Fetal outcome in mothers with impaired glucose tolerance in pregnancy

The effects of adjuvant insulin therapy among pregnant women with IGT who failed to achieve the desired glycemia levels by diet and moderate physical activity

OBJECTIVE

Evaluation of adjuvant insulin therapy effects on glycemic control, perinatal outcome and postpuerperal glucose tolerance in impaired glucose tolerance (IGT) pregnant women who failed to achieve desired glycemic control by dietary regime.

METHODS

A total of 280 participants were classified in two groups: Group A patients continued with dietary regime and Group B patients were treated with adjuvant insulin therapy. Glycemic control was assessed by laboratory and ultrasonograph means. Pregnancy outcomes were evaluated by prevalence of pregnancy induced hypertension (PIH), high birth weight, neonatal hypoglycemia and caesarean section rates. Postpuerperal glucose tolerance was assessed by oral glucose tolerance test (oGTT).

RESULTS

All laboratory and ultrasound indicators of glycemic control had significantly lower values in Group B. Group A women were more likely to develop the EPH (Edema, Proteinuria, Hypertension) syndrome, 20% versus 7.86% (p = 0.003). High birth weight occurred more frequently in Group A, but the difference was not significant (p = 0.197). Higher rate of caesarean delivery was in Group A than in Group B, 16.43% versus 26.43% (p = 0.041). The difference in neonatal hypoglycemia was not significant (p = 0.478). Pathological oGTT results were observed in 73 Group A patients and in 15 Group B patients.

CONCLUSION

Lower caesarean section rates and the EPH syndrome incidence are the benefits of adjuvant insulin therapy in IGT patients.

Does nuchal translucency thickness in the first trimester predict GDM onset during pregnancy?

BACKGROUND AND AIMS

This study was planned to evaluate whether increased nuchal translucency (NT) thickness in the first trimester of gestation can be related to onset of gestational diabetes mellitus (GDM) during pregnancy.

METHODS

From January 2006 to August 2008, a group of 678 singleton pregnancies who had developed GDM has been selected as a study group among a total of 3966 pregnant women who had undergone first trimester screening for aneuploidies at 11-14 weeks of gestation. A group of 420 single pregnant women with physiological pregnancy were enrolled as control group. Both fetal structural and karyotype's anomalies were excluded in the two groups. NT was mesured by a Fetal Medicine Foundation certificated operator; GDM was diagnosed at 24-28 weeks of gestation following Carpenter and Coustan criteria. In the analyses of continuos variables, study and control group were compared by Student's t-test and Anova test.

RESULTS

There was no significative difference (p = 0.585) between NT values in the study (mean = 1.56) and control group (mean = 1.54).

CONCLUSIONS

NT thickness does not show a significative increase in those women who subsequently develop GDM. Therefore, NT assessment does not prove to be an useful ultrasound parameter for predicting GDM onset during pregnancy.

Diagnostic criteria for gestational diabetes mellitus

AIM

To answer two questions: is there a threshold for pathological hyperglycaemia after 24 weeks of gestation? What are the diagnostic criteria for gestational diabetes mellitus?

MATERIALS AND METHODS

Review of the literature considering the relationships between glucose values and complications during pregnancy in women without specific care for this condition. Only the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study meets sufficient quality criteria.

RESULTS

Increasing glucose values during pregnancy, either at fasting and after a 75-g oral glucose tolerance test, are independently associated according to a continuum with an increased risk of maternal-foetal complications, especially birth weight above the 90th percentile for gestational age, Caesarean delivery and foetal hyperinsulinemia. There is no obvious threshold at which risks increase. The International Association of Diabetes Pregnancy Study Group has proposed the following criteria, considering the glycemic values associated with a 1.75-fold increased risk of macrosomia, foetal hyperinsulinemia and adiposity in the HAPO study: fasting plasma glucose ≥ 0.92 g/L (5.1 mmol/L) and/or 1-hour plasma glucose value ≥ 1.80 g/L (10.0 mmol/L) and/or 2-hour plasma glucose value ≥ 1.53 g/L (8.5 mmol/L).

CONCLUSION

The choice of glycemic thresholds for defining gestational diabetes mellitus is necessarily arbitrary because of a continuum (NP2). Only experts may propose definition criteria.

Normal glucose tolerance and gestational diabetes mellitus: what is in between?

OBJECTIVE

The aim of this article was to define the metabolic phenotype of pregnant women with one abnormal value (OAV) during an oral glucose tolerance test (OGTT) and to test whether OAV could be considered metabolically comparable to gestational diabetes mellitus (GDM) or a specific entity between GDM and normal pregnancy.

RESEARCH DESIGN AND METHODS

After 100-g 3-h OGTTs, 4,053 pregnant women were classified as having GDM, OAV, or normal glucose tolerance (NGT). Those with OAV were subdivided into three subgroups: fasting hyperglycemia (one abnormal value at fasting during an OGTT), 1-h hyperglycemia (one abnormal value at 1 h during an OGTT [1h-OAV]), or 2- or 3-h hyperglycemia (one abnormal value at 2 or 3 h during an OGTT). As derived from the OGTT, we measured insulin sensitivity (insulin sensitivity index [ISI] Matsuda) and insulin secretion (homeostasis model assessment for the estimation of beta-cell secretion [HOMA-B], first- and second-phase insulin secretion). The product of the first-phase index and the ISI was calculated to obtain the insulin secretion-sensitivity index (ISSI).

RESULTS

GDM was diagnosed in 17.9% and OAV in 18.7% of pregnant women; women with GDM and OAV were older and had higher BMI and serum triglyceride levels than those with NGT (all P < 0.05). Women with NGT had the highest ISI followed by those with OAV (-21.7%) and GDM (-32.1%). HOMA-B results were comparable with those for OAV and GDM but significantly (P < 0.01) lower than those for NGT; first- and second-phase insulin secretion appeared progressively reduced from that in women with NGT to that in women with OAV and GDM (P < 0.01). ISSI was higher in women with NGT than in women with either OAV (-34%) or GDM (-51.7%) (P < 0.001). Among OAV subgroups, the 1h-OAV subgroup showed the lowest ISSI (P < 0.05).

CONCLUSIONS

OAV and GDM are clinically indistinguishable, and both groups are different from women with NGT. Women with GDM and OAV showed impaired insulin secretion and insulin sensitivity, although these defects are more pronounced in women with GDM. Compared with other OAV subgroups, 1h-OAV could be considered a more severe condition.

Evaluating the therapeutic approach in pregnancies complicated by borderline glucose intolerance: a randomized clinical trial

AIMS

Most studies relating minor gestational metabolic alterations to macrosomia refer to glucose intolerance classified on the basis of the National Diabetes Data Group or previous World Health Organization diagnostic thresholds. Our aim was to evaluate the consequences of very mild forms of gestational glucose intolerance, defined by an elevated 50-g glucose challenge test followed by a normal oral glucose tolerance test, using the more restrictive Carpenter and Coustan's criteria (Borderline Gestational Glucose Intolerance, BGGI).

METHODS

Three hundred BGGI women were randomly assigned to: Group A (standard management), Group B (dietary treatment and regular monitoring). A control group (C) was also considered. Newborns were classified as macrosomic, large (LGA), or small for gestational age (SGA).

RESULTS

The three groups were similar in age, body mass index and parity. Therapy in Group B significantly improved fasting (from 4.68 +/- 0.45 to 4.28 +/- 0.45 mmol/l) and 2-h postprandial glycaemia (from 6.01 +/- 0.57 to 5.13 +/- 0.68 mmol/l). Fasting glycaemia at delivery was significantly lower in B (4.20 +/- 0.38 mmol/l) than in A (4.84 +/- 0.45 mmol/l), and was also lower than in C (4.31 +/- 0.39 mmol/l). Significantly fewer LGA babies were born to Group B (6.0%) than Group A (14.0%) and Group C (9.1%). No difference was found in the SGA rate. The neonatal Ponderal Index was higher (P = 0.030) in group A (2.73 +/- 0.35) than in C (2.64 +/- 0.30) and B (2.64 +/- 0.24).

CONCLUSIONS

Even very mild alterations in glucose tolerance can result in excessive or disharmonious fetal growth, which may be prevented by simple, non-invasive therapeutic measures.

Gestational Diabetes mellitus in Women in the Fourth Decade – Is Treatment Worthwhile?

AIM

To examine the influence of diet-treated gestational diabetes mellitus on the obstetric performance of mothers aged 40 and above.

METHOD

We reviewed the delivery records of 205 mothers aged 40 and above who delivered over a 3-year period. A 75-gram oral glucose tolerance test was performed in all cases and 64 (31.2%) (18 primiparas and 46 multiparas) had gestational diabetes mellitus. This affected group of patients was compared with a group of age- and parity-matched controls to determine the impact of gestational diabetes mellitus on the obstetric outcome.

RESULTS

There was no difference in the maternal anthropometric parameters, antenatal complications, or labor performance. While no statistically significant difference was found in the infant anthropometric parameters, the study group had a lower incidence (p = 0.043) of large-for-gestational age infants.

CONCLUSION

Our findings suggested the adverse effects of gestational diabetes mellitus on pregnancy outcome were confounded to a large extent by other factors such as age, parity, and obesity. Once compared with matched controls, gestational diabetes mellitus that can be successfully treated with diet therapy probably had minimal adverse effect on the obstetric outcome. Furthermore, diet treatment can probably reverse the effect of advanced maternal age on infant size in these women.

Features and outcome of pregnancies complicated by impaired glucose tolerance and gestational diabetes diagnosed using different criteria in a Spanish population

The main objective of this study was to determine the prevalence and risk of complications of a population of Spanish pregnant women with GDM diagnosed following the O'Sullivan-Mahan "standard" criteria, compared with pregnant women with GDM diagnosed using the "new" Carpenter-Coustan criteria. In Spain, limited data are published concerning as the prevalence of GDM and its morbidity. In this sense, the "new" criteria for GDM diagnosis has not been adopted in Spain due to the absence of adequate studies. We retrospectively reviewed all pregnancies handled at our center from 1999 to 2001 (n=6248). Using the standard and the new criteria, the prevalence of GDM was 6.46 and 6.75%, respectively. GDM patients diagnosed using the new criteria showed the same pregnancy evolution that patients diagnosed with the classic criteria. Those patients complicated only with impaired glucose intolerance (IGT) (0.94%) showed a worst outcome. Based on the pregnancy evolution observed, it is not recommended that the new GDM diagnostic criteria be adopted in Spain. More accurate follow-up of patients with IGT is needed.

Gestational diabetes: the consequences of not treating

OBJECTIVE

Untreated gestational diabetes mellitus carries significant risks of perinatal morbidity at all severity levels; treatment will enhance outcome.

STUDY DESIGN

A matched control of 555 gravidas, gestational diabetes mellitus diagnosed after 37 weeks, were compared with 1110 subjects treated for gestational diabetes mellitus and 1110 nondiabetic subjects matched from the same delivery year for obesity, parity, ethnicity, and gestational age at delivery. The nondiabetic subjects and those not treated for gestational diabetes mellitus were matched for prenatal visits.

RESULTS

A composite adverse outcome was 59% for untreated, 18% for treated, and 11% for nondiabetic subjects. A 2- to 4-fold increase in metabolic complications and macrosomia/large for gestational age was found in the untreated group with no difference between nondiabetic and treated subjects. Comparison of maternal size, parity, and disease severity revealed a 2- to 3-fold higher morbidity rate for the untreated groups, compared with the other groups.

CONCLUSION

Untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome.

Epidemiology of gestational diabetes mellitus and its association with Type 2 diabetes

Gestational diabetes (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. Although it is a well-known cause of pregnancy complications, its epidemiology has not been studied systematically. Our aim was to review the recent data on the epidemiology of GDM, and to describe the close relationship of GDM to prediabetic states, in addition to the risk of future deterioration in insulin resistance and development of overt Type 2 diabetes. We found that differences in screening programmes and diagnostic criteria make it difficult to compare frequencies of GDM among various populations. Nevertheless, ethnicity has been proven to be an independent risk factor for GDM, which varies in prevalence in direct proportion to the prevalence of Type 2 diabetes in a given population or ethnic group. There are several identifiable predisposing factors for GDM, and in the absence of risk factors, the incidence of GDM is low. Therefore, some authors suggest that selective screening may be cost-effective. Importantly, women with an early diagnosis of GDM, in the first half of pregnancy, represent a high-risk subgroup, with an increased incidence of obstetric complications, recurrent GDM in subsequent pregnancies, and future development of Type 2 diabetes. Other factors that place women with GDM at increased risk of Type 2 diabetes are obesity and need for insulin for glycaemic control. Furthermore, hypertensive disorders in pregnancy and afterwards may be more prevalent in women with GDM. We conclude that the epidemiological data suggest an association between several high-risk prediabetic states, GDM, and Type 2 diabetes. Insulin resistance is suggested as a pathogenic linkage. It is possible that improving insulin sensitivity with diet, exercise and drugs such as metformin may reduce the risk of diabetes in individuals at high risk, such as women with polycystic ovary syndrome, impaired glucose tolerance, and a history of GDM. Large controlled studies are needed to clarify this issue and to develop appropriate diabetic prevention strategies that address the potentially modifiable risk factors.

Maternal and fetal outcomes if gestational impaired glucose tolerance is not treated

OBJECTIVE

To evaluate whether there is increased maternal or neonatal morbidity in connection with impaired glucose tolerance (IGT) during pregnancy when the condition is not treated.

RESEARCH DESIGN AND METHODS

During the study period of 1997-2001, in a defined geographical area in Sweden, the diagnostic criteria for gestational diabetes mellitus (GDM) were limited to the criteria for diabetes. Prospectively, 213 women who were identified with IGT during pregnancy were undiagnosed and untreated. Data on maternal and fetal outcome was collected from records. For each case subject, four control subjects were taken from the same delivery department.

RESULTS

The proportion of women who underwent cesarean section was significantly higher in the case subjects than in the control subjects and was independently associated with IGT. The adjusted odds ratio (OR) was 1.9 (95% CI 1.2-2.9). The proportion of infants who were large for gestational age (LGA), defined as birth weight >2 SDs greater than the mean for gestation and sex, was independently significantly associated with untreated IGT during pregnancy (OR 7.3, 95% CI 4.1-12.7). Admission to a neonatal intensive care unit (NICU) for 2 days or longer was more common (adjusted OR 2.0, 95% CI 1.1-3.8). However, 71.3% of the children in the IGT group and 87.3% of the control subjects had no neonatal complications.

CONCLUSIONS

There is increased independent association between cesarean section rate, prematurity, LGA, and macrosomic infants born to mothers with untreated IGT. Most of the children were healthy, but there is still increased morbidity. Therefore, to evaluate the effects of treatment, there is a need for a randomized study.

The association between impaired glucose tolerance and birth weight among black and white women in central North Carolina

OBJECTIVE

This study examines the relationship of glucose intolerance during pregnancy to birth weight among black and white participants of the Pregnancy, Infection, and Nutrition Study.

RESEARCH DESIGN AND METHODS

This prospective cohort study recruited women from prenatal clinics in central North Carolina at 24-29 weeks' gestation. A 1-h 50-g glucose challenge test (GCT) and 100-g oral glucose tolerance test (OGTT) were conducted. Impaired glucose tolerance (IGT) was defined as one high value on the OGTT, gestational diabetes mellitus (GDM) as two or more high values, and normal glucose tolerance (NGT) was defined as a low or high value on the GCT screen but no high values on the OGTT. Women with known glucose status and birth outcome information were included in this analysis (n = 2055).

RESULTS

Black women with IGT had higher rates of both macrosomia (38.5%) and large for gestational age (LGA) (53.9%) compared with white women (10.0% and 13.2%). Black infants' birth weights (3800 g) and prevalence of macrosomia and LGA were significantly higher among mothers with IGT compared with NGT women (birth weight, 3184 g; macrosomia, 7.0%; LGA, 11.6%). In contrast, among white infants, there was no significant increase in birth weight, macrosomia, or LGA associated with the mother's glucose tolerance status. In addition, there was no effect of GDM on birth weight in either group.

CONCLUSIONS

This study suggests that, independent of maternal prepregnant weight, there may be significant increased risk of macrosomia among black IGT women but not among white IGT women. Further investigations into factors that may contribute to the observed results are needed.

Women with impaired glucose tolerance during pregnancy have significantly poor pregnancy outcomes

OBJECTIVE

This article tests the hypothesis that women with impaired glucose tolerance (IGT) have the same pregnancy outcomes as those of their counterparts with normal glucose tolerance.

RESEARCH DESIGN AND METHODS

From December 1998 to December 1999, 84 of 90 antenatal care base units (ACBUs) under the Tianjin Antenatal Care Network in China participated in the first screening program for gestational diabetes mellitus (GDM). A total of 9,471 pregnant women under the care of participating ACBUs were screened. Of the women screened, 154 were positive for IGT. Of the 154 women, 102 opted for conventional obstetric care. The comparison group was 302 women of normal glucose tolerance (NGT). The initial screening consisted of a 50-g 1-h glucose test, and was carried out at 26-30 gestational weeks. Women with a serum glucose > or =7.8 mmol/l were followed up with a 75-g 2-h oral glucose tolerance test. The World Health Organization's diagnostic criteria for GDM were used.

RESULTS

Women with IGT were at increased risk for premature rupture of membranes (P-ROM) (odds ratio [OR] 10.07; 95% CI 2.90-34.93); preterm birth (6.42; 1.46-28.34); breech presentation (3.47; 1.11-10.84); and high birth weight (90th percentile or 4,000 g) (2.42; 1.07-5.46); adjusting for maternal age, pregravid BMI, hospital levels, and other confounding factors.

CONCLUSIONS

The presence of IGT in pregnancy is predictive of poor pregnancy outcomes.

Gestational diabetes diagnosed in third trimester pregnancy and pregnancy outcome

BACKGROUND

The clinical significance of gestational diabetes diagnosed in the third trimester is unclear. A prospective observational study was performed on a cohort of women without pre-existing gestational diabetes or other medical disorders to examine the effect of gestational diabetes on pregnancy complications and infant outcome.

METHODS

Four hundred and eighty-nine consecutive women were assessed at 28-30 weeks by random glucose screening and/or a 75 g oral glucose tolerance test. The subsequent management was according to established departmental protocols. The outcome of pregnancy was compared among the groups with negative screening, positive screening but normal glucose tolerance, and gestational diabetes which was controlled with diet therapy.

RESULTS

Women with gestational diabetes (n=67 or 13.7%) had significantly increased maternal age, pre-pregnancy weight and body mass index, hemoglobin levels at booking and at 36-38 weeks, and incidences of parity >1, pre-eclampsia, and female infants, while the gestational age was shorter and there was no significant difference in the birthweight outcome or neonatal morbidity.

CONCLUSIONS

Despite diet treatment, gestational diabetes diagnosed in the last trimester is associated with increased risk of pre-eclampsia and shorter length of gestation, and this is likely to reflect a pathological process rather than the physiological effect of pregnancy on maternal glucose tolerance.

Comparison of National Diabetes Data Group and World Health Organization criteria for detecting gestational diabetes mellitus

We compared the criteria for diagnosis of gestational diabetes mellitus (GDM) of the National Diabetes Data Group (NDDG) and the World Health Organization (WHO) and studied the outcomes of pregnancy. A 50-g glucose screening test and 75-g oral glucose tolerance test (OGTT) were scheduled for 709 pregnant women in the same week between the 24th and 28th week of pregnancy. Blood glucose was measured 1 h after the 50-g glucose screening test and if found to be 7.8 mmol/l or more, a 100-g OGTT was scheduled within 7 days after a 75-g OGTT. The prevalence of GDM was found to be 1.4% (10/709) and 15.7% (111/709) by NDDG and WHO criteria (2 h > or = 7.8 mmol/l), respectively. Using NDDG criteria, all the GDM patients had abnormal 75-g OGTT by WHO criteria. NDDG and WHO criteria were significantly different when compared with normal OGTT by each criteria for age, BMI, pregnancy-induced hypertension, Caesarian delivery, macrosomia and neonatal hypoglycaemia. Of 14 women with macrosomic infants 6 had an abnormal WHO test while only 3 of 14 had an abnormal NDDG test. These findings suggest that WHO criteria GDM patients had significantly worse outcomes of pregnancy and fewer perinatal complications were missed than with the more cumbersome NDDG criteria, and no case of GDM as diagnosed by NDDG criteria was missed.

The medical management of gestational diabetes in Australia within a solo private practice

This study reports the obstetric and fetal outcomes of 266 consecutive patients with gestational diabetes managed by a solo practitioner in private practice. Labour was spontaneous in 75.6% and 93.2% had a gestational age of delivery between 37 and 41 weeks. The elective Caesarean section rate of 14.7% was slightly higher than the rate for the overall obstetric population. Insulin therapy was required in 12.8% of the patients with a mean daily dose of 35.3 units. The rate of insulin use increased to 23.8% during 1993 when the criteria for its use was revised. This was associated with a significantly lower macrosomic rate of 3.6%. Overall there was a significant reduction in the number of babies weighing < or = 2500 g and no increase in the number of babies weighing > or = 4000 g. One patient only was admitted to hospital during this 30-month period and there was 1 neonatal death. These results indicate that successful medical management of gestational diabetes, with obstetric and fetal results similar to the overall obstetric population, is possible outside of tertiary institutions and specialized clinics.