Pregnancy outcomes in women of very advanced maternal age

OBJECTIVE: To assess outcomes for pregnancies progressing beyond 20 weeks' gestation in women of very advanced maternal age. DESIGN: Retrospective cohort study. SETTING: Two tertiary level obstetric hospitals. POPULATION: Women aged 45 years or more at the time of delivery over a 10-year period from 1 January 1992 to 31 December 2001. METHODS: Information regarding maternal, pregnancy and neonatal outcomes was obtained from the medical records. For comparison, routinely collected data from the obstetric database was obtained for women aged 20-29 years. RESULTS: Seventy-seven pregnancies in 76 women aged 45 years and over were registered in the 10-year period. There were 74 liveborn singletons, two sets of liveborn twins and one set of twins stillborn at 20 weeks' gestation. Sixteen women were primiparous. Eighty-four percent of pregnancies were conceived naturally and 53% underwent prenatal chromosomal determination; 53% of women had no pre-existing medical problems, 13% had hypertensive disorders of pregnancy and 8% of women developed gestational diabetes. There were 10 preterm and six post dates deliveries. The Caesarean section rate was 49%, compared to 23% in the 20-29 years age group (P < 0.001). Ten percent of neonates were small for gestational age, and 8% were large for gestational age. Seventeen percent required admission to the special care nursery and 6% had congenital abnormalities. CONCLUSIONS: Maternal and neonatal outcomes in this series were generally good. There was a significantly increased rate of Caesarean section. Overall, this study is reassuring for women aged 45 and over who have good general health and a chromosomally normal fetus.     

糖耐量异常的晚期妊娠妇女胰岛素分泌与胰岛素抵抗的研究

OBJECTIVE: To investigate whether insulin secretion and resistance are different in glucose tolerant and intolerant women with normal pre-pregnant body mass index (BMI) during late pregnancy and to find out if there is association between gestational diabetes and insulin resistance syndrome. METHODS: On the basis of a 4-hour oral glucose tolerance test (OGTT), 32 gestational diabetes mellitus (GDM) patients, 21 gestational impaired glucose tolerant (GIGT) patients, and 50 normal glucose tolerant (NGT) cases were selected from uncomplicated pregnant women. Those had normal pre-pregnant BMI who had a 1-hour 50-g glucose-screening test (> or = 7.2 mmol/L), performed between 24-28 weeks of gestation. During the OGTT, several indexes of insulin resistance, insulin secretion, lipid metabolism were measured in addition to the standard glucose measurements. RESULTS: Glucose area under curve (GAUC), insulin area under curve (IAUC), insulin sensitivity index (ISI) transformed to natural logarithm and triglycerides (TG) are all significantly higher (P < 0.05) in GDM women. The means of these indexes in GDM group are 26.3 mmol/L.h-1, 276.5 mU/L.h-1, 4.2 and 3.2 mmol/L, respeetively. On the other hand, however, the differences of these indexes (except TG) between GIGT and NGT women are not statistically significant. The ratio of IAUC/GAUC has an increasing trend from GDM group, GIGT group to NGT group (10.5, 11.4 and 11.7, respectively), but the difference is not statistically significant. Multiple correlation coefficient study demonstrated that ISI is significantly positively correlated with GAUC, IAUC and TG (P < 0.01). CONCLUSIONS: Compared with NGT women, GDM women has impaired insulin secretion, abnormally increased insulin resistance, and relatively dyslipidemia. GDM seems to be a component of the syndrome of insulin resistance that provides an excellent model for study and prevention in a relatively young aged group.     

Diabetic pregnancy outcomes in mothers treated with basal insulin lispro protamine suspension or NPH insulin: a multicenter retrospective Italian study

Objective: The aim of this study was to study the efficacy and safety of long-acting insulin analog insulin lispro protamine suspension (ILPS) in diabetic pregnant women.

Methods: In a multicenter observational retrospective study, we evaluated pregnancy outcome in 119 women affected by type 1 diabetes and 814 with gestational diabetes (GDM) treated during pregnancy with ILPS, compared with a control group treated with neutral protamine hagedorn (NPH) insulin.

Results: Among type 1 diabetic patients, fasting blood glucose at the end of pregnancy was significantly lower in ILPS-treated than in NPH-treated patients. HbA1c levels across pregnancy did not differ between groups. Caesarean section and preterm delivery rates were significantly lower in the ILPS-women. Fetal outcomes were similar in the ILPS and NPH groups. Among GDM women, fasting blood glucose at the end of pregnancy was significantly lower in ILPS-treated than in NPH-treated patients. Duration of gestation was significantly longer, caesarian section and preterm delivery rates were lower in the ILPS-treated group. In addition, there were significantly fewer babies with an excessive ponderal index or neonatal hypoglycemic episodes in the ILPS group than in the NPH group.

Conclusions: Association of ILPS with rapid-acting analogs in pregnancy is safe in terms of maternal and fetal outcomes.     

Increased chemerin concentrations in fetuses of obese mothers and correlation with maternal insulin sensitivity

Objective: The aim of this study was to determine the effect of maternal obesity and gestational diabetes mellitus (GDM) on (i) the circulating concentrations of chemerin in cord and maternal plasma, and (ii) gene expression and release of chemerin from human placenta and adipose tissue. Design: Chemerin concentrations were measured in maternal and cord plasma from 62 normal glucose tolerant women (NGT) and 69 women with GDM at the time of term elective Caesarean section. Placenta and adipose tissue expression and release of chemerin was measured from 22 NGT and 22 GDM women. Results: There was no effect of maternal obesity or GDM on maternal chemerin concentrations. Chemerin concentrations were significantly higher in cord plasma from women with maternal obesity. Cord chemerin concentrations in NGT women negatively correlated with the concentrations of maternal insulin sensitivity. There was no effect of GDM on maternal and cord chemerin concentrations, and on the release of chemerin from placenta and adipose tissue. Conclusions: At the time of term Caesarean section, preexisting maternal obesity, and its associated insulin resistance, is associated with higher cord plasma chemerin concentrations.     

Trial of Labour Compared to Elective Caesarean in Twin Gestations with a Previous Caesarian Delivery

Objective: To compare maternal and neonatal outcomes in twin gestations with a vertex presenting first twin undergoing either an elective repeat Caesarean section or a trial of labour subsequent to having had a Caesarean delivery in a prior pregnancy.Methods: Maternal and newborn data from 1980 to 1999 in twin gestations, having I or more previous lower-segment Caesarean section(s) and a vertex presentation of the first twin, were analyzed from the Nova Scotia Atlee Perinatal Database. Categorical data were compared using chi-square or Fisher exact tests and continuous data by the Student t test. Logistic regression was used to control for covariates.Results: Of the 121 women eligible for the data analysis, 38 chose to have a trial of labour, and 28 delivered vaginally with no uterine ruptures, scar dehiscences, maternal deaths, or increase in neonatal morbidity or mortality reported. Two Caesareans in the trial-of-labour group were for the delivery of the second twin. Women choosing elective Caesarean section had a higher incidence of infectious morbidity (p = 0.04).Conclusion: In twin pregnancies with twin A presenting as a vertex, a cautious trial of labour may be an effective and safe alternative to elective repeat Caesarean section. Further research on a trial of labour after previous Caesarean section in twin gestations is warranted, as the studies published to date do not have sufficiently large numbers to detect adverse maternal and neonatal outcomes.     

Vaginal birth after Caesarean versus elective repeat Caesarean for women with a single prior Caesarean birth: a systematic review of the literature

AIMS: To assess the benefits and harms of planned elective repeat Caesarean section with planned vaginal birth after Caesarean section (VBAC). METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an; trial of labo(u)r; elective C(a)esare(i)an; C(a)esare(i)an section, repeat; randomis(z)ed controlled trial; randomis(z)ed trial; clinical trial; and prospective cohort study, to identify all published randomised controlled trials and prospective cohort studies. Primary outcomes related to success of trial of labour, need for Caesarean section, maternal and neonatal mortality, and morbidity. RESULTS: There were no randomised controlled trials identified that compared planned elective repeat Caesarean birth with planned vaginal birth. Two prospective cohort studies were identified where all 449 women compared had a single prior Caesarean section in their immediately preceding pregnancy and were suitable for an attempted VBAC in their next pregnancy. For all outcomes, data were available from a single study only. Reported outcome data were available for maternal deaths (0/137 women), in utero fetal deaths (2/312 fetuses), neonatal deaths (0/137 infants), uterine scar dehiscence (2/137 women), uterine scar rupture (1/312 women), and infant Apgar score of less than seven at 5 min of age (9/312 infants). There were no statistically significant differences between planned elective repeat Caesarean section and planned VBAC. CONCLUSIONS: There is a paucity of quality information available to assist women and their caregivers regarding optimal mode of birth for women with a single prior Caesarean section in their next pregnancy.     

Obstetric and perinatal outcome in women with twin pregnancy and gestational diabetes

Objective: The aim of this study was to evaluate pregnancy complications and obstetric and perinatal outcomes in women with twin pregnancy and GDM. Study Design: An observational multicentre retrospective study was performed and 534 pregnant woman and 1068 twins infants allocated into two groups, 257 with GDM and 277 controls, were studied. Main Outcome Measures: Pregnant women characteristics, hypertensive complications, preterm delivery rate, mode of delivery and birthweight were analysed. Results: Pregnant women with GDM were older (p?<?0.001) and had higher body mass index (p?<?0.001) than controls. GDM was associated with higher risk of prematurity in twin pregnancy (odds ratio 1.64, 95% confidence interval [1.14–2.32], p?=?0.005). This association was based on the association with other pregnancy complications. Birthweight Z-scores were significantly higher in the GDM group (p?=?0.02). The rate of macrosomia was higher in the GDM group (p?=?0.002) and small for gestational age (SGA) babies were significantly less frequent (p?=?0.03). GDM was an independent predictor of macrosomia (p?=?0.006). Conclusion: The presence of GDM in twin pregnancy was associated with a higher risk of hypertensive complications, prematurity and macrosomia, but significantly reduces the risk of SGA infants. Prematurity was related to the presence of other associated pregnancy complications.     

The Relationship Between Gestational Age and the Incidence of Classical Caesarean Section

Summary: Improved neonatal survival has led to a rise in the number of Caesarean sections being performed in the presence of extreme prematurity. Many of these operations require an incision in the upper uterine segment with consequent ramifications for the management of any subsequent pregnancy. In this analysis of obstetric patients in a tertiary referral institution over a 9-year period, there was an overall Caesarean section rate of 18%. A classical incision was performed in 1% of all Caesarean sections, but at 24 weeks' gestation, 20% of Caesarean sections were 'classicaľ. This frequency decreased to less than 5% at 30 weeks and less than 1% from 34 weeks' gestation. Most women having a classical Caesarean section at term had either a transverse lie or a major degree of placenta praevia.     

孕期血糖监测频率对饮食控制的妊娠期糖尿病围产结局的影响

目的:探讨血糖监测频率对饮食控制的妊娠期糖尿病(GDM)孕妇围产结局的影响。方法:选取2015年11月至2018年4月在浙江大学医学院附属妇产科医院产检并分娩单胎、孕前无糖尿病高血压疾病的5453例饮食控制的GDM孕妇。根据OGTT试验时的血糖水平将孕妇分为高危组2699例(49.5%)和低危组2754例(50.5%)。分别在高危和低危组中比较不同血糖监测频率组间临床资料及围产结局差异。采用单因素方差分析、χ2检验及二元logistic回归分析对数据进行统计分析。结果:高危组孕妇的平均年龄(33.21±4.50)岁vs(32.30±4.34)岁、孕前BMI(21.77±3.38)kg/m2 vs(21.26±3.20)kg/m2、经产妇比例(51.0%vs 47.9%)、糖尿病家族史(4.4%vs 3.3%)及巨大儿生产史比例(5.2%vs 4.1%)均显著高于低危组孕妇(P均<0.05),两组间血糖监测频率无显著差异。在围产结局方面,高危组孕妇的早产(10.8%vs 8.8%)及初次剖宫产比例(35.9%vs 31.3%)均显著高于低危组孕妇(P均<0.05)。高危组孕妇中,大于胎龄儿的发生率与血糖监测频率呈负相关(P<0.05);与从不监测血糖相比,偶尔监测和定期监测血糖均为大于胎龄儿的负相关独立影响因素(P<0.05,OR=0.708、0.644)。低危组孕妇中,不同血糖监测频率组间大于胎龄儿发生率差异无统计学意义。无论在低危还是高危孕妇中,其围产结局发生率在各血糖监测频率组间差异无统计学意义。结论:对于饮食控制的GDM孕妇,应在评估其高危程度后拟定个体化血糖监测方案。对于低危孕妇,单纯增加血糖监测频率对围产结局无明显助益;对于高危孕妇,增加血糖监测频率可显著减少大于胎龄儿的发生。     

妊娠合并糖代谢异常孕妇的妊娠结局分析

目的 探讨妊娠合并糖代谢异常孕妇的发生率变化趋势及经规范治疗后的不同类型糖代谢异常的母、儿结局。方法 1995年1月至2004年12月,在北京大学第一医院妇产科分娩的妊娠合并糖代谢异常患者共1490例,按照糖代谢异常情况分为糖尿病合并妊娠79例（DM组）,妊娠期糖尿病777例（GDM组,其中A1型355例,A2型316例,分型不明106例）,妊娠期糖耐量异常634例（GIGT组）。采用回顾性分析的方法对3组的母、儿结局进行分析,并对糖代谢异常孕妇的发生率进行统计。同期分娩的19013例糖代谢正常孕妇作为对照组。结果 （1）妊娠合并糖代谢异常的总发生率为7．3％,呈逐年上升的趋势。第一阶段即1995年1月至1999年12月,发生率呈缓慢增长,平均为4．3％（376／8739）;第二阶段即2000年1月至2001年12月,发生率呈快速增长趋势,平均为10．8％（445／4133）;第三阶段为2002年1月至2004年12月,基本稳定于8．9％（678／7640）。（2）3组糖代谢异常孕妇总的巨大胎儿、子痫前期、早产的发生率分别为12．1％（180／1490）、9．5％（141／1490）和9．4％（140／1490）,均明显高于对照组孕妇（P〈0．01）。3组糖代谢异常孕妇子痫前期、早产、宫内感染、羊水过多、酮症的发生率相互比较,差异有统计学意义（P〈0．05）,而3组的巨大儿发生率比较,差异无统计学意义（P〉0．05）。（3）3组糖代谢异常孕妇围产儿总死亡率为1．19％（18／1513）,其中,DM组为4．93％（4／81）,显著高于GDM组的1．14％（9／787）和GIGT组的0．78％（5／645）（P〈0．05）。而且,DM组新生儿窒息、低血糖及转诊的发生率均高于GDM组和GIGT组（P〈0．01）。（4）3组1505例新生儿中仅有0．6％（9／1505）发生呼吸窘迫综合征（RDS）,均发生于早产儿。结论 （1）妊娠合并糖代谢异常的发生率逐年上升,应重视提高对孕期糖尿病的筛查、诊断和处理。（2）经过孕期规范化管理,巨大儿、子痫前期和早产仍是糖代谢异常孕妇最常见的并发症,DM孕妇的母、儿合并症显著高于GDM和GIGT孕妇,今后应进一步加强该类型糖尿病孕妇管理。（3）新生儿RDS已不再是新生儿的主要合并症。     

Impact of insulin resistance on pregnancy complications and outcome in women with polycystic ovary syndrome

The aim of the study was to determine the risk of developing gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH)/pre-eclampsia in a cohort of pregnant women with the polycystic ovary syndrome (PCOS) and known insulin sensitivity status. Pregnancies and neonatal outcome were recorded in a prospective cohort study comprising 29 non-insulin-resistant PCOS women, 23 insulin-resistant PCOS women and a control group of 355 women who had conceived after assisted reproduction. Hypertension, pre-eclampsia and GDM were recorded as well as pregnancy duration, method of delivery and birth weight. The frequency of hypertension was significantly elevated in PCOS women (11.5%) compared to controls (0.3%), p < 0.01. However, the frequency of pre-eclampsia was significantly elevated only in the insulin resistant PCOS women (13.5%) compared to controls (7.0%), p < 0.02. GDM was significantly more frequent in PCOS women (7.7%) than controls (0.6%), p < 0.01. Insulin resistance prior to pregnancy, determined by continuous infusion of glucose with model assessment (CIGMA) test, did not further increase the frequency of GDM. Newborns from PCOS pregnancies were significantly more often delivered by Caesarean section than controls (40.3 vs. 27.3%, p < 0.05) and transferred to neonatal intensive care unit more often than controls (19.2 vs. 9.0%, p < 0.01). Thus we show that the frequencies of pre-eclampsia and GDM are increased in PCOS pregnancies.     

Insulin detemir versus glyburide in women with gestational diabetes mellitus

Aim: To evaluate the safety, efficacy and pregnancy outcomes of insulin detemir (IDet) versus glyburide treatment in women with gestational diabetes mellitus (GDM).

Methods: We conducted a retrospective cohort study of women with GDM who were treated with either glyburide or IDet for GDM in a university-affiliated tertiary hospital.

Results: Ninety-one patients with GDM were enrolled, 62 were administered glyburide and 29 IDet. Maternal age, pregestational body mass index (BMI) and rate of abnormal oral glucose tolerance test (OGTT) blood glucose values were not significantly different between groups. Good glycemic control rates were comparable. Hypoglycemic episodes were reported only in the glyburide group (19.4% versus 0%, p?=?0.01). Maternal weight gain during pregnancy was significantly higher among women in the glyburide group (8.8?±?5.1?kg, p?p?=?0.71).

Conclusions: To the best of our knowledge, this is the first study on IDet treatment in patients with GDM. By our preliminary results, IDet is a viable treatment option in women with GDM. Further large prospective studies are needed to determine the efficacy and safety of IDet in GDM patients.     

妊娠期糖尿病孕妇甲状腺功能减退的临床分析

目的:探讨妊娠期糖尿病(GDM)患者甲状腺功能减退(甲减)的情况,以及GDM并发甲减对妊娠结局的影响。方法:(1)根据75g糖耐量试验结果,将2011年9月至2013年3月在产科门诊常规产检的妊娠中期妇女分为GDM组(244例)及对照组(674例)。比较两组患者的甲状腺功能;(2)将2011年9月至2013年3月收入院的妊娠晚期GDM患者分为单纯GDM组(Ⅰ组,370例)、GDM并发甲减组(Ⅱ组,79例),回顾分析两组患者的妊娠结局。结果:(1)与对照组相比,妊娠中期GDM组患者的低甲状腺素血症发生率较高(P0.05),血清游离甲状腺素(FT4)显著降低(P0.01)。两组妇女的促甲状腺激素(TSH)、游离三碘甲状腺原氨酸(FT3)、抗甲状腺过氧化物酶抗体(TPOAb)无显著差异,但TPOAb阳性的妊娠妇女TSH平均值高于正常值上限,且显著高于TPOAb阴性妇女(P0.05);(2)GDM并发甲减组的子痫前期、巨大儿、剖宫产发生率均显著高于单纯GDM组(P0.05)。结论:GDM妊娠妇女更易引发甲减,且GDM并发甲减将进一步加重不良妊娠结局。     

Screening for gestational diabetes: the effect of varying blood glucose definitions in the prediction of adverse maternal and infant health outcomes

BACKGROUND: Impaired glucose tolerance in pregnancy and gestational diabetes are associated with increased maternal and fetal risks. There is considerable uncertainty in the literature relating to the merits of screening for gestational diabetes and impaired glucose tolerance, and variable definitions in the cut-off values to be used. AIMS: To assess different levels of glucose intolerance in predicting adverse pregnancy outcomes. METHODS: Retrospective cohort study involving screening pregnant women with a 50-g oral glucose load, followed by a formal 75-g oral glucose tolerance test for women who screened positive (defined as a plasma glucose level > or = 7.8 mmol/L). Plasma glucose results were correlated with pregnancy and birth outcomes, and receiver-operator curves were constructed. RESULTS: A total of 16,975 women were screened with a glucose challenge test, with pregnancy outcome information available for 1804 women who screened positive on glucose challenge test. With increasing plasma glucose values, there was a significant increase in pre-eclampsia, Caesarean section, shoulder dystocia and neonatal hypoglycaemia. CONCLUSIONS: The risk of adverse maternal and infant pregnancy outcomes increases with increasing levels of glucose impairment despite treatment.     

Induction of labour after 1 previous Caesarean section

The aim of this study was, after induction of labour in women with a previous Caesarean section, to compare the outcome in women with a history of a previous vaginal delivery with women who had never delivered vaginally. A retrospective analysis was performed over a 2-year period, in a Dublin teaching hospital. One hundred and three women who had had 1 previous lower segment Caesarean section had labour induced. Particular attention was given to delivery outcome, history of a vaginal delivery, cervical effacement at induction, influence of epidural analgesia, indication for induction and incidence of uterine rupture. The repeat Caesarean section rate after induction was 20.4%. Of the 51 women who had never previously delivered vaginally, the repeat section rate was 37.3% compared with only 3.9% of the 52 women who had previously delivered vaginally (p < 0.01). Fourteen women who had never delivered vaginally had an uneffaced cervix at induction and the repeat Caesarean section rate in this group was 64.3%. The commonest indication for induction was a postdates pregnancy. The use of epidural analgesia was greater in women who had never delivered vaginally. There were 2 cases of uterine scar rupture. Induction of labour following Caesarean section is associated with a significantly higher incidence of repeat Caesarean section in women who have not had a previous vaginal delivery. If the cervix is not effaced at induction, the repeat Caesarean section rate is higher than if the cervix has started to efface.     

Subclinical abnormalities of glucose metabolism in Brazilian women with a history of gestational diabetes mellitus

BACKGROUND: To evaluate insulin release and insulin sensitivity in women with prior gestational diabetes mellitus (GDM) to gain a better understanding of type 2 diabetes pathogenesis. METHODS: GDM women were individually matched for age, body mass index, and waist/hip ratio with those who were normal glucose tolerant in a previous pregnancy (NGT). All women presented with normal glucose tolerance. Twenty pairs were submitted to the oral glucose tolerance test (OGTT) with plasma glucose, insulin, and C-peptide determinations. Of the 20 pairs, 18 participated in hyperglycemic (10.0 mmol/l) clamp experiments with frequent plasma glucose and insulin determinations, allowing us to calculate first- and second-phase insulin release and the insulin sensitivity index. GDM and NGT women were compared using Student's t-test, the Mann-Whitney U-test, Friedman's non-parametric test, and the two proportion test for independent groups. RESULTS: GDM women showed higher glycosylated hemoglobin values; at OGTT, they showed late insulin peak with increased plasma insulin levels only during the second hour, and a similar plasma C-peptide response despite a higher plasma glucose curve; during hyperglycemic clamp procedures, they showed similar biphasic insulin release and insulin sensitivity index. Considering that a woman with previous GDM had a defect in insulin release and/or insulin sensitivity, if its magnitude was at least 25% lower than that of the matched NGT woman, 43.8% showed impairment of first-phase insulin release and 55.6% insulin resistance. CONCLUSIONS: GDM women showed some degree of glucose intolerance. It is therefore necessary to follow them for a longer time.     

Induction of labour for women with a previous Caesarean birth: a systematic review of the literature

AIMS: To compare the benefits and harms of planned elective repeat Caesarean section with induction of labour and to assess different methods of cervical ripening and induction of labour for women with a previous Caesarean birth who require induction of labour in a subsequent pregnancy. METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an, trial of labo(u)r, elective C(a)esare(i)an, C(a)esare(i)an repeat, induction of labo(u)r, prostaglandins, prostaglandin E(2), misoprostol, prostaglandin E(1) analogs, mifepristone, oxytocin, Syntocinon, randomis(z)ed controlled trial, randomis(z)ed trial and clinical trial, to identify all published randomised controlled trials with reported data comparing outcomes for women and infants who have a planned elective repeat Caesarean section with induction of labour; and different methods of induction of labour, where a prior birth was by Caesarean section. RESULTS: There were no randomised controlled trials identified where women with a prior Caesarean birth, whose labour required induction in a subsequent pregnancy, compared elective repeat Caesarean section with induction of labour. There were three randomised controlled trials identified in which women with a prior Caesarean section were allocated to different methods of induction of labour - vaginal prostaglandin E(2) versus intravenous oxytocin; mifepristone versus placebo; and vaginal misoprostol versus intravenous oxytocin. These studies varied considerably in the methods used and meta-analysis was not appropriate. CONCLUSIONS: There is a paucity of safety information for induction of labour agents in the women with a scarred uterus, and caution should be exercised in their use.     

Impaired glucose tolerance in pregnant women with polycystic ovary syndrome.

OBJECTIVE: To determine whether women with polycystic ovary syndrome (PCOS) are more likely to develop gestational diabetes mellitus compared with age- and weight-matched controls. METHODS: This retrospective cohort study compared reproductive-age women with and without PCOS who received prenatal care at the University of North Carolina Hospitals between April 1989 and June 1998. We reviewed the medical charts of 22 women with PCOS diagnosis before pregnancy based on menstrual histories, elevated androgen levels, and LH-FSH ratios greater than 2. These women were compared with 66 women without PCOS matched for age and weight. Gestational diabetes mellitus (GDM) was diagnosed in women if they had abnormal results on a 50-g glucose screening test and at least two abnormal plasma glucose values during a 100-g glucose tolerance test. Medical complications of pregnancy, pregnancy complications, and birth outcomes were compared between women with and without PCOS. RESULTS: Nine of 22 women with PCOS also had GDM diagnosis, compared with two of 66 controls (odds ratio [OR] 22.2; 95% confidence interval [CI] 3.8, 170.0), and these women exhibited increased plasma glucose values for all measurements except fasting. Five of 22 women with PCOS developed preeclampsia compared with one of 66 controls (OR 15.0; 95% CI 1.9, 121.5). CONCLUSION: Women with PCOS are at increased risk of glucose intolerance and preeclampsia during pregnancy.     

Pregnancy outcome in obese and morbidly obese gestational diabetic women

OBJECTIVE: We sought to determine whether pregnancy outcome differs between obese and morbidly obese GDM patients and to assess pregnancy outcome in association with mode of treatment and level of glycemic control. METHODS: A cohort study of 4,830 patients with gestational diabetes (GDM), treated in the same center using the same diabetic protocol, was performed. Obesity was defined as prepregnancy BMI >30 and <35 kg/m(2); morbid obesity was defined as prepregnancy BMI >or=35 kg/m(2). Well-controlled GDM was defined as mean blood glucose <105 mg/dl. Pregnancy outcome measures included the rates of large for gestational age (LGA) and macrosomic babies, metabolic complications, the need for NICU admission and/or respiratory support, rate of shoulder dystocia, and the rate of cesarean section. RESULTS: Among the GDM patients, the rates of obesity and morbid obesity were 15.7% (760 out of 4830, BMI: 32.4+/-1.6 kg/m(2)) and 11.6% (559 out of 4830, BMI: 42.6+/-2.2 kg/m(2)), respectively. No differences were found with regard to maternal age, ethnicity, gestational age at delivery or oral glucose tolerance test (OGTT) results. Moreover, similar rates of cesarean section, fetal macrosomia, shoulder dystocia, composite outcome, and metabolic complications were noted. Insulin treatment was initiated for 62% of the obese and 73% of the morbidly obese GDM patients (P<0.002). Similar rates of obese and morbidly obese patients achieved desired levels of glycemic control (63% versus 61%, respectively). In both obese and morbidly obese patients who achieved a desired level of glycemic control (<105 mg/dl), no difference was found in pregnancy outcome except that both neonatal metabolic complications and composite outcomes were more prevalent in diet-treated subjects in comparison to insulin-treated GDM patients. CONCLUSION: In obese women with GDM, pregnancy outcome is compromised regardless of the level of obesity or treatment modality.     

A ten-year gestational diabetes mellitus cohort at a university clinic of the mid-Anatolian region of Turkey

OBJECTIVE: The study attempts to analyze a 10-year retrospective cohort of gestational diabetes mellitus (GDM) cases, elucidating the maternal complications and perinatal morbidity and mortality. STUDY DESIGN: The study participants were 110 diabetic singleton pregnancies receiving obstetric care at the Department of Obstetrics and Gynecology, Osmangazi University School of Medicine in Eskisehir, Turkey from January 1995 to December 2004. In 70 of the GDM cases, mean age, diagnostic criteria used to define GDM, gestational age at delivery, presence of additional risk factors, method of clinical management, mode of delivery, fetal birthweights and newborn characteristics were assessed. RESULTS: The prevalence of GDM in the past ten-year period was 3.1% (110/3548). Mean age of enrolled GDM cases was 32.6 +/- 5.3 years. With regard to diagnostic criteria of GDM, 24 (37.1%) cases were diagnosed based on a 100 g, three-hour oral glucose tolerance test (OGTT), while 18 (25.7%) cases were referred to our unit without any information on the specific criteria of GDM diagnoses. In less than a third of the cases (25.7%), a one-hour 50 g glucose challenge test (GCT) resulted > or =185 mg/dl completing the diagnoses. More than half of the cases (57.1%) revealed controlled glucose homeostasis on diet, while 30 (42.9%) pregnant women needed insulin therapy to control blood glucose levels to within normal physiologic limits. Fetal macrosomia was present in 18 (25.7%) pregnancies. Meanwhile, most of the fetuses (62.9%) were within the normal growth percentiles throughout the pregnancy. There was no difference detected in body mass index (BMI) of women undergoing cesarean section and spontaneous vaginal births (25.1 +/- 1.2 vs 26.2 +/- 2.3 kg/m2, respectively, p = 0.45). Vacuum extraction and forceps applications were indicated in 10% of all GDM groups. Fetuses born to women having cesarean section were heavier at birth compared to those of women having vaginal births (3940 +/- 320 g vs 430 +/- 117 g, p = 0.08) Most frequent neonatal morbidity was hyperbilirubinemia in 25 (35.7%) newborns. Interestingly, of those women with GDM, only ten (14.3%) cases consented to follow-up evaluation of glucose intolerance between six and eight weeks postpartum. CONCLUSIONS: Proposed risks from abnormal glucose intolerance in pregnancy are multiple. Early diagnosis, patient education, proper follow-up and postpartum testing in women with GDM will certainly decrease poor perinatal outcomes, enabling also a secondary prevention of type 2 diabetes in the long term.