Management of diabetes mellitus complicating pregnancy

Twenty years of pediatric diabetes surveillance: what do we know and why it matters

SEARCH for Diabetes in Youth (SEARCH) was initiated in 2000 as a multicenter study to address major gaps in the understanding of childhood diabetes in the United States. An active registry of youth diagnosed with diabetes at age <20 years since 2002 assessed prevalence, annual incidence, and trends by age, race/ethnicity, sex, and diabetes type. An observational cohort nested within the population-based registry was established to assess the natural history and risk factors for acute and chronic diabetes-related complications, as well as the quality of care and quality of life of children and adolescents with diabetes from diagnosis into young adulthood. SEARCH findings have contributed to a better understanding of the complex and heterogeneous nature of youth-onset diabetes. Continued surveillance of the burden and risk of type 1 and type 2 diabetes is important to track and monitor incidence and prevalence within the population. SEARCH reported evidence of early diabetes complications highlighting that continuing the long-term follow-up of youth with diabetes is necessary to further our understanding of its natural history and to develop the most appropriate approaches to primary, secondary, and tertiary prevention of diabetes and its complications. This review summarizes two decades of research and suggests avenues for further work.

The impact of a vegan diet on pregnancy outcomes

OBJECTIVE

To determine the effect of a maternal vegan diet on pregnancy outcome.

STUDY DESIGN

This is a prospective observational study. Women with a singleton pregnancy who maintained the same diet prior to, and throughout current pregnancy were enrolled. Stratification was performed according to diet type: vegans, lacto-ovo-vegetarians, fish-eaters, and omnivores.

RESULTS

Overall, 273 women were enrolled, of them, 112 omnivores, 37 fish-eaters, 64 lacto-ovo-vegetarians, and 60 vegans. The vegan diet was significantly associated with an increased risk of small-for-gestational-age newborns compared only to an omnivore diet (RR = 5.9, 95% CI, 1.2-21.8). The incidence of preterm birth was similar in all groups. Vegans had lower birthweight compared to lacto-ovo-vegetarians (3015 ± 420 g vs. 3285 ± 482 g, P = 0.004), and to omnivores (3328 ± 495 g, P < 0.001), but not to fish-eaters. Vegans also had a lower mean gestational weight gain compared only to omnivores (11.6 ± 4.2 kg vs. 14.3 ± 4.6 kg, P = 0.001).

CONCLUSION

The vegan diet is associated with an increased risk for small-for-gestational-age newborns and lower birthweight.

Magnitude of Pre-Existing Diabetes Mellitus Among Pregnant Women in Southern Ethiopia: A Cross-Sectional Study

Background

The presence of maternal diabetes mellitus (DM) during pregnancy has complications for both mother and child. Pre-existing DM can result in higher risk of maternal and child mortality and morbidity. In Ethiopia, the magnitude of pre-existing DM among pregnant women is not well studied. The aim of this study was to assess the magnitude of pre-existing DM among pregnant women in Wolaita Zone, Southern Ethiopia.

Methods

A retrospective document review was carried out to determine the magnitude of pre-existing DM in three hospitals and four health centers in Wolaita Zone, Southern Ethiopia. A total of 600 pregnant mothers who attended maternity services at the study health facilities in one year period from January 1, to December 31, 2017 were included in the study. Data were collected from medical records of mothers. Chi-square and logistic regression analysis model were used to check the relationship between pre-existing DM and independent variables.

Results

A total of 600 mothers were included in the analysis. The magnitude of pre-existing DM among mothers receiving maternity care within a one year period was 2.8% (95% CI: 1.5, 4.2). The magnitudes among urban and rural residents were 3.4% and 1.4%, respectively. Pre-existing DM is significantly associated with family history of diabetes (Chi square 24.8, P-value, 0.001). Previous history of spontaneous abortion (aOR: 5.3; 95% CI: 1.6–17.4) and fetal macrosomia (aOR: 3.9; 95% CI: 1.2–13.1), was identified to be significantly associated with pre-existing DM. The magnitude of pre-existing DM is comparable with International Diabetes Federation Estimate to Ethiopia in the study area. Family history of DM was found to be associated with pre-existing DM. Pre-existing DM is associated with increased risk of abortion and fetal macrosomia.

Conclusion

The magnitude of pre-existing DM is comparable with previous estimates to the country. A nationwide, large-scale study is important to estimate the burden of pre-existing DM and associated risk factors among pregnant mothers at national level.

Diseases and conditions that impact maternal and fetal health and the potential for nanomedicine therapies

Maternal mortality rates in the United States have steadily increased since 1987 to the current rate of over 16 deaths per 100,000 live births. Whereas most of these deaths are related to an underlying condition, such as cardiovascular disease, many pregnant women die from diseases that emerge as a consequence of pregnancy. Both pre-existing and emergent diseases and conditions are difficult to treat in pregnant women because of the potential harmful effects of the treatment on the developing fetus. Often the health of the woman and the health of the baby are at odds and must be weighed against each other when medical treatment is needed, frequently leading to iatrogenic preterm birth. However, the use of engineered nanomedicines has the potential to fill the treatment gap for pregnant women. This review describes several conditions that may afflict pregnant women and fetuses and introduces how engineered nanomedicines may be used to treat these illnesses. Although the field of maternal-fetal nanomedicine is in its infancy, with additional research and development, engineered nanotherapeutics may greatly improve outcomes for pregnant women and their offspring in the future.

Prevalence, risk factors and morbidities of gestational diabetes among pregnant women attending a hospital in an urban area of Bhubaneswar, Odisha

Background

Gestational diabetes mellitus (GDM) causes several maternal and neonatal complications.

Aims

This exploratory study was conducted to estimate the prevalence, determine the risk factors and morbidities among pregnant women.

Methods

In this prospective study, 1557 pregnant women attending the Gyn. & Obs. clinic of a hospital in an urban area of Bhubaneswar were enrolled. Various socio-demographic factors and clinical profiles were assessed. We used a Glucometer for the diagnosis of GDM.

Results

More younger pregnant women residing in slums, sedentary and overweight were having diabetes. A large percentage of pregnant women living in rural areas and slums visit the government hospitals as they are benefitted by the State govt.'s scheme, Mamata. Pregnant women residing in the urban areas prefer to go for ante-natal check-ups in private Nursing homes/Clinics owing to the crowd and prolonged waiting hours. In this study, body mass index (BMI) and family history of the pregnant women appeared to be the significant risk factors for the gestational diabetes. Out of 1557 pregnant women, 154 were having diabetes, the prevalence being 9.89%. This is low when compared to the studies reported from other regions of the country.

Conclusions

Gluco-One is suitable for screening gestational diabetes using the optimal threshold capillary glucose level of 140 mg/dl. As the pregnant women find it difficult to come the next day just to collect the results, this facilitated in getting the test results promptly and appropriate consultation by Doctor the same day. Glucometer can be used for accurate screening of gestational diabetes mellitus. Pregnant women with screening values not normal were identified on the spot and followed up at regular intervals. Screening for diabetes among pregnant women would result in early case detection indirectly resulting in better outcomes of treatment and prevention of complications.

Definition and Multiple Factors of Recurrent Spontaneous Abortion

Recurrent spontaneous abortion (RSA) is usually defined as three or more spontaneous abortions prior to 20-28 weeks gestation. RSA affects approximately 2-5% of all women of childbearing age, and it brings tremendous psychological and psychiatric trauma to the women and also results in economic burden. The causes could be female age, anatomical and chromosomal abnormalities, genetic, endocrinological, placental anomalies, infection, smoking and alcohol consumption, psychological factor, exposure to environmental factors such as heavy metal, environment pollution, and radiation.

Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes

BACKGROUND

There are a number of ways of monitoring blood glucose in women with diabetes during pregnancy, with self-monitoring of blood glucose (SMBG) recommended as a key component of the management plan. No existing systematic reviews consider the benefits/effectiveness of different techniques of blood glucose monitoring on maternal and infant outcomes among pregnant women with pre-existing diabetes. The effectiveness of the various monitoring techniques is unclear. This review is an update of a review that was first published in 2014 and subsequently updated in 2017.

OBJECTIVES

To compare techniques of blood glucose monitoring and their impact on maternal and infant outcomes among pregnant women with pre-existing diabetes.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM), automated telemedicine monitoring or clinic monitoring among pregnant women with pre-existing diabetes mellitus (type 1 or type 2). Trials investigating timing and frequency of monitoring were also eligible for inclusion. RCTs using a cluster-randomised design were eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This review update includes a total of 12 trials (863) women (792 women with type 1 diabetes and 152 women with type 2 diabetes). The trials took place in Europe, the USA and Canada. Three of the 12 included studies are at low risk of bias, eight studies are at moderate risk of bias, and one study is at high risk of bias. Four trials reported that they were provided with the continuous glucose monitors free of charge or at a reduced cost by the manufacturer.Continuous glucose monitoring (CGM) versus intermittent glucose monitoring, (four studies, 609 women)CGM may reduce hypertensive disorders of pregnancy (pre-eclampsia and pregnancy-induced hypertension) (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.85; 2 studies, 384 women; low-quality evidence), although it should be noted that only two of the four relevant studies reported data for this composite outcome. Conversely, this did not translate into a clear reduction for pre-eclampsia (RR 0.65, 95% CI 0.39 to 1.08; 4 studies, 609 women, moderate-quality evidence). There was also no clear reduction in caesarean section (average RR 0.94, 95% CI 0.75 to 1.18; 3 studies, 427 women; I² = 41%; moderate-quality evidence) or large-for-gestational age (average RR 0.84, 95% CI 0.57 to 1.26; 3 studies, 421 women; I² = 70%; low-quality evidence) with CGM. There was not enough evidence to assess perinatal mortality (RR 0.82, 95% CI 0.05 to 12.61, 71 infants, 1 study; low-quality evidence), or mortality or morbidity composite (RR 0.80, 95% CI 0.61 to 1.06; 1 study, 200 women) as the evidence was based on single studies of low quality. CGM appears to reduce neonatal hypoglycaemia (RR 0.66, 95% CI 0.48 to 0.93; 3 studies, 428 infants). Neurosensory disability was not reported.Other methods of glucose monitoringFor the following five comparisons, self-monitoring versus a different type of self-monitoring (two studies, 43 women); self-monitoring at home versus hospitalisation (one study, 100 women), pre-prandial versus post-prandial glucose monitoring (one study, 61 women), automated telemedicine monitoring versus conventional system (three studies, 84 women), and constant CGM versus intermittent CGM (one study, 25 women), it is uncertain whether any of the interventions has any impact on any of our GRADE outcomes (hypertensive disorders of pregnancy, caesarean section, large-for-gestational age) because the quality of the evidence was found to be very low. This was due to evidence largely being derived from single trials, with design limitations and limitations with imprecision (wide CIs, small sample sizes, and few events). There was not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Other important outcomes, such as neurosensory disability, were not reported in any of these comparisons.

AUTHORS' CONCLUSIONS

Two new studies (406 women) have been incorporated to one of the comparisons for this update. Although the evidence suggests that CGM in comparison to intermittent glucose monitoring may reduce hypertensive disorders of pregnancy, this did not translate into a clear reduction for pre-eclampsia, and so this result should be viewed with caution. No differences were observed for other primary outcomes for this comparison. The evidence base for the effectiveness of other monitoring techniques analysed in the other five comparisons is weak and based on mainly single studies with very low-quality evidence. Additional evidence from large well-designed randomised trials is required to inform choices of other glucose monitoring techniques and to confirm the effectiveness of CGM.

The efficacy of omega-3 fatty acid for gestational diabetes: a meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of omega-3 fatty acid to treat gestational diabetes remains controversial. We conduct a systematic review and meta-analysis to explore the influence of omega-3 fatty acid versus placebo on gestational diabetes.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through March 2018 for randomized controlled trials (RCTs) assessing the effect of omega-3 fatty acid versus placebo on gestational diabetes. This meta-analysis is performed using the random-effect model.

RESULTS

Five RCTs are included in the meta-analysis. Overall, compared with control group for gestational diabetes, omega-3 fatty acid can significantly reduce fasting plasma glucose (FPG) (mean difference (MD) = -4.91; 95% confidence interval (CI) = -8.16 to -1.66; p = .003), homeostatic model of assessment for insulin resistance (HOMA-IR, MD = -0.99; 95% CI = -1.61 to -0.37; p = .002), high sensitivity C-reactive protein (hs-CRP, MD = -1.43; 95% CI = -2.54 to -0.31; p = .01), but has no remarkable influence on preterm delivery (RR = 1.61; 95% CI = 0.36-7.16; p = .53), gestational age (MD = 0.09; 95% CI = -0.01 to 0.20; p = .08), macrosomia (RR = 0.64; 95% CI = 0.26-1.62; p = .3), newborn weight (MD = 3.37; 95% CI = -15.75 to 22.50; p = .73), and 5-min Apgar score (MD = 0; 95% CI = -0.02 to 0.02; p = .92).

CONCLUSIONS

Omega-3 fatty acids is associated with significantly reduced FPG, HOMA-IR, and hs-CRP in patients with gestational diabetes.

Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes

BACKGROUND

Self-monitoring of blood glucose (SMBG) is recommended as a key component of the management plan for diabetes therapy during pregnancy. No existing systematic reviews consider the benefits/effectiveness of various techniques of blood glucose monitoring on maternal and infant outcomes among pregnant women with pre-existing diabetes. The effectiveness of the various monitoring techniques is unclear.

OBJECTIVES

To compare techniques of blood glucose monitoring and their impact on maternal and infant outcomes among pregnant women with pre-existing diabetes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), searched reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM) or clinic monitoring among pregnant women with pre-existing diabetes mellitus (type 1 or type 2). Trials investigating timing and frequency of monitoring were also included. RCTs using a cluster-randomised design were eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This review update includes at total of 10 trials (538) women (468 women with type 1 diabetes and 70 women with type 2 diabetes). The trials took place in Europe and the USA. Five of the 10 included studies were at moderate risk of bias, four studies were at low to moderate risk of bias, and one study was at high risk of bias. The trials are too small to show differences in important outcomes such as macrosomia, preterm birth, miscarriage or death of baby. Almost all the reported GRADE outcomes were assessed as being very low-quality evidence. This was due to design limitations in the studies, wide confidence intervals, small sample sizes, and few events. In addition, there was high heterogeneity for some outcomes.Various methods of glucose monitoring were compared in the trials. Neither pooled analyses nor individual trial analyses showed any clear advantages of one monitoring technique over another for primary and secondary outcomes. Many important outcomes were not reported.1. Self-monitoring versus standard care (two studies, 43 women): there was no clear difference for caesarean section (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.40 to 1.49; one study, 28 women) or glycaemic control (both very low-quality), and not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Hypertensive disorders of pregnancy, large-for-gestational age, neurosensory disability, and preterm birth were not reported in either study.2. Self-monitoring versus hospitalisation (one study, 100 women): there was no clear difference for hypertensive disorders of pregnancy (pre-eclampsia and hypertension) (RR 4.26, 95% CI 0.52 to 35.16; very low-quality: RR 0.43, 95% CI 0.08 to 2.22; very low-quality). There was no clear difference in caesarean section or preterm birth less than 37 weeks' gestation (both very low quality), and the sample size was too small to assess perinatal mortality (very low-quality). Large-for-gestational age, mortality or morbidity composite, neurosensory disability and preterm birth less than 34 weeks were not reported.3. Pre-prandial versus post-prandial glucose monitoring (one study, 61 women): there was no clear difference between groups for caesarean section (RR 1.45, 95% CI 0.92 to 2.28; very low-quality), large-for-gestational age (RR 1.16, 95% CI 0.73 to 1.85; very low-quality) or glycaemic control (very low-quality). The results for hypertensive disorders of pregnancy: pre-eclampsia and perinatal mortality are not meaningful because these outcomes were too rare to show differences in a small sample (all very low-quality). The study did not report the outcomes mortality or morbidity composite, neurosensory disability or preterm birth.4. Automated telemedicine monitoring versus conventional system (three studies, 84 women): there was no clear difference for caesarean section (RR 0.96, 95% CI 0.62 to 1.48; one study, 32 women; very low-quality), and mortality or morbidity composite in the one study that reported these outcomes. There were no clear differences for glycaemic control (very low-quality). No studies reported hypertensive disorders of pregnancy, large-for-gestational age, perinatal mortality (stillbirth and neonatal mortality), neurosensory disability or preterm birth.5.CGM versus intermittent monitoring (two studies, 225 women): there was no clear difference for pre-eclampsia (RR 1.37, 95% CI 0.52 to 3.59; low-quality), caesarean section (average RR 1.00, 95% CI 0.65 to 1.54; I² = 62%; very low-quality) and large-for-gestational age (average RR 0.89, 95% CI 0.41 to 1.92; I² = 82%; very low-quality). Glycaemic control indicated by mean maternal HbA1c was lower for women in the continuous monitoring group (mean difference (MD) -0.60 %, 95% CI -0.91 to -0.29; one study, 71 women; moderate-quality). There was not enough evidence to assess perinatal mortality and there were no clear differences for preterm birth less than 37 weeks' gestation (low-quality). Mortality or morbidity composite, neurosensory disability and preterm birth less than 34 weeks were not reported.6. Constant CGM versus intermittent CGM (one study, 25 women): there was no clear difference between groups for caesarean section (RR 0.77, 95% CI 0.33 to 1.79; very low-quality), glycaemic control (mean blood glucose in the 3rd trimester) (MD -0.14 mmol/L, 95% CI -2.00 to 1.72; very low-quality) or preterm birth less than 37 weeks' gestation (RR 1.08, 95% CI 0.08 to 15.46; very low-quality). Other primary (hypertensive disorders of pregnancy, large-for-gestational age, perinatal mortality (stillbirth and neonatal mortality), mortality or morbidity composite, and neurosensory disability) or GRADE outcomes (preterm birth less than 34 weeks' gestation) were not reported.

AUTHORS' CONCLUSIONS

This review found no evidence that any glucose monitoring technique is superior to any other technique among pregnant women with pre-existing type 1 or type 2 diabetes. The evidence base for the effectiveness of monitoring techniques is weak and additional evidence from large well-designed randomised trials is required to inform choices of glucose monitoring techniques.

Endocrine dysfunction and recurrent spontaneous abortion: An overview

Miscarriage is the spontaneous loss of a fetus before it is viable, occurring at a rate of 15–20%. Recurrent spontaneous abortion (RSA) or habitual miscarriage is defined as repeated occurrence of 3 or more miscarriages before 20^th week of gestation accounting for the most common complication of early pregnancy in humans. Various etiological factors responsible for recurrent miscarriage are anatomical, genetical, endocrinological, immunological, and infectious. The endocrinological abnormalities may be polycystic ovarian syndrome, hyperprolactinemia, luteal phase defect, thyroid dysfunction, diabetes, or hyperandrogenism contributing to recurrent pregnancy loss. In the present article, the role of endocrinological disorders in patients with RSA has been reviewed. The article search was done using electronic databases, Google scholarly articles, and PubMed based on different key words. We have further combined the searches and made grouping as per various endocrine abnormalities, which might be responsible to cause spontaneous loss of fetus.

Dysregulated LIF-STAT3 pathway is responsible for impaired embryo implantation in a Streptozotocin-induced diabetic mouse model

The prevalence of diabetes is increasing worldwide with the trend of patients being young and creating a significant burden on health systems, including reproductive problems, but the effects of diabetes on embryo implantation are still poorly understood. Our study was to examine effects of diabetes on mouse embryo implantation, providing experimental basis for treating diabetes and its complications. Streptozotocin (STZ) was applied to induce type 1 diabetes from day 2 of pregnancy or pseudopregnancy in mice. Embryo transfer was used to analyze effects of uterine environment on embryo implantation. Our results revealed that the implantation rate is significantly reduced in diabetic mice compared to controls, and the change of uterine environment is the main reason leading to the decreased implantation rate. Compared to control, the levels of LIF and p-STAT3 are significantly decreased in diabetic mice on day 4 of pregnancy, and serum estrogen level is significantly higher. Estrogen stimulates LIF expression under physiological level, but the excessive estrogen inhibits LIF expression. LIF, progesterone or insulin supplement can rescue embryo implantation in diabetic mice. Our data indicated that the dysregulated LIF-STAT3 pathway caused by the high level of estrogen results in the impaired implantation in diabetic mice, which can be rescued by LIF, progesterone or insulin supplement.

Vascular complications in the diabetic pregnancy

Long-standing hyperglycemia frequently leads to vasculopathy. Microvascular disease is characterized by retinopathy and nephropathy, while macrovascular involvement can affect coronary arteries. Diabetic autonomic neuropathy, when present, is generally associated with retinal and/or renal involvement. Early identification of these diabetic complications allows appropriate counseling and early treatment. Among women with diabetic vasculopathy, nephropathy, chronic hypertension, preeclampsia, preterm delivery, and fetal growth restriction are frequently observed. Furthermore, women with impaired renal function in early pregnancy have increased risk of long-term deterioration of glomerular filtration rate. Proliferative retinopathy can progress during pregnancy and 1 year after delivery, but long-term effects are not likely to occur. When coronary artery disease or gastroparesis diabeticorum are present, excessive maternal and fetal morbidity is observed. When modern management is synchronized with early medical care, favorable maternal and perinatal outcomes can be expected.

Omega-3 fatty acid supplementation affects pregnancy outcomes in gestational diabetes: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

This study was designed to assess the effects of omega-3 fatty acid supplementation on inflammatory factors, biomarkers of oxidative stress, and pregnancy outcomes among pregnant women with gestational diabetes (GDM).

METHODS

This randomized, double-blind, placebo-controlled clinical trial was performed among 56 women with GDM. Subjects were randomly selected to receive either 1000 mg omega-3 fatty acid supplements (containing 180 mg eicosapentaenoic acid and 120 mg docosahexanoic acid) (n = 27) or a placebo (n = 27) for 6 weeks. Fasting blood samples were taken at study baseline and after 6 weeks of intervention to quantify biochemical variables. Newborn's weight, height, head circumference, Apgar score, and hyperbilirubinemia were determined.

RESULTS

At the end of the 6 weeks, taking omega-3 fatty acid significantly decreased serum high-sensitivity C-reactive protein (hs-CRP) (change from baseline: -245.1 ± 1570.5 versus + 913.9 ± 2329.4 ng/mL, p = 0.03) and plasma malondialdehyde (MDA) concentrations (-0.4 ± 1.3 versus + 0.6±2.3, p = 0.04) compared with the placebo. Supplementation with omega-3 had a low incidence of hyperbilirubinemiain newborns (7.7% versus 33.3%, p = 0.02) and decreased newborns' hospitalization rate (7.7% versus 33.3%, p = 0.02).

CONCLUSIONS

Taken together, omega-3 fatty acid supplementation in GDM women had beneficial effects on maternal serum hs-CRP, plasma MDA levels, incidence of newborn's hyperbilirubinemia, and hospitalization.

Glucose and metformin modulate human first trimester trophoblast function: a model and potential therapy for diabetes-associated uteroplacental insufficiency

PROBLEM

Diabetes confers an increased risk of preeclampsia, but its pathogenic role in preeclampsia is poorly understood. The objective of this study was to elucidate the effects of excess glucose on trophoblast function and whether any changes could be reversed by metformin.

METHOD OF STUDY

The human first trimester trophoblast cell line (Sw.71) was treated with glucose at 5, 10, 25, and 50 mm, in the presence and absence of metformin. Trophoblast migration was quantified and supernatant cytokine, chemokine, and angiogenic factors measured.

RESULTS

Increasing concentrations of glucose significantly increased trophoblast secretion of the inflammatory cytokines/chemokines: IL-1β, IL-6, IL-8, GRO-α, RANTES, and G-CSF; significantly increased trophoblast secretion of the anti-angiogenic factors sFlt-1 and sEndoglin; and significantly decreased trophoblast migration. Excess glucose-induced trophoblast IL-1β production was inhibited by disabling the Nalp3/ASC inflammasome. Metformin partially reduced the glucose-induced inflammatory response, but had no effect on the anti-angiogenic or antimigratory response.

CONCLUSION

Excess glucose induced a pro-inflammatory, anti-angiogenic, and antimigratory state in first trimester trophoblast cells. Glucose-induced trophoblast IL-1β secretion was mediated by the inflammasome. Glucose-induced inflammation was partially reversed by metformin. These findings demonstrate the pleiotropic effects of hyperglycaemia on the trophoblast, providing potential explanations for the strong link between diabetes and preeclampsia.

Role of ultrasound in the management of diabetes in pregnancy

The purpose of this review is to discuss the established role of ultrasound (US) in the management of pregnancy complicated by diabetes mellitus (DM), as well as new developments with regard to the use of US in this situation. We choose to explore the role of US in pregnancy complicated by DM in three areas: (1) Role of US in estimation of fetal weight. (2) Role of US in diagnosis of congenital malformation. (3) Role of US in monitoring diabetic pregnant patients.

The effect of DASH diet on pregnancy outcomes in gestational diabetes: a randomized controlled clinical trial

BACKGROUND/OBJECTIVES

The current study was performed to investigate the effects of the Dietary Approaches to Stop Hypertension (DASH) eating plan on pregnancy outcomes in pregnant women with gestational diabetes mellitus (GDM).

SUBJECTS/METHODS

This randomized controlled clinical trial was performed among 52 women diagnosed with GDM. Participants were randomly assigned to consume either the control (n=26) or the DASH diet (n=26) for 4 weeks. The control diet was designed to contain 45-55% carbohydrates, 15-20% protein and 25-30% total fat. The DASH diet was rich in fruits, vegetables, whole grains and low-fat dairy products, and contained lower amounts of saturated fats, cholesterol and refined grains with a total of 2400 mg/day sodium. The numbers of women who commenced insulin therapy after dietary intervention, the mode of delivery and prevalence of polyhydramnios were assessed. The length, weight and head circumference of infants were measured during the first 24 h after birth.

RESULTS

Whereas 46.2% of women in the DASH diet needed to have a cesarean section, this percentage for the control group was 80.8% (P=0.01). The percentage of those who needed to commence insulin therapy after intervention was also significantly different between the two groups (23% for DASH vs 73% for control group, P<0.0001). Infants born to mothers on the DASH diet had significantly lower weight (3222.7 vs 3818.8 g, P<0.0001), head circumference (34.2 vs 35.1 cm, P=0.01) and ponderal index (2.50 vs 2.87 kg/m(3), P<0.0001) compared with those born to mothers on the control diet.

CONCLUSIONS

In conclusion, consumption of DASH diet for 4 weeks among pregnant women with GDM resulted in improved pregnancy outcomes.

Macrophage infiltration and stress-signaling in omental and subcutaneous adipose tissue in diabetic pregnancies

OBJECTIVE

To examine if, as in obesity, pregnancies complicated by gestational diabetes mellitus (GDM) exhibit increased macrophage infiltration and activated MAP-kinases in omental adipose tissue.

METHODS

Paired omental (OM) and abdominal subcutaneous (SC) fat samples were collected from 11 GDM and 20 normal pregnancies during cesarean delivery. Tissues were stained to detect macrophages, and analyzed to assess MAP-kinases.

RESULTS

OM had higher macrophage counts than SC in GDM (6.10 ± 2.20 versus 2.53 ± 1.45, p = 0.04), but not in normal pregnancies (p = 0.346). GDM pregnancies had more macrophages than normal pregnancies in OM (6.10 ± 2.20 versus 1.29 ± 0.55, p = 0.01), while only a trend was observed in SC fat (p = 0.08). Significant correlation (R = 0.619, p = 0.005) was observed between OM-macrophage infiltration and insulin resistance. Using multivariate analysis, only obesity independently associated with GDM. Expression of total p38MAP-kinase was higher in OM versus SC in both normal and GDM pregnancies, without significant differences between these groups. However, expression of activated p-p38MAP-kinase, and its upstream kinase MKK4, was comparable between fat depots.

CONCLUSION

GDM pregnancies demonstrate increased macrophage infiltration to OM fat, correlating with higher insulin resistance. As in non-pregnant-patients obesity and OM macrophage infiltration may be on the same causal pathway, leading to GDM. Yet, this occurs without activation of p38MAP-kinase signaling.

New concepts in diabetic embryopathy

Diabetes mellitus is responsible for nearly 10% of fetal anomalies in diabetic pregnancies. Although aggressive perinatal care and glycemic control are available in developed countries, the birth defect rate in diabetic pregnancies remains higher than that in the general population. Major cellular activities (ie, proliferation and apoptosis) and intracellular metabolic conditions (ie, nitrosative, oxidative, and endoplasmic reticulum stress) have been shown to be associated with diabetic embryopathy using animal models. Translating advances made in animal studies into clinical applications in humans requires collaborative efforts across the basic research, preclinical, and clinical communities.

Amniotic fluid oxidative and nitrosative stress biomarkers correlate with fetal chronic hypoxia in diabetic pregnancies

BACKGROUND

In spite of improvement in obstetrical care, pregnancy in women with type 1 diabetes mellitus is associated with increased perinatal morbidity and mortality. Hyperglycemia during pregnancy causes excessive fetal growth and chronic fetal hypoxia as reflected in increased erythropoietin (EPO) levels in amniotic fluid (AF).

OBJECTIVES

We hypothesized that the degree of fetal hypoxia would correlate with fetal oxidative and nitrosative stress as evidenced ty the concentration of specific biomarkers in AF.

MATERIAL AND METHODS

19 pregnant women with type 1 or insulin-treated gestational diabetes mellitus were studied. AF samples were collected and processed for EPO, meta-tyrosine, nitro-tyrosine and 8-hydroxy-2-deoxiguanosine by chemiluminescent immunoassay and high-performance liquid chromatography coupled to tandem mass spectrometry methods, respectively.

RESULTS

The mean (SD) of the last HbA1c concentration before delivery was 7.7% (1.1). Median gestational age was 258 days (range 231-268). Birth weight was 3,868 ± 695 g with a z-score >2 SD in 47% of the cases. A significant correlation was found between the concentrations of AF EPO and meta-tyrosine/phenylalanine ratio (p < 0.001), nitro-tyrosine (p < 0.01) and 8-oxo-dG/2dG ratio (p < 0.001).

CONCLUSIONS

We confirmed that fetuses of type 1 diabetes or insulin-treated gestational diabetes pregnancies experience chronic hypoxia as reflected by increased EPO concentrations in AF near term. Moreover, EPO levels significantly correlated with the concentration of oxidative and nitrosative stress biomarkers in AF. This pro-oxidant status may predispose newborn infants to poor postnatal adaptation and early neonatal complications.

Frontiers in research on maternal diabetes-induced neural tube defects: Past, present and future

Diabetes mellitus rightly regarded as a silent-epidemic is continually on the rise and estimated to have a global prevalence of 6.4 % as of 2010. Diabetes during pregnancy is a well known risk factor for congenital anomalies in various organ systems that contribute to neonatal mortality, including cardiovascular, gastrointestinal, genitourinary and neurological systems, among which the neural tube defects are frequently reported. Over the last two to three decades, several groups around the world have focussed on identifying the molecular cues and cellular changes resulting in altered gene expression and the morphological defects and in diabetic pregnancy. In recent years, the focus has gradually shifted to looking at pre-programmed changes and activation of epigenetic mechanisms that cause altered gene expression. While several theories such as oxidative stress, hypoxia, and apoptosis triggered due to hyperglycemic conditions have been proposed and proven for being the cause for these defects, the exact mechanism or the link between how high glucose can alter gene expression/transcriptome and activate epigenetic mechanisms is largely unknown. Although preconceptual control of diabetes, (i.e., managing glucose levels during pregnancy), and in utero therapies has been proposed as an effective solution for managing diabetes during pregnancy, the impact that a fluctuating glycemic index can have on foetal development has not been evaluated in detail. A tight glycemic control started before pregnancy has shown to reduce the incidence of congenital abnormalities in diabetic mothers. On the other hand, a tight glycemic control after organogenesis and embryogenesis have begun may prove insufficient to prevent or reverse the onset of congenital defects. The importance of determining the extent to which glycemic levels in diabetic mothers should be regulated is critical as foetal hypoglycemia has also been shown to be teratogenic. Finally, the major question remaining is if this whole issue is negligible and not worthy of investigation as the efficient management of diabetes during pregnancy is well in place in many countries.

Effect of pregnancy for females born small on later life metabolic disease risk

There is a strong inverse relationship between a females own birth weight and her subsequent risk for gestational diabetes with increased risk of developing diabetes later in life. We have shown that growth restricted females develop loss of glucose tolerance during late pregnancy with normal pancreatic function. The aim of this study was to determine whether growth restricted females develop long-term impairment of metabolic control after an adverse pregnancy adaptation. Uteroplacental insufficiency was induced by bilateral uterine vessel ligation (Restricted) or sham surgery (Control) in late pregnancy (E18) in F0 female rats. F1 Control and Restricted female offspring were mated with normal males and allowed to deliver (termed Ex-Pregnant). Age-matched Control and Restricted Virgins were also studied and glucose tolerance and insulin secretion were determined. Pancreatic morphology and hepatic glycogen and triacylglycerol content were quantified respectively. Restricted females were born lighter than Control and remained lighter at all time points studied (p<0.05). Glucose tolerance, first phase insulin secretion and liver glycogen and triacylglycerol content were not different across groups, with no changes in β-cell mass. Second phase insulin secretion was reduced in Restricted Virgins (-34%, p<0.05) compared to Control Virgins, suggestive of enhanced peripheral insulin sensitivity but this was lost after pregnancy. Growth restriction was associated with enhanced basal hepatic insulin sensitivity, which may provide compensatory benefits to prevent adverse metabolic outcomes often associated with being born small. A prior pregnancy was associated with reduced hepatic insulin sensitivity with effects more pronounced in Controls than Restricted. Our data suggests that pregnancy ameliorates the enhanced peripheral insulin sensitivity in growth restricted females and has deleterious effects for hepatic insulin sensitivity, regardless of maternal birth weight.

Accuracy of Fetal Weight Estimation in Women with Diet Controlled Gestational Diabetes

Purpose: To evaluate whether ultrasound accuracy of estimated fetal weight (EFW) differs in women with diet controlled gestational diabetes mellitus (GDM) compared to nondiabetic pregnant women. Material and Methods: We included 363 patients, 121 patients with diet controlled GDM and 242 patients with a normal oral glucose tolerance test (oGTT). Each case of diet controlled GDM was matched with 2 unaffected controls. All patients were screened/diagnosed for GDM by means of an oGTT. Both groups received ultrasound examination including fetal biometry, using Hadlock's Formula, within 7 days to delivery. After birth, gestational age, birthweight and Apgar scores were collected from each newborn. Results: There was a good correlation between EFW and birth weight (coefficient = 0.747, p < 0.001 by Pearson correlation, even after adjustment for glucose status). Regression analyses, including noGDM/GDM, maternal age, maternal body mass index, birth weight and time interval between ultrasound and delivery revealed that only fetal birth weight significantly influences weight difference between ultrasound EFW and actual birth weight at term. Conclusion: Our data suggests that ultrasound accuracy of EFW using Hadlock's Formula at term does not differ in women with diet controlled GDM compared to women with normal glucose tolerance.

Contraception, and pregnancy in adolescents with type 1 diabetes: a review

Adolescence is a critical period for girls with type 1 diabetes mellitus (T1D). Reproductive issues, such as menstrual abnormalities, risk of an unplanned pregnancy, and contraception, should be addressed during this phase of life. This paper reviews several reproductive issues that are important in the care of adolescents, including pubertal development, menstrual abnormalities, ovulatory function, reproductive problems, the effects of hyperglycemia, contraception, and treatment of an unplanned pregnancy. A review of the literature was conducted. A MEDLINE search January 1966 to March 2011 was performed using the following MESH terms: puberty, menarche, ovary, polycystic ovary syndrome, menstruation, contraception, contraception-barrier, contraceptives-oral-hormonal, sex education, family planning services, and pregnancy in adolescence. This literature search was cross-referenced with an additional search on diabetes mellitus-type 1, diabetes complications, and pregnancy in diabetes. All published studies were searched regardless of the language of origin. Bibliographies were reviewed to extract additional relevant sources.

Prevalence of gestational diabetes and associated maternal and neonatal complications in a fast-developing community: global comparisons

Background

The prevalence of gestational diabetes (GDM) is increasing all over the world. Hence, the impact of GDM on maternal and infant health is an important topic of research. No study has been conducted in Qatar to evaluate the outcome of pregnancies complicated by diabetes mellitus.

Objective

The aim of the study was to determine the prevalence of GDM, compare the maternal–neonatal complications among women with GDM and non-GDM pregnant women, and investigate the risk factors and potential outcomes associated with GDM.

Design

This is a prospective cohort study.

Setting

The survey was carried out at the antenatal clinics of the Women’s Hospital, Qatar.

Subjects and methods

A representative sample of 2056 pregnant women who attended the antenatal clinics of the Women’s Hospital were surveyed during the period from the first week of January 2010 to April 2011. From this sample, 1608 women (78.2%) expressed their consent to participate in the study. Questionnaires were administered to pregnant women who were seeking antenatal care at this urban hospital. The questionnaire covered variables related to sociodemographic factors, family history, medical history, maternal complications, and neonatal outcome.

Results

The prevalence of GDM in Qatar was 16.3%. Women with GDM were significantly higher in the age group of 35–45 years (45%; P = 0.001). Family history of diabetes (31.7%; P < 0.001), increased parity (55.3%; P = 0.004), and obesity (59.2%; P < 0.001) were determinants of GDM in pregnant women. Maternal complications like pregnancy-induced hypertension (19.1% vs 10.3%; P < 0.001), pre-eclampsia (7.3% vs 3.8%; P = 0.012), antepartum hemorrhage (19.2% vs 14.6%; P = 0.05), and cesarean (27.9% vs 12.4%; P < 0.001) were significantly higher in GDM women. Neonates were at increased risk of preterm birth (12.6% vs 8.3%; P = 0.03), macrosomia (10.3% vs 5.9%; P = 0.01), and birth trauma (8% vs 3%; P < 0.001).

Conclusion

The study findings revealed that GDM was higher in women in Qatar and that they were at increased risk of developing maternal and neonatal complications. Obesity emerged as an essential risk factor for subsequent GDM. The advanced maternal age, low monthly income, family history of diabetes, and obesity were the main significant risk factors for GDM.

Gestational diabetes mellitus: Get, set, go From diabetes capital of the world to diabetes care capital of the world

Screening and diagnosis for gestational diabetes mellitus (GDM) as well as interventions for its management evoke considerable controversy. There are different types of screening methods: universal or risk-based, one step or two step. Different thresholds for diagnosis of GDM have been in vogue. Previous definition and diagnostic criteria had no place for diagnosis of overt diabetes in pregnancy. Following Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study and International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations, new screening and diagnostic criteria around the world seem to be gaining consensus. The present recommendation given by IADPSG for screening and diagnosis of diabetes mellitus in pregnancy has two discrete phases. The first is detection of women with overt diabetes not previously diagnosed or treated outside of pregnancy. Universal early testing in populations is recommended at the first prenatal visit. The second phase is a 75-g OGTT at 24-28 week gestation in all women not previously found to have overt diabetes or GDM. ACHOIS and MFMU Network trails have proven benefit in treating hyperglycemias less than what is diagnostic for diabetes. DIPSI has shown the alternative way for resource-challenged communities. Efforts from all stake holders with interest in GDM are required to make the diabetes capital of the world into the diabetes care capital of the world.

Developmental considerations in working with newborn infants of mothers with diabetes

Infants of diabetic mothers (IDMs) are at risk for an altered developmental course beginning with physiologic alterations in utero. This article describes physiologic and behavioral factors that impact the fetus and newborn infant and may have long-term developmental consequences. A clinical reasoning process to support development optimizes the outcomes of IDMs while in the NICU. Specific interventions are suggested.

Islet transplantation reverses the effects of maternal diabetes on mouse oocytes

Maternal diabetes adversely affects preimplantation embryo development and oocyte maturation. Thus, it is important to identify ways to eliminate the effects of maternal diabetes on preimplantation embryos and oocytes. The objectives of this study were to investigate whether islet transplantation could reverse the effects of diabetes on oocytes. Our results revealed that maternal diabetes induced decreased ovulation; increased the frequency of meiotic spindle defects, chromosome misalignment, and aneuploidy; increased the relative expression levels of Mad2 and Bub1; and enhanced the sensitivity of oocytes to parthenogenetic activation. Islet transplantation prevented these detrimental effects. Therefore, we concluded that islet transplantation could reverse the effects of diabetes on oocytes, and that this technique may be useful to treat the fundamental reproductive problems of women with diabetes mellitus.

The possible role of epigenetics in gestational diabetes: cause, consequence, or both

Gestational diabetes mellitus (GDM) is defined as the glucose intolerance that is not present or recognized prior to pregnancy. Several risk factors of GDM depend on environmental factors that are thought to regulate the genome through epigenetic mechanisms. Thus, epigenetic regulation could be involved in the development of GDM. In addition, the adverse intrauterine environment in patients with GDM could also have a negative impact on the establishment of the epigenomes of the offspring.

Gestational diabetes: risks, management, and treatment options

Gestational diabetes mellitus (GDM) is commonly defined as glucose intolerance first recognized during pregnancy. Diagnostic criteria for GDM have changed over the decades, and several definitions are currently used; recent recommendations may increase the prevalence of GDM to as high as one of five pregnancies. Perinatal complications associated with GDM include hypertensive disorders, preterm delivery, shoulder dystocia, stillbirths, clinical neonatal hypoglycemia, hyperbilirubinemia, and cesarean deliveries. Postpartum complications include obesity and impaired glucose tolerance in the offspring and diabetes and cardiovascular disease in the mothers. Management strategies increasingly emphasize optimal management of fetal growth and weight. Monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy can decrease comorbidities associated with GDM. Consensus is lacking on ideal glucose targets, degree of caloric restriction and content, algorithms for pharmacotherapy, and in particular, the use of oral medications and insulin analogs in lieu of human insulin. Postpartum glucose screening and initiation of healthy lifestyle behaviors, including exercise, adequate fruit and vegetable intake, breastfeeding, and contraception, are encouraged to decrease rates of future glucose intolerance in mothers and offspring.

Obstetric problems in diabetic pregnancy - The role of fetal hypoxia

Perinatal mortality has not decreased over the last two decades in pregestational diabetic pregnancies. Stillbirth rate is 4-6 times and neonatal mortality 2-4 times higher in diabetic than in non-diabetic pregnancies despite modern electronic fetal surveillance methods. Majority of late stillbirths are "unexplained", many of which are presumably caused by fetal hypoxia. Both experimental and clinical studies have shown that fetal hyperglycaemia and hyperinsulinaemia can independently cause fetal hypoxia, which ultimately can lead to fetal death. Poor glycaemic control is associated with perinatal complications. Sharp increases in amniotic fluid erythropoietin levels indicate fetal hypoxia in diabetic pregnancy. Fetal erythropoietin concentrations correlate directly with maternal HbA(1c) levels. It is therefore important to maintain near-normal glycaemic level throughout pregnancy. Measurement of amniotic fluid erythropoietin level is a new way to detect fetal hypoxia antenatally. Sufficiently large controlled studies are needed before definitive answer of the clinical utility of amniotic fluid erythropoietin measurements in diabetic pregnancies can be determined.

Cost of gestational diabetes mellitus in the United States in 2007

The objective of this study was to estimate the national medical costs associated with gestational diabetes mellitus (GDM) in 2007. We analyzed the National Hospital Discharge Survey to estimate the national prevalence of GDM. Using Poisson regression analysis with medical claims for about 27,000 newborns and their mothers, we estimated rate ratios that reflect the increase in use of health care services associated with GDM. Combining GDM prevalence rates with these rate ratios, we calculated etiological fractions that reflect the proportion of national health care resource use associated with GDM. We then multiplied these fractions by estimates of national health care use and costs in 2007. GDM prevalence increases with age, rising from 1.3% of pregnancies of women younger than age 21 to 8.7% of pregnancies of women older than age 35. For the estimated 180,000 GDM pregnancies resulting in delivery, average expenditures increased $3,305 per pregnancy plus $209 in the newborn's first year of life. GDM increased national medical costs by $636 million in 2007-$596 million for maternal costs and $40 million for neonatal costs. Approximately $230 million (36%) of GDM-related medical costs are covered by government programs (primarily Medicaid), $355 million (56%) are covered by private insurers, and $51 million (8%) are covered by self-pay and charity care. GDM imposes a significant economic burden. These estimates of the economic burden of GDM are likely conservative because we focus on near-term medical costs, omitting the increased risk for long-term sequelae.

Consequences of routine delivery at 38 weeks for A-2 gestational diabetes

OBJECTIVE

To report our intrapartum experience with routine delivery at 38 weeks of gestation of A-2 diabetic pregnancies requiring primarily oral hypoglycemic therapy.

METHODS

This retrospective study consisted of 143 consecutive women with gestational diabetes not controlled with diet alone (A-2). Each underwent a routine trial of labor at 38 weeks of gestation. The preinduction condition of the cervix, need for oxytocin, and primary cesarean rates were primary endpoints. For comparison, a control group during that same period consisted of 137 consecutive diet-controlled diabetic (A-1) pregnancies with the same eligibility criteria who underwent expectant management at 38 weeks.

RESULTS

The study group was more likely to have an unfavorable cervix (75% versus 45%; p < 0.001) and to require oxytocin (76% versus 56%; p < 0.001). Early onset meconium was less common in the study group (3.5% versus 13.1%; p < 0.01). Primary cesarean rates were low and not different between the study and control groups (12.7% versus 11.7%; p < 0.8). The only stillbirth was in the control group and was associated with a tight double nuchal cord encirclement. Mean birth weights and the frequency of birth weights > 4000 g were not different between groups. Shoulder dystocia, low Apgar scores, and admissions to the special care nursery were infrequent in either group. No respiratory difficulties requiring resuscitation or prolonged nursery care were encountered.

CONCLUSION

Routine delivery at 38 weeks in an A-2 diabetic population is not associated with additional intrapartum morbidity or a greater need for cesarean delivery.

Biochemical profile and outcome in normal and high risk subjects

The present study was carried out to assess the biochemical profile and outcome of pregnancy and study the adverse consequences if any, among normal and high risk pregnant women. The study group included 182 normal and 168 high risk cases attending to private and Government Hospitals in Bangalore. The high risk groups were: Pregnancy induced hypertension (PIH), gestational diabetes mellitus (GDM), Adolescents and anemic cases. Lipid peroxidation was enhanced in PIH and GDM groups (5.56 nmol/ml and 3.98 nmol/ml) MDA values as compared to other groups. Vitamin E levels were significantly (p< 0.05) lower in PIH group (0.38 mg/dl) as compared to other groups. Caesarean as a mode of delivery indicating more number of complications were higher among GDM (61.9%) followed by PIH group. Incidences of low birth weight were observed more in PIH group. The study revealed occurrence of oxidative stress and adverse outcome among high risk pregnancy groups.

Establishing diagnosis of gestational diabetes mellitus: Impact of the hyperglycemia and adverse pregnancy outcome study

The diagnosis of gestational diabetes mellitus (GDM) remains controversial, without universal acceptance of a particular set of diagnostic criteria, and, in fact, a lack of consensus as to whether this is an entity worth diagnosis. Some of the debate derives from differences of opinion about what degree of glucose intolerance should be labeled as GDM. Therefore, it is to be expected that there are different viewpoints on how to detect and screen for GDM. It is believed that early diagnosis will result in a significant improvement in perinatal outcome in these patients. In this review, we discuss the current data concerning screening for GDM and new strategies for GDM diagnosis in light of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study.

Placental weight and placental weight-to-birth weight ratio are increased in diet- and exercise-treated gestational diabetes mellitus subjects but not in subjects with one abnormal value on 100-g oral glucose tolerance test

The aim of the present study was to determine whether the placental weight and placental weight-to-birth weight ratio (PW/BW) increased in pregnant women with one abnormal value (OAV) on 100-g oral glucose tolerance test (OGTT) and diet- and exercise-treated, non-insulin-requiring gestational diabetes mellitus (GDM) subjects. The 50-g glucose challenge test (GCT) was administered to 324 pregnant women. Women with abnormal 50-g test received a 100-g, 3-h OGTT using National Diabetes Data Group criteria. Women with GDM and OAV were treated with diet and exercise. Twenty subjects who required insulin or met exclusion criteria were excluded from the study. After the exclusion of 20 subjects, the GDM group consisted of 30 (9.7%) pregnant women and the OAV group consisted of 32 (9.9%) pregnant women. The control group consisted of 242 pregnant women. Birth weight (GDM: 3288.3+/-364.2 g; OAV: 3278.1+/-409.9 g; control group: 3270.6+/-346.5 g) did not differ significantly between groups (P>.05). Significantly higher placental weights (GDM: 694.8+/-152.1 g; OAV: 622.2+/-105.3 g; control group: 610.2+/-116.6 g; P<.01) and PW/BW (GDM: 0.21+/-0.03; OAV: 0.193+/-0.04; control group: 0.188+/-0.04; P<.01) were observed in GDM group compared to OAV and control group. No significant difference was found for OAV group in terms of placental weight and PW/BW compared to the control group. Our data indicated that women with OAV delivered infants and placenta of similar weight to those of normal pregnancies.