Diabetic fetal macrosomia: significance of disproportionate growth

Embryonic, Fetal, and Neonatal Complications in Infants of Diabetic Mothers: Insights from the Cincinnati Diabetes in Pregnancy Program Project Grant

This study aimed to review how the Cincinnati Diabetes in Pregnancy Program Project Grant (PPG) contributed to the understanding and treatment of neonatal complications in infants of diabetic mothers (IDMs). This is a retrospective review of all PPG work on glycemic control at different pregnancy time points and its association with embryonic, fetal, and neonatal complications, such as congenital malformations (CMs), intrauterine growth restriction, macrosomia, hypoglycemia, respiratory distress syndrome (RDS), asphyxia, and polycythemia. We found that maternal vasculopathy and poor glycemic control during embryogenesis, but not frequency of maternal hypoglycemic episodes or insulin therapy, are independent risk factors for major CMs. A suggestive association of major CMs with maternal Magnesium deficiency was also observed. Poor glycemic control during late embryogenesis and early fetal development was associated with an increased risk of minor CMs. We described a biphasic pattern of fetal growth whereby early growth delay was followed by enhanced fetal growth associated with neonatal macrosomia. Macrosomia was associated with poorer glycemic control in the third trimester and an increased risk of birth trauma. Macrosomia was also correlated with animal-origin insulin concentrations in cord blood, demonstrating that insulin bound to antibodies can cross the placenta and may affect the fetus. We also showed that neonatal hypoglycemia was significantly associated with third-trimester glycemic control, in addition to hyperglycemia occurring during labor. With modern management and adequate prenatal care, IDMs are no longer at increased risk for RDS. Perinatal asphyxia was associated with increased proteinuria appearing in pregnancy, maternal hyperglycemia before delivery, and prematurity. Polycythemia in IDMs is prevalent and correlates with proxy measurements of fetal hypoxemia (nucleated red blood cells at delivery) and poorer glycemic control in late pregnancy. The PPG in its various phases revealed the important role of glycemic control at nearly every stage of pregnancy including labor. KEY POINTS: · Poor glycemic control during embryogenesis is a major risk factor for CMs.. · Magnesium deficiency might contribute to major malformations.. · Macrosomia is associated with poor glycemic control in the third trimester.. · Strict glycemic control reduces fetal and neonatal morbidity in pregnancies with insulin-dependent diabetes mellitus..

A Queen City Legacy: 45 Years of Research in Pregnant Women with Insulin-Dependent Diabetes Mellitus, The Diabetes in Pregnancy Program Project Grant

The Diabetes in Pregnancy Program Project Grant (PPG) was a 15-year program focused on enhancing the care for women with insulin-dependent diabetes mellitus (IDDM) during pregnancy and improving the well-being of their offspring. Launched in July 1978 at the University of Cincinnati, the PPG pursued a multifaceted research agenda encompassing basic science, animal and placental studies, and maternal and neonatal clinical trials to understand the physiological and pathophysiological aspects of IDDM during pregnancy. A total of 402 singleton pregnancies in 259 women with IDDM were enrolled prior to 10 weeks gestation over the 15-year period. Of the 402 pregnancies, there were 295 live births, 1 stillbirth, 4 neonatal deaths, and 15 infants were born with major congenital malformations. Central to the program's methodology was the management of diabetes during pregnancy, involving intensive insulin therapy and meticulous monitoring using the cutting-edge technology of the time to achieve glycemic control. The extensive research of the PPG yielded profound insights into the effects of maternal diabetes on embryonic and fetal development and neonatal health. Through animal studies, notably using pregnant sheep, the program clarified the mechanisms of fetal hypoxia and metabolic disorders. Clinical trials underscored the significance of early glycemic control in mitigating the risks of spontaneous abortions, congenital malformations, and neonatal complications. The program also examined the influence of pregnancy on the progression of microvascular diseases, the role of maternal weight and weight gain in pregnancy outcomes, and the distinctive growth patterns of fetuses in IDDM pregnancies. Furthermore, the PPG probed the incidence and underlying mechanisms of hypoglycemia during pregnancy and the heightened risk of obstetric complications in IDDM patients. Our findings established a foundation of knowledge to aid clinicians, researchers, and health care providers in best practices and ensure a lasting impact on the care of pregnant women with pregestational diabetes. KEY POINTS: · Prepregnancy management reduces maternal, fetal, and neonatal complications in IDDM.. · Strict glycemic control improves many pregnancy outcomes in IDDM.. · Fetal glycemic exposure may have lifelong effects..

Shoulder dystocia in babies born to Aboriginal mothers with diabetes: a population-based cohort study, 1998-2015

BACKGROUND

Australian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP.

METHODS

Stratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg.

RESULTS

Rates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg.

CONCLUSIONS

Aboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

The association between plasma angiopoietin-like protein 4, glucose and lipid metabolism during pregnancy, placental function, and risk of delivering large-for-gestational-age neonates

BACKGROUND

Large-for-gestational-age (LGA) neonates have increased risk of adverse pregnancy outcomes and adult metabolic diseases. We aimed to investigate the relationship between plasma angiopoietin-like protein 4 (ANGPTL4), a protein involved in lipid and glucose metabolism during pregnancy, placental function, growth factors, and the risk of LGA.

METHODS

We conducted a prospective cohort study and recruited women with singleton pregnancies at the National Taiwan University Hospital between 2013 and 2018. First trimester maternal plasma ANGPTL4 concentrations were measured.

RESULTS

Among 353 pregnant women recruited, the LGA group had higher first trimester plasma ANGPTL4 concentrations than the appropriate-for-gestational-age group. Plasma ANGPTL4 was associated with hemoglobin A1c, post-load plasma glucose, plasma triglyceride, plasma free fatty acid concentrations, plasma growth hormone variant (GH-V), and birth weight, but was not associated with cord blood growth factors. After adjusting for age, body mass index, hemoglobin A1c, and plasma triglyceride concentrations, plasma ANGPTL4 concentrations were significantly associated with LGA risk, and its predictive performance, as measured by the area under the receiver operating characteristic curve, outperformed traditional risk factors for LGA.

CONCLUSIONS

Plasma ANGPTL4 is associated with glucose and lipid metabolism during pregnancy, plasma GH-V, and birth weight, and is an early biomarker for predicting the risk of LGA.

Risk of hypoglycemia by anthropometric measurements in neonates of mothers with diabetes

Macrosomia in neonates of diabetic women is a risk factor for neonatal hypoglycemia, with an over-risk for asymmetric macrosomia. This study aimed to study the association between anthropometric measurements and hypoglycemia in neonates of mothers treated for gestational diabetes. This is a secondary analysis of the INDAO trial study conducted between May 2012 and November 2016 in 13 French tertiary care university hospitals in 890 pregnant women with gestational diabetes treated with either insulin or glyburide. Neonatal anthropometric measurements were birthweight and weight-length ratio (WLR, defined as birth weight/length). Neonatal hypoglycemia was defined as capillary blood glucose below 36 mg/dL (2 mmol/L) or below 45 mg/dL (2.5 mmol/L) associated with clinical signs after 2 h of life. Their relationships were modeled with logistic regressions using fractional polynomials. Extreme categories of birthweight or WLR adjusted for gestational age at birth and sex were defined as Z-score <  -1.28 or > 1.28. These categories were compared to Z-score between -1.28 and 1.28 by estimating odds ratios and confidence intervals for neonatal hypoglycemia. Neonatal hypoglycemia occurred in 9.1% of cases. The relationship between birthweight and WLR Z-scores and neonatal risk of hypoglycemia adjusted for maternal treatment was a U-shaped curve. Adjusted odds ratios for the risk of hypoglycemia were 9.6 (95% CI 3.5, 26.8) and 2.3 (95% CI 1.1, 4.9) for WLR Z-score below -1.28 and above 1.28, respectively, compared with WLR Z-score between -1.28 and 1.28.    Conclusion: Birthweight Z-score was associated with the risk of neonatal hypoglycemia in neonates from mothers treated for gestational diabetes. The risk of neonatal hypoglycemia was increased for both extreme birthweight Z-scores, regardless of maternal treatment. Small for gestational age neonates of diabetic mothers require special attention for the risk of neonatal hypoglycemia. What is Known: • Macrosomia in neonates of diabetic women is a risk factor for neonatal hypoglycemia, with an over-risk for asymmetric macrosomia. Few retrospective studies have assessed the risk for neonatal hypoglycemia among small for gestational age neonates born to diabetic mothers. What is New: • The risk of neonatal hypoglycemia among neonates of diabetic mothers increased for both low and high weight-length ratio, regardless of maternal medicinal treatment, gestational age at birth, and sex of the newborn.

Does Birthweight Represent Imprinting for Life? Preliminary Findings from the Level and Timing of Diabetic Hyperglycemia in Utero: Transgenerational Effect on Adult Morbidity (TEAM) Study

Women with pre-gestational diabetes have a high rate of large for gestational age (LGA) babies compared to women without diabetes. In particular, there is a high rate of asymmetric LGA defined as ponderal index (PI) > 90th percentile for gestational age. We examined the association of birth weight and PI, with body mass index (BMI) and obesity status in adulthood, in a cohort of offspring of women with pre-gestational diabetes. The women participated in the Diabetes in Pregnancy (DiP) study at the University of Cincinnati from 1978 to 1995. The offspring of these women are the cohort participating in an observational study being conducted at Cincinnati Children’s Hospital Medical Center. Once located, the offspring were invited to come in for a one-day clinic visit to assess anthropometrics, and their metabolic, renal and cardiovascular status. Linear and logistic regression was used to assess the association between birth weight and PI with current BMI. We report on 107 offspring. A statistically significant association was found between offspring current BMI with birth PI (β = 1.89, 95% CI 0.40–3.38), and between offspring current obesity status and birth asymmetric LGA (aOR = 2.44, 95% CI 1.01–5.82). This is consistent with in utero “metabolic programming”.

Determinants of the persistency of macrosomia and shoulder dystocia despite treatment of gestational diabetes mellitus

Aims

to identify potentially modifiable risk factors associated with the persistency of macrosomia and/or shoulder dystocia in infants born to women treated for gestational diabetes mellitus (GDM).

Methods

this case-control retrospective study included 113 cases complicated by macrosomia (ponderal index ≥97^th percentile) and/or shoulder dystocia, and 226 controls without these complications. Factors associated with macrosomia and/or shoulder dystocia and with failure of diabetes management were assessed by multivariable analyses.

Results

Macrosomia and/or shoulder dystocia were associated with previous delivery of a large for gestational age (LGA) infant (adjusted odds ratio, 2.34, 95% confidence interval [1.01–5.45]), three abnormal glucose values during oral glucose tolerance test (2.83 [1.19–6.72]), a higher gestational weight gain before treatment (1.08 [1.01–1.15]), and failure of diabetes management (2.68 [1.32–5.45]). A non-Euro Caucasian origin (3.08 [1.37–6.93]), previous delivery of a LGA infant (3.21 [1.31–7.87]), institution of treatment after 32 weeks of gestation (3.92 [1.86–8.25]), and insulin therapy (2.91 [1.20–7.03]) were associated with failure of diabetes management.

Conclusions

supportive care in at risk women, limitation of weight gain in early pregnancy, shortened delay between diagnosis and treatment of GDM, and intensive insulin dosage adjustments might be means to improve the neonatal prognosis of GDM.

Predictors of Large-for-Gestational-Age Birthweight Among Pregnant Women With Type 1 and Type 2 Diabetes: A Retrospective Cohort Study

OBJECTIVE

Our aim in this study was to compare the effects of risk factors for large-for-gestational-age (LGA) birthweight between women with type 1 and type 2 diabetes mellitus (TIDM and T2DM, respectively).

METHODS

A retrospective cohort study was conducted for women with T1DM (n=152) and T2DM (n=255) attending a diabetes/pregnancy clinic during the period from 2009 to 2016. Multiple logistic regression analysis was used to identify variables associated with LGA birthweight.

RESULTS

LGA was significantly higher in those with T1DM (39%) than T2DM (17%) (p<0.001). Among those with T1DM, there was a nonsignificant association between LGA and continuous subcutaneous insulin infusion (odds ratio, 1.17; 95% confidence interval, 0.99 to 1.39; p=0.06) and excess maternal weight gain (T1DM odds ratio, 1.19; 95% confidence interval, 0.99 to 1.43; p=0.069). In those with T2DM, there was an association between LGA and glycated hemoglobin at delivery (T2DM odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; p=0.01).

CONCLUSIONS

In the study population, glycemic control at delivery was predictive of LGA in women with T2DM, and there was a trend toward an association of maternal weight gain and continuous subcutaneous insulin infusion with LGA infants in T1DM. Further study is warranted to better guide targeted interventions to reduce high rates of LGA birthweight in T1DM/T2DM.

Pseudoacromegaly

Individuals with acromegaloid physical appearance or tall stature may be referred to endocrinologists to exclude growth hormone (GH) excess. While some of these subjects could be healthy individuals with normal variants of growth or physical traits, others will have acromegaly or pituitary gigantism, which are, in general, straightforward diagnoses upon assessment of the GH/IGF-1 axis. However, some patients with physical features resembling acromegaly - usually affecting the face and extremities -, or gigantism - accelerated growth/tall stature - will have no abnormalities in the GH axis. This scenario is termed pseudoacromegaly, and its correct diagnosis can be challenging due to the rarity and variability of these conditions, as well as due to significant overlap in their characteristics. In this review we aim to provide a comprehensive overview of pseudoacromegaly conditions, highlighting their similarities and differences with acromegaly and pituitary gigantism, to aid physicians with the diagnosis of patients with pseudoacromegaly.

Infant of diabetic mother: what one needs to know?

The global incidence of diabetes mellitus, including diabetes in pregnant women, is on the rise. Diabetes mellitus in a pregnant woman jeopardizes not only maternal health but can also have significant implications on the child to be born. Therefore, timely diagnosis and strict glycemic control are of utmost importance in achieving a safe outcome for both the mother and fetus. The treating physician should be aware of the complications that can arise due to poor glycemic control during pregnancy. The objective of this article is to discuss the key concerns in a neonate born to diabetic mother, the underlying pathogenesis, and the screening schedule during pregnancy.

Outcomes of vacuum-assisted vaginal deliveries of mothers with gestational diabetes mellitus

Objective: To evaluate the outcomes of vacuum-assisted vaginal deliveries (VAD) among neonates of mothers with gestational diabetes mellitus (GDM). Study design: Retrospective cohort study of women with singleton gestation ≥37 + 0 weeks of gestation who underwent VAD at a single, tertiary, medical center (2007-2014). Women with GDM and their neonates were compared to women without diabetes and their neonates. Composite neonatal outcome was defined as ≥1 of the following: shoulder dystocia, 5-min Apgar score <7, asphyxia, seizure, subgaleal, subarachnoid or subdural hemorrhage, fracture of the clavicle, humerus or skull, or Erb's palsy. Results: Overall, 251 (5.2%) women with GDM were compared with 4534 (94.8%) women without GDM. Women with GDM were older, delivered earlier, with higher rates of mild preeclampsia and induction of labor. Their neonates had higher mean birth weight percentile, and higher rates of hypoglycemia, phototherapy, fracture of the humerus (3.2 versus 1.1%, aOR 2.95, 95%CI 1.38-6.30), and subarachnoid hemorrhage (1.2 versus 0.3%, aOR 4.56, 95%CI 1.28-16.26). No difference was found with regards to the composite neonatal outcome (9.2 versus 11.1%, p = .34). Conclusions: GDM is associated with a higher risk for certain birth injuries in VAD at ≥37 + 0 weeks of gestation, yet the overall risk of adverse neonatal outcomes is comparable to women without GDM.

Assessing the Impact of Excessive Gestational Weight Gain Among Women With Type 1 Diabetes on Overweight/Obesity in Their Adolescent and Young Adult Offspring: A Pilot Study

Aims/hypothesis: We sought to determine the impact of intrauterine exposure to excessive gestational weight gain (GWG) on overweight/obesity in adolescent/young adult offspring of women with type 1 diabetes mellitus (TIDM). Methods: In 2008, a pilot study was conducted among 19 randomly-selected adolescent and adult offspring of mothers with TIDM who participated in the Diabetes in Pregnancy Program Project (DiP) between 1978 and 1995. Body mass index (BMI)-specific Institute of Medicine (IOM) guidelines for gestational weight gain (GWG) were defined as: 12.5-18.0 kilograms (kg) GWG; 11.5-16.0 kg GWG: 7.0-11.5 kg GWG; 5.0-9.0 kg GWG, for women classed as underweight, normal, overweight and obese according to pre-pregnancy BMI, respectively. Generalized estimating equations were used to estimate adjusted odds ratios (aOR, [95% confidence intervals, CI]) for overweight/obesity among offspring, related to IOM adherence, adjusting for pre-pregnancy BMI and mean maternal daily insulin units/kg body weight. Results: Mean age of offspring at follow-up was 20.3 ± 3.3 years, 12(63%) were male, 4(21%) Black and 12(63%) overweight/obese. There were 9(82%) overweight/obese offspring among the 11 mothers who exceeded IOM guidelines for GWG compared with 3(38%) overweight/obese offspring among the 8 mothers with GWG within guidelines. Exceeding vs. adhering to IOM guidelines (OR = 7.50, [95%CI: 0.92-61.0]) and GWG per kilogram (OR = 1.39, [95%CI: 0.98-1.97]) were associated with offspring overweight/obesity at follow-up. Conclusions/interpretation: Our pilot study suggests potential long-term implications of excessive GWG on metabolic health in offspring of mothers with TIDM, warranting future research examining the health impact of GWG in this population.

Maternal lipids associated with large-for-gestational-age birth weight in women with type 1 diabetes: results from a prospective single-center study

INTRODUCTION

Despite improvement in diabetes care over the years, the incidence of macrosomia in type 1 diabetic mothers is still very high and even shows an increasing tendency. It is suggested that other factors that maternal hyperglycemia might be associated with excessive fetal growth in diabetic mothers. The aim of this study was to determine whether maternal lipids might contribute to high rates of large-for-gestational-age (LGA) newborns in women with type 1 diabetes (T1DM).

MATERIAL AND METHODS

This prospective, single-center study was performed in a population of women with T1DM admitted to the perinatal center for women with diabetes. Data were collected in the first trimester (< 12^th week), in mid-pregnancy (20^th-24^th weeks), and before delivery (34^th-39^th weeks).

RESULTS

Among 114 women included in the analysis, 30 (26.3%) delivered LGA newborns. The remaining 84 (73.7%) newborns were appropriate for gestational age (AGA). Lower high-density lipoprotein (HDL) HDL concentration in the first trimester was significantly associated with LGA (p = 0.01). Similar associations were observed for the HDL concentrations in mid-pregnancy (p = 0.04) and before delivery (p = 0.03). Higher triglyceride concentrations in the first trimester (p = 0.02) and before delivery (p = 0.008) were associated with LGA. Higher glycated haemoglobin (HbA_1c) levels in mid-pregnancy and before delivery were associated with LGA. The associations between maternal lipids and LGA were independent of maternal body mass index at onset of the study, gestational weight gain and HbA_1c concentrations.

CONCLUSIONS

Decreased HDL and increased triglycerides during pregnancy might contribute to the development of LGA in women with type 1 diabetes.

Risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control

Macrosomia risk remains high in type 1 diabetes (T1DM) complicated pregnancies. A linear relationship between macrosomia risk and glycated hemoglobin A_1c (HbA_1c) was described; however, low range of HbA_1c has not been studied. We aimed to identify risk factors and examine the impact of HbA_1c on the occurrence of macrosomia in newborns of T1DM women from a cohort with good glycemic control. In this observational retrospective one-center study we analyzed records of 510 consecutive T1DM pregnancies (1998-2012). The analyzed group consisted of 375 term singleton pregnancies. We used multiple regression models to examine the impact of HbA_1c and self-monitored glucose in each trimester on the risk of macrosomia and birth weight. The median age of T1DM women was 28 years, median T1DM duration-11 years, median pregestational BMI-23.3 kg/m². Median birth weight reached 3520 g (1st and 3rd quartiles 3150 and 3960, respectively) at median 39 weeks of gestation. There were 85 (22.7 %) macrosomic (>4000 g) newborns. Median HbA_1c levels in the 1st, 2nd, and 3rd trimester were 6.4, 5.7, and 5.6 %. Third trimester HbA_1c, mean fasting self-monitored glucose and maternal age were independent predictors of birth weight and macrosomia. There was a linear relationship between 3rd trimester HbA_1c and macrosomia risk in HbA_1c range from 4.5 to 7.0 %. Macrosomia in children of T1DM mothers was common despite excellent metabolic control. Glycemia during the 3rd trimester was predominantly responsible for this condition.

Camel whey protein improves lymphocyte function and protects against diabetes in the offspring of diabetic mouse dams

The prevalence of health problems in the offspring of pregnant diabetic mothers has recently been verified. Therefore, the present study was designed to investigate the influence of dietary camel whey protein (CWP), administered as a supplement to streptozotocin (STZ)-induced diabetic pregnant mice, on the efficiency of the immune system of the offspring. Three groups of female mice (n = 10) were used: non-diabetic control mice, diabetic mice, and diabetic mice orally administered CWP during the pregnancy and lactation periods. We then tested the immune response of B and T cells in adult male offspring (n = 15 in each group) by using flow cytometry, western blotting, and ELISAs. Our data demonstrated that the offspring of diabetic dams exhibited several postpartum complications, such as significant aberrant overexpression of activating transcription factor-3 (ATF-3), significant elevation of the plasma levels of pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) and reactive oxygen species (ROS), marked decreases in the plasma levels of IL-2 and IL-7, significant inhibition of CCL21- and CXCL12-mediated chemotaxis of B- and T-lymphocytes, and a marked decrease in the proliferative capacity of antigen-stimulated B- and T-lymphocytes. Interestingly, administration of CWP to diabetic dams substantially restored the expression of ATF-3 and the levels of ROS, pro-inflammatory cytokines, IL-2, and IL-7 in the offspring. Furthermore, the chemotaxis of B- and T-lymphocytes toward CCL21 and CXCL12 and the proliferative capacities of these lymphocytes were restored in the male offspring of diabetic mice administered CWP. Our data provide evidence of a protective role of CWP in decreasing the tendency of the offspring of diabetic mothers to develop diabetes and related complications.

Outcome of Diabetic Pregnancies in a Tertiary Referral Centre, Varanasi

AIM

The study was done to determine the maternal and fetal outcome of pregnancies complicated by maternal diabetes either Gestational Diabetes Mellitus (GDM) or preexisting (type 1 or type 2) diabetes over a period from March 2011 to Feb 2013 in a tertiary care hospital, Varanasi.

METHODS

This is a retrospective audit of the maternal and fetal outcome of women who presented to the Sir Sundar Lal Hospital, Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India from March 2011 to Feb 2013, with GDM or pre-existing type 1 or type 2 Diabetes with pregnancy. The audit group comprised 65 pregnancies (67 babies), of whom 27 had preexisting diabetes and 38 cases developed gestational diabetes. Pregnant women who were found to be diabetic preconceptionally or in the first trimester were classified as 'pre-existing diabetes'.

RESULTS

There were total of 65 diabetic women in this retrospective study, 39 women were GDM (60 %) while 26 women (40 %) were having pre-existing diabetes (24 type 1 diabetes and 2 women were in type 2 diabetes group). There were 35 multigravid women (53.85 %) and 30 primigravid women (46.15 %). There were 39 (60 %) women on Insulin. There were 42 Lower Segment Caesarean Section (64.62 %) and 23 Spontaneous Vaginal Delivery (35.38 %). In fetal and neonatal complications, there were three still births, one case of intrapartum death, and one case of shoulder dystocia. Fetal anomalies were less frequent, one case of Gastroschisis with Hydrocephalus associated with Menigomyelocoele, there was one case of isolated Hydrocephalus, and there was also one case of Truncus arteriosus.

CONCLUSIONS

The study analyses maternal and fetal complication in the GDM group and also preexisting diabetes group. In our centre, the 60 % women were GDM while 40 % were having pre-existing diabetes. Total rate of fetal/neonatal complication rate was 7.69 % and of congenital anomaly rate it was 9.23 %. Proportion of still birth, Intrauterine death, and congenital malformations was higher in the pre-existing diabetes group although the data are not large enough to draw a statistically significant conclusion. LSCS rate was little higher in the GDM group (69.23 %) in comparison to the preexisting diabetes group where it was 57.69 %. SVD (Spontaneous Vaginal Delivery) rate was 30.77 % in GDM and 42.31 % in the pre-existing diabetes group. HbA1c was within normal range 84.62 % of GDM group while in 15.38 % it was raised >6 %. In the pre-existing diabetes group, only 19.23 % of women had HbA1c within acceptable range and 80.77 % had it >6. The aim of St Vincent Declaration is to 'achieve pregnancy outcome in the diabetic woman that is similar to that of the non-diabetic woman.' But, so far we have not been able to achieve this. Our HbA1c level is remarkably high in the pre-existing diabetes group. Only 3 out of 65 patients' women took Folic Acid periconceptionally. We need to work to achieve it our best. It is well known that insulin treatment during pregnancy results in reduction in the rate of macrosomia, fetal/neonatal, and maternal complications. Therefore, we need to use insulin judiciously and advocate its usage in the situations where it is needed.

Macrosomic newborns of non-diabetic mothers: anthropometric measurements and neonatal complications

OBJECTIVE

To assess the association of anthropometric measurements with neonatal complications in macrosomic newborns of non-diabetic mothers.

DESIGN

Retrospective cohort study.

PATIENTS

All liveborn, singleton, full term newborns with birth weight ≥4000 g born to non-diabetic mothers at a tertiary medical centre in 1995-2005 (n=2766, study group) were matched to the next born, healthy, full term infant with a birth weight of 3000-4000 g (control group). Exclusion criteria were multiple birth, congenital infection, major malformations and pregnancy complications.

INTERVENTION

Data collection by file review.

OUTCOME MEASURES

Complication rates were compared between study and control groups and between symmetric and asymmetric macrosomic newborns, defined by weight/length ratio (WLR), Body Mass Index and Ponderal Index.

RESULTS

The 2766 non-diabetic macrosomic infants identified were matched to 2766 control infants. The macrosomic group had higher rates of hypoglycaemia (1.2% vs 0.5%, p=0.008), transient tachypnoea of the newborn (1.5% vs 0.5%, p<0.001), hyperthermia (0.6% vs 0.1%, p=0.012), and birth trauma (2% vs 0.7%, p<0.001), with no cases of symptomatic polycythaemia, and only one case of hypoglycaemia. Hypoglycaemia was positively associated with birth weight. It was significantly higher in the asymmetric than the symmetric macrosomic newborns, defined by WLR (1.7% vs 0.3%, p<0.001).

CONCLUSIONS

Macrosomic infants of non-diabetic mothers are at increased risk of neonatal complications. However, routine measurements of haematocrit and calcium may not be necessary. Symmetric macrosomic infants (by WLR) have a similar rate of hypoglycaemia as normal-weight infants. Thus, repeat glucose measurements in symmetric macrosomic infants are not justified.

Fetal growth profiles of macrosomic and non-macrosomic infants of women with pregestational or gestational diabetes

OBJECTIVE

To assess fetal growth profiles in an unselected group of pregnant women with either type-1 diabetes (DM1), type-2 diabetes (DM2) or gestational diabetes (GDM), with emphasis on intergroup differences and development of disproportionate fetal growth and macrosomia.

METHODS

Second- and third-trimester longitudinal ultrasound measurements of fetal growth were made in 77 women with DM1, 68 women with DM2 and in 99 women with GDM. Altogether 897 ultrasound examinations were performed and 145 uncomplicated pregnancies with 843 ultrasound examinations were included as controls. Ultrasound data included head circumference (HC), abdominal circumference (AC), femur length (FL) and HC/AC ratio.

RESULTS

The AC, but not HC and FL, evolved differently in diabetic pregnancies, with a smaller AC in early pregnancy and larger AC at term (significant for DM1 and DM2). The most striking differences were found for the HC/AC ratio, especially in DM1 pregnancies. HC/AC growth trajectories of both macrosomic and non-macrosomic fetuses differed from that of the controls, and the HC/AC ratio at term was lower in all diabetic subgroups except in non-macrosomic DM2 cases.

CONCLUSION

We found altered (disproportionate) fetal growth in macrosomic and non-macrosomic fetuses of women with DM1, DM2 and GDM. This indicates that the abnormal intrauterine environment affects the majority of these infants. Growth profiles differed among these groups, the most prominent growth deviations being found in the fetuses of women with DM1. The latter was most probably caused by poor glucose control. In monitoring fetal growth in diabetic pregnancies the HC/AC ratio should be used to assess altered fetal growth.

Asymmetric large for gestational age newborns in pregnancies complicated by diabetes mellitus: is maternal obesity a culprit?

OBJECTIVE

Evaluate the association between body mass index (BMI) and the delivery of an asymmetrically large for gestational age (A-LGA) newborn in women with diabetes.

METHODS

Retrospective analysis of 306 pregnancies complicated by Type 1 and 55 by Type 2 diabetes.

RESULTS

The prevalence of Type 1 and Type 2 diabetics delivering large for gestational age (LGA) infants was 42% and 49%, respectively. Of these 49% and 55% were A-LGA, respectively. Pre-pregnancy BMI was not associated with increased odds of delivering an A-LGA newborn in women with Type 1 or 2 diabetes. However, in Type 1 diabetics, each one-pound increase in maternal weight during pregnancy resulted in 4% increased odds of delivering an A-LGA newborn. For Type 2 diabetics, the odds of delivering an A-LGA infant was decreased by 10% for each 0.1 unit/kg increase in insulin dose.

CONCLUSION

Although there is a known association between obesity and LGA in women with diabetes, we found that overweight and obese women with Type 1 or Type 2 diabetes do not have increased odds of delivering an A-LGA newborn. However, insulin dose in Type 2 diabetes and maternal weight gain in Type 1 diabetes were significantly associated with the odds of delivering an A-LGA neonate.

Disproportionate body composition and perinatal outcome in large-for-gestational-age infants to mothers with type 1 diabetes

OBJECTIVE

To determine if disproportionate body composition is a risk factor for perinatal complications in large-for-gestational-age infants born to mothers with type 1 diabetes.

DESIGN

Population-based cohort study.

SETTING

Data from the Swedish Medical Birth Registry from 1998 to 2007.

POPULATION

National cohort of 3517 infants born to mothers with type 1 diabetes. Only singletons with gestational age 32-43 weeks were included.

METHODS

Large for gestational age (LGA) was defined as birthweight > 90th centile and appropriate for gestational age (AGA) as birthweight between 10th and 90th centiles. Disproportionate (D) infants were defined as having a ponderal index [PI: calculated as birthweight in grams/(length in cm)(3) > 90th centile] and proportionate (P) as PI ≤ 90th centile. LGA infants were classified as P-LGA or D-LGA. Odds ratios were calculated for D-LGA and P-LGA infants, with AGA infants as the reference category. Odds ratios were adjusted for mode of delivery, fetal distress and stratified by gestational age.

MAIN OUTCOME MEASURES

The primary outcome was a composite of neonatal morbidities, i.e. any of the following diagnoses: Apgar score < 7 at 5 minutes, birth trauma (Erb's palsy or clavicle fracture), respiratory disorder, hyperbilirubinaemia or hypoglycaemia requiring treatment.

RESULTS

Composite morbidity was significantly more frequent in LGA as opposed to AGA infants, but there was no difference in risk between P-LGA and D-LGA infants.

CONCLUSIONS

High birthweight, irrespective of body proportionality, is a risk factor for neonatal complications in offspring of women with type 1 diabetes.

Pregnancy outcome of women with gestational diabetes in a tertiary level hospital of north India

BACKGROUND

Women with gestational diabetes mellitus (GDM) pose an important public health problem because diabetes not only affects the maternal and fetal outcome, but these women and their fetuses are also at an increased risk of developing diabetes and related complications later in their life.

OBJECTIVES

The study was conducted to determine the maternal and fetal outcomes of 50 diabetic vs 50 normoglycemic pregnancies.

MATERIALS AND METHODS

This was a retrospective analytical record-based study conducted in a tertiary level hospital. Detailed information regarding maternal, fetal, and labor outcome parameters was recorded in a prestructured proforma and compared in normoglycemic and diabetic pregnancies.

RESULTS

Patients with obesity, history of diabetes in the family, spontaneous abortions, and gestational diabetes in previous pregnancies had a greater incidence of GDM in current pregnancy (P<0.05 for all). Hypertension, polyhydramnios, macrosomia, fetopelvic disproportion, and cesarean sections were more (P<0.001) among diabetic pregnancies. Congenital anomalies, polycythemia, hypocalcemia, and hyperbilirubinemia were also observed to be more (P<0.05) in neonates born to diabetics, suggesting an adverse effect of hyperglycemia in utero.

CONCLUSION

Diabetes during pregnancy is associated with higher maternal and fetal morbidity. Therefore, early screening, detection, close monitoring, and intervention is essential to reduce maternal and fetal short- and long-term adverse effects, especially in high-risk groups. Pregnancy provides an opportunity to the clinician to control the disease process and inculcate healthy lifestyle practices in these patients.

Birth size distribution in 3,705 infants born to mothers with type 1 diabetes: a population-based study

OBJECTIVE

To characterize birth size distribution in infants born to mothers with type 1 diabetes. In particular, the relationship between birth weight (BW) and length (BL) was studied because it may provide information on different causal pathways of fetal macrosomia commonly seen in diabetic pregnancies.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study of 3,705 infants of type 1 diabetic mothers (1,876 boys), with a gestational age of 28-43 weeks, born in Sweden between 1998 and 2007. BW and BL were retrieved from the Medical Birth Registry and expressed as SD scores (SDS). Ponderal index (PI) was calculated as BW in g/length in cm³. A BW >90th and a PI ≤ 90th percentile was defined as proportionate large-for-gestational age (LGA), whereas if both BW and PI > 90th percentile, the infant was categorized as disproportionately large. Values are mean (SD).

RESULTS

The BW distribution for offspring of type 1 diabetic mothers was bell-shaped, significantly broader, and markedly shifted to the right (BWSDS: 1.27 [1.48]) of the reference. Of the infants born to diabetic mothers, 47% were LGA, and among them, 46% were disproportionately large compared with 35% in nondiabetic LGA infants (P < 0.001). Female offspring of type 1 diabetic mothers had significantly higher BWSDS than males (1.34 vs. 1.20, P < 0.01), and preterm infants had higher BWSDS than term infants (1.41 vs. 1.23, P < 0.01)

CONCLUSIONS

Fetal macrosomia in type 1 diabetic pregnancies is due to a right-shift and broadening of the entire BW distribution. The large number of disproportionate LGA infants born to type 1 diabetic mothers suggests an underlying metabolic problem. Fetal macrosomia was more pronounced in preterm and female offspring of type 1 diabetic mothers.

Infants of diabetic mothers with abnormal fetal growth missed by standard growth charts

Diabetic pregnancies may result in fetal macrosomia when glycaemia is poorly controlled, and when associated with diabetic vasculopathy, with small for gestational age (SGA) neonates. Both groups of infants have high neonatal morbidity. As fetal growth depends on maternal genetic influences, ethnic group or parity, relying exclusively on population-based growth charts may wrongly categorise the growth pattern of these infants. We compared neonatal morbidity and mortality of a cohort of 214 infants of diabetic mothers (IDM), identified either by population standards or by customised birth weight percentiles (adjusted for maternal height, booking weight, parity, ethnic origin, gestational age at delivery and sex). A total of 68 (31.8%) were diagnosed with macrosomia, 11 (16%) of whom were identified by the customised growth method alone, and 16 were diagnosed as SGA (7.5%), of whom the majority (13 or 81.2%) were identified by the customised growth method alone. None had increased mortality and morbidity.

Long-term effects of diabetes during pregnancy on the offspring

BACKGROUND

Many epidemiological and experimental studies have proven that some adult diseases might have their origin in fetal life. It has been also hypothesized that intra-uterine environment in pregnancy complicated with diabetes might influence the development of obesity, type 2 diabetes, and cardiovascular diseases in the offspring.

OBJECTIVES

To assess glucose metabolism, insulin secretion, and prevalence of obesity in the offspring of mothers with pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM) and to evaluate the relationship between maternal metabolic control during pregnancy and metabolic disturbances in children.

SUBJECTS

Children of mothers with PGDM (n = 43) and GDM (n = 34) were examined at 4-9 yr of age and compared with the control group (n = 108; metabolic parameters available for n = 29).

METHODS

The incidence of overweight and obesity, impaired glucose tolerance, and insulin resistance were analyzed based on anthropometric and biochemical measurements. Statistical analysis was performed with statistica package.

RESULTS

In children of GDM mothers, body mass index z-score (0.81 +/- 1.01 vs. -0.04 +/- 1.42 PGDM vs. 0.07 +/- 1.28 control group) and insulin resistance indices (homeostasis model assessment index - insulin resistance 1.112 vs. 0.943 PGDM vs. 0.749 control group) were significantly higher than in other groups. Obesity and insulin resistance were also most frequent in GDM group [not significant (NS)]. In addition, we observed the relationship between maternal hemoglobin A1c and mean glycemia in perinatal period and insulin resistance in children. There was not such correlation for the class of maternal diabetes.

CONCLUSION

Children born to mothers with gestational diabetes seem to be at risk for obesity and metabolic disturbances.

Continuous glucose monitoring during pregnancy

Diabetes throughout gestation presents challenges that greatly influence maternal and fetal outcomes. Since the degree of maternal hyperglycemia is the most deterministic of these risks, glucose monitoring has become a fundamental tool in the management of diabetes in pregnancy. While most patients with diabetes are in need of improved glucose control, certain circumstances beg for more detailed glucose information than is available by conventional methods alone. In this article, we will review the state of diabetes during pregnancy and the serious outcomes that persist despite the overall improvement in glycemic control today. We will discuss the advantages of incorporating continuous glucose monitoring (CGM), specifically in the treatment of pregnancies complicated by diabetes. In addition to its clinical utility, CGM can advance our understanding and classification of normoglycemia during pregnancy. Demarcation of the normal glucose profile that is present during gestation better defines the therapeutic goals for women with diabetes and ultimately promotes success in pregnancy.

Associations of Type 1 diabetes mellitus, maternal vascular disease and complications of pregnancy

BACKGROUND

Maternal diabetes increases the risk of pre-eclampsia and abnormalities of fetal growth. We studied the additional impact of maternal vascular disease on these risks.

METHODS

The first viable (> 23 weeks) pregnancies of 138 women with Type 1 diabetes mellitus (Type 1 DM), delivered between 1994 and 2003 at the Queen's Medical Centre, Nottingham, UK were studied. Women were divided into groups with and without vascular disease (retinopathy and/or nephropathy and/or pre-existing hypertension). Primary outcomes were pre-eclampsia and fetal customized birthweight percentile (cbp) (adjusted for maternal weight, height, parity, ethnicity, gestational age and gender). Secondary outcomes were perinatal outcome (miscarriage, intrauterine or neonatal death), preterm birth, birth asphyxia, neonatal hypoglycaemia and delivery mode.

RESULTS

Women with vascular disease were more likely to develop pre-eclampsia (OR 3.5; CI 1.28-9.53) and deliver infants with lower cbp (median 89.0, range 0-100 vs. 98.0, range 0-100; P < or = 0.005). Infants were less likely to be macrosomic (OR 0.46; CI 0.224-0.928) but more likely to have intrauterine growth restriction (IUGR; OR 6.0; CI 1.54-23.33). Women with vascular disease had higher Caesarean section rates (90 vs. 56%, P < or = 0.001).

CONCLUSIONS/INTERPRETATION

Women with Type 1 DM and vascular disease are at greater risk of pre-eclampsia and pathological fetal growth. This should influence counselling and merit increased pregnancy surveillance.

Females born large for gestational age have a doubled risk of giving birth to large for gestational age infants

AIM

To analyse if females born large for gestational age (LGA) have an increased risk to give birth to LGA infants and to study anthropometric characteristics in macrosomic infants of females born LGA.

METHODS

The investigation was performed as an intergenerational retrospective study of women born between 1973 and 1983, who delivered their first infant between 1989 and 1999. Birth characteristics of 47,783 females, included in the Swedish Birth Register both as newborns and mothers were analysed. LGA was defined as >2 SD in either birth weight or length for gestational age. The infants were divided into three subgroups: born tall only, born heavy only and born both tall and heavy for gestational age. Multiple logistic and linear regression analyses were performed.

RESULTS

Females, born LGA with regard to length or weight, had a two-fold (adjusted OR 1.96, 95% Cl 1.54-2.48) increased risk to give birth to an LGA infant. Females, born LGA concerning weight only, had a 2.6 (adjusted OR 2.63, 95%, 1.85-3.75) fold increased risk of having an LGA offspring heavy only and no elevated risk of giving birth to an offspring that was tall only, compared to females born not LGA. In addition, maternal obesity was associated with a 2.5 (adjusted OR 2.56, 95%, 2.20-2.98) fold increased risk of having an LGA newborn, compared to mothers with normal weight.

CONCLUSION

Females, born LGA, have an increased risk to give birth to LGA infants, compared to mothers born not LGA. Maternal overweight increases this risk even further.

Lipid profile, glucose homeostasis, blood pressure, and obesity-anthropometric markers in macrosomic offspring of nondiabetic mothers

OBJECTIVE

The study was to determine whether being the macrosomic offspring of a mother without detected glucose intolerance during pregnancy has an impact on lipid profile, glucose homeostasis, and blood pressure during childhood.

RESEARCH DESIGN AND METHODS

Plasma total, HDL, and LDL cholesterol; triglycerides; apolipoprotein (Apo) A-1, -B, and -E; lipoprotein (a); fasting glucose and insulin; homeostasis model assessment of insulin resistance (HOMA-IR) index; blood pressure; BMI; and detailed anthropometry were evaluated in 85 children aged 3-10 years old, born appropriate for gestational age (AGA; n = 48) and large for gestational age (LGA; n = 37) of healthy mothers.

RESULTS

At the time of the assessment, body weight, height, skinfold thickness, BMI, waist circumference, and blood pressure did not differ between the LGA and AGA groups with the exception of head circumference (P < 0.01). There were no significant differences in plasma total or LDL cholesterol; triglycerides; Apo A-1, -B, or -E; lipoprotein (a); Apo B-to-Apo A-1 ratio; or glucose levels between the groups. The LGA group had significantly higher HDL cholesterol levels (P < 0.01), fasting insulin levels (P < 0.01), and HOMA-IR index (P < 0.01) but lower values of the glucose-to-insulin ratio (P < 0.01) as compared with the AGA group.

CONCLUSIONS

Children born LGA of mothers without confirmed impaired glucose tolerance during pregnancy show higher insulin concentrations than AGAs.

Diabetes mellitus in pregnancy

This article reviews normal and abnormal carbohydrate metabolism in pregnancy, with an emphasis on the challenges that are faced by those who care for the pregnant woman who has hyperglycemia. The growing problem of type 2 diabetes in pregnancy, the controversial use of oral antihyperglycemic agents for the treatment of gestational diabetes, and the long-term issue of diabetes prevention in those whose hyperglycemia resolves postpartum are also addressed.

Exposure to maternal diabetes is associated with altered fetal growth patterns: A hypothesis regarding metabolic allocation to growth under hyperglycemic-hypoxemic conditions

The prevalence of diabetes is rising worldwide, including women who grew poorly in early life, presenting intergenerational health problems for their offspring. It is well documented that fetuses exposed to maternal diabetes during pregnancy experience both macrosomia and poor growth outcomes in birth size. Less is known about the in utero growth patterns that precede these risk factor expressions. Fetal growth patterns and the effects of clinical class and glycemic control were investigated in 37 diabetic pregnant women and their fetuses and compared to 29 nondiabetic, nonsmoking maternal/fetal pairs who were participants in a biweekly longitudinal ultrasound study with measurements of the head, limb, and trunk dimensions. White clinical class of the diabetic women was recorded (A2-FR) and glycosylated hemoglobin levels taken at the time of measurement assessed glycemic control (median 6.9%, interquartile range 5.6-9.2%). No significant difference in fetal weight was found by exposure. The exposed sample had greater abdominal circumferences from 21 weeks (P < or = 0.05) and shorter legs, but greater upper arm and thigh circumferences accompanied increasing glycemia in the second trimester. In the third trimester, exposed fetuses had a smaller slope for the occipital frontal diameter (P = 0.00) and were brachycephalic. They experienced a proximal/distal growth gradient in limb proportionality with higher humerus / femur ratios (P = 0.04) and arms relatively long by comparison with legs (P = 0.02). HbA1c levels above 7.5% accompanied shorter femur length for thigh circumference after 30 gestational weeks of age. Significant effects of diabetic clinical class and glycemic control were identified in growth rate timing. These growth patterns suggest that hypoxemic and hyperglycemic signals cross-talk with their target receptors in a developmentally regulated, hierarchical sequence. The increase in fetal fat often documented with diabetic pregnancy may reflect altered growth at the level of cell differentiation and proximate mechanisms controlling body composition. These data suggest that the maternal-fetal interchange circuit, designed to share and capture resources on the fetal side, may not have had a long evolutionary history of overabundance as a selective force, and modern health problems drive postnatal sequelae that become exacerbated by increasing longevity.

Care of diabetes in pregnancy

Diabetes, whether existing before pregnancy or brought on by changes in maternal physiology, poses risks to the mother and developing fetus. Excellent preconceptional and pregnancy care can help to minimize, or even to eliminate, these risks. This article reviews the problems that are associated with diabetes in pregnancy and evidence-based strategies to avoid them.

Ponderal index is a poor predictor of in utero growth retardation

OBJECTIVE

To evaluate the usefulness of ponderal index (PI) and related indices of weight and length in identifying asymmetric growth, body thinness and organ asymmetry associated with IUGR.

DESIGN

Cross sectional study.

SETTING

Aberdeen Maternity Hospital.

POPULATION

The population includes term (>/=37 weeks) singleton live births (n= 53,934) between 1986 and 1996, ultrasound measurements in 2522 pregnancies, 712 unselected term pregnancies in 1979/1980 and stillbirths (24-36 weeks) between 1986 and 1995 where the fetus was diagnosed as suffering from acute (n= 73) or chronic (n= 30) anoxic death.

METHODS

The strength of association between direct measures of IUGR and various indices of weight and length was determined by linear and multiple stepwise linear regression.

MAIN OUTCOME MEASURES

Weight, length, PI and skinfold thicknesses (triceps, biceps, flank thighs, back) were measured at birth. Abdominal circumference, biparietal diameter and femur length were measured by ultrasound at >/=37 weeks. Ratio of liver, heart and kidney to brain were measured in stillbirths.

RESULTS

Weight alone was a better predictor of skinfold thickness, abdominal circumference and the ratio of abdominal circumference to biparietal diameter than weight divided by length raised to the power 1, 2, 3 (PI), 4 or 5. The inclusion of gestational age made little difference to the predictive ability of weight for these full term births. Weight, but not PI, was significantly different between the two groups of stillborn fetuses (chronic and acute), which had significantly different (P < 0.001) organ ratios.

CONCLUSION

Body weight alone was a better predictor of anthropometric ratios, organ asymmetry and measures of thinness at birth thought to be associated with IUGR than the PI. The inclusion of a length term generally reduced the predictive ability with the highest powers resulting in the poorest prediction.

Hypoglycemia and the full-term newborn: how well does birth weight for gestational age predict risk?

OBJECTIVE

To determine whether anthropometric characteristics could be used to accurately predict risk of hypoglycemia in full-term newborns during the early post-birth period.

DESIGN

Descriptive, utilizing newborn anthropometric measurements singly and in combination to determine risk of neonatal hypoglycemia. The following measurements were obtained twice for each newborn: weight, head circumference, chest circumference, abdominal circumference, mid-arm circumference, thigh circumference, and length. The investigator was blind to all measurements except weight.

SETTING

Mothers' rooms or the newborn nursery in a community hospital.

INTERVENTIONS

All measurements were obtained twice, and a physical examination was completed on each newborn by the principal investigator. These newborns were classified as large-, average-, and small-for-gestational age, using a tool typically used in many newborn nurseries.

SAMPLE

One hundred fifty-seven full-term newborns (94 White and 63 African American).

MAIN OUTCOME MEASURES

The differences in anthropometric measurements by race and gender were calculated using two-way analysis of variance. The risk of hypoglycemia was calculated using logistic regression modeling.

RESULTS

There were significant differences in measurements by race and by gender. Additionally, there was a subset of newborns classified as average for gestational age who had an increased risk of hypoglycemia (OR = 4.17, 95% CI = 1.33-13.08). Newborns with a mid-arm circumference/head circumference ratio that varied from .26 to .29 have an odds ratio of 6.10 (95% CI = 1.89-19.66) for risk of hypoglycemia. Plotting a newborn's birth weight on a published fetal growth curve clearly did not accurately predict his or her risk of hypoglycemia.

CONCLUSIONS

These findings indicate that extremes in newborn birth weight are not always correctly defined, may vary by race and ethnic group, and may not be the best method for determining under- or overnourishment and risk of neonatal hypoglycemia.

Overgrowth

The predominant influences on fetal growth are maternal and placental factors. Post-natal growth is regulated by a complex interaction between genetic, environmental and hormonal influences. The role of the growth hormone insulin-like growth factor (GH-IGF) system is explored, including the emerging role of IGF-2 in fetal growth. Increasing understanding of the genetics of overgrowth and short stature syndromes is contributing greatly to basic understanding of growth regulation. A range of prenatal overgrowth syndromes is discussed, including those associated with neonatal hyperinsulinism and hypoglycaemia.Post-natal overgrowth may be caused by a diverse range of normal variant conditions, endocrine disorders, chromosomal abnormalities and other genetic syndromes. An approach to diagnosis is presented and major conditions discussed in detail. Sex-steroid therapy for height limitation continues to be a controversial area with uncertainty about height prediction, benefits achieved and possible long-term side-effects.

A spectrum of glucose thresholds may effectively prevent complications in the pregnant diabetic patient

This article outlines the probable positive relationship between levels of maternal glycemia and perinatal morbidity and mortality. A spectrum of different glucose thresholds can be established and used appropriately to prevent each complication. This article also outlines the concept of normality and what definitions of normality should be used to evaluate the relationship between the level of glycemia and perinatal outcome. Definitive conclusions are hampered by a lack of uniformity in definitions and interventions, and by a failure in some analyses to control for confounding variables. However, it is suggested that different levels of glycemia are required to prevent different diabetic complications. Thus, although it is not always possible to achieve targeted levels of glycemic control in all patients, any improvement will be beneficial because it will affect fetal complications associated with that glucose threshold.

Normalization of pregnancy outcome in pregestational diabetes through functional insulin treatment and modular out-patient education adapted for pregnancy

AIM

To investigate whether modular out-patient group education for flexible, Functional Insulin Treatment (FIT) adapted for pregnancy can eliminate diabetes-associated neonatal complications in pregestational diabetes.

RESEARCH DESIGN AND METHODS

Outcome analysis of the modular out-patient group education and FIT based on separate insulin dosages for fasting, eating or correcting hyperglycaemia in 76 consecutive pregnancies (in 20 cases first after conception) of 59 patients with pregestational diabetes (Type 1 diabetes, n = 54).

CONTROLS

(a) diabetic pregnancies: historical controls; (b) non-diabetic pregnancies: retrospective case-controlled study; (c) population-based data of all Austrian newborns registered within the respective time period.

RESULTS

HbA1c of 113 +/- 18% of mean value (= 100%) of non-diabetic, non-pregnant population (103 +/- 14% during the last pregnancy trimester), and self-monitored blood glucose of 5.6 +/- 0.7 mmol/l (5.3 +/- 0.7 mmol/l during the last trimester) was achieved throughout all FIT pregnancies. Severe hypoglycaemia occurred in 14 pregnancies. The gestational age at delivery was 39.2 +/- 1.5 weeks (four cases (5.4%) < 37 weeks) with a birth weight of 3305 +/- 496 g. Four newborns (5.3%) were above the 90th, and nine (11.8%) below the 10th percentile for weight of reference population-based data. Hypoglycaemia was recorded in six newborns (8%). Malformations were found in two infants whose mothers booked for diabetes FIT education only after conception. The caesarean delivery rate was 25%. In comparison with historical diabetic pregnancy controls we demonstrated a reduction in major complications, and compared with non-diabetic women, a lowering of diabetes-related neonatal complication rates to general population levels.

CONCLUSIONS

Structured, comprehensive, modular out-patient group education promoting self-choice of insulin dose for flexible, normal eating prior to conception normalizes pregnancy outcome in diabetes.

Diabetes during pregnancy does not alter whole body bone mineral content in infants

A previous study using single photon absorptiometry has reported low bone mineral density of the radius in infants of diabetic mothers. The aim of this study was to assess by dual x-ray absorptiometry the whole body bone mineral content (WbBMC) and the body composition of 40 infants of diabetic mothers at birth (mean gestational age +/- SD, 37.5 +/- 1.3 weeks; mean birth weight +/- SD, 3815 +/- 641 g). WbBMC was not correlated with gestational age, but was well correlated with birth weight (r = 0.73; P = 0.0001) and also with fat mass (r = 0.87; P = 0.0001) and lean mass (r = 0.42; P = 0.008). The z-scores +/- SD adjusted for weight for WbBMC and fat mass were significantly increased (1.3 +/- 0.9 and 2.6 +/- 1.3, respectively (P < 0.0001), but were not significantly influenced either by in utero growth or by the type of the diabetes mellitus of the mother. Bone mineralization and fat mass studied by whole body dual x-ray absorptiometry are increased at birth in these infants compared with reference curves.

Fetal growth in diabetic pregnancy

In summary, fetal macrosomia occurs in almost one third of diabetic pregnancies regardless of class. Abnormal fetal fat stores lead to difficult labor, dystocia, and birth injury as well as postnatal metabolic transition. The abnormal body fat distribution at birth may destine some of these infants to lifelong obesity. Abnormal fetal growth in diabetic pregnancy appears to occur with any elevations in maternal glucose levels, however modest. Detection of macrosomia is therefore a major goal of diabetic pregnancy management.

Perinatal morbidity and mortality in offspring of diabetic mothers in Qatif, Saudi Arabia

Diabetic mothers and their offspring were prospectively studied. Perinatal and neonatal morbidity and mortality data were analysed. Out of 11,677 deliveries in the hospital, 133 (1.14%) were delivered by diabetic mothers. They were made up of six (4.5%) stillbirths and 127 (95.5%) live births. Seventy-seven (57.9%), 55 (41.3%) and 1 (0.8%) were large, appropriate and small for gestational age, respectively. Hypoglycemia occurred in 49 (38.6%) of the 127 infants. Other associated problems were bacterial infections, congenital anomalies, birth trauma, preterm delivery, respiratory distress, polycythaemia and anaemia. Only 52 (39.1%) of the mothers received appropriate treatment for their diabetes during pregnancy. Poor maternal diabetic control resulted in high perinatal morbidity and mortality in the offspring. In order to improve the outcome in offspring of diabetic mothers in Qatif and probably Saudi Arabia as a whole, health education and improved care of the diabetic mothers during pregnancy urgently needed. This may be true of other developing countries where data on diabetes in pregnancy are scarce.

The infant of the diabetic mother

The history of the medical success in treatment of the pregnant diabetic woman and her infant in the twentieth century illustrates how the combined efforts of dedicated clinicians and researchers have resulted in dramatic improvements in outcome for this patient group. This article discusses fetal growth, metabolic complications of the infant of the diabetic mother, risk of respiratory distress syndrome, hypertrophic cardiomyopathy, and congenital anomalies.

Growth promoting peptides in diabetic and non-diabetic pregnancy: interactions with trophoblastic receptors and serum carrier proteins

Infantile macrosomia in diabetic pregnancy (DP) is commonly attributed to fetal hyperinsulinism. However, insulin-like growth factors in the mother and the fetus, their binding proteins and their placental receptors may also play roles in the process of fetal overgrowth. We measured levels of maternal and cord serum IGF-I, IGF-II, C-peptide, IGFBP-1, IGFBP-2 and IGFBP-3 in 8 White Class B insulin dependent DP and 8 non-diabetic pregnancies (NP). These results were correlated with the concentration and affinity of placental trophoblastic membrane receptors (TR) for insulin (IN), IGF-I and IGF-II as well as with infant and placenta weights and maternal body mass indices. Significant respective differences between the diabetic and non-diabetic groups were found in mean infant weight, 4248 +/- 114 vs 3555 +/- 119 g (p < 0.001), placental weight 765 +/- 51 vs 575 +/- 24 g (p < 0.01), maternal body mass index 32.8 +/- 3.8 vs 21.3 +/- 1.2 (p < 0.02), cord serum IGF-I 136.8 +/- 6.6 vs 85.9 +/- 5.7 ng/ml (p < 0.01), cord serum C-peptide 18.7 +/- 3.5 vs 9.0 +/- 1.7 ng/ml (p < 0.025), cord serum IGFBP-1 21.9 +/- 4.7 vs 133.2 +/- 43.2 ng/ml (p < 0.025), cord serum IGFBP-2 672.0 +/- 76 vs 1206 +/- 220 ng/ml (p < 0.05) and cord serum IGFBP-3 11.5 +/- 1.0 vs 5.6 +/- 0.6 ng/ml (p < 0.001). No significant differences were found between DP and NP with respect to cord serum IGF-II, maternal serum IGF-I, IGF-II, C-peptide, IGFBP-1, IGFBP-2 and IGFBP-3, and the concentration and affinity of TR for IN, IGF-I and IGF-II. Analysis of variance revealed an interaction between infant weight and the weight of the placenta (p < 0.01), cord IGF-I (p < 0.02), cord C-peptide (p < 0.01) and cord IGFBP-3 (p < 0.01). Regression analysis revealed significant correlations of cord IGF-I with cord values of IGFBP-2 (r = -0.52, p = 0.04) and IGFBP-3 (r = 0.66, p < 0.005). Maternal serum IGF-I significantly correlated only with maternal IGFBP-3 (r = 0.65, p < 0.01). These results suggest that increased fetal production of insulin and IGF-I may contribute to the development of infantile macrosomia in DP. Concomitant changes in fetal production of IGFBPs, particularly IGFBP-2 and IGFBP-3, may modulate the action of insulin and IGFs. The lack of change in number or binding affinity of placental trophoblastic receptors for insulin, IGF-I and IGF-II tends to exclude a significant regulatory role of these receptors in the production of fetal macrosomia.

Toward universal criteria for gestational diabetes: the 75-gram glucose tolerance test in pregnancy

OBJECTIVES

The purpose of this study was to determine the distribution of values for the 75 gm glucose tolerance test in pregnancy and to define glucose intolerance by the relationship between maternal glucose values and neonatal macrosomia.

STUDY DESIGN

A total 3505 unselected pregnant women were given a 75 gm, 2-hour glucose tolerance test. Diet or insulin therapy was offered only to patients with a fasting plasma glucose level > or = 105 mg/dl or a 2-hour post-glucose-load value > or = 200 mg/dl. Birth weights of live-born singletons delivered from 36 to 42 weeks whose mothers had a fasting plasma glucose level < 105 mg/dl and 2-hour post-glucose-load value < 200 mg/dl were used to calculate relationships between glucose levels and birth weights.

RESULTS

At 24 to 28 weeks' gestation the mean and SD plasma glucose values were fasting 83.6 (8.9) mg/dl, 1 hour 128.4 (32.9) mg/dl, and 2 hour 108.4 (24.8) mg/dl. In a multiple logistic regression model the factors found to be statistically significantly associated with macrosomia were maternal race, parity, prepregnancy body mass index, weight gain, gestational age at testing, fasting plasma glucose level, and 2-hour post-glucose-load value. A positive association was found between maternal glucose values and birth weight percentiles. No clinically meaningful glucose threshold values relative to birth weight or macrosomia were found.

CONCLUSION

In the absence of a meaningful threshold relationship between glucose tolerance test values and clinical outcome, criteria defining gestational diabetes will probably be established by consensus.

Accuracy of anthropometric measurements in predicting symptomatic SGA and LGA neonates

Mid-arm circumference, mid-arm circumference/head circumference ratio, ponderal index and skinfold thickness at five sites (biceps, triceps, quadriceps, subscapular and flank) were measured in 91 small-for-gestational-age (SGA) and 101 large-for-gestational-age (LGA) neonates to investigate their accuracy in identifying neonates at high risk of complications resulting from disturbed intrauterine growth. Thirty-one of 91 SGA and 19 of 101 LGA neonates who developed hypoglycaemia and/or polycythaemia were regarded as symptomatic. Mean values of all of the anthropometric parameters differed significantly between symptomatic and asymptomatic SGA or LGA neonates. The quadriceps skinfold thickness was the most sensitive index in predicting symptomatic SGA and LGA neonates (sensitivity 0.93 and 0.95, respectively). The mid-arm circumference was also a very sensitive index in predicting symptomatic SGA neonates (sensitivity 0.94) but its specificity was extremely low (0.20). The rest of the parameters showed lower sensitivity than quadriceps skinfold thickness associated with similarly low specificity and validity. The findings of this study indicate that the quadriceps skinfold thickness is the most reliable index for use as a screening test for clinical evaluation of SGA and LGA neonates who are likely to develop complications as a result of disturbed intrauterine nutrition.