null embryos develop cardiac enlargement, and that this phenotype is dependent, at least in part, on the maternal genotype. Neonates born to AhR-null females had increased heart weights regardless of the neonatal genotype, an outcome also observed in gestational diabetes. The cardiac hypertrophy markers, beta-myosin heavy chain and atrial natriuretic factor, and the cardiac proliferative index were increased in AhR-null embryos, indicating that the cardiac enlargement is associated with myocyte hypertrophy and hyperplasia, which begins prior to birth. Importantly, two- to three-month-old pregnant and seven-month old non-pregnant females, but not non-pregnant three-month-old AhR-null females had significantly decreased fasting plasma insulin levels, and a reduced ability to respond to exogenous insulin compared to controls. Despite these alterations in insulin regulation and responsiveness, pregnant AhR females had normal glucose tolerance tests and did not develop hyperglycemia, classic characteristics of gestational diabetes. However, twenty-three percent of seven-month-old AhR-null females did have altered glucose tolerance tests, but did not show hyperglycemia or increased hemoglobin A1C concentration under normal feeding conditions. While the ultimate cause of the neonatal phenotype remains unclear, these studies establish that the AhR is required for normal insulin regulation in pregnant and older mice, and cardiac development in embryonic mice.

PMID: 12970579 [PubMed - as supplied by publisher]

13: J Clin Endocrinol Metab. 2003 Sep;88(9):4355-61.

Related Articles, Links

Human placental growth hormone, insulin-like growth factor I and -II, and insulin requirements during pregnancy in type 1 diabetes.

Fuglsang J, Lauszus F, Flyvbjerg A, Ovesen P.

Gynecological/Obstetrical Research Department Y, Aarhus University Hospital, Skejby Sygehus, DK-8200 Aarhus N, Denmark. jens_fuglsang@hotmail.com

Human placental GH (hPGH) replaces pituitary GH during pregnancy. hPGH is correlated to serum IGF-I in normal pregnancies and in pregnancies complicated by fetoplacental disorders. In gestational diabetes and type 2 diabetes no correlation between hPGH and IGF-I has been found. The relationship between hPGH and IGF-I in type 1 diabetes mellitus has not been investigated thoroughly. Furthermore, hPGH may be involved in the development of insulin resistance during pregnancy. In this prospective, longitudinal study, 51 type 1 diabetic subjects were followed with repeated blood sampling during pregnancy (median, 14 blood samples/subject; range, 8-26). Maternal concentrations of serum hPGH, IGF-I, and IGF-II were measured and compared with insulin requirements and birth characteristics. hPGH was detected from as early as 6 wk gestation. In all subjects, a rise in serum hPGH was observed during pregnancy, and the rise between wk 16 and 25 was correlated to the rise between wk 26 and 35 (P < 0.001). From wk 26 onward, the increase in hPGH values was significantly correlated to the birth weight, expressed as a z-score (r(s) = 0.54; P < 0.001), as were the absolute hPGH values. Also, a positive influence of hPGH on placental weight was found. Serum IGF-I values decreased significantly from the first to the second trimester (P < or = 0.021). Serum hPGH correlated to serum IGF-I from wk 24- 35, and changes in IGF-I followed the increase in hPGH between wk 26-35 (r(s) = 0.53; P < 0.001), as did IGF-II (r(s) = 0.37; P = 0.008). Changes in IGF-I and IGF-II between wk 26-35 also correlated to the birth weight z-score (P < or = 0.020), but only hPGH remained significant in multiple regression analysis. Similar results were found in the subgroup delivering at term. Interestingly, the increase in hPGH was not correlated to the increase in insulin requirements, nor was any consistent relationship revealed during each gestational period. In conclusion, our study suggests a role for hPGH in the regulation of both IGFs and fetal growth in type 1 diabetes. In contrast, the increase in insulin requirements during pregnancy in type 1 diabetic subjects could not be related to hPGH levels.

Publication Types:

Clinical Trial

PMID: 12970310 [PubMed - indexed for MEDLINE]

: Does maternal glucose intolerance affect the length of gestation in singleton pregnancies?

Lao TT, Ho LF.

Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong, People's Republic of China

This study determined whether maternal glucose tolerance has a progressive effect on the length of gestation in singleton pregnancies and whether there is an increasing tendency towards spontaneous preterm birth with increasing glucose intolerance.A total of 2168 consecutive Chinese women with singleton pregnancies who underwent the 75-g oral glucose tolerance test (OGTT) over a 24-month period were categorized by their OGTT 2-hour value (mmol/L) into the following six groups: 5.9 or less, 6.0-6.9, 7.0-7.9, 8.0-8.9, 9.0-10.9, and 11.0 or greater mmol/L. Women with a 2-hour glucose value of 8.0 or more mmol/L were considered to have gestational diabetes mellitus (GDM) and received diet treatment. Women who eventually required insulin were excluded from the final analysis. The mean gestational age, birth weight, incidence of preterm birth, large for gestational age (LGA, birth weight > 90th percentile), and macrosomic (birth weight >/= 4.0 kg) infants were compared among the six groups.The incidence of preterm birth correlated significantly with increasing glucose intolerance. On further analysis, incidence of spontaneous birth before 37 weeks in the lowest to the highest 2-hour value groups was as follows: 5.5%, 2.6%, 3.7%, 4.9%, 8.5%, and 10.3% (P =.015) and that before 32 weeks went from 0.4%, 0.3%, 0.8%, 0.4%, 2.2%, to 3.4% (P =.018), respectively. There was no significant difference in the incidence of LGA or macrosomic infants. Regression analysis confirmed that the OGTT 2-hour glucose value was an independent determinant of gestational length.Gestational glucose intolerance affects gestation length and incidence of preterm birth, which should be considered a confounding factor in the analysis of the neonatal outcome of GDM pregnancies.

PMID: 12969780 [PubMed - in process]

: Unexpected fetal death during pregnancy-a problem of unrecognized fetal disorders during antenatal care?

Kunzel W, Misselwitz B.

Department of Obstetrics and Gynaecology, University of Giessen, Klinikstrasse 28, D-35385, Giessen, Germany

OBJECTIVE: To investigate the causes of ante partum fetal death (APFD) and to evaluate the diagnostic methods for prevention. MATERIAL AND METHODS: A population-based retrospective study was conducted in 293091 deliveries from 1996 to 2000 in the State of Hesse, Germany. The investigations focus on mortality of infants during pregnancy, separated between singletons of 37-42 weeks (n=361) and 23-36 weeks (n=550), and multiple births (n=76). In 44 cases, the gestational age was unknown and in 19 cases lower than 23 weeks or greater than 43 weeks. In total 1006 cases remained and were subject for evaluation. RESULTS: Perinatal mortality (PM) was 0.56%. APFD occurred in 1050 cases (0.3%), i.e. 63.5% of PM. Risk factors from the medical history during pregnancy could be identified in 515 cases (51.2%). Significant risk factors were social burden (odds ratio (OR) 58.3), diabetes mellitus (OR 5.4) and gestational diabetes (OR 2.1), psychological burden (OR 4.8), proteinuria (OR 2.8), maternal age (OR 1.7) and maternal smoking, depending on the number of cigarettes. The risk factors show a difference in significance, if related to the gestational age and multiple pregnancies. The contribution of malformations to APFD was 7.8%. There was however a number of unexpected fetal deaths with unidentified risk factors: n=415 (41.3%). In this group, fetal growth restriction was observed in 38.1%. Compared to control, APFD was three to five times higher in fetal growth retardation below the 10th percentile. Fetal death was closely related to fetal surveillance, i.e. the number of antenatal visits, ultrasound measurements, and fetal heart rate monitoring. CONCLUSION: Fetal ante partum fetal death can be reduced at least by 50%, if the available methods for fetal surveillance are employed aiming to detect indications of fetal oxygen deprivation at an early stage.

PMID: 12965095 [PubMed - in process]

: New concepts in insulin resistance of pregnancy and gestational diabetes: long-term implications for mother and offspring.

Barbour L.

PMID: 12963518 [PubMed - as supplied by publisher]

: [Recognition of gestational diabetes]

[Article in German]

Buhling KJ, Dudenhausen JW.

Klinik fur Geburtsmedizin, Charite Campus Virchow-Klinikum, Berlin. kai.buehling@charite.de

In Germany, the diagnosis of gestational diabetes is recognized in only 10% of the patients with gestational diabetes. Therefore 36,000 pregnant patients per year are undiagnosed. The reason is an insufficient screening system which plans only the determination of the glucosuria at each prenatal visit. Several studies have shown the low sensitivity of glucosuria in the detection of gestational diabetes. The majority of the gynecologists are under the assumption of having a healthy pregnant woman in front of them. Therefore a screening with the 50 g-glucose screening test or the 75 g-oral glucose tolerance test is necessary. Our observations have shown an influence of the previous meal on the 50 g-glucose screening test. Therefore we would prefer the one-step screening with the 75 g-oral glucose test. The costs of the one-step or two-step regimen are similar. Also a screening only of high risk pregnancies appears insufficient. Using an average age below 25 years and body-mass index below 25 kg/mg2, only 13.7% of our patients would not be screened. Of those, 3.1% have gestational diabetes. The decision to offer the screening as an individual health achievement, which has to be paid by the patients, does not take into consideration the importance of the illness. A general screening, preferably one-step screening should be offered to each pregnant woman.

PMID: 12961104 [PubMed - in process]

18: Lakartidningen. 2003 Aug 7;100(32-33):2508-11.

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[Pregnancy complications can impair placental transport systems. Aberrant fetal growth, for example in diabetes, is only now beginning to be understood]

[Article in Swedish]

Jansson T, Wennergren M, Powell T.

Institutionen for fysiologi och farmakologi, Sahlgrenska akademin, Goteborgs universitet. thomas.jansson@fysiologi.gu.se

The reduced fetal growth in intrauterine growth restriction (IUGR) has been attributed to decreased placental blood flow whereas maternal hyperglycemia is believed to represent the primary cause of accelerated fetal growth in pregnancies complicated by diabetes. However, recent research has demonstrated specific changes in placental transport function in association to these pregnancy complications that are likely to contribute to the altered fetal growth patterns. For example, in IUGR the activity of certain key amino acid transporters is reduced in the placental barrier and accelerated fetal growth in diabetes is associated with an increased activity of placental glucose and amino acid transporters. Therefore, placental insufficiency in IUGR is not just a question of reduced placental blood flow and up-regulation of placental nutrient transporters in diabetes may explain the high incidence of accelerated fetal growth despite rigorous maternal glycemic control.

Publication Types:

Review
Review, Tutorial

PMID: 12959009 [PubMed - indexed for MEDLINE]

: Cord serum glycodelin concentrations in normal pregnancies and pregnancies complicated by diabetes.

Loukovaara M, Leinonen P, Teramo K, Koistinen R.

Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Haartmaninkatu 2, 00290, Helsinki, Finland.

OBJECTIVE. Glycodelin is a glycoprotein released by secretory/decidualized endometrial glands. Its synthesis increases during pregnancy. Hormonal factors whose levels have been shown to change in diabetes (vascular endothelial growth factor, relaxin) may mediate the actions or regulate the synthesis of glycodelin. Cord serum glycodelin levels have not been studied in pregnancies complicated by diabetes. METHODS. Cord serum glycodelin concentrations were measured at birth by an immunofluorometric assay in 62 normal pregnancies, in 67 pregnancies complicated by type 1 diabetes, and in 28 pregnancies complicated by insulin-treated gestational diabetes. RESULTS. The mean glycodelin concentration in cord serum was 2.7 ng/ml (standard error of the mean 0.6) in normal pregnancies. The concentration was not altered in pregnancies complicated by diabetes. Cord serum glycodelin concentrations were also unaltered in diabetic pregnancies with hypertensive disorders (chronic hypertension, pregnancy-induced hypertension or pre-eclampsia) or fetal macrosomia. There was a negative borderline correlation between cord serum glycodelin concentrations and the birth weight in pregnancies complicated by diabetes ( r=-0.21, p=0.049). CONCLUSIONS. Decidual function, as assessed by cord serum glycodelin levels, is not markedly altered in diabetic pregnancies. The negative correlation between cord serum glycodelin and the birth weight of the newborns in diabetic pregnancies may be due to the decline in glycodelin levels with advancing pregnancy in the third trimester.

PMID: 12955531 [PubMed - as supplied by publisher]

: Computerized analysis of fetal heart rate indices during oral glucose tolerance test.

Weissman A, Goldstick O, Geva A, Zimmer EZ.

Departments of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel. wamir@netvision.net.il

AIMS: To study the effect of maternal glucose ingestion during a 100 g oral glucose tolerance test on fetal heart rate indices. STUDY DESIGN: Prospective study including 50 pregnant patients with an abnormal glucose challenge test who underwent a 100 g glucose tolerance test at 26-28 weeks gestation. Fetal heart rate was recorded and analyzed with the computerized Sonicaid Fetal Monitor System (Oxford 8000). RESULTS: Baseline fetal heart rate significantly increased 120 and 180 minutes following glucose ingestion (p < 0.05) both in patients who were subsequently diagnosed to have gestational diabetes and in these in whom the diagnosis was excluded. No significant changes were noted in other fetal heart indices. CONCLUSIONS: The significant and consistent increase in baseline fetal heart rate following maternal glucose ingestion indicates that the fetus responds to changes in its' environment. The exact mechanism which causes this response has yet to be defined.

PMID: 12951885 [PubMed - in process]