Care of the pregnant woman with insulin-dependent diabetes mellitus

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

AIMS

Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

METHODS

Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17-40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

RESULTS

Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

CONCLUSIONS

Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care.

Quantitative risk estimation for large for gestational age using the area under the 100-g oral glucose tolerance test curve

We devised a complementary quantitative method for gestational diabetes (GDM) that uses the area under the curve (AUC) of the results of the oral glucose tolerance test (OGTT), and evaluated its efficacy in predicting neonates that would be large for gestational age (LGA). The study subjects were 648 pregnant women. The AUC-OGTT (concentration x time) was calculated from the 100-g OGTT results. The incidence of LGA according to each range of the AUC-OGTT was estimated and odds ratios were analyzed using multiple logistic regression analysis.The incidence of LGA increased with the AUC-OGTT value and was 0% for AUC<300, 7.8% for 300-400, 14.9% for 400-500, 20.8% for 500-600, and 45.5% for > or = 600. The odds ratio of LGA increased by approximately two-fold with an increase of 100 in the AUC-OGTT. The results indicated that the AUC-OGTT can be used to quantify the risk of LGA in GDM. The AUC-OGTT could complement a diagnosis of GDM using conventional diagnostic criteria.

Vaginally administered misoprostol for outpatient cervical ripening in pregnancies complicated by diabetes mellitus

OBJECTIVE

To compare the use of vaginally administered misoprostol to placebo for outpatient labor induction in patients with diabetes.

STUDY DESIGN

In this double-masked, controlled clinical trial, pregnant women with diabetes and gestational age of >38(1/2) weeks were randomized to receive 25 microg misoprostol or placebo vaginally on days 1 and 4 of a 7-day outpatient cervical ripening period. If necessary, inpatient labor induction was managed by using a standard protocol.

RESULTS

Of 120 women included in the study, 57 received misoprostol and 63 received placebo. Most of the women had been diagnosed with gestational (Class A) diabetes. Similar numbers of misoprostol and placebo-treated women delivered within 7 days of the first dose (31/57 [54%] vs 36/63 [57%], P =.63). The mean (+/-SEM) interval from induction to delivery was similar (8530.5 minutes +/-1439.7 minutes vs 6712.5 minutes +/-606.4 minutes, P =.23).

CONCLUSION

Vaginally administered misoprostol was no more effective than placebo in reducing the need for inpatient labor induction or the induction-delivery interval. Outpatient cervical ripening with use of vaginally administered misoprostol was well tolerated.

Preconception care of women with diabetes: the unrevealed obstacles

In spite of the widely accepted knowledge that elevated blood glucose levels in early pregnancy are associated with a significantly increased risk of birth defects in infants of women with established diabetes, the majority of diabetic women do not plan their pregnancies and enter pregnancy with inadequate blood glucose control. This article reviews the current research on circumstances and factors associated with unplanned diabetic pregnancies and offers recommendations to encourage effective pregnancy planning and preconception care among women with diabetes.

Fetal size at birth in relation to quality of blood glucose control in pregnancies complicated by pregestational diabetes mellitus

OBJECTIVE

To determine the relation between maternal levels of blood glucose and glycated haemoglobin (HbA1c) and infant size at birth in pregestational diabetes.

DESIGN

Longitudinal study from 6 to 14 weeks gestation. Women were treated intensively with insulin, aiming at normoglycaemia but avoiding hypoglycaemia. Blood glucose was determined six times daily, HbA1c every four weeks. Individual mean fasting and postprandial glucose levels were calculated for three-week periods of gestation. Birthweight > 2 SD or within +/- 2 SD for gestational age and gender was classified as large (LGA) or appropriate (AGA), respectively. Birthweight ratio was calculated as the ratio of birthweight to normal mean birthweight after correction for gestational age and gender.

PARTICIPANTS

One hundred and thirteen consecutive pregnant women with pregestational diabetes and their newborn infants.

RESULTS

Perinatal mortality was nil, the rates of spontaneous preterm delivery (8.9%) and severe maternal hypoglycaemia (4.4%) were low. Mothers with LGA infants (26%) had a significantly higher fasting glucose between weeks 27 and 32 than mothers of AGA infants (P < 0.01). Relative birthweight was significantly and independently associated with pre-pregnancy bodyweight (r = 0.24, P < 0.05) and fasting glucose at weeks 27 to 29 (r = 0.27, P < 0.01) but together could only explain 12.3% of the variation in birthweight (mult. r = 0.35, P < 0.01). HbA1c correlated with glucose levels but was unrelated to birthweight ratio. The fasting glucose level between weeks 30 and 32 was significantly interrelated with the fasting glucose level from each of the six preceding three-week periods.

CONCLUSION

Near normoglycaemia cannot be obtained in all patients, presumably due to intrinsic differences in glucoregulatory ability between individuals. The incidence of LGA infants was unexpectedly high. The modest abnormality in glycaemic control in mothers with LGA infants could only partly explain fetal oversize, suggesting that other factors must be implicated to explain fetal growth acceleration.

Fuel metabolism in deviant fetal growth in offspring of diabetic women

Fetal growth and development from its very first stages of intrauterine life is significantly influenced by the metabolic environment in which the conceptus develops. Maternal disease states such as gestational diabetes and hypertensive pregnancy, representing maternal conditions involved in extremes of impaired fetal growth (macrosomia versus growth restriction), can serve as excellent examples of the various factors that are involved in intrauterine growth.

Pregnancy in diabetes: reducing the risks

Meticulous glucose control that begins long before conception is fundamental to protecting the fetus and mother. Maternal hypertension, retinopathy, renal disease, and neuropathy may lead to complications, but optimal education, care, and fetal monitoring can reduce the risks.

Embryonic growth impaired by maternal hypoglycemia during early organogenesis in normal and diabetic rats

The effect of maternal hypoglycemia on early organogenesis was studied in normal and diabetic rats. Female Wistar rats were made diabetic by an intravenous injection of streptozotocin (45 mg/kg) 2-3 weeks before conception. On day 9.5 or 10.5 of embryo development, both control and diabetic dams received saline or Actrapid human insulin (400 mU/rat) intraperitoneally after 19-h starvation. The fasting plasma glucose levels in diabetic dams decreased from approximately 23 to 8 mM. Hypoglycemia as low as 3.5 mM was maintained for 60 min in insulin-treated mother rats. Pregnancy was terminated on day 11.6 of embryo development. A significant growth retardation was found in diabetic embryos as compared with normal embryos. Maternal hypoglycemia lowered the DNA content in normal but not diabetic embryos, while the teratogenic effect of maternal hypoglycemia was not pronounced in either normal or diabetic embryos. These data may suggest that maternal hypoglycemia in vivo in early pregnancy influences the embryogenesis but not teratogenesis of rat embryos.

Managing diabetic patients with nephropathy and other vascular complications

Since the metabolic changes in normal pregnancy are diabetogenic, pregnancy imposes a severe stress on the metabolic milieu of diabetic patients. Moreover, many patients with long-standing diabetes have vascular complications, including retinopathy, renal insufficiency, nephrotic syndrome and hypertension, all representing separate risk factors for optimal fetal development. Recent experience has suggested that maternal hyperglycaemia, and associated fetal hyperinsulinaemia, may represent an important factor in the development of fetal complications. During the past two to three decades the incidence of perinatal deaths in all categories of diabetics has been reduced to a level that approaches the rate in healthy gravidas when severe congenital anomalies are excluded. Fetal and neonatal morbidity have also been reduced, although rates of congenital anomalies, hydramnios and respiratory distress syndrome remain high. Although the morbidity associated with oedema formation and hypertension is elevated, with meticulous management of patients with diabetic nephropathy, especially in the absence of severe renal insufficiency and/or severe hypertension, pregnancy performance and outcome can be similar to that of other insulin-dependent diabetic patients.

Insulin-requiring diabetes in pregnancy: a randomized trial of active induction of labor and expectant management

OBJECTIVE

Our purpose was to assess whether a program of expectant management of uncomplicated pregnancies in mothers with insulin-requiring gestational or pregestational class B reduces the incidence of cesarean birth.

STUDY DESIGN

Two hundred women with uncomplicated, insulin-requiring diabetes at 38 weeks' gestation who were compliant with care and whose infants were judged appropriate for gestational age were randomly assigned to (1) active induction of labor within 5 days or (2) expectant management. The expectant management group was monitored with weekly physical examination and twice-weekly nonstress tests and amniotic fluid volume estimation until delivery.

RESULTS

Expectant management increased the gestational age at delivery by 1 week. Approximately half (49%) of the mothers in the expectant management group required induction of labor for obstetric indications. The cesarean delivery rate was not significantly different in the expectant management group (31%) from the active induction group (25%). The mean birth weight (3672 +/- 407 gm) and percentage large for gestational age, as defined by birth weight > or = 90th percentile, of infants in the expectantly managed group (23%) was greater than those in the active induction group (3466 +/- 372 gm, p < 0.0001, 10% large for gestational age). This difference persisted after controlling for gestational age and maternal age and body weight (p < 0.01).

CONCLUSION

In women with uncomplicated insulin-requiring gestational or class B pregestational diabetes, expectant management of pregnancy after 38 weeks' gestation did not reduce the incidence of cesarean delivery. Moreover, there was an increased prevalence of large-for-gestational-age infants (23% vs 10%) and shoulder dystocia (3% vs 0%). Because of these risks, delivery should be contemplated at 38 weeks and, if not pursued, careful monitoring of fetal growth must be performed.

Five year audit of peripartum blood glucose control in type 1 diabetic patients

An audit was conducted of the degree of blood glucose control achieved during labour using a simple glucose/insulin infusion regimen. Records were examined of 40 pregnancies in 37 women over a 5-year period. Mean blood glucose was 5.2 +/- 2.2 (SD) mmol-1 7 h before delivery and 4.7 +/- 1.8 mmol-1 1 h before delivery. Four women experienced mild symptomatic hypoglycaemia before delivery and two during the 6 h after delivery. Seven neonates had blood glucose levels of 2.2 mmol-1 or less recorded at any time, but there was no relationship between neonatal hypoglycaemia and maternal hyperglycaemia during labour in the range of achieved maternal blood glucose levels. The mean HbA1 at booking was 8.4 +/- 1.2% (non-diabetic range 5.0-7.5%) and fell to a steady plateau from 12 weeks gestation to delivery averaging 7.5% (2SD above the non-diabetic mean). These data demonstrate the practical applicability of a simple regimen for control of blood glucose during labour in insulin-dependent diabetic women and suggest that less stringent aims of blood glucose control than originally adopted may be appropriate.

The breast-feeding experience of women with type I diabetes

The purpose of this exploratory study was to identify the factors influencing the initiation and maintenance of breast-feeding in women with insulin-dependent diabetes. The lack of research in this area and the need for in-depth data necessitated exploratory methodology. Twenty-two mothers who were insulin dependent before pregnancy and who had given birth in the past 2 years were interviewed. Diabetes was not a principal factor in the decision to breast-feed or bottle-feed for the majority of the women. When diabetes was a factor, women were seeking a "normal" childbearing experience, including breast-feeding. Although the women did not perceive diabetes as influencing their breast-feeding experiences, they did find that maintaining good diabetic control required greater effort and flexibility during breast-feeding.

Prevalence of minor congenital anomalies in newborns of diabetic mothers

Minor congenital anomalies (MCA) were assessed in the offspring of 802 gestational diabetic mothers, 117 pre-gestational diabetic mothers, and 380 offspring born to normal mothers. The prevalence of infants with MCA ranged between 19.4% and 20.5% in the three groups without any significant difference between them. There was no correlation between the prevalence and type of MCA and the severity of the diabetic state. Neither was there any correlation between the prevalence or type of MCA and the appearance or type of major congenital anomalies.

Prevention: the cost-effectiveness of the California Diabetes and Pregnancy Program

BACKGROUND

The California Diabetes and Pregnancy Program is a new preventive approach to improving pregnancy outcomes through intensive diabetes management preconception and early in pregnancy.

METHODS

Hospital charges and length of stay data were collected on 102 program enrollees and 218 control cases. Ninety program enrollees and 90 control cases were matched on mother's age. White's classification, and race. Regression models controlled for these variables in addition to MediCal status, birth weight, and enrollment in the program.

RESULTS

Hospital charges were about 30% less for program participants and days in the hospital were roughly 25% less. The program effects were larger for women that enrolled before 8 weeks gestation. More serious diabetics were also found to have larger reductions in charges and days.

CONCLUSION

After adjusting for inflation and differences in charges across hospitals, $5.19 is saved for every dollar spent on the program.

Protection by free oxygen radical scavenging enzymes against glucose-induced embryonic malformations in vitro

This study addresses the possibility that the teratogenic effects of a diabetic pregnancy are associated with increased embryonic activities of free oxygen radicals. Rat embryos were cultured in 50 mmol/l glucose for 48 h and subsequently showed pronounced growth retardation and severe malformations. The enzyme inducer citiolone and the free oxygen radical scavenging enzymes superoxide dismutase, catalase and glutathione peroxidase protected against the disturbed growth and development of the embryos at 50 mmol/l glucose when added to the culture media. Enzymatic measurements indicated that citiolone induced an increased activity of superoxide dismutase in the embryonic tissues and that the added enzymes were taken up by both the yolk sac and the embryo proper. The protection against embryonic maldevelopment was thus conferred by agents that increased the free oxygen radical scavenging capacity of the embryonic tissues. The results suggest that a high glucose concentration in vitro causes embryonic dysmorphogenesis by generation of free oxygen radicals. An enhanced production of such radicals in embryonic tissues may be directly related to the increased risk of congenital malformations in diabetic pregnancy.

The daytime glucose profile as a standardized model for metabolic management of diabetes mellitus in pregnancy

On the basis of normative data from non-diabetic gravidae, the daytime glucose profile (DGP) is introduced as a model for insulin management of diabetes mellitus in pregnancy. The DGP employs four preprandial (target level = 70 mg/dl) and three 1-h postprandial glucose determinations (target level = 140 mg/dl). Insulin changes are based on a simple equation applied to individual glucose value difference between the patient (P) and target (T) levels (P - T/20). With the aid of this model, the average (+/- SD) of the daytime mean plasma glucose (DMG) levels of 22 pregnant women requiring insulin treatment (183 +/- 36 mg/dl) approached normalization (114 +/- 15 mg/dl) after 2-7 profile determinations (median = 3.5).

Maternal serum fructosamine and maternofetal glucose and insulin homeostasis in normal pregnancy

Well-defined normal values are necessary to identify pregnancies complicated by gestational diabetes (GD) and thus further reduce perinatal morbidity and mortality from this condition. The present study defined the range for the oral glucose tolerance test (oGTT) in 2578 pregnancies. After exclusion of abnormal results 822 randomized patients were used to define normal values for fructosamine, HbA1c, insulin, glucose and C-peptide in the maternal serum; insulin, glucose and fructosamine in the amniotic fluid; and insulin, glucose, C-peptide and fructosamine in the cord blood.

[Normoglycemia as a therapy goal in diabetes treatment--concept and realization]

In diabetic patients (near-)normoglycemic control of blood glucose can only rarely be achieved by conventional insulin treatment. Novel strategies for this goal include transplantation of pancreatic tissue (whole organ, segment or isolated islets), the artificial pancreas with continuous blood glucose monitoring, insulin pump treatment and the intensified conventional treatment both of the latter including self-measurement of blood glucose and self-adaptation of the insulin dosis. The results of pancreas transplantation in recent years have shown a marked improvement, the one-year survival rate of a functioning organ is in the range of 50-70%. Due to the lifelong immunosuppression pancreas transplantation should be considered in diabetic patients who need a kidney transplantation and for this reason already require immunosuppression. In spite of encouraging results in animals islet transplantation in humans has been disappointing to date. The artificial pancreas at present cannot be used for long-term treatment mainly due to the problems of the glucose sensor. The application of insulin pump treatment without continuous monitoring of blood glucose (open loop) and intensified conventional treatment both can lead to improved glycemic control in spite of a more flexible life style. Only this way of treatment made it possible to perform randomized prospective studies in diabetic patients on the effect of (near-)normoglycemic control on secondary complications. The first results show a tendency towards a positive effect on mild to moderate diabetic retinopathy over 2 years. Thus, every juvenile diabetic patient should be informed about these possibilities of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent advances in carbohydrate nutrition and metabolism in diabetes mellitus

The last decade has brought a tremendous turnaround in nutritional recommendations for diabetes management, moving from low-carbohydrate, high-fat diets to high-carbohydrate, high-fiber, low-fat diets. Clinical studies which furthered understanding of carbohydrate metabolism greatly contributed to the change. This paper reviews recent advances in selected aspects of carbohydrate nutrition and metabolism in diabetes mellitus.

Abnormal ambient glucose levels inhibit proteoglycan core protein gene expression and reduce proteoglycan accumulation during chondrogenesis: possible mechanism for teratogenic effects of maternal diabetes

Using a tissue culture system based on a nearly pure population of avian precartilage mesenchymal cells, we have found that ambient glucose levels as little as 50% lower, or 100% higher, than normally present in embryonic sera are deleterious to cartilage development, as measured by the accumulation of highly sulfated proteoglycan and the corresponding cartilage-specific chondroitin sulfate core protein mRNA. Abnormal glucose concentrations in the ranges studied did not selectively influence cell replication, and the effects on chondrogenesis were not due to differences in overall protein synthesis or glucose utilization in the treatment groups. Core protein gene expression was more severely affected than accumulation of extracellular product, suggesting the existence of posttranscriptional compensatory mechanisms. The sensitivity to ambient glucose levels of both expression of the cartilage-specific chondroitin sulfate core protein gene and the accumulation of the corresponding extracellular matrix macromolecules during chondrogenesis suggest a molecular mechanism for the well-known adverse effect of maternal diabetes on embryonic skeletogenesis. The results further suggest that hypoglycemia resulting from stringent control of diabetes may also be deleterious to skeletal development.

Fuel-mediated teratogenesis: biochemical effects of hypoglycemia during neurulation in mouse embryos in vitro

Hypoglycemia has been reported to induce congenital malformations and growth retardation in rodent embryos during the period of neural tube closure in vitro. However, the biochemical alterations responsible for the production of the dysmorphogenic effects have not been evaluated. Therefore, the rates of glucose metabolism by glycolysis, citric acid cycle, oxidative pentose phosphate pathway (PPP), and anabolic utilization were evaluated in mouse embryos and extraembryonic membranes using the whole embryo culture technique. Altered glucose metabolism by glycolysis and oxidative PPP, as well as altered anabolic synthesis, were produced by exposure to hypoglycemia. In embryos exposed to mild hypoglycemia (80 mg/dl) altered metabolism by the PPP and an associated effect on nucleic acid synthesis were in part responsible for the dysmorphogenic effects of this treatment. In contrast, severe hypoglycemia (40 mg/dl) appeared to have an immediate effect on glycolytic metabolism in addition to effects on the PPP and nucleic acid synthesis. Therefore, a multifactorial biochemical mechanism contributes to the induction of malformations by severe hypoglycemia in mouse embryos in vitro. Furthermore, the differential effects of moderate vs. severe hypoglycemia on glycolytic metabolism, and possibly energy production, may account for the differences in the severity of these treatments on embryonic growth and the incidence of malformations.

Diabetes and pregnancy

Prior to the introduction of insulin, a vast majority of pregnancies complicated by diabetes ended in perinatal death, with an associated risk of maternal death. Currently, virtually all diabetic women can undergo pregnancy with the expectation of good maternal and fetal outcome. However, many challenges still remain in preventing congenital anomalies and macrosomia.

Diabetes in pregnancy: maternal and infant outcome

Previous studies have shown that diabetic women more commonly have complications of pregnancy and adverse infant outcomes than do other women. However, most of the studies have not evaluated women with gestational diabetes separately. The purpose of this study was to evaluate pregnancy complications and infant morbidity and mortality among births to women with gestational diabetes and women with established diabetes. Birth certificate data from 1984 in Washington State linked with death certificate data provided information on complications of pregnancy and infant outcome for 422 gestational diabetics and 144 established diabetics. A comparison group of 856 non-diabetic women who delivered a child was selected at random. Both established and gestational diabetic women were more likely to be reported to develop pre-eclampsia (relative risk (RR) = 4.0 and 9.6). Established and gestational diabetic women were also at increased risk of delivery by Caesarean section (RR = 2.1 and 5.0). Infants of established diabetics had a higher risk of congenital anomalies (RR = 7.6) than infants of non-diabetics and were at increased risk of death in the first 4 weeks (RR = 7.9) and the first year of life (RR = 5.0). Gestational diabetics were more likely to have high birthweight babies (greater than 4000 g) (RR = 2.1) while established diabetics were more likely to have babies at either extreme of birthweight (greater than 4000 g, RR = 1.7; less than 2500 g, RR = 3.2). We conclude that both gestational and established diabetes are associated with important increases in risk of pregnancy complications and adverse infant outcomes.

Lack of relation of increased malformation rates in infants of diabetic mothers to glycemic control during organogenesis

To determine how much insulin-dependent diabetes increases a woman's risk of giving birth to a malformed infant and how that risk is influenced by metabolic control, we followed 347 diabetic and 389 control women who enrolled in the study within 21 days of conception (the early-entry group) and 279 diabetic women who entered later (the late-entry group). We detected major malformations in the infants of 4.9 percent of the early-entry diabetic women, 2.1 percent of the controls, and 9.0 percent of the late-entry diabetic women. Malformation rates were significantly higher among offspring of early-entry diabetic women than among those of controls (odds ratio, 2.45; lower one-sided 95 percent confidence limit, 1.12; P = 0.027), and higher among late-entry than among early-entry diabetic women (odds ratio, 1.91; lower one-sided 95 percent confidence limit, 1.07; P = 0.032). Mean blood glucose and glycosylated hemoglobin levels during organogenesis were not significantly higher in women whose infants were malformed. Hypoglycemia (glucose, less than or equal to 50 mg per deciliter [2.8 mmol per liter]) was not significantly more common in the same group. Hyperglycemia and glycosylated hemoglobin were not correlated with malformation. The data suggest that more sensitive measures are needed to identify the teratogenic mechanisms, or that not all malformation can be prevented by good glycemic control. Despite the increased malformation rate among infants of the early-entry diabetic women, as compared with the controls, the more favorable outcome seen in the former group as compared with the late-entry group justifies the attempt to achieve good metabolic control around the time of conception.

Hypoglycemia: how little is too much for the embryo?

The effects of hypoglycemia on mammalian embryos undergoing neurulation (third to fourth week of human development) were investigated. Mouse embryos were maintained for 28 hours in whole embryo culture in serum collected from rats that had received 50 units of 100 United States Pharmacopeia insulin units per milliliter. Glucose concentrations used were 40, 60, 80, and 147 mg/dl (normal blood glucose in the pregnant mouse is 125 mg/dl). After the culture period embryos were evaluated for malformations and growth and compared with those maintained under euglycemic conditions. The results demonstrate that glucose concentrations approximately 50% of normal maternal levels were teratogenic but not growth inhibitory, whereas concentrations in the range of 30% to 40% of maternal levels were lethal to the embryo. Furthermore, a 14-hour exposure to reduced blood sugar in either the first or second half of the culture period produced malformations.

The effect of maternal illness on perinatal health

Only healthy animals should be included in a breeding program. The potential effects of maternal illness and therapeutic agents on the fetus or neonate are often ignored until veterinary assistance becomes an absolute necessity. We must be mindful of these effects in order to minimize maternal and neonatal morbidity and mortality.

Diabetes and pregnancy: control can make a difference

In pregnant patients who have diabetes mellitus, metabolic control has been demonstrated to improve neonatal outcome considerably. All pregnant patients should be screened for gestational diabetes at 24 to 28 weeks of gestation with use of a glucose challenge test. Dietary therapy, and insulin therapy when appropriate, reduces the neonatal mortality associated with gestational diabetes to that of normal pregnancy. Macrosomia remains a problem, but aggressive use of insulin therapy may minimize this complication. Intensive control of insulin-dependent diabetes both before conception and during pregnancy is essential. The risk of congenital malformations can be reduced to that associated with normal pregnancy if diabetes is well controlled during the first 8 weeks of pregnancy. Neonatal survival, macrosomia, and hypoglycemia also are directly related to the degree of control of maternal diabetes during the pregnancy.

Embryotoxic effects of brief maternal insulin-hypoglycemia during organogenesis in the rat

To test whether maternal hypoglycemia can impair organogenesis, we induced brief glucopenia with insulin in conscious pregnant rats during either the headfold stage or the early neural tube closure stage of embryogenesis. At each time, 10 pairs of animals received identical insulin infusions for 1 h. Half the animals were maintained at euglycemia during the infusions, while the others were allowed to become hypoglycemic. Euglycemia was maintained or restored in all animals immediately after the insulin was stopped. Spontaneous activity was diminished during the hypoglycemia but consciousness was preserved. Embryos were removed from mothers and examined 2 d later. This examination revealed that embryos from the hypoglycemic mothers were growth-retarded and displayed a small but significant incidence of gross developmental anomalies compared with embryos from the insulin-infused euglycemic mothers. Thus, brief, mild maternal hypoglycemia during early organogenesis can disrupt normal embryo development in the rat. The effect is due to the hypoglycemia per se rather than to the insulin employed for its induction.

Management of diabetes mellitus

The past decade has seen a rapid advancement in our understanding of diabetes and in our ability to treat it. A new diagnostic classification has been established. Guidelines for diet therapy have been revised. New oral hypoglycemic agents have been approved for use, and the rationale for using oral agents expanded. Insulin therapy has been expanded by development of human insulin and new modes of injection, including insulin pumps. Several new techniques are available for monitoring control of diabetes.

Pregnancy outcome in patients with insulin-dependent diabetes mellitus with preconceptional diabetic control: a comparative study

Forty-four of 75 pregnant women with juvenile-onset insulin-dependent diabetes, who attended a preconceptional clinic, were seen regularly by a diabetologic team. Glycemic control was obtained by intensified insulin therapy and monitored by blood glucose self-monitoring. When these patients were compared with a group of 31 nonattenders of the preconceptional clinic, in the former normoglycemia and normal hemoglobin A1 values were achieved before conception, whereas in the latter good control was reached by the second trimester. This group had also more maternal complications, such as preeclampsia, and higher cesarean section rates. Congenital anomalies were 9.6% among offspring of nonattenders, while none occurred in those with preconceptional counseling. We confirm the evidence accumulated in the recent literature that congenital malformations in pregnancy complicated by diabetes may be linked to disturbances in maternal metabolism during the period of embryogenesis. Consequently we concur with the recommendation that tight diabetic control is required before the patient attempts to conceive.

Insulinoma complicating pregnancy: case report and review of the literature

A 24-year-old woman, gravida 1, para 0, experienced recurrent attacks of headaches and bizarre behavior from the sixth week of gestation onward. Three days before confinement, she lapsed into coma and was delivered of a normal child. Plasma glucose, insulin, and C-peptide levels were diagnostic of insulinoma. Subsequently, after she spontaneously regained consciousness, a pancreatic tumor was removed at laparotomy with complete resolution of symptoms. The problems of diagnosing insulinoma during pregnancy are discussed.