Fetal size and growth velocity in the prediction of the large for gestational age (LGA) infant in a glucose impaired population

OBJECTIVES: To evaluate the performances of estimated fetal weight (EFW) and fetal growth velocity (FGV) in the prediction of birth weight>95th centile amongst women with impaired glucose tolerance (IGT); the prediction of neonatal hypoglycaemia was a secondary endpoint. STUDY DESIGN: Two hundred and forty-two consecutive women (61 type 1 diabetes mellitus, 14 type 2 diabetes mellitus, 49 gestational diabetics and 118 with impaired glucose tolerance) receiving routine care at the combined diabetes/antenatal clinic, Jessop Hospital for Women, Sheffield. EFW was routinely calculated at approximately two-week intervals in the third trimester with the last EFW prior to delivery used in the analysis. FGV was calculated from two estimates of fetal weight between 21 and 35 days apart. EFW and FGV were both expressed as standard deviation (Z) scores. RESULTS: The mean gestational age at delivery was 37 weeks (range 26-40 weeks). Sixty-five (27%) infants were of birth weight>95th centile. Mean EFW Z scores were 2.7 and 0.99 for >95th and <95th centile, respectively (p<0.001). Receiver operator characteristics (ROC) curve analysis gave area under the curve 0.8; using a cut-off Z score of 1.7 (=95.5 centile), EFW has sensitivity 80% and specificity 72% in predicting an LGA neonate (likelihood ratios 2.8 and 0.27 for positive and negative test). Mean FGV Z scores were 0.85 and 0.4 for >95th and <95th centile, respectively (p>0.05); ROC curve analysis indicated no discriminatory capacity. Estimates of fetal size and growth performed poorly in the prediction of neonatal hypoglycaemia. CONCLUSION: In routine clinical practice, EFW has limited utility in the prediction of the LGA infant. FGV does not identify the LGA infant. EFW and FGV do not predict neonatal hypoglycaemia.     

Is abnormal glucose metabolism during pregnancy related to endothelial dysfunction?

Objective: Endothelial dysfunction is an independent risk factor for cardiovascular events. We aimed to investigate the relationship between endothelial dysfunction and gestational diabetes mellitus and impaired glucose tolerance.

Methods: Pregnant women who had impaired glucose metabolism in the 75-g oral glucose tolerance test (OGTT) and their age- and body mass index-matched controls were included in the study and assessed for flow-mediated vasodilatation to evaluate endothelial dysfunction.

Results: A total of 51 patients participated in the study. There were 20 patients in the control group, 13 in the impaired glucose tolerance group and 18 in the gestational diabetes mellitus group. Flow-mediated vasodilatation measured at the 60th and 120th seconds were significantly lower in the impaired glucose tolerance and gestational diabetes mellitus groups than in the control group (8.5?±?5.7 and 8.9?±?6.5 versus 14.9?±?9.0, p?=?0.022 and 6.2?±?6.7 and 5.2?±?5.0 versus 12.0?±?8.3, p?=?0.011, respectively).

Conclusions: Patients with gestational diabetes mellitus and impaired glucose tolerance have impaired endothelial dysfunction. Delivery might have protective effects on endothelial functions. The significance of impaired endothelial dysfunction for pregnant women must be investigated, and if needed, lifestyle changes might be suggested, according to the determined importance of the endothelial dysfunction.     

Evaluation of body composition of large-for-gestational-age infants of women with gestational diabetes mellitus compared with women with normal glucose tolerance levels

OBJECTIVE: The purpose of this study was to determine whether there is a difference in body composition and the factors that are associated with fat mass in the large-for-gestational-age infants of women with gestational diabetes mellitus compared with the large-for-gestational-age infants of women with normal glucose tolerance levels. STUDY DESIGN: Large for gestational age was defined as weight >90th percentile for gestational age, race, and sex on the basis of our population's normative data. Anthropometric measurements and/or total body electrical conductivity estimated body composition that included fat mass, percent body fat, and lean body mass were obtained. Multiple stepwise regression was used to determine factors correlating with fat mass. RESULTS: Fifty cases of women with gestational diabetes mellitus and 52 cases of women with normal glucose tolerance levels were evaluated. Infants of mothers with gestational diabetes mellitus had increased fat mass (662 vs 563 g; P = .02) and percent body fat (16.2% vs 13.5%; P = .002) but decreased lean body mass (3400 vs 3557 g; P = .0009), as compared with infants of mothers with normal glucose tolerance levels, despite similar birth weights. Stepwise regression on all 102 women showed gestational age and a diagnosis of gestational diabetes mellitus correlated with fat mass (r2 = 0.11; P = .001). For gestational diabetes mellitus alone, both gestational age and fasting value of the oral glucose tolerance test correlated with fat mass and percent body fat (r2 = 0.33 [P = .0009] and r2 = 0.26 [P = .005], respectively). CONCLUSION: Large-for-gestational-age infants of mothers with gestational diabetes mellitus have increased fat mass and decreased lean body mass compared with infants of mothers with normal glucose tolerance levels. In gestational diabetes mellitus, gestational age and fasting value of the oral glucose tolerance test correlated best with fat mass.     

Glycosylated hemoglobin (HbA1), glucose tolerance and neonatal outcome in gestational diabetic and non-diabetic mothers

Glycosylated hemoglobin (HbA1) was determined in three subject groups: 69 non-diabetic mothers who were delivered of normal weight infants at term (Group I), 33 non-diabetic mothers who were delivered of macrosomic infants (greater than 4000 g) at term (Group II), 51 gestational diabetics in the 3rd trimester--before onset of the diabetes therapy (Group III). In all three groups diagnostic assessment of glucose regulation was done by means of the oral glucose tolerance test during the 3rd trimester. Glycosylated hemoglobin was assayed by cation-exchange chromatography in small disposable columns. The mean values and standard deviations of HbA1 were 6.51 +/- 0.46% in Group I, 6.59 +/- 0.42% in Group II and 7.11 +/- 0.56% in Group III. Between the HbA1 values of Group III (gestational diabetes) on the one hand and those of the non-diabetic groups I and II on the other, there were highly significant differences (p less than 0.001; x2-test). HbA1 values above 7.4%--i.e. above mean + 2 s. d. of HbA1 in the non-diabetic mothers--were with 95% probability abnormal and indicative of gestational diabetes. HbA1 values between 7.0% and 7.4% were suspected of impaired glucose tolerance and gestational diabetes respectively. Between the HbA1 levels in the non-diabetic groups and those in the gestational diabetic group there was a vast zone with overlapping values. HbA1 data situated in this transitional area could be found both in non-diabetic subjects and also in those with abnormal glucose regulation. HbA1 values below 6.0% excluded gestational diabetes or otherwise impaired glucose tolerance with a high degree of probability.     

Increased nuchal translucency with normal karyotype

Nuchal translucency (NT) measurement in first trimester screening between 11 and 14 weeks' gestation has now been clearly identified as a marker for aneuploidies and in particular for trisomy 21. Even in the absence of aneuploidy increased fetal nuchal translucency has been shown to be a marker for fetal heart malformations and numerous other fetal defects and genetic syndromes when the measure is>or=95th centile which is around 3,5 mm for each gestational age. Fetuses with NT thickness above the 99th centile and normal karyotype have a high risk of adverse prenatal outcome and this increase in risk is exponential as the nuchal translucency measurement increases. However, among children born alive with normal ultrasound at 22 weeks of gestation, there was no significant association between NT thickness and development at 2 years as assessed by clinical examination and ASQ scores, when with a control population. Counselling should emphasize that when the karyotype is normal and no fetal structural malformation was missed prenatally following resolution of nuchal thickening, the prognosis is not impaired at the age of 2.     

Amniotic Fluid Insulin Values in Women with Gestational Diabetes as a Predictor of Emerging Diabetes Mellitus

Summary: Amniotic fluid insulin levels were estimated in 30 women with insulin-dependent diabetes, 216 with gestational diabetes and 27 with normal glucose tolerance. Results were correlated with birth-weight, incidences of fetal macrosomia and neonatal hypoglycaemia, and the risk of the mothers with gestational diabetes developing diabetes mellitus on follow-up.
The women with prepregnaney diabetes had significantly higher amniotic fluid insulin values and showed a significant correlation between raised liquor insulin values (>97th percentile) and hypoglycaemia in the infant (p = 0.039).
In the gestational diabetic pregnancies there were highly significant associations between elevated liquor insulin values and macrosomia (p <0.0045) and birth-weight (p <0.00004), and a weak correlation with neonatal blood glucose levels (p = 0.042).
Women with gestational diabetes who later developed permanent diabetes mellitus had higher mean amniotic fluid insulin levels than those whose glucose tolerance remained normal on follow-up (p ≤0.0072) and more of them had a level greater than the 97th percentile than those whose glucose tolerance remained normal (odds ratio 6.48, 95% confidence interval 1.51–27.8, p = 0.0094). However a high amniotic fluid insulin level was of less clinical value for detection of women destined to develop diabetes (7 of 25, 28%) than was the need for insulin therapy during pregnancy (18 of 39, 46%) .     

Abnormal glucose screening tests in pregnancy: a risk factor for fetal macrosomia

Of 2276 patients who underwent screening for gestational diabetes mellitus, 1854 (81.5%) had normal glucose screening tests after a 50-g carbohydrate load (serum glucose below 135 mg/dL). Three hundred fifty-seven patients (15.7%) had abnormal glucose screening tests and went on to complete three-hour glucose tolerance tests, of whom 176 (48.7%) were shown to be nondiabetic when further tested using a carbohydrate-loaded, 100-g glucose, three-hour glucose tolerance test. The 176 women with abnormal glucose screens but normal glucose tolerance tests were compared with the 1854 who had normal screening values. The frequency of infants weighing more than 4000 g (greater than 95th percentile at our institution) was 11.9% in the study group and 6.4% in the control group (P = .0086). When the data were corrected for other macrosomia risk factors (advanced age, high parity, obesity, white race, and prolonged gestation), there was still a significantly higher frequency of macrosomia in the study group; this fact suggests that patients with minor abnormalities of carbohydrate metabolism during pregnancy are at risk for delivering a macrosomic infant.     

孕妇血清瘦素水平测定对妊娠期糖耐量异常的预测价值

目的　探讨孕妇血清瘦素水平测定对妊娠期糖耐量异常有无预测价值。方法　采用葡萄糖负荷试验法对 583例孕妇行妊娠期糖尿病筛查,根据筛查结果分为糖耐量正常组及糖耐量异常组(包括妊娠期糖耐量低减和妊娠期糖尿病)孕妇。同时检测两组孕妇不同孕周的血清瘦素水平。结果　(1)糖耐量正常组 507例孕妇血清瘦素水平由孕 24周的 (7.0±1.8)μg/L逐渐缓慢上升,至孕 34~35周时上升最为明显,形成峰值为(9.4±2.1)μg/L,之后略有下降。(2)糖耐量异常组 76例(妊娠期糖耐量低减 61例、妊娠期糖尿病 15例 )孕妇血清瘦素水平波动在 ( 11.3±3.1 )μg/L至(14.5±4.3)μg/L之间,不同孕周间的血清瘦素水平比较,差异无统计学意义 (P>0.05)。(3)糖耐量异常组孕妇平均血清瘦素水平为(12.5±3.5)μg/L,显著高于糖耐量正常组的 (8.5±2.6 )μg/L,且在任何孕周,糖耐量异常组孕妇血清瘦素水平均比糖耐量正常组显著升高,两组比较,差异有统计学意义(P<0.05)。(4) 15例妊娠期糖尿病孕妇中,有 10例血清瘦素水平超过 14.0μg/L。当瘦素水平≥17.0μg/L时, 64.7%的孕妇有不同程度的糖耐量异常。瘦素水平与妊娠期糖耐量低减和妊娠期糖尿病的患病率呈正相关。结论　血清瘦素水平与妊娠期糖耐量异常有相关性, 血清瘦素水平升高对妊娠期     

The significance of one abnormal glucose tolerance test value on adverse outcome in pregnancy

A matched control study of 126 women equally divided into three groups (normal oral glucose tolerance test, one abnormal test value, and gestational diabetes mellitus) was undertaken to examine the relationships among oral glucose tolerance test results, glycemic control in pregnancy, and adverse perinatal outcome. Characterization of metabolic control for the one abnormal oral glucose tolerance test value and the gestational diabetes mellitus groups (before treatment) showed no significant difference. After the start of treatment, however, a significant (p less than 0.01) difference between the groups in level of control was found. While no significant difference in the average birth weight between the three groups was discovered, the incidence of large infants (macrosomia and large for gestational age) was found to be significantly higher in the one abnormal oral glucose tolerance test group when compared with the normal (34% versus 9%; p less than 0.01) and gestational diabetes mellitus group (34% versus 12%; p less than 0.01). No significant difference for the incidence of an infant large for gestational age was found between the normal group and the patients with gestational diabetes mellitus after treatment. Neonatal metabolic disorders were found to be significantly higher for the one abnormal oral glucose tolerance test group (15%) when compared with the control and the gestational diabetes mellitus groups (3%). We conclude that, if left untreated, one abnormal value on an oral glucose tolerance test is strongly associated with adverse perinatal outcome.     

Increased fetal adiposity: a very sensitive marker of abnormal in utero development

OBJECTIVE: Because offspring of women with gestational diabetes mellitus have an increased risk of obesity and diabetes mellitus as young adults, our purpose was to characterize body composition at birth in infants of women with gestational diabetes mellitus and normal glucose tolerance. STUDY DESIGN: One hundred ninety-five infants of women with gestational diabetes mellitus and 220 infants of women with normal glucose tolerance had anthropometric measurements and total body electrical conductivity body composition evaluations at birth. Parental demographic, anthropometric, medical and family history data, and diagnostic glucose values were used to develop a stepwise regression model that related to fetal growth and body composition. RESULTS: There was no significant difference in birth weight (gestational diabetes mellitus [3398+/-550 g] vs normal glucose tolerance [3337+/-549 g], P=.26) or fat-free mass (gestational diabetes mellitus [2962+/-405 g] vs normal glucose tolerance [2975+/-408 g], P=.74) between groups. However, infants of women with gestational diabetes mellitus had significantly greater skinfold measures (P=.0001) and fat mass (gestational diabetes mellitus [436+/-206 g] vs normal glucose tolerance [362+/-198 g], P=.0002) compared with infants of women with normal glucose tolerance. In the gestational diabetes mellitus group, although gestational age had the strongest correlation with birth weight and fat-free mass, fasting glucose level had the strongest correlation with neonatal adiposity. CONCLUSION: Infants of women with gestational diabetes mellitus, even when they are average weight for gestational age, have increased body fat compared with infants of women with normal glucose tolerance. Maternal fasting glucose level was the strongest predictor of fat mass in infants of women with gestational diabetes mellitus. This increase in body fat may be a significant risk factor for obesity in early childhood and possibly in later life.     

Plasminogen activator inhibitor 1 gene polymorphism and gestational diabetes mellitus

OBJECTIVE: Plasminogen activator inhibitor 1 is thought to play a role in the pathogenesis of obesity and insulin resistance. Therefore, we examined a single nucleotide exchange in this gene in women with gestational diabetes mellitus. METHODS: A total of 887 unselected women were prospectively screened for gestational diabetes mellitus by oral glucose testing between the 24th and 28th weeks of gestation. Eighty white women of this collective, 40 patients with a pathological oral glucose tolerance test and 40 normal control subjects, were randomly selected. DNA samples were isolated from the sera and analyzed for the functional -675 4G/5G promotor polymorphisms of the plasminogen activator inhibitor 1 gene. RESULTS: Women with gestational diabetes mellitus were significantly older and had a significantly higher body mass index (BMI) than those who did not have gestational diabetes mellitus. Women with normal glucose tolerance were significantly more often homozygous for the 5G allele (P = .01), independently of maternal age or BMI. Low fasting glucose values in the oral glucose tolerance test were significantly related to homozygosity for 5G (P = .02). CONCLUSION: Homozygosity for the 5G allele of the plasminogen activator inhibitor 1 gene is associated with normal glucose tolerance in pregnant women. These findings further support a possible role of plasminogen activator inhibitor in the development of gestational diabetes mellitus. LEVEL OF EVIDENCE: II-2.     

Occurrence of gestational diabetes mellitus and the value of different screening indicators for the oral glucose tolerance test

BACKGROUND: The objective of the present study was to determine prevalence of gestational diabetes mellitus (GDM) in terms of impaired glucose tolerance (IGT) and diabetes mellitus (DM), and the value of traditional anamnestic risk factors for predicting outcome of the oral glucose tolerance test (OGTT). METHODS: A prospective population-based study in a defined geographic area in Sweden. All pregnant nondiabetic women (n = 4918) attending maternal health care from July 1994 to June 1996 were offered a 75g OGTT in gestational weeks 28-32. Traditional anamnestic risk factors, as well as results of the OGTT in terms of fasting-B-glucose and 2h-B-glucose, were registered. RESULTS: 3616 (73.5%) women agreed to perform the OGTT. Sixty-one (1.7%) of those had GDM [47 (1.3%) had impaired glucose tolerance and 14 (0.4%) had diabetes mellitus]. 15.8% fulfilled traditional risk factor criteria. Traditional anamnestic risk factors as an indicator to perform an OGTT identified 29/61 GDM women and 9/14 women with DM. Among primiparas, 4/21 with gestational diabetes mellitus were detected. CONCLUSION: Using traditional risk factors as an indicator to perform an OGTT gives a low sensitivity to detect GDM and even DM especially among primiparas.     

Risk factors for pre-eclampsia in pregnant Chinese women with abnormal glucose metabolism.

OBJECTIVES: To investigate the incidence and risk factors for pre-eclampsia in pregnant Chinese women with abnormal glucose metabolism. METHODS: A retrospective cohort study was performed on 1499 pregnant women with abnormal glucose metabolism at Peking University First Hospital from January 1995 to December 2004. RESULTS: The overall prevalence of pre-eclampsia in women with abnormal glucose metabolism was 9.4% (141/1499). The prevalence of pre-eclampsia in women diagnosed with diabetes mellitus prior to pregnancy was higher than that of gestational diabetes mellitus and gestational impaired glucose tolerance patients (29.1% vs 8.7% and 7.8%, P<0.01). Pre-pregnancy body mass index was significantly higher in women with pre-eclampsia than in those without. A higher rate of pre-eclampsia was found in women with chronic hypertension and those with poor glucose control. The independent risk factors for pre-eclampsia were chronic hypertension and elevated pre-pregnancy body mass index. CONCLUSIONS: The type of diabetes, chronic hypertension, and elevated pre-pregnancy body mass index are high risk factors for pre-eclampsia in pregnant women with abnormal glucose metabolism.     

Excessive Birth Weight and Maternal Glucose Tolerance A 19-year Review

The incidence of birth-weight of 4,540 g (10 lb) or more rose from 0.87% in the years 1971 to 1977 to 1.16% in the 12 years from 1978 to 1989 with a concomitant increase in hyperglycaemia in our antenatal population. The relationship between excessive birth-weight and maternal glucose tolerance was investigated in the light of these observations. The results from glucose tolerance tests performed routinely during the pregnancies of 510 women who delivered infants with a birth-weight of 4,540 g or more were compared with those from a control series of 5,003 women with consecutively tested pregnancies. Glucose tolerance in subsequent pregnancies was also compared with the control series, and in 1991 the study group women were investigated for emergence of permanent diabetes mellitus. Excessive birth-weight was associated with maternal hyperglycaemia (p < 0.05) but not with gestational diabetes; 79% of infants with birth-weight > or = 4,540 g were born to mothers who were not hyperglycaemic. There was no increase in glucose intolerance in subsequent pregnancies in the study group and only 2 of 49 women with follow-up testing had diabetes mellitus. Birth-weight > or = 4,540 g occurred in 1.1% of the total population and 1.1% of women with gestational diabetes, and was related to maternal hyperglycaemia in about 1 in 5 cases. The increased incidence of excessive birth-weight infants was not related to the increased incidence of gestational diabetes in our pregnant population. Birth-weight > or = 4,540 g had a poor association with later development of diabetes.     

Clinical impact of mild carbohydrate intolerance in pregnancy: a study of 2904 nondiabetic Danish women with risk factors for gestational diabetes mellitus

OBJECTIVE: The objective was to study the clinical impact of mild carbohydrate intolerance in pregnant women with risk factors for gestational diabetes mellitus. STUDY DESIGN: This was a historical cohort study of 2904 pregnant women examined for gestational diabetes on the basis of risk factors. Information on oral glucose tolerance test results and clinical outcomes was collected from laboratory charts and medical records. RESULTS: The following outcomes increased significantly with increasing glucose values during the oral glucose tolerance test: shoulder dystocia, macrosomia, emergency cesarean section, assisted delivery, hypertension, and induction of labor. However, when corrections were made for other risk factors, hypertension and induction of labor were only marginally associated with glucose levels. CONCLUSION: In a group of nondiabetic pregnant women with risk factors for gestational diabetes, there was a graded increase in the frequency of shoulder dystocia and other maternal-fetal complications with increasing glucose levels during an oral glucose tolerance test.     

First trimester sonographic detection of chromosomal abnormalities in an unselected population

Objective To investigate the role of first trimester sonography in detecting chromosomal abnormalities in an unselected obstetric population.
Methods 2281 women (mean maternal age 30 years [range 16-47]; mean gestational age 12⁺³ weeks [range 11-14]) underwent transabdominal scanning to assess fetal structure and, if anatomical survey was considered to be incomplete (31% of cases), transvaginal sonography was also performed. Measurement of nuchal translucency was included and karyotyping performed as considered appropriate.
Results There were 16 chromosomal abnormalities; 13 (81%) were diagnosed at 11-14 weeks either because of a nuchal translucency greater than or equal to the 99th centile for gestational age (7/16; 44% [95% CI 25-63]) or due to the presence of structural abnormalities (6/16; 38% [95%CI 14.2–61.81). Seventy-five percent of cases of trisomy 21 were also diagnosed either because of having a nuchal translucency greater than or equal to the 99th centile (5/8; 63%) or due to the presence of a structural abnormality (1/8; 13%).
Conclusions A significant proportion of fetal chromosomal abnormalities can be detected by first trimester sonographic screening to assess fetal structural appearance. The sensitivity of detection can be improved by combining measurement of nuchal translucency with detailed examination of fetal anatomy.     

Oral glucose tolerance test is a poor predictor of hyperglycemia during pregnancy

In an effort to assess the efficacy of the oral glucose tolerance test to detect patients with gestational diabetes mellitus who require therapeutic measures to maintain normoglycemia, we compared the results of an oral glucose tolerance test with those of a home glucose profile consisting of three postprandial glucose values in 250 pregnant women. The OGTT overestimated the occurrence of hyperglycemia by 28%, while the home glucose profile underestimated the occurrence of hyperglycemia by 5%. Pregnancy outcome was not significantly different between spontaneously normoglycemic women and those who required therapy. One cannot effectively identify the ten percent largest infants in the population by screening for gestational diabetes.     

A trial of simple versus intensified dietary modification for prevention of progression to diabetes mellitus in women with impaired glucose tolerance

Women with impaired glucose tolerance are at high risk of developing noninsulin dependent diabetes mellitus (NIDDM). The Mercy Hospital for Women has a long-term follow-up programme for women with gestational diabetes, which identifies many women with impaired glucose tolerance. Two hundred of these women were entered into a randomized controlled trial of intensive versus routine dietary advice. Seven women were lost to follow-up. The annual incidence rates of diabetes mellitus for the 2 groups were 6.1% (intervention) and 7.3% (control), an incident rate ratio of 0.83, 95% confidence interval 0.47-1.48, p = 0.50. Overall, there was a return to normal glucose tolerance in 44% of patients. Multivariate analysis showed that body mass index, fasting and 2-hour plasma glucose levels at trial entry were significantly associated with an increased risk of diabetes mellitus. Impaired glucose tolerance is an important condition that should be treated with advice about lifestyle modification (diet and/or exercise). We consider that future trials in the management of women with previous gestational diabetes who have impaired glucose tolerance should investigate the effect of pharmacological intervention in addition to diet and/or exercise, the latter providing a therapy that it would be unethical to exclude on the evidence presently available.     

Circulating levels of MCP-1 are increased in women with gestational diabetes

OBJECTIVE: We investigated whether gestational diabetes mellitus is associated with monocyte-chemoattractant-protein-1 (MCP-1) and soluble CD40 ligand (sCD40L), the functional relevant proteins in the inflammatory process. METHODS: In all 32 women with gestational diabetes mellitus, 18 women without gestational diabetes mellitus and 40 nonpregnant women were included. MCP-1 and sCD40L were measured at the time of the oral glucose tolerance test (second trimester), in the third trimester and postpartum. RESULTS: MCP-1 was higher in pregnant women (women with gestational diabetes mellitus and without) than in nonpregnant women (p < 0.001) in the third trimester, and also in the second trimester and postpartum. MCP-1 was elevated in patients with gestational diabetes mellitus in the third trimester compared to healthy pregnant women (p = 0.007). In gestational diabetes mellitus, MCP-1 increased from the second to the third trimester (p = 0.003). We found no association of sCD40L and gestational diabetes mellitus. CONCLUSION: The elevation of MCP-1 in the third trimester in gestational diabetes mellitus suggests an association between inflammation and GDM. Copyright (c) 2008 John Wiley & Sons, Ltd.     

Clinical predictors for a high risk for the development of diabetes mellitus in the early puerperium in women with recent gestational diabetes mellitus

OBJECTIVE: The purpose of this study was to identify which maternal, antepartum, or neonatal clinical parameters were predictive for a high risk of diabetes mellitus in the puerperium in women with recent gestational diabetes mellitus and to calculate the associated diabetes mellitus rates and odds ratios. STUDY DESIGN: One thousand six hundred thirty-six women underwent an oral glucose tolerance test within 1 to 4 months of delivery. Demographic, historic, and antenatal glycemic parameters and neonatal outcome parameters were tested by univariate and multivariate logistic regression for risk of postpartum diabetes mellitus. Continuous variables were divided into quartiles that compared the upper to lower quartile adjusted odds ratio and prevalence of diabetes mellitus. RESULTS: Postpartum diabetes mellitus was diagnosed in 230 women (14.1%) according to the American Diabetes Association criteria (1997). No maternal demographic or neonatal parameters were significantly associated with diabetes mellitus. The final model of independent predictors in decreasing significance included the highest fasting plasma glucose level during pregnancy, any fasting plasma glucose level of > or = 105 mg/dL (class A(2)), the area under the curve of pregnancy oral glucose tolerance test, gestational age at diagnosis, previous gestational diabetes mellitus history, and 50-g glucose challenge test results. The fasting plasma glucose level was the best discriminator, with a 21-fold (95% CI, 4.6-96.3) increased odds ratio comparing the 4th quartile (fasting plasma glucose level, >121 mg/dL; diabetes mellitus rate, 36.7%) to 1st quartile (fasting plasma glucose level, < 95 mg/dL; diabetes mellitus rate, 0.5%). The presence of previous gestational diabetes mellitus or current class A(2) gestational diabetes mellitus approximately doubled the odds ratio for diabetes mellitus. The odds ratio increased 3- to 4-fold when the area under the curve was > or = 33.36 min small middle dot g/dL (4th quartile) or the glucose challenge test was > or = 155 mg/dL (2nd-4th quartiles) and decreased > 50% if gestational diabetes mellitus was diagnosed at > 27 weeks (3rd-4th quartile). CONCLUSION: During pregnancy, the highest fasting glucose level, followed by the severity of glucose intolerance, and earlier gestational diabetes mellitus diagnosis were the best predictors for postpartum diabetes mellitus. Diabetic education should begin during pregnancy, especially for women who are identified to be at a high risk when they are highly motivated and under medical care.