Glycemic control in gestational diabetes mellitus--how tight is tight enough: small for gestational age versus large for gestational age?

The relationship between optimal levels of glycemic control and perinatal outcome was assessed in a prospective study of 334 gestational diabetic women and 334 subjects matched for control of obesity, race, and parity. All women with gestational diabetes mellitus were instructed in the use of a memory-based reflectance meter. They were treated with the same metabolic goal according to a predetermined protocol. Three groups were identified on the basis of mean blood glucose level throughout pregnancy (low, less than or equal to 86 mg/dl; mid, 87 to 104 mg/dl; and high, greater than or equal to 105 mg/dl). The low group had a significantly higher incidence of small-for-gestational-age infants (20%). In contrast, the incidence of large-for-gestational-age infants was 21-fold higher in the mean blood glucose category than in the low mean blood glucose category (24% vs. 1.4%, p less than 0.0001). An overall incidence of 11% small-for-gestational-age and 12% large-for-gestational-age infants was calculated for the control group. A significantly higher incidence of small-for-gestational-age infants (20% vs. 11%, p less than 0.001) was found between the control and the low category. In the high mean blood glucose category an approximate twofold increase was found in the incidence of large-for-gestational-age infants when compared with the control group (p less than 0.03). No significant difference was found between the control and mean blood glucose categories (87 to 104 mg/dl). Our data suggest that a relationship exists between level of glycemic control and neonatal weight. This information is helpful in targeting the level of glycemic control while optimizing pregnancy outcome in gestational diabetes comparable to the general population.     

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.     

Management of women with one abnormal oral glucose tolerance test value reduces adverse outcome in pregnancy

In this study we sought to test the hypothesis that treatment of women with one abnormal oral glucose tolerance test value will result in reduction of adverse outcome. One hundred twenty-six women with one abnormal oral glucose tolerance test value and 146 women in the control group (normal oral glucose tolerance test values) participated in a prospective study during the third trimester of pregnancy. The subjects with one abnormal test result were randomized into treated (group 1) and untreated groups (group II). Group 1 subjects were treated with a strict diabetic protocol to maintain tight glycemic control by means of diet and insulin therapy. Group 2 subjects tested their capillary blood glucose for a baseline period. The study revealed that the level of glycemic control was similar before initiation of therapy (mean capillary blood glucose 118 +/- 14 vs. 119 +/- 15 mg/dl, p = NS) for groups 1 and 2, respectively. There was a significant difference in mean capillary blood glucose (95 +/- 10 vs. 119 +/- 15 mg/dl, p less than 0.0001), preprandial, and postprandial determinations between the treated and untreated groups. The overall incidence of neonatal metabolic complications (4% vs. 14%, p less than 0.05) and large infants (6% vs. 24%, p less than 0.03) was significantly lower in the treated group. Comparison between the control (normal oral glucose tolerance test) and the untreated groups showed a significantly higher incidence of large infants and metabolic complications. No difference was found between the normal and treated groups. Thus we conclude that treatment of individuals with one abnormal oral glucose tolerance test value will result in significant reduction in adverse outcome in pregnancy.     

GDM women in good glycemic control: which meal-related measure enhances fetal well-being?

OBJECTIVE: To determine which meal-related glucose measure maximizes perinatal outcome in gestational diabetes mellitus (GDM) women who have achieved established levels of glycemic control. METHODS: Two thousand two hundred and ninety-eight GDM women were stratified by meal-related blood glucose measures: fasting (<95 mg/dL); pre-meal (< or =90 mg/dL); 2-h post-meal (< or =120 mg/dL); mean (< or =100 mg/dL). The rates of unidentified adverse outcome for composite outcome, neonatal intensive care unit (NICU), metabolic and respiratory complications and cesarean section delivery within each meal-related glucose threshold were calculated. RESULTS: Overall, 25-69% of large-for-gestational-age (LGA)/macrosomic infants were not identified within the recommended meal-related glucose threshold measurements. The lowest rates of unidentified morbidity were found in the pre-meal and mean blood glucose categories while the highest rates were in the post-meal category despite subjects achieving recommended levels of glycemic control. The increased rate of LGA/macrosomia within 10 mg/dL increments for each meal-related glucose category revealed that regardless of the meal-related category, the rate of LGA was significantly higher (15-25%). Logistic regressions (dependent variable= composite outcome or LGA) showed that mean blood glucose was the only significant contributor. CONCLUSION: Currently recommended meal-related glucose measures do not preclude adverse fetal outcome.     

Continuous subcutaneous insulin infusion (CSII) in pregnant diabetic patients

The efficacy of the insulin infusion pump (CSII) in pregnancy was examined in 12 diabetic patients and compared with intermittent insulin therapy (IIT). In patients poorly controlled on IIT constant and rapid equilibrium was achieved with CSII (mean of glucose levels: CSII versus IIT = 84 versus 137 mg/dl; S.D. = 36 versus 63 mg/dl; mean amplitude of glycemic excursion (MAGE) = 65 versus 112 mg/dl. In patients well controlled on IIT, CSII led to a reduction in the variation of glucose excursions (S.D. = 29 versus 36 mg/dl; MAGE = 48 versus 76 mg/dl). CSII generally produced a reduction of 20-37 per cent of daily insulin dose (in three cases there was an increase of dose with the achievement of glycemic control). Furthermore in CSII treated-patients amniotic glucose, insulin and C-peptide concentrations were found to be in the normal range (22.1 +/- 10.1 mg/dl; 5.2 +/- 2.7 microU/ml; 1.25 +/- 0.71 ng/ml, respectively). All infants were born at or near-term, had no macrosomia or neonatal problems. It is concluded that CSII is a highly efficient way to achieve normal glucose levels in pregnancy, not only in type I, but also in type II or gestational diabetes.     

Rate and risk factors of hypoglycemia in large-for-gestational-age newborn infants of nondiabetic mothers

OBJECTIVE: The purpose of this study was to investigate the rate of hypoglycemia in large-for-gestational-age infants of nondiabetic mothers in relation to maternal or neonatal risk factors. STUDY DESIGN: Hospital charts of all term large-for-gestational-age infants born between 1994 and 1998 (n = 1136) were analyzed for the rate of neonatal hypoglycemia (capillary glucose level, < or =30 mg/dL) during the first 24 hours of life. Infants of women with preexisting or gestational diabetes mellitus were excluded (n = 180). Neonatal glucose testing was performed at 1 or 2 hours of life, with subsequent measurements every 4 to 6 hours. Maternal and neonatal parameters were compared between neonates with and without hypoglycemia, including recent oral glucose tolerance test values in those women who were tested (n = 358). RESULTS: Of 956 infants, 69 infants (7.2%) were not tested for hypoglycemia. In the remaining 887 infants, hypoglycemia occurred in 142 infants (16%) within the first 24 hours of life. The incidence of hypoglycemia decreased sharply during the first few hours of life, from 9.2% within the first hour of life, to 3.5% between 2 to 5 hours (cumulative) of life, and 2.4% between 6 and 24 hours of life. Gestational age at delivery was the only neonatal parameter that differed significantly between infants with and without hypoglycemia (39.5 vs 39.3 weeks, P =.01). The antenatal 1-hour oral glucose tolerance test value was the only predictive maternal parameter (141.5 vs 163.0 mg/dL, P <.006). There was an incremental risk of hypoglycemia with increasing 1-hour oral glucose tolerance test values, with hypoglycemia rates of 2.5%, 9.3%, 22.0%, and 50.0% that were associated with maternal 1-hour glucose values of <120, 120-179, 180-239, and > or =240 mg/dL, respectively (P <.05, for all comparisons). CONCLUSION: Routine glucose testing is indicated in large-for-gestational-age newborn infants of nondiabetic mothers. The 1-hour glucose value of the maternal oral glucose tolerance test is a fairly good predictor of subsequent neonatal hypoglycemia. A single elevated 1-hour value of > or =180 mg/dL markedly increases the risk of neonatal hypoglycemia.     

Overweight and obese in gestational diabetes: the impact on pregnancy outcome

OBJECTIVE: We sought to investigate the relationship between prepregnancy weight, treatment modality (diet or insulin), level of glycemic control, and pregnancy outcome. STUDY DESIGN: We recruited women with gestational diabetes (GDM) from inner city prenatal clinics. All women were instructed in the use of an intensified management protocol using memory reflectance meters. Outcomes were analyzed according to maternal prepregnancy body mass index (BMI, kg/m 2 ) categories: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI > or =30), and by diet or insulin therapy and glycemic control (mean blood glucose <100 mg/dL = good control). Pregnancy outcome variables included a composite outcome (at least 1 of the following: neonatal metabolic complications, large-for-gestational age or macrosomic infants, NICU admission for >24 hours, and the need for respiratory support) (not including oxygen therapy). In addition to composite outcome, a bivariate analysis was performed for each single variable, including preeclampsia and cesarean section delivery. RESULTS: Four thousand and one women were enrolled. Obese women who achieved targeted levels of glycemic control had comparable pregnancy outcomes to normal weight and overweight women only when they were treated with insulin. Normal weight women treated with diet therapy who achieved targeted levels of glycemic control had good outcomes, but obese women treated with diet therapy who achieved targeted levels of glycemic control, nevertheless, had a 2- to 3-fold higher risk for adverse pregnancy outcome when compared with overweight and normal weight patients with well-controlled GDM. Women with GDM who failed to achieve established levels of glycemic control had significantly higher adverse pregnancy outcomes in all 3 maternal weight groups. CONCLUSION: In obese women with BMI > or =30 with GDM, achievement of targeted levels of glycemic control was associated with enhanced outcome only in women treated with insulin.     

Effects of longitudinal maternal glucose control on infants of diabetic mothers

Between 1980 and 1987, 45 pregnant women with diabetes mellitus who required insulin therapy were delivered at Kagoshima Municipal Hospital. The perinatal mortality rate in the present study was zero. Twelve infants were large for gestational age, ten were small for gestational age, and 23 were appropriate for gestational age. Tight maternal glucose control (fasting values of less than 100mg/dl and 2 hours post-prandial values of less than 120mg/dl) obtained before 32 weeks of gestation significantly decreased the incidence of large for gestational age infants. However, longitudinal control patterns of maternal glucose during pregnancy have little effect on the incidence of small for gestational age infants and neonatal complications. The former was more closely related to maternal vascular complications. Congenital malformations were found in two cases.     

Factors influencing neonatal morbidity in gestational diabetic pregnancy

Summary. The influence of obstetric factors and indices of maternal blood glucose control on neonatal morbidity was examined in 261 women with gestational diabetes. A reference group of 218 women, matched for age and day of delivery, within 1 week, was used for comparison. Perinatal morbidity was significantly more frequent in the gestational diabetic pregnancies (23%) than in the reference group (13%), whereas the occurrence of large-for-gestational-age infants was not different between the groups. Infants born to women with gestational diabetes were categorized to a no-morbidity group ( n =200) and a morbidity group ( n =61). The group with morbidity had significantly shorter gestational age at delivery, higher frequency of caesarean section, higher maternal pre-pregnancy weight and higher area under the glucose tolerance curve. There was no significant difference in third-trimester blood glucose between the groups. Discriminant analysis revealed that the most significant influence on neonatal morbidity was gestational age at delivery. After correction for this factor the only factor with added significance for neonatal morbidity was maternal pre-pregnancy weight. The present study clearly illustrates that other factors beside blood glucose control are of importance for neonatal outcome in gestational diabetic pregnancy.     

Factors influencing neonatal morbidity in gestational diabetic pregnancy

The influence of obstetric factors and indices of maternal blood glucose control on neonatal morbidity was examined in 261 women with gestational diabetes. A reference group of 218 women, matched for age and day of delivery, within 1 week, was used for comparison. Perinatal morbidity was significantly more frequent in the gestational diabetic pregnancies (23%) than in the reference group (13%), whereas the occurrence of large-for-gestational-age infants was not different between the groups. Infants born to women with gestational diabetes were categorized to a no-morbidity group (n = 200) and a morbidity group (n = 61). The group with morbidity had significantly shorter gestational age at delivery, higher frequency of caesarean section, higher maternal pre-pregnancy weight and higher area under the glucose tolerance curve. There was no significant difference in third-trimester blood glucose between the groups. Discriminant analysis revealed that the most significant influence on neonatal morbidity was gestational age at delivery. After correction for this factor the only factor with added significance for neonatal morbidity was maternal pre-pregnancy weight. The present study clearly illustrates that other factors beside blood glucose control are of importance for neonatal outcome in gestational diabetic pregnancy.     

Appraisal of "rigid" blood glucose control during pregnancy in the overtly diabetic woman

The degree of maternal glucose control achieved during the third trimester of pregnancy was evaluated for 120 overtly diabetic women hospitalized on a high-risk pregnancy ward. "Rigid" blood glucose control, defined as a mean preprandial plasma glucose concentration less than 115 mg/dl was achieved in only 14% of these women. Although mean preprandial plasmal glucose concentrations ranged between 115 and 172 mg/dl in 66% of women and exceeded 172 mg/dl in 20%, the perinatal salvage rate was greater than 95%. Pregnancies of those women whose mean plasma glucose levels exceeded 172 mg/dl required earlier intervention for signs of fetal jeopardy, but the degree of glucose control was not significantly related to either perinatal death or neonatal morbidity. These results suggest that maternal hyperglycemia exceeding a mean preprandial glucose concentration of 172 mg/dl is to be avoided, whereas, at the other extreme, mean glucose levels less than 115 mg/dl or "rigid" control is unnecessary for a successful perinatal outcome.     

Neonatal morbidity in pregnancy complicated by diabetes mellitus: predictive value of maternal glycemic profiles

The relationship between glycemic control and perinatal outcome was assessed in a relatively uniform population of 75 White Class B through D pregnant diabetic women. All patients used glucose reflectance meter self-monitoring and performed a minimum of four determinations daily. Mean capillary blood glucose was calculated from a minimum of 16 weeks of determinations. Regression analysis confirmed a correlation between these values and third-trimester hemoglobin A1 (p less than 0.001). The study population was divided into two groups on the basis of mean capillary blood glucose values: group I, mean capillary blood glucose less than 110 mg/dl (43 patients) (mean = 96.8 +/- 7.1); group II, mean capillary blood glucose greater than 110 mg/dl (32 patients) (mean = 126 +/- 9.0). Of the 32 patients in group II, eight had mean capillary blood glucose greater than or equal to 130 mg/dl. The degree of maternal glycemic control appeared to affect perinatal outcome. At least one form of infant morbidity was present in 33% of group I infants compared with 53% of group II. Significant differences were observed for the incidence of hypoglycemia (p less than 0.05), macrosomia (p less than 0.05), and respiratory distress syndrome (p less than 0.01). One of six group I infants delivered at 35 to 36 weeks developed respiratory distress syndrome, compared with four of seven group II patients. The appearance of phosphatidylglycerol in amniotic fluid appeared delayed in group II patients at term. These data suggest that maintaining mean capillary blood glucose values less than 110 mg/dl may serve to reduce several major forms of morbidity in the infant of the diabetic mother. This information is helpful in establishing objectives for glycemic control in pregnant women using self-monitoring techniques.     

Obesity-related complications of pregnancy vary by race

Objectives: The first objective was to assess the association of renal function with maternal and fetal pregnancy outcome in women with diabetic nephropathy. The second objective was to examine the feasibility of a multicenter surveillance program to determine the rates of maternal and fetal pregnancy complications in women with diabetic nephropathy, and to study the effect of pregnancy on the natural history of diabetic renal disease. Methods: In order to address the first objective, we analyzed data from women with type 1 diabetes and nephropathy enrolled in the Diabetes in Pregnancy Program at our institution. Women were assigned to one of three groups according to enrolment serum creatinine concentration: ≤ 1.0 mg/dl, > 1.0 to 1.5 mg/dl and > 1.5 mg/dl. A pilot surveillance program at six centers included women experiencing pregnancy complicated by diabetic nephropathy. In both studies, medical and obstetric history, and maternal and neonatal outcomes, were recorded. Statistical analysis included χ², logistic regression and analysis of variance. Results: There were 72 pregnancies in 58 women with diabetic nephropathy who enrolled in the pregnancy program. High serum creatinine concentration at enrolment was associated with delivery before 32 weeks' gestation, very low birth weight and increased incidence of neonatal hypoglycemia, independent of quantity of total urinary protein excretion and glycemic control in any trimester. To date, pilot surveillance data have been obtained from six centers on 16 women. Serum creatinine concentrations ranged from 0.4 to 1.1 mg/dl and creatinine clearance from 32 to 317 ml/min. Gestational age at delivery ranged from 22 to 39 weeks. Conclusions: High serum creatinine concentration at enrolment is a risk factor for adverse maternal and neonatal outcome, independent of quantity of total urinary protein excretion and glycemic control during any trimester. A multicenter surveillance program is needed, in order to study less frequent maternal and neonatal outcomes as well as the long-term effects of pregnancy on the natural course of diabetic renal disease.     

Large-for-gestational-age infants of type 1 diabetic mothers: An effect of preprandial hyperglycemia?

Objective. To determine how the frequency, timing and magnitude of hyperglycemia are associated with large-for-gestational-age (LGA) infants in pregnancies complicated by type 1 diabetes.

Methods. Charts from pregnant women with type 1 diabetes (n = 70) were reviewed. Indices of maternal glycemic control were determined for seven gestational periods (weeks 7–10, 11–15, 16–19, 20–24, 25–28, 29–32 and 33–38) and compared between women who delivered LGA infants and appropriate-for-gestational-age (AGA) infants.

Results. Of the 70 pregnancies, 57% of the infants were LGA (4.3 ± 0.4 kg) and 43% were AGA (3.2 ± 0.4 kg). Total maternal weight gain and rate of weight gain were significantly higher in mothers with LGA infants. The glycemic variables associated with an LGA infant were percentage of preprandial values above target for weeks 11–15, 25–28 and 29–32, and percentage of all values above target for weeks 33–38. For the entire pregnancy, the strongest predictors of an LGA infant were percentage of preprandial blood glucose values above target during weeks 29–32 and maternal weight gain.

Conclusions. In pregnant women with type 1 diabetes, frequent episodes of preprandial hyperglycemia in the third trimester significantly impact the development of LGA infants.     

Does intensive glycemic control in diabetic pregnancies result in normalization of other metabolic fuels?

Intensive treatment of insulin-dependent diabetes mellitus during pregnancy often normalizes plasma glucose levels. However, it is unclear whether this adversely affects other metabolic fuels that are essential to normal fetal growth and development. Metabolic studies were conducted after the subjects ingested a standardized mixed meal during each trimester in 7 normal and 15 insulin-dependent diabetic pregnant women. The latter were treated with continuous subcutaneous insulin infusion or multiple injections, which were adjusted to achieve strict glucose control throughout pregnancy. Insulin, alanine, branched-chain amino acids, triglycerides, free fatty acids, and ketones were measured every 15 to 30 minutes before a standardized breakfast and for 150 minutes after the breakfast. Patients with insulin-dependent diabetes mellitus were studied while they received their unusual insulin dosages. Fasting glucose levels (87 +/- 7 mg/dl) and glucose levels 150 minutes after the meal (112 +/- 11 mg/dl) were near normal. However, normoglycemia was achieved at the expense of increased plasma insulin levels (area under insulin response curves, p less than 0.01, vs nondiabetic curves). Nevertheless, fasting and post-prandial plasma branched-chain amino acids, alanine, and free fatty acids were similar in both groups. Fasting cholesterol, triglyceride, and ketone levels were also normalized. We conclude that normalization of circulating amino acids and lipids in conjunction with correction of hyperglycemia may contribute to favorable outcomes in infants of intensively treated diabetic mothers.     

A study of fetal macrosomia

We describe the maternal characteristics in pregnancy with fetal macrosomia, fetal and maternal complications related to macrosomia, and the risk of impaired glucose tolerance. The study is based on a comparison of maternal and neonatal data in 956 cases of fetal macrosomia (birthweight > or =4000 g) in non-diabetic pregnancy with data in a control group of 6407 mothers with non-macrosomic infants (birthweight 3000-3999 g). The main factors investigated were maternal age, weight, parity, gestosis rate, maternal and fetal birth injuries, maternal oral glucose tolerance test results and umbilical blood insulin levels. Macrosomic infants occurred in 9.1% of all deliveries. Mothers delivering macrosomic infants were significantly older, of higher parity and of greater weight than mothers of the control group. Fetal macrosomia was associated with a higher frequency of gestosis, operative deliveries, birth injuries and postpartum haemorrhages. 26.2% of the mothers had abnormal of oGTT results. The macrosomic infants were more often male and had a significantly higher risk of shoulder dystocia and birth injuries. No essential differences could be observed in the Apgar-scores and umbilical artery pH values. 34% of macrosomic infants had higher insulin levels in umbilical blood.     

Early neonatal predictors of neonatal hypocalcemia in infants of diabetic mothers: an epidemiologic study

Prematurity, neonatal asphyxia, hypomagnesemia, and advanced maternal diabetes are traditional risk factors for hypocalcemia in infants of diabetic mothers (IDMs). The aim of this study was to determine the relative contribution of these factors separately and combined in a cohort of diabetic pregnancies managed prospectively in the recent 9 years and to find accurate predictors of neonatal hypocalcemia in infants of diabetic mothers. We hypothesized that these factors plus low cord blood calcium (Ca) concentration allow prediction of IDMs who develop neonatal hypocalcemia. We studied 186 IDMs (White class B-RT); gestational age (GA, weeks) was by last menstrual period, confirmed +/- 2 weeks by Ballard score. The goals of glycemic control were: preprandial blood glucose less than 100 mg/dl and 90-minute postprandial blood glucose less than 140 mg/dl. Apgar scores, and cord, 24-, 48- and 72-hour serum calcium (Ca) (mg/dl) and magnesium (Mg; mg/dl) were determined. In univariate analysis, lowest serum Ca correlated with cord blood Ca (r = 0.48, p less than 0.001), GA (r = 0.37, p less than 0.001), and 1-minute Apgar score (r = 0.18, p = 0.09), but did not correlate with cord Mg or with advanced White class. In multiple regression, cord Ca and GA were dominant effects and other variables became insignificant. Lowest Ca (mg/dl) was predicted as follows: lowest Ca = 34.05 - 3.22 (Ca cord) - 0.84 (GA) + 0.10 (GA) (Ca cord). This equation predicts neonatal hypocalcemia (lowest Ca less than 8 mg/dl) with a sensitivity of 72% and a specificity of 75%. Thus, GA and cord Ca allow determination of IDMs at risk for neonatal hypocalcemia.     

The effect of third-trimester glycemic control on maternal and perinatal morbidities in pregestational diabetes mellitus.

From May 1974 to March 1989, 48 cases of pregestational diabetes mellitus treated during the third trimester of pregnancy at the Obstetric Clinic of the National Taiwan University Hospital had complete maternal-fetal chart, and were enrolled into this retrospective review. Of these cases, 28 were class B, 13 were class C and seven were class D-R. The maternal complications and perinatal morbidities of each class were reviewed. The mean fasting, postprandial plasma glucose concentrations and the mean excursion of plasma glucose levels were calculated for statistical analysis. Among the maternal complications, urinary tract infections and preterm labor were significantly associated with mean fasting plasma glucose concentrations. Among perinatal morbidities, neonatal respiratory distress and metabolic problems (including neonatal hyperbilirubinemia, symptomatic hypoglycemia, hypocalcemia and polycythemia) were significantly associated with mean plasma fasting glucose concentrations, and perinatal asphyxia was associated with a mean excursion of plasma glucose levels. In view of the paucity of knowledge about the etiology of complications in diabetic pregnancies, it is necessary to conduct a prospective multi-center study with well-characterized morbidities to search for the role of glycemic control in obstetric and perinatal complications.     

A population-based study of maternal and perinatal outcome in patients with gestational diabetes

A prospective population-based study of gestational diabetes mellitus was done with 2272 patients to determine perinatal and maternal outcomes. A large data base was collected on all patients. Patients with gestational diabetes mellitus were older, shorter, heavier, and had more children than did the control group. The higher cesarean section rate in the patients with gestational diabetes mellitus was explained by their increased rate of repeat cesarean section compared with control patients. This was associated with increased infectious complications. Other maternal complication rates were similar in the two groups. Acceptable glucose control did not normalize birth weight percentiles in patients with gestational diabetes mellitus. Maternal weight at delivery was the only significant predictor of birth weight percentile in the group with gestational diabetes mellitus. Plasma glucose levels were a poor predictor of birth weight percentile. Factors associated with maternal obesity in well-controlled gestational diabetes mellitus may be more significant than glucose control in the development of large-for-gestational-age infants.     

Insulin and glyburide therapy: dosage, severity level of gestational diabetes, and pregnancy outcome

OBJECTIVE: We sought to investigate the association between glyburide dose, degree of severity in gestational diabetes mellitus (GDM), level of glycemic control, and pregnancy outcome in insulin- and glyburide-treated patients. STUDY DESIGN: In a secondary analysis of our previous randomized study, 404 women were analyzed. The association among glyburide dose, severity of GDM, and selected maternal and neonatal factors was evaluated. Severity levels of GDM were stratified by fasting plasma glucose (FPG) from the oral glucose tolerance test (OGTT). Infants with birth weight at or above the 90th percentile were considered large-for-gestational age (LGA). Macrosomia was defined as birth weight > or =4000 g. Well-controlled was defined as mean blood glucose < or =95 mg/dL. The association between glyburide- and insulin-treated patients by severity of GDM and neonatal outcome was evaluated. RESULTS: The dose received for the glyburide-treated patients was 2.5 mg-32%; 5 mg-23%; 10 mg-17%; 15 mg-8%; and 20 mg-20%. Patients were grouped into low (< or =10 mg) and high (>10 mg) daily dose of glyburide. A comparison between severity of the disease (fasting plasma glucose categories) and highest dose of glyburide revealed a significant difference between the low-95 FPG and the other severity categories (P = .02). Of patients in the well-controlled glycemic group, only 6% required the high dose of glyburide (>10 mg). In patients with poor glycemic control (mean blood glucose >95 mg/dL), 38% received the high dose of glyburide (P = .0001). Comparison between the high glyburide (>10 mg) and the low glyburide dosages (< or =10 mg) revealed that the rate of macrosomia was 16% vs 5% and LGA 22% vs 8%, (P = .01), respectively. No significant difference was found in composite outcome, metabolic complications, and Ponderal Index between the 2 dose groups. Stratification by disease severity revealed a significantly lower rate of LGA for both the glyburide- and insulin-treated subjects. No significant difference was found between metabolic, respiratory, and neonatal intensive care unit (NICU) for patients within each fasting plasma glucose severity category. CONCLUSION: Glyburide and insulin are equally efficient for treatment of GDM in all levels of disease severity. Achieving the established level of glycemic control, not the mode of pharmacologic therapy, is the key to improving the outcome in GDM.