Acute Myocardial Infarction in the First Trimester of Pregnancy

Acute myocardial infarction rarely occurs in women during pregnancy. However, when it does occur, it usually carries a high risk of maternal and perinatal mortality. There is a lack of awareness that this condition can occur in pregnancy since coronary artery disease is uncommon in women of childbearing age. In this report, a 43-year-old lady with acute anterior myocardial infarction in her eighth week of pregnancy is presented. The challenges involved in diagnosing this condition in pregnancy are briefly discussed.

n-3 Fatty Acids Modulate T-Cell Calcium Signaling in Obese Macrosomic Rats

OBJECTIVE

We investigated the effects of a diet containing EPAX-7010, rich in PUFAs such as eicosapentaenoic acid [20:5(n-3)] and docosahexaenoic acid [22:6(n-3)], i.e., a PUFA/EPAX regimen, on T-cell activation in diabetic pregnant rats and their obese pups.

RESEARCH METHODS AND PROCEDURES

Mild hyperglycemia in pregnant rats was induced by intraperitoneal injection of streptozotocin on Day 5 of gestation. T-cell blastogenesis was assayed by using (3)H-thymidine, whereas intracellular free calcium concentrations ([Ca(2+)]i) were measured by using Fura-2 in diabetic pregnant rats and their obese offspring.

RESULTS

Concavalin-A-stimulated T-cell proliferation was decreased in both pregnant diabetic rats and their obese pups as compared with control animals. Feeding the PUFA/EPAX diet restored T-cell proliferation in both groups of animals. We also employed ionomycin, which at 50 nM opens calcium channels, and thapsigargin (TG), which recruits [Ca(2+)]i from endoplasmic reticulum pool. We observed that ionomycin-induced increases in [Ca(2+)]i in T-cells of diabetic mothers and obese offspring were greater than in those of control rats. Furthermore, feeding PUFA/EPAX diet diminished significantly the ionomycin-evoked rise in [Ca(2+)]i in diabetic and obese animals. TG-induced increases in [Ca(2+)]i in T-cells of diabetic pregnant rats and their obese offspring were greater than in those of control rats. The feeding of the experimental diet significantly curtailed the TG-evoked increases in [Ca(2+)]i in both diabetic and obese rats.

DISCUSSION

Together, these observations provide evidence that T-cell activation and T-cell calcium signaling are altered during gestational diabetes and macrosomia. Hence, dietary fish oils, particularly eicosapentaenoic acid and docosahexaenoic acid, may restore these T-cell abnormalities.

Free radicals and birth defects

Maternal diabetes significantly increases the risk for birth defects. Studies using animal models indicate that oxidative stress may play a causative role. Oxidative stress can result from exposure to certain drugs, ionizing radiation and folic acid deficiency. Therefore, study of the mechanisms by which maternal diabetes affects embryogenesis may provide insight into general processes by which birth defects occur. Study of embryonic gene expression has demonstrated that maternal diabetes causes birth defects by disturbing expression of genes that control essential developmental processes, and that oxidative stress is involved. A model in which oxidative stress-induced deficient gene expression leads to congenital defects involving p53-dependent apoptosis is discussed.

Independent predictors of Cesarean delivery in women with diabetes

OBJECTIVES

To identify independent risk factors for Cesarean delivery in women with pregnancy complicated by diabetes.

METHODS

Retrospective analysis of pregnancies from 5735 diabetic women delivering liveborn infants. Maternal demographic, medical, obstetric historical factors and index pregnancy obstetric, glycemic and neonatal outcome parameters were evaluated for association with Cesarean delivery after a trial of labor. Individual risk factors were analyzed for association by chi2 and ANOVA. Independent predictors of Cesarean delivery and adjusted relative risk (RR) were identified by stepwise logistic regression.

RESULTS

Trial of labor was permitted in 90.8% and 59.4% of women without (n = 4643) and with prior Cesarean delivery (n = 1092) and was successful in 85.2% and 56.9%, respectively. Eleven independent predictors were found. Five were related to obstetric history and maternal age: prior Cesarean delivery (RR 5.34, 95% CI 3.94-7.25), no prior live birth (RR 3.17, 95% CI 1.98-5.07), no prior vaginal delivery (RR 2.28, 95% CI 1.50-3.44), prior stillbirth (RR 1.71, 95% CI 1.09-2.68%) and maternal age > or = 35 years (RR 1.53, 95% CI 1.20-1.93). Two were related to the severity of diabetes at entry to diabetes care: requiring insulin (RR 1.53, 95% CI 1.20-1.93) and highest fasting plasma glucose level (RR 1.04, 95% CI 1.01-1.07). Two were related to obstetric factors: pre-eclampsia/hypertension (RR 2.56, 95% CI 2.00-3.27) and labor induction (RR 3.32, 95% CI 2.70-4.10). The remaining two were birth weight (per 250 g, RR 1.12, 95% CI 1.09-1.17) and pre-delivery body mass index (RR, 1.03, 95% CI 1.00-1.05).

CONCLUSION

The majority of predictors were not modifiable, relating to obstetric history, maternal age and diabetes severity. Possible modifiable interventions to avoid/improve labor induction, and decrease birth weight and maternal weight gain might decrease risk of Cesarean delivery. Future studies must address these multiple predictors.

Consequences of smoking and caffeine consumption during pregnancy in women with type 1 diabetes

OBJECTIVE

To test the hypothesis that, in women with type 1 diabetes, prenatal smoking and caffeine consumption during pregnancy are associated with an increased risk of adverse maternal and perinatal outcomes.

METHODS

A secondary analysis of data on pregnant women with type 1 diabetes from an interdisciplinary program of Diabetes in Pregnancy. Women were interviewed monthly, by a trained non-medical member of the research team, using a standardized questionnaire, to ascertain daily smoking habits and caffeine consumption.

RESULTS

Smoking and caffeine information were available on 191 pregnancies, 168 progressing beyond 20 weeks of gestation. Early pregnancy smoking (OR 3.3, 95% CI 1.2, 8.7) and caffeine consumption (OR 4.5, 95% CI 1.2, 16.8) were associated with increased risk of spontaneous abortion when controlling for age, years since diagnosis of diabetes, previous spontaneous abortion, nephropathy and retinopathy. Smoking throughout pregnancy was significantly associated with decreased birth weight and prolonged neonatal hospital stay. Smoking throughout pregnancy (OR 0.2, 95% 0.1, 1.0) and caffeine consumption after 20 weeks (OR 0.3, 95% CI 0.1, 1.0) were associated with reduced risk of pre-eclampsia.

CONCLUSIONS

Caffeine consumption during early pregnancy, regardless of glycemic control, increases the risk of spontaneous abortion. Smoking throughout pregnancy and caffeine consumption are associated with reduced risk of pre-eclampsia.

Mode of delivery and birth outcomes of macrosomic infants

This review examines and summarises the literature regarding the mode of delivery of macrosomic infants and subsequent perinatal outcomes. A search of electronic databases was conducted and supplemented with investigation of the references cited in the original articles. Although the rates of obstetric complications differ among high birth weight infants delivered by caesarean section compared to those delivered vaginally, there is currently little evidence that perinatal mortality differs significantly by delivery method. Shoulder dystocia and birth injury occur with greater frequency among macrosomic infants, yet the relative inaccuracy of clinical and ultrasonographic estimates of birth weight among high birth weight infants indicates that a trial of labour may be warranted among non-diabetic mothers with a suspected macrosomic fetus. The majority of studies identified in this review utilised small sample sizes and observational design, thereby hindering valid assessments of the impact of delivery method on the mortality of this population. Consequently, an optimal management strategy has yet to be defined.

Hearing screening outcomes in infants of pregestational diabetic mothers

PURPOSE

Hearing screening results for newborns of diabetic mothers were compared with those of nondiabetic controls.

METHOD

This study was a retrospective chart review of mothers with pregestational diabetes mellitus and their neonates (n=73) who received newborn hearing screening between January 1, 2000, and May 1, 2002. A group of nondiabetic mothers and their infants (n=73), with birth dates that matched the diabetic group, served as controls. A 2-tiered hearing screening protocol, employing distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (A-ABR) screening techniques, was used.

RESULTS

The DPOAE screening failure rate was 5.5% (4/73) for babies in the nondiabetic control group and 11.0% (8/73) for infants of diabetic mothers; this difference was not statistically significant. The A-ABR failure rate was 9.1% (1/11) for the diabetic group compared with 0% (0/4) for the controls, but the A-ABR was measured for only a small number of participants in each group. The frequency of premature birth and abnormal birth weight was significantly greater for the infants of diabetic mothers compared with controls.

CONCLUSIONS

Given the greater frequency of prematurity and abnormal birth weight in the population of neonates born to diabetics, additional research using A-ABR is recommended.

Echocardiographic measurements in infants of diabetic mothers and macrosomic infants of nondiabetic mothers

AIM

To compare echocardiographic findings of infants of diabetic mothers (IDMs), macrosomic infants of nondiabetic mothers and healthy full term appropriate-for-gestational-age (AGA) infants.

METHODS

Included in this study were 83 infants, admitted to our Neonatology Unit. Thirty-three IDMs, including both macrosomic and nonmacrosomic, comprised Group A, 25 macrosomic infants of nondiabetic mothers comprised group B, and 25 healthy full term AGA infants comprised group C. Echocardiographic measurements were performed in the first three days after birth and compared by using one-way ANOVA, Post Hoc Tukey HSD and Student's t tests.

RESULTS

The left ventricular end-systolic/left ventricular end-diastolic diameter ratio of group A was significantly smaller than that of group C (P<0.05). The interventricular septum/posterior wall thickness ratios of groups A and B were greater than those of group C (P<0.05). The left ventricular mass index of group A was greater than those of groups B and C (P<0.05). The shortening fraction and ejection fraction of group A were increased in comparison to group C (P<0.05). When comparing the values of echocardiographic measurements of macrosomic IDMs (n=9) with nonmacrosomic ones (n=24), and infants of pregestational diabetic mothers (n=11) with those of gestational diabetes mothers (n=22), no statistical difference was found.

CONCLUSION

The present study suggests that underlying mechanisms common to both macrosomic infants of nondiabetic mothers and IDMs lead to less cardiac alterations in the macrosomic infants of nondiabetic mothers than in IDMs.

[Maternal diabetes and congenital malformations]

Maternal diabetes is a known risk factor for congenital malformations. Maternal hyperglycemia is a non-specific teratogen. The risk of congenital malformations, even with optimal metabolic control, is considerably elevated compared with non-diabetic pregnancies. The relationship between maternal hyperglycemia in early pregnancy and the risk of congenital malformations seems to be linear without any threshold level. To diminish the risk of congenital malformations, close preconceptional and first-trimester diabetic control and folic acid supplementation of 5 mg/day are recommended.

Severe diabetic fetopathy despite strict metabolic control

In pregnant women, diabetes mellitus (DM) can cause severe complications for both mother and child during pregnancy and delivery; for example, hypertension, pre-eclampsia, macrosomia or intrauterine fetal death. It is therefore essential to achieve good metabolic control in the mother from before conception to the postpartum period. A 35-year-old primipara with type 2 DM presented herself at our outpatient department at 21 weeks of gestation. Until this time her DM had been treated with oral antidiabetic drugs; these were withdrawn and conventional insulin therapy was initiated. Except for the first two weeks after insulin adjustment, blood glucose values were within the required range. Biometric tests performed until week 30 of gestation showed discreet fetal growth. In the week 31, fetal abdominal girth near the 95% limit was observed for the first time; this was soon followed by an explosion-like enlargement of the abdomen along with glycemic values at the lower limit. A cesarean section was performed in week 35 of gestation because of the excessive macrosomia. The female newborn had a birth weight of 4920 g and, one hour after delivery, a blood glucose of 10 mg/dl requiring an intravenous glucose bolus. In addition, the child needed oxygen and also needed both an enteral and a parenteral supply of glucose until day 7 after delivery. Mother and child were discharged from the clinic 19 days postpartum in good general condition. This case illustrates the complexity of treatment of glucose-tolerance disturbances during pregnancy and underlines the importance of fetal monitoring by ultrasound, given that measurement of maternal blood glucose does not always provide sufficient information on the metabolic situation of the fetus.

Pregnancy in women with pre-existing diabetes: management issues

Despite significantly increased input from multidisciplinary teams during the antenatal period, pregnancy outcomes for women with type 1 and type 2 diabetes remain substantially worse than that of the general obstetric population. Regarding fetal congenital malformations, these are likely to be preventable only by strategies introduced prior to pregnancy. The relationship between fetal macrosomia and glycaemic control is complex, and reducing the incidence of macrosomia may be possible only by novel management strategies that address the wide fluctuations in blood glucose over a 24-hour period. Irrespective of pregnancy diabetes control, the complication of neonatal hypoglycaemia can largely be avoided by tight control of glucose values during labour and delivery. The continued lack of understanding of the pathophysiology of late fetal death in diabetic pregnancies and the shortcomings of current methods of antenatal fetal surveillance make it likely that infants of diabetic mothers will continue to be delivered preterm, with the attendant implications of neonatal morbidity and cost.

Suspicion and treatment of the macrosomic fetus: a review

OBJECTIVE

To review the prevalence of and our ability to identify macrosomic (birthweight >4000 g) fetuses. Additionally, based on the current evidence, propose an algorithm for treatment of suspected macrosomia.

STUDY DESIGN

A review.

RESULTS

According to the National Vital Statistics, in the United States, the prevalence of newborns weighing at least 4000 g has decreased by 10% in seven years (10.2% in 1996 and 9.2% in 2002) and 19% for newborns with weights >5000 g (0.16% and 0.13%, respectively). Bayesian calculations indicates that the posttest probability of detecting a macrosomic fetus in an uncomplicated pregnancy is variable, ranging from 15% to 79% with sonographic estimates of birth weight, and 40 to 52% with clinical estimates. Among diabetic patients the post-test probability of identifying a newborn weighing >4000 g clinically and sonographically is over 60%. Among uncomplicated pregnancies, there is sufficient evidence that suspected macrosomia is not an indication for induction or for primary cesarean delivery. For pregnancies complicated by diabetes, with a prior cesarean delivery or shoulder dystocia, delivery of a macrosomic fetus increases the rate of complications, but there is insufficient evidence about the threshold of estimated fetal weight that should prompt cesarean delivery.

CONCLUSION

Due to the inaccuracies, among uncomplicated pregnancies suspicion of macrosomia is not an indication for induction or for primary cesarean delivery.

Current perspectives on the causes of neural tube defects resulting from diabetic pregnancy

Maternal diabetes increases the risk for neural tube, and other, structural defects. The mother may have either type 1 or type 2 diabetes, but the diabetes must be existing at the earliest stages of pregnancy, during which organogenesis occurs. Abnormally high glucose levels in maternal blood, which leads to increased glucose transport to the embryo, is responsible for the teratogenic effects of maternal diabetes. Consequently, expression of genes that control essential developmental processes is disturbed. In this review, some of the biochemical pathways by which excess glucose metabolism disturbs neural tube formation are discussed. Research from the author's laboratory has shown that expression of Pax3, a gene required for neural tube closure, is significantly reduced by maternal diabetes, and this is associated with significantly increased neural tube defects (NTD). Pax3 encodes a transcription factor that has recently been shown to inhibit p53-dependent apoptosis. Evidence in support of this model, in which excess glucose metabolism inhibits expression of Pax3, thereby derepressing p53-dependent apoptosis of neuroepithelium and leading to NTD will be discussed.

Severe hypothyroidism caused by hepatic hemangioendothelioma in an infant of a diabetic mother

Hemangioendotheliomas can express type 3 iodothyronine deiodinase and cause severe hypothyroidism. The risk of congenital malformations such as vertebral and cardiac abnormalities in infants of diabetic mothers is higher than in babies of healthy women. Here we report an infant of a diabetic mother with hypothyroidism caused by liver hemangioendothelioma. Consumptive hypothyroidism should be an indicator to search for a vascular tumor in infants. Supranormal doses of L-thyroxine might be required for normalization of thyroid function until the tumor involutes or is resected.

Absent or reversed end-diastolic flow in the umbilical artery: outcome at a community hospital

OBJECTIVE

To describe the peripartum outcome and risk factors for neonatal death among pregnancies complicated with umbilical arterial absent end diastolic or reverse flow (AREDF UA), in a community hospital.

STUDY DESIGN

The inclusion criteria of this retrospective analysis were: AREDF UA detected and managed at a community hospital.

RESULTS

During the 46 months, 50 cases of AREDF UA were detected and the pregnancies were complicated by hypertensive disease in 52%, twins in 26%, and diabetes mellitus in 14%. Excluding four (8%) stillbirths of non-anomalous fetuses, nine newborns died and the significant differences between those who died and lived (n = 36) were: oligohydramnios (odds ratio [OR] 34.00, 95% confidence intervals [CI] 4.65, 248.50), non-immune hydrops (OR 24.33, 95% CI 1.01, 560.60) and respiratory distress syndrome (OR 7.00, 95% CI 1.27, 38.59).

CONCLUSIONS

The risk factors for neonatal mortality with AREDF UA are oligohydramnios, non-immune hydrops, or respiratory distress syndrome.

Maternal diabetes adversely affects preovulatory oocyte maturation, development, and granulosa cell apoptosis

Maternal diabetes adversely affects preimplantation embryo development and pregnancy outcomes. The objective of this study was to determine whether diabetes has an impact at an earlier stage of development, the preovulatory oocyte. Models of both acute and chronic insulin-dependent diabetes were used. Acute hyperglycemia was induced by a single streptozotocin injection. Akita mice, which harbor an autosomal dominant mutation causing them to be chronically hypoinsulinemic and hyperglycemic, were used. In both models, preovulatory oocytes were markedly smaller when compared with control animals. A significantly greater number of control oocytes had progressed to meiotic maturation before diabetic oocytes. Both models were found to have smaller, less developed ovarian follicles with a greater number of apoptotic foci by histological evaluation as well as by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling staining. Immunohistochemistry displayed a greater amount of TNF-related apoptosis-inducing ligand (TRAIL) and KILLER, a key murine ligand and receptor involved in the extrinsic pathway, expressed in cumulus cells from hyperglycemic mice compared with controls, suggesting that this apoptotic pathway may be up-regulated under diabetic stress. Elevated KILLER expression was also confirmed through Western blotting. Connexin-43 expression was found to be lower by immunohistochemistry and Western blot analysis in the diabetic samples. Both models of maternal hyperglycemia and hypoinsulinemia may have a detrimental effect on oocyte maturation and development as detailed by the smaller sizes of oocytes and developing ovarian follicles, the lowered percentage reaching germinal vesicle breakdown, and the greater amount of apoptosis. In addition, there may be dysfunctional or decreased communication in diabetic oocytes, as demonstrated by lower expression of connexin-43.

[Pregnancy in a diabetic woman: practical recommendations to prevent complications]

Pregnancy in a diabetic woman should be considered as a high risk pregnancy. Indeed, it may lead to complications in both the mother and the baby. A careful management can significantly reduce the risk of complications. Some practical recommendations are given in order to optimize the overall management of diabetic women (mainly type 1) who would like to be successful in giving birth to a child.

Controversies around gestational diabetes. Practical information for family doctors

OBJECTIVE

To summarize some of the issues facing primary care physicians who are seeing increasing numbers of patients with gestational diabetes mellitus (GDM) and to explore new developments in use of oral hypoglycemics during pregnancy.

QUALITY OF EVIDENCE

All the literature on screening for GDM offers level III evidence. Much of the literature on treatment is also level III, but newer studies offer level I evidence and are more useful for daily practice. Existing research leaves many important questions unanswered; research findings are inconsistent among studies, and treatment strategies are challenging to implement.

MAIN MESSAGE

Recent studies have clarified that rates of neonatal mortality and congenital malformations are not higher among the offspring of mothers with GDM. Treatment might affect birth weight, but whether treatment is associated with reductions in rates of shoulder dystocia and cesarean section is unclear. Several level I studies conclude that the oral hypoglycemic glyburide can be used safely and effectively during the second and third trimesters of pregnancy.

CONCLUSION

Management of GDM remains a controversial area in obstetric care. It is a growing area of research, and new developments that might clarify risk and simplify treatment are expected in the coming years.

Risk factors and obstetric complications associated with macrosomia

OBJECTIVE

Macrosomia is associated with adverse maternal outcomes. The objective of this study was to characterize the epidemiology of macrosomia and related maternal complications.

METHOD

Live births (146,526) were identified between 1995 and 1999 in the Kaiser Permanente Medical Care Program's Northern California Region (KPMCP NCR) database. Bivariate and multivariate analyses were performed for risk factors and complications associated with macrosomia (birth weight >4500 g).

RESULT

Male infant sex, multiparity, maternal age 30-40, white race, diabetes, and gestational age >41 weeks were associated with macrosomia (p<0.001). In bivariate and multivariate analyses, macrosomia was associated with higher rates of cesarean birth, chorioamnionitis, shoulder dystocia, fourth-degree perineal lacerations, postpartum hemorrhage, and prolonged hospital stay (p<0.01).

CONCLUSION

Macrosomia was associated with adverse maternal outcomes in this cohort. More research is needed to determine how to prevent complications related to excessive birth weight.

[Neonatal suppurative parotitis]

This report describes the case of a 10 days old newborn of a diabetic mother with gestosis, who developed erythema and swelling of the right cheek. A diagnosis of acute suppurative parotitis due to S. aureus was made. Following this case report the most important facts of epidemiology, pathogenesis, clinical manifestation, diagnostics, and therapy of suppurative parotitis are discussed.

Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies

OBJECTIVE

To determine the risk of pre-eclampsia associated with factors that may be present at antenatal booking.

DESIGN

Systematic review of controlled studies published 1966-2002.

DATA SYNTHESIS

Unadjusted relative risks were calculated from published data.

RESULTS

Controlled cohort studies showed that the risk of pre-eclampsia is increased in women with a previous history of pre-eclampsia (relative risk 7.19, 95% confidence interval 5.85 to 8.83) and in those with antiphospholipids antibodies (9.72, 4.34 to 21.75), pre-existing diabetes (3.56, 2.54 to 4.99), multiple (twin) pregnancy (2.93, 2.04 to 4.21), nulliparity (2.91, 1.28 to 6.61), family history (2.90, 1.70 to 4.93), raised blood pressure (diastolic > or = 80 mm Hg) at booking (1.38, 1.01 to 1.87), raised body mass index before pregnancy (2.47, 1.66 to 3.67) or at booking (1.55, 1.28 to 1.88), or maternal age > or = 40 (1.96, 1.34 to 2.87, for multiparous women). Individual studies show that risk is also increased with an interval of 10 years or more since a previous pregnancy, autoimmune disease, renal disease, and chronic hypertension.

CONCLUSIONS

These factors and the underlying evidence base can be used to assess risk at booking so that a suitable surveillance routine to detect pre-eclampsia can be planned for the rest of the pregnancy.

Diabetes teratogenicity is accompanied by alterations in macrophages and T cell subpopulations in the uterus and lymphoid organs

Insulin-dependent diabetes mellitus is a well-known teratogen, which might cause growth retardation, malformations and fetal death. We have previously shown, that potentiation of the maternal immune system (immunopotentiation) might protect the embryo from diabetes teratogenicity. Therefore, in the present study we further inquired whether diabetes teratogenicity might be associated with alterations in the level of immune effector cells in systemic and local lymphoid organs as well as in the uterus throughout pregnancy and whether the protection exerted by maternal immunopotentiation might be realized through its effect on those cells. Streptozotocin-induced diabetes in ICR mice was found to reduce pregnancy rate and fetal weight while increasing the resorption rate and the percentage of litters with malformed fetuses. These teratogenic effects were accompanied by a decreased percentage of cells expressing Mac-1, Thy-1.2, CD4 or CD8 in the spleen and inguinal as well as paraaortic lymph nodes, except for Mac-1 expression by splenocytes, which increased significantly in the beginning of pregnancy and decreased later. A different pattern was observed in the uterus, when the percentage of cells expressing these markers tended to increase in the beginning of pregnancy and decrease later. Intrauterine immunopotentiation with rat splenocytes was found to improve the reproductive performance of diabetic animals. This protective effect was accompanied by a general normalization of the level of the various cell surface markers, when in most cases their expression returned to that found in nonimmunopotentiated mice. Our results suggest that the protection exerted by maternal immunopotentiation on the embryo against diabetes teratogenicity might be mediated via its effect on the level of immune effector cells localized to uterus and lymphoid organs, which was found to be altered in diabetic mice.

Effects of alpha-lipoic acid supplementation on maternal diabetes-induced growth retardation and congenital anomalies in rat fetuses

The mechanism of diabetic embryopathy is not known. Excessive reactive oxygen species (ROS) produced in diabetes may be causally related to foetal anomalies. The objective of this study was to determine whether supplementation with the antioxidant lipoic acid (LA) could prevent maternal diabetes-related foetal malformations and intrauterine growth retardation (IUGR) in rats. Pregnant rats were non-treated (Group I) or made diabetic on gestation day (GD) 2 by injecting streptozotocin (Group II). Group III was injected with 20 mg kg(-1) of LA daily starting on GD 6 and continued through GD 19. Group IV was administered only Tris buffer on the corresponding days. Group V was a set of STZ-treated animals, which were supplemented with a daily dose of 20 mg kg(-1) of LA from GD 6 through GD 19. All fetuses were collected on GD 20. Lipoic acid did not affect the blood sugar levels of diabetic animals significantly but improved their body weight gain and reduced food and water consumption. Diabetic group had a high incidence of embryonic resorption, IUGR, craniofacial malformations, supernumerary ribs and skeletal hypoplasia. Lipoic acid significantly reduced these abnormalities. These data support the hypothesis that ROS are causally related to fetal maldevelopment and IUGR associated with maternal diabetes in the rat. They also highlight the possible role of antioxidants in the normal processes of embryo survival, growth and development.

[Diabetes and pregnancy; the prevention of hypoglycaemia]

In women with type-1 diabetes, the prevalence of maternal and fetal complications is high despite the overall adequate blood glucose control (HbA1c < 7%). Further improvements are hampered by the high incidence of maternal hypoglycaemia, including coma, especially during the first trimester of pregnancy. The reasons for this include the intensified insulin treatment, the decrease in hypoglycaemia awareness and the increase in glucose fluctuations. A further improvement of glucose control would provisionally seem possible only by using short-acting insulin analogues. These agents are currently under investigation. Continuous subcutaneous glucose measurements early in pregnancy show considerable glucose fluctuations despite almost normal HbA1c values. Moreover, they often reveal a hypoglycaemic event that the pregnant woman has not recognised. It is possible that these glucose fluctuations, rather than the too high average blood glucose levels, are responsible for congenital malformations and fetal macrosomia. Neonatal hypoglycaemia is associated with poor psychoneurological development. This relationship has not been established for maternal hypoglycaemia during pregnancy.

Risk factors for pre-eclampsia in nulliparous and parous women: the Jerusalem perinatal study

Pre-eclampsia has been described as a 'disease of first pregnancies' and many believe that its occurrence in a later pregnancy signals a fundamentally different entity. We sought to compare risk factors in first and subsequent pregnancies. We studied 1319 cases of pre-eclampsia recorded in a historical cohort of 82,436 deliveries in Jerusalem in 1964-76. Logistic regression was used to control for covariates. The adjusted odds ratio (OR) for pre-eclampsia in first births was 2.58 (95% confidence interval[CI] 2.23, 2.97), compared with all later birth order groups, between which there were no detectable differences in risk. Other risk factors included increasing maternal age, diabetes (OR 5.64, 95% CI 4.33, 7.35), multiple gestations (OR 3.38, 95% CI 2.54, 4.49), fetal haemolytic disease (OR 2.24, 95% CI 1.43, 3.50) and lower maternal education. The risk of pre-eclampsia was not associated with the mother's employment outside the home and did not differ between immigrants vs. Israeli-born mothers or between groups of women whose fathers had been born in Western Asia, North Africa or Europe. Effects of each risk factor were similar within first and subsequent births. These results lend no support to the hypothesis that there is a fundamental difference between pre-eclampsia in a first pregnancy compared with that occurring in a later pregnancy; conclusions may be moderated, however, by the knowledge that the incidence of pre-eclampsia was low in this historical cohort.

[Upper extremity gangrene in an infant of a diabetic mother, presenting at birth]

In utero gangrene of an extremity because of an arterial thrombosis is rare. More than 20% of the reported cases concern infants of diabetic mothers (IDM) with poor control of diabetes. Changes in coagulation related to deviation of clotting factors and low plasminogen activity may be the cause. We report a case of an IDM who presented at birth with upper extremity gangrene. The Dopplersonography has shown missing pulsations and thrombosis of a.brachialis sin, which was confirmed after amputation of the arm on the 5th day. The postoperative period was complicated by septicaemia, necrotising enterocolitis and disseminated intravasal coagulation resulting in the baby's death 10 days after birth.

[Upper extremity gangrene in an infant of a diabetic mother, presenting at birth]

In utero gangrene of an extremity because of an arterial thrombosis is rare. More than 20% of the reported cases concern infants of diabetic mothers (IDM) with poor control of diabetes. Changes in coagulation related to deviation of clotting factors and low plasminogen activity may be the cause. We report a case of an IDM who presented at birth with upper extremity gangrene. The Dopplersonography has shown missing pulsations and thrombosis of a. brachialis sin, which was confirmed after amputation of the arm on the 5th day. The postoperative period was complicated by septicaemia, necrotising enterocolitis and disseminated intravasal coagulation resulting in the baby's death 10 days after birth.

[Glucooxidative stress and spontaneous abortion in pregnant women with diabetes mellitus type 1]

The pregnancies in women with Diabetes mellitus are in condition of increased glucooxidative stress, which could be toxic for the developing embryo. END-POINTS: To evaluate the levels of selenium and glutation peroxidase in pregnant women with Diabetes mellitus type 1 in the first trimester of pregnancy and to establish whether there is a correlation between the diabetic glycemic control and occurrence of spontaneous abortions.

STUDY DESIGN

Prospective study of 75 women for 1 year period. he pregnant women were divided in 3 groups as follows: 1st group--30 pregnant women with Diabetes mellitus type 1 with normal outcome; 2nd group--16 pregnant women with Diabetes mellitus type 1 with spontaneous abortion; 3rd group--29 healthy pregnant controls. The activity of GI-Px in red blood cells was measured in hemolysat of EDTA plasma in Germany. The levels of glucosylated haemoglobin were also evaluated.

RESULTS

1. In all pregnant women the levels of selenium were lower without significant difference between them 1st group--0.12 +/- 0.6 mmol/l, 2ndd group 0.13 +/- 0.1 mmol/l, 3rd group 0.13 +/- 0.7 mmol/l (P > 0.05). 2. There is an increase in the activity of GI-Px, which is statistically significant in the healthy pregnant women 47.8 +/- 13.3 U/g Hb and diabetic pregnant women with normal outcome 48. 6 +/- 8.4 U/g Hb. There is no statistically significant difference in the activity of GI-Px in diabetic pregnant women with spontaneous abortions and the healthy controls (P > 0. 05). 3. Negative correlation between the levels of selenium and the activity of GI-Px was proved in healthy pregnant women (r = - 0.4; P < 0.05). No correlation was found between the level of the selenium and the activity of GI-Px into the two groups of diabetic pregnant women. 4. There is a correlation in the levels of diabetic pregnant women with spontaneous abortions (r = -0.38; P < 0.001).

CONCLUSIONS

The increased activity of GI-Px in diabetic pregnant women with spontaneous abortions is a result of increased antioxidative defense of the cell. Probably the ineffective antioxidant defense, leading to a spontaneous abortion is due to the low levels of selenium and high level of pre-prandial glycaemia.

DiGeorge anomaly in a patient with isochromosome 18p born to a diabetic mother

The DiGeorge anomaly (DGA) is an etiologically heterogeneous developmental field defect in which cardiovascular malformations, hypocalcemia, thymic hypoplasia, and characteristic dysmorphisms are major clinical features. The 22q11.2 deletion is the most common single etiology of DGA, although a number of other chromosomal abnormalities and teratogens, including maternal diabetes, have been implicated as well. We present a patient, born to a diabetic mother, with interrupted aortic arch type B (IAA-B), neonatal hypocalcemia, thymic hypoplasia, and dysmorphic features including microcephaly, thick, overfolded helices, and anteriorly-placed anus. Cytogenetic studies showed the presence of a marker chromosome, identified by fluorescence in-situ hybridization (FISH) as an isochromosome 18p [i(18p)]. We did not detect a 22q11.2 deletion by FISH using a cosmid probe corresponding to locus D22S75. The patient is the first example of either DGA or IAA-B in a patient with i(18p). We review the genetic abnormalities associated with DGA, and discuss the potential contributions of maternal diabetes and i(18p) in our patient.

[The frequency of mild and severe fetal malformations in diabetic women with high values of glycosilated hemoglobin in early pregnancy]

PURPOSE

To evaluate the correlation between maternal hyperglycemia in early pregnancy and the risk of fetal abnormalities in pregnant women with type 1 diabetes mellitus.

STUDY DESIGN

A retrospective study over 124 pregnant women with diabetes mellitus type 1 hospitalized in High Risk Pregnancy Department--SHATOG "Maichin dom" has been done from January. 1998 to January 2004. The diabetic pregnant women were divided in two groups: first group pregnant women without malformations n = 105 and second group pregnant women with malformations n = 19. The pregnant women with fetal malformations were divided into two subgroups: with major malformations n = 13 and with minor malformations n = 6. The diabetic pregnant women were divided in classes according to Whites Classification: Class B - 38, Class C - 35; Class D - 39 and Class R/F - 12. The values of preprandial glucose, postprandial glucose and glycosilated hemoglobin has been measured at 13 week of gestation.

RESULTS

104 pregnancies of total 124 pregnancies were without abnormalities. The fetal malformations were observed in 19 (15.3%) of total 124 pregnancies. The rate of major abnormalities were - 13 (10.4%) and minor abnormalities were - 7 (5.6%). The highest rate of abnormalities there has been within the complicated diabetic women of class D - n = 7 (17.9 %) and class R/F n = 3 (25%). The initial values of preprandial glucose 9.54 (SD +/- 3.59) mmol/l and postprandiai glucose 10.52 (SD +/- 1.81) mmol/l between the women whit pregnancies with abnormalities were significantly higher then those values of preprandial glucose 7.39 (SD +/- 2.82) mmol/l (P - 0.021) and values of postprandial glucose 10.52 (SD +/- 1.81) mmol/l (P = 0.014) between the women without fetal malformations. The mean values of glycosilated hemoglobin were significantly higher HbA 1 c = 9. 01% (SD +/- 1.53) in pregnancies complicated with malformations than those values measured in pregnancies without fetal malformations 8.06% (SD +/- 1.64, P = 0.022). A positive correlation between the observed abnormalities and metabolic control in the early pregnancy exist. The values of Hbeta A1-c is significantly higher Hbeta A1-c - 9.9% (SD +/- 1.2) in pregnancies complicated with fetal malformations than those measured in pregnancies without malformations. Hbeta A1-c 8.2% (SD +/- 1.5) n = 125. Significant differences in the value of Hbeta A1-c between pregnancies with mild and those with severe abnormalities have not been established. A correlation between the levels of Hbeta A1-c in early pregnancy and the rate of the observed abnormalities exist. Within the values of Hbeta A1-c < 7.9%, the rate of malformations is 6.9%, Hbeta A1-c > 8.0% < 10%, the rate of malformations is 19.0% and within the values of Hbeta A1-c > 10%, the rate of the observed abnormalities is 31.5%. A logistic regression between the higher values of postprandial glucose and Hbeta A1-c values and the relative risk of congenital malformations has been observed. The relative risk is evaluated by odds ratio (OR) When the levels of Hbeta A1-c rise with 1% the relative risk of congenital malformations is evaluated by odds ratio OR = 2.02 (limited in 1.46 - 2.81 by 95% conf. interval) and when the levels of postprandial glucose rise with 1 mmol/l the relative risk OR = 1.21 (limited in 1.06 - 1.37: 95% conf. interval).

CONCLUSION

Fetal abnormalities are more frequent in pregnant women with long lasting diabetes complicated with vasculopathy. Fetal abnormalities are associated with higher levels of Hbeta A1-c in the first trimester of pregnancy. In diabetic women who planed their pregnancy an optimal metabolic control must been established.

[Risk factors for fetal macrosomia]

AIM

To determine the influence of some of the risk factors on fetal macrosomia.

MATERIALS AND METHODS

A retrospective study was provided at the Department of Obstetrics and Gynecology, Medical University, Pleven, from January, 1, 2001 to December, 31, 2002 over 625 deliveries: 225 cases of fetal macrosomia--fetal birth weight (FBW) more than 4000 g and/or over 90. percentile (macrosomic group--MG) and 400 cases of singleton term newborns--with FBW between 10. and 90. percentile (nonmacrosomic group--NMG). Analysis included influence of: maternal age, height, prepregnant weight, BMI, weight gain and weight before delivery, previous delivery of macrosomic infant, maternal diabetes mellitus, fetal sex and gestational age.

RESULTS

A comparative analysis of data for both of groups was performed. It was found significant correlation (p = 0.001) for influence of maternal age (r = 0.34); height (r = 0.33); prepregnant weight (r = 0.42); BMI (r = 0.32); weight before delivery (r = 0.49); weight gain (r = 0.34); previous delivery of macrosomic infant (r = 0.41); maternal diabetes mellitus (r = 0.54); fetal sex (r = 0.37) and gestational age (r = 0.39). Correlations are different in both of groups.

CONCLUSION

Positive correlations between analysed factors and delivering of macrosomic infants and differences in both of groups suggest that analysed factors can't explain completely fetal macrosomia.

Pregnancy outcome following recurrent spontaneous abortions

OBJECTIVE

The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy.

METHODS

A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders.

RESULTS

During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001).

CONCLUSION

A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.

The Diabetes and Pre-eclampsia Intervention Trial

OBJECTIVE

Rates of pre-eclampsia in women with type 1 diabetes are two to four times higher than in normal pregnancies. Diabetes is associated with antioxidant depletion and increased free radical production, and an increasing body of evidence suggests that oxidative stress and endothelial cell activation may be relevant to disease pathogenesis in pre-eclampsia. The Diabetes and Pre-eclampsia Intervention Trial (DAPIT) aims to establish if pregnant women with type 1 diabetes supplemented with vitamins C and E have lower rates of pre-eclampsia and endothelial activation compared with placebo treatment.

METHODS

DAPIT is a randomised multicentre double-blind placebo-controlled trial that will recruit 756 pregnant women with type 1 diabetes from 20 metabolic-antenatal clinics in the UK over 4 years. Women are randomised to daily vitamin C (1000 mg) and vitamin E (400 IU) or placebo at 8-22 weeks of gestation until delivery. Maternal venous blood is obtained at randomisation, 26 and 34 weeks, for markers of endothelial activation and oxidative stress and to assess glycaemic control. The primary outcome of DAPIT is pre-eclampsia. Secondary outcomes include endothelial activation (PAI-1/PAI-2) and birthweight centile.

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.

Oculoauriculovertebral spectrum in an infant of diabetic mother

This report concerns a neonatal case of oculoauriculovertebral spectrum born to a thirty-five years old preexisting diabetic mother. The clinical presentation included left atretic external auditory canal with pre-auricular skin tag, asymmetric hypoplastic left face, bilateral additional 13th ribs, left torticollis, micrognathia, and low hair line. The possible association of oculoauriculovertebral spectrum and maternal diabetes is discussed, and the literature is reviewed.

Contemporary management of type 1 diabetes mellitus in pregnancy

Type 1 diabetes in pregnancy can result in significant short- and long-term morbidity to both mother and offspring if management is suboptimal. This morbidity imposes a considerable financial and health burden on the individual and society at large. There is currently a significant body of knowledge to offer guidance on optimal obstetric management of the woman with type 1 diabetes. Utilization of appropriate management guidelines preconception and during pregnancy is an effective strategy to limit complications of type 1 diabetes and should therefore become the standard of care.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the features of a type I diabetic patient, to outline the goals of preconception care in this population of patients, to list the potential adverse effects of diabetes in pregnancy, and to summarize a potential strategy for the management of insulin administration in pregnancy.

Factors predictive of failed operative vaginal delivery

OBJECTIVE

The purpose of this study was to determine what factors are independently associated with an increased likelihood of failed operative vaginal delivery.

STUDY DESIGN

We conducted a population-based case-control study evaluating maternal, pregnancy, provider, care setting, and fetal factors associated with failed operative vaginal delivery. Subjects were identified using Washington state birth certificates for infants born between 1992 and 2001. Cases (n = 1750) were live-born singletons with both labored cesarean delivery and an operative vaginal delivery ("failure") coded on the birth certificate. Controls (n = 3500), frequency matched by delivery year to the cases, were randomly selected from among singletons undergoing a successful operative vaginal delivery. Odds ratios (OR) and associated 95% CI, estimated with Mantel-Haenszel methods, measured the association between case status and potential risk factors.

RESULTS

Failed operative vaginal delivery was associated with increased maternal age, African American race, higher body mass index (BMI), diabetes, polyhydramnios, induction of labor, dysfunctional labor, and prolonged labor. Case compared with control mothers were more likely to deliver a low-birth weight or macrosomic infant.

CONCLUSION

Identification of maternal and fetal factors associated with failed operative vaginal delivery may enable providers to better counsel patients, and allow improved planning and allocation of surgical resources.

Glucose tolerance of 2- to 5-yr-old offspring of diabetic mothers

The aim of this study was to determine the prevalence of and some risk factors for impaired glucose tolerance (IGT) in 2- to 5-yr-old offspring of diabetic mothers (ODM). The glucose tolerance of 51 offspring born to women with pregnancies complicated by diabetes (type 1) and of 109 children of the control group was analyzed. Our results showed that the fasting glycemia of ODM was similar, when compared to the controls, but 2 h after the glucose loading the glycemia of ODM was significantly higher than that in the control group (5.47 +/- 1.79 mmol/L vs. 4.86 +/- 1.13 mmol/L). Normal glucose tolerance was found in 68.6% of ODM and 86.2% of controls; IGT was found in 17.6% of ODM and 4.6% of controls. Children with macrosomia at birth or overweight at 2-5 yr had IGT at 2-5 yr more often than children with normal weight at birth or normal weight at 2-5 yr. A significant, though relatively low, positive correlation was found between the duration of breastfeeding and fasting glycemia (r=0.241, p <0.01), and positive correlation was found between the duration of breastfeeding and glycemia 2 h after glucose loading (r=0.458, p=0.002) in the offspring of diabetic mothers. In conclusion, the average glycemia of ODM after glucose loading was higher than that in the control group. Macrosomia after birth, overweight, and obesity in childhood had a significant influence on the glucose tolerance of the ODM. The results of the oral glucose tolerance test correlated with the length of breastfeeding.

Risk of cesarean wound complications in diabetic gestations

OBJECTIVE

This study was undertaken to examine the association between pregestational diabetes mellitus (DM) and wound complications after cesarean delivery (CD).

STUDY DESIGN

This was a retrospective, observational cohort study in patients with type 1 and 2 DM compared with non-DM controls undergoing CD. Wound complications were defined as wound infection, wound separation greater than 1 cm, and wound dehiscence.

RESULTS

There was an overall incidence of wound complications of 18.4% (34/185) in DM versus 5.8% (10/174) in non-DM (unadjusted odds ratio of 3.7; 95% CI = 1.8-7.7). Mean body mass index before pregnancy was 30.9 in DM versus 26.5 kg/m 2 in non-DM (P < .01). A multivariable logistic regression model adjusting for body mass index, length of surgery, and previous CD demonstrated a 2.5-fold increased risk of wound complications in DM patients compared with non-DM patients (95% CI = 1.1-5.5).

CONCLUSION

Pregestational diabetes is associated with a 2.5-fold increase in wound complications after CD.

The influence of obesity and diabetes on the risk of cesarean delivery

OBJECTIVE

To determine the influence of pregravid obesity and diabetes on cesarean delivery (CD) risk.

STUDY DESIGN

Women with singleton pregnancies of 23 weeks or more estimated gestational age who were undergoing a trial of labor January 1997 through June 2001 were categorized by pregravid body mass index (underweight [<19.8 kg/m 2 ], normal [19.8-25 kg/m 2 ], overweight [25.1-30 kg/m2], obese [>30 kg/m2]). Diabetes (DM) was divided into categories of gestational, treated with diet modification (A1GDM) or insulin (A2GDM), and pregestational (PDM). Prior CDs were excluded. CD rates for each group were compared in univariate analyses stratified by estimated gestational age (term, preterm, total). Other variables examined included DM, macrosomia (birth weight 4500 g or more), induction, and parity. Multiple regression included significant variables to predict the influence of diabetes and obesity on CD risk.

RESULTS

Records for 12,303 deliveries were evaluated (obese: 2828 [22.9%]; overweight: 2605 [21.2%]; A1GDM: 270 [2.2%]; A2GDM: 93 [0.8%]; PDM: 126 [1%]). Obese and overweight subjects had a higher risk for CD, compared with normal subjects (13.8% and 10.4% versus 7.7%, P < .0001 for each). Other CD risk factors were macrosomia (25% versus 9.4%), nulliparity (16.5% versus 4.7%), induction (17.4% versus 8.3%), diabetes (A1GDM: 16.7% versus 9.4%; A2GDM: 24.7% versus 9.5%; PDM: 34.9% versus 9.3%) and black race (10.7% versus 8.8%) ( P < .0001 for each). In multiple regression models including term deliveries, obesity and PDM were independent CD risk factors ([adjusted OR overweight: 1.5, P < .0001; adjusted OR PDM: 2.9, P = .01]; [adjusted OR obese: 2.4, P < .0001, PDM: 2.9, P = .0002]).

CONCLUSION

Pregravid obesity and diabetes independently increase the risk for CD. Given the disparate prevalence of obesity and diabetes in the United States, body habitus has a significantly larger impact on CD risk.

The influence of obesity and diabetes on the prevalence of macrosomia

OBJECTIVE

This study was undertaken to determine the relative contribution of abnormal pregravid maternal body habitus and diabetes on the prevalence of large-for-gestational-age infants.

STUDY DESIGN

Maternal and neonatal records for singleton term (> or =37 weeks' estimated gestational age) deliveries January 1997 through June 2001 were reviewed. Subjects were characterized by pregravid body mass index (BMI), divided into underweight (BMI <19.8 kg/m2), normal (BMI 19.8-25 kg/m2), overweight (BMI 25.1-30 kg/m2), and obese (BMI >30 kg/m2) subgroups. Diabetes was classified as gestational, treated with diet alone (A1GDM), or with insulin (A2GDM), and pregestaional diabetes (PDM). Newborn weight greater than the 90th percentile for gestational age, based on published local birth weight data, defined large for gestational age (LGA). The risk of LGA delivery for underweight, overweight, and obese women were compared with that of women with normal pregravid BMI. Multiple regression models, including parity, newborn sex, BMI, race, and diabetes, were constructed to examine the relative effect of abnormal BMI and diabetes on the risk of the delivery of an LGA infant.

RESULTS

Complete data for 12,950 deliveries were included (1,640 [13.0%] underweight, 2,991 [23.7%] overweight, and 2,928 [23.2%] obese). LGA delivery affected 11.8% of the study sample; 303 (2.3%) of subjects had A1GDM, whereas 94 (0.7%) had A2GDM, and 133 (1.6%) had PDM. Compared with normal BMI subjects, obese women were at elevated risk for LGA delivery (16.8% vs 10.5%; P < .0001) as were overweight women (12.3% vs 10.5%; P = .01). Diabetes was also a risk factor for LGA delivery (A1GDM: [29.4% vs 11.4%]; A2GDM: [29.8% vs 11.7%]; PDM: [38.3% vs 11.6%]; P < .0001 for each). Other risk factors for LGA delivery included parity (13.2% vs 9.5%; P < .0001), and male gender (14.3% vs 9.3%; P < .0001). Black race and low pregravid BMI were associated with a lower risk of LGA delivery (9.0% vs 13.7%; P < .0001) and (6.4% vs 10.5%; P = .006), respectively. Multiple regression revealed the independent influence of pregravid obesity and PDM, increasing the risk of LGA delivery (BMI >30kg/m 2 [Adjusted odds ratio (AOR) = 1.6]), and PDM (AOR = 4.4).

CONCLUSION

Obesity and pregestational diabetes are independently associated an increased risk of LGA delivery. The impact of abnormal body habitus on birth weight grows as BMI increases. Diabetes has the greatest affect on the normal and underweight population. With the increasing prevalence and relative frequency of overweight and obese women in pregnancy compared with diabetes (46.7% vs 4.1%), abnormal maternal body habitus exhibits the strongest influence on the prevalence of LGA delivery in our population.

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.