Gestational diabetes: impact of home glucose monitoring on neonatal birth weight

Two groups of 58 gestational diabetic women matched for age, prepregnancy weight, height, and parity were studied. The home glucose monitoring study group performed fasting and 1-hour postprandial capillary blood glucose testing after every meal. The control group was followed by conventional treatment. The incidence of macrosomia (birth weight of greater than or equal to 4000 gm) and large (greater than or equal to 90%) for gestational age infants was significantly reduced in the home glucose monitoring group. The mean birth weight of the study group was 3231 +/- 561 gm, while that of the control group was 3597 +/- 721 gm (p less than 0.002). Significantly more patients in the home glucose monitoring group were receiving insulin therapy (50% versus 21%). We believe that intensive home glucose monitoring will allow for the early identification of those gestational diabetic patients needing insulin and thus reduce the incidence of macrosomia and large for gestational age infants.     

Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization

OBJECTIVE: This study was undertaken to compare the use of glyburide with insulin for the treatment of gestational diabetes mellitus (GDM) unresponsive to diet therapy. STUDY DESIGN: A retrospective study was performed among women with singleton pregnancies who had GDM diagnosed, with fasting plasma glucose 140 mg/dL or less on glucose tolerance testing, between 12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified 584 women and compared those treated with insulin between 1999 and 2000 with women treated with glyburide between 2001 and 2002. Maternal and neonatal outcomes and complications were assessed. Statistical methods included univariate analyses and multivariable logistic regression. RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide. The 2 groups were similar with regard to age, nulliparity, and historical GDM risk factors; however, women in the insulin group had a higher mean body mass index (31.9 vs 30.6 kg/m 2 , P=.04), a greater proportion identified themselves as white (43%, 28%, P<.001) and fewer as Asian (24%, 37%, P=.001), and they had a significantly higher mean fasting on glucose tolerance test (105.4 vs 102.4 mg/dL , P=.005) compared with the glyburide group. There were no significant differences in birth weight (3599+/-650 g vs 3661+/-629 g, P=.3), macrosomia (24%, 25%, P=.7), or cesarean delivery (35%, 39 %, P=.4). Women in the glyburide group had a higher incidence of preeclampsia (12%, 6%, P=.02), and neonates in the glyburide group were more likely to receive phototherapy (9%, 5%, P<.05), and less likely to be admitted to the neonatal intensive care unit (NICU) (15%, 24%, P=.008) though they had a longer NICU length of stay (4.3+/-9.6 vs 8.0+/-10.1, P=.002). Posttreatment glycemic control data were available for 122 women treated with insulin and 137 women treated with glyburide. More women in the glyburide group achieved mean fasting and postprandial goals (86%, 63%, P<.001). These findings remained significant in logistic regression analysis. CONCLUSION: In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study.     

Comparison of glyburide and insulin for the management of gestational diabetics with markedly elevated oral glucose challenge test and fasting hyperglycemia.

OBJECTIVE: To compare the effectiveness of glyburide and insulin for the treatment of Gestational diabetes mellitus (GDM) in women who had OGCT >or=200 mg/dl and fasting hyperglycemia. STUDY DESIGN: A retrospective study was performed among a subset of women treated with glyburide or insulin for GDM from 1999 to 2002 with an OGCT >or=200 mg/dl and pretreatment fasting plasma glucose >or=105 mg/dl. Exclusion criteria included pretreatment fasting >or=140 mg/dl, gestational age >or=34 weeks and multiple gestation. Maternal and neonatal outcomes were assessed. Statistical methods included bivariate and multivariable logistic regression analyses. RESULTS: In 1999 to 2000, 78 women were treated with insulin; in 2001 to 2002, 44 of 69 (64%) received glyburide. There were no statistically significant differences between the two groups with regards to mean OGCT (230+/-25 vs 223+/-23 mg/dl, P=0.07) and mean pretreatment fasting (120+/-10 vs 119+/-11 mg/dl, P=0.45). Seven women (16%) failed glyburide. Women in the insulin group were younger (31.5+/-5.8 vs 35.2+/-4.7 years, P<0.001) and had a higher mean BMI (32.4+/-6.4 vs 29.1+/-5.8 kg/m(2), P=0.003) compared to glyburide group. There were no significant differences in birth weight (3524+/-548 vs 3420+/-786 g, P=0.65), macrosomia (19 vs 23%, P=0.65), pre-eclampsia (12 vs 11%, P=0.98) or cesarean delivery (39 vs 46%, P=0.45). Neonates in the glyburide group were diagnosed more frequently with hypoglycemia (34 vs 14%, P=0.01). When controlled for confounders, macrosomia was found to be associated with glyburide treatment (OR 3.5, 95% CI 1.1 to 11.4). CONCLUSION: In women with GDM who had a markedly elevated OGCT and fasting hyperglycemia, glyburide achieved similar birth weights and delivery outcomes but was associated with an increased risk of macrosomia. The possible increased risk of neonatal hypoglycemia in the glyburide group warrants further investigation.     

Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia

Infant macrosomia is a serious medical concern. Pregnant women who do not meet the specific diagnosis for gestational diabetes may still have glucose-mediated macrosomia. In Santa Barbara County all pregnant women are screened for gestational diabetes at 24-28 weeks with a 50-g, 1-hr glucose challenge test (GCT). All patients who fail this test are placed on a standard euglycemic diet (40% carbohydrate, 20% protein, 40% fat) and perform home glucose monitoring of fasting and postprandial glucose levels. The objective of this study was to examine the effectiveness of this treatment program in decreasing infant macrosomia, maternal and infant morbidity, maternal complications, and operative delivery. We studied 103 women who had a positive GCT, but a negative 100-g, 3-hr oral glucose tolerance test (OGTT). The women were randomly assigned to either experimental or control groups with experimental women receiving dietary counseling and home glucose monitoring instruction (HBGM). HBGM diaries were reviewed weekly by clinic nurses. All women had hemoglobin A1c (HbA1c) tests at 28 and 32 weeks. Maternal and fetal charts were reviewed to determine delivery type and complications, indications for cesarean section (C-section), and infant gestational age, gender, Apgar scores, birth weight, morbidities, and congenital anomalies. Of the 103 women, 5 women required insulin treatment, 1 woman had an abortion, and 14 women were indeterminate regarding compliance or were control women who received diet counseling and HBGM. The results are based on 83 women--48 control and 35 experimental. There were no significant differences between the groups for age, parity, or weight at 28-30 weeks or 37 weeks to delivery, or HbA1c at 28 weeks. HbA1c was significantly higher in control women at 32 weeks. Birth weight expressed in grams or as a percentile specific for gender, ethnicity, and gestational age was significantly higher in control infants. Birth weight was significantly correlated with maternal intake weight, weight at 28-30 weeks, and weight at delivery and with HbA1c at 32 weeks' gestation. There were no significant differences between groups for maternal complications. Groups were significantly different for mode of delivery with experimental women having more induced vaginal deliveries but fewer repeat C-sections than control women. Groups were not different for primary C-sections. Women who fail the GCT, but not the OGTT and thus do not receive the diagnosis of GDM are still at risk for delivering a macrosomic infant and operative delivery. Our program of treatment for all women who fail the GCT improves outcome by reducing infant birth weight and the number of cesarean sections.     

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.     

Birth trauma in insulin-dependent diabetic pregnancies.

Infants of insulin-dependent diabetic mothers are considered to be at high risk for birth trauma, presumably due to macrosomia. With current management of diabetes in pregnancy, including strict glycemic control, the rate and the severity of macrosomia should be decreased. The frequent use of ultrasound to assess fetal growth and weight and the use of cesarean delivery in case of fetal macrosomia should further decrease the risk for birth trauma in these infants. We therefore undertook this study to test the null hypothesis that with current management, insulin-dependent diabetic mothers have a rate of birth trauma similar to that of infants of nondiabetic mothers (normal glucose challenge test at 28 weeks' gestation) matched for gestational age at birth, presence or absence of labor, delivery method (vaginal versus cesarean), and race. We studied 118 insulin-dependent diabetic mothers (White classes B-RT) and 354 control subjects (three matches for each insulin-dependent diabetic mother). The rate of birth trauma was 3.4% in insulin-dependent diabetic mothers, not significantly different from controls (2.5%). Logistic regression analysis in which birth trauma was the dependent variable and diabetes, race, presence or absence of labor, mode of delivery (vaginal versus cesarean), infant weight, and infant head circumference were independent variables revealed that only vaginal delivery was a significant risk factor for birth trauma in infants in both groups (p = 0.01). Most frequently observed birth traumas were brachial plexus injury, facial nerve injury, and cephalohematoma. Of the three infants with brachial plexus injury (insulin-dependent diabetic mothers, two; controls, one), two were delivered with use of midforceps.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prophylactic insulin in gestational diabetes

Patients with gestational diabetes were divided into two groups according to the results of three-hour oral glucose tolerance tests. Those with fasting euglycemia (serum glucose 95 mg/dL or lower) on oral glucose tolerance test (class A) were treated with diet alone, whereas those with fasting hyperglycemia on oral glucose tolerance test (class A/B) were treated with both diet and insulin (15 U neutral protamine Hagedorn insulin before breakfast). The frequency of macrosomia (birth weight more than 4000 g) among class A/B gestational diabetics was 16.2%, which was significantly greater than the 5.6% incidence in class A diabetics and the 6.4% incidence in controls. After controlling for potential confounding risk factors, it was determined that class A diabetics had a frequency of macrosomia no different from that of nondiabetics. Nonobese gestational diabetics with fasting hyperglycemia (class A/Bs), who were treated with diet and prophylactic insulin, also had a frequency of macrosomia no different from that of nondiabetics or class A diabetics. However, the diet and insulin regimen did not prevent excess macrosomia in class A/B diabetics who were obese.     

Macrosomia in well controlled CSII treated Type I diabetic pregnancy

Objective. To survey the effect of tight glycemic control by insulin pumps, of pre-gestational Type 1 diabetic women on pregnancy outcome.

Methods. Twelve consecutive Type 1, insulin pump treated, diabetic patients followed in the high risk maternal – fetal clinic were ascertained. Data regarding glucose control was assessed and correlated with pregnancy outcome.

Results. A total of 14 deliveries (10 singleton) were assessed. There were no miscarriages, one baby that was born with a ventricular septal defect (VSD). Glycemic control was within the acceptable guidelines. HbA1c (%) by trimesters: 6.5 ± 0.9, 5.9 ± 0.7, 5.8 ± 0.6 and average glucose (mg/dL) 121.0 ± 15.2, 114.8 ± 13.2, 116.0 ± 21.1. Average birth weight was 3312.1 ± 750.2 g with five babies (35%) weighting over 4.0 kg at birth. Birth weight was significantly correlated with HbA1c at the first trimester, mean glucose at trimester 1 and 2, and maternal weight at delivery (r = 0.74, p = 0.045; r = 0.72, p = 0.051; r = 0.74, p = 0.046; r = 0.74, p = 0.04, respectively).

Conclusions. Our study of a limited number of patients suggest that women with pre-gestational diabetes obtaining acceptable glycemic goals with insulin pump therapy have increased risk of macrosomia. Current glycemic goals and therapies in treating pre-gestational diabetic patients therefore might not be sufficient to normalise pregnancy outcomes in of women with pre-gestational diabetes.     

Glucose threshold for macrosomia in pregnancy complicated by diabetes

We analyzed 205 diabetic women treated with insulin during pregnancy to assess the effects of several maternal factors on the development of fetal macrosomia. A total of 95 women were selected for study because they had clearly defined gestational criteria, two or more daytime glucose profiles during the third trimester, and no other complications known to affect fetal growth. The incidence of macrosomia was not found to increase significantly until the mean glucose concentration reached 130 mg/dl; macrosomia occurred in 65% of mothers with glucose values greater than or equal to 130 mg/dl compared with 27% in those with lower values. Other factors strongly associated with fetal macrosomia were maternal weight and insulin dosage. Multiple logistic analysis was performed to control for each risk factor and to obtain estimates of the relative risk for macrosomia. The risk of macrosomia was two times greater in women with mean glucose concentrations greater than or equal to 130 mg/dl, approximately threefold in women whose weight exceeded 80 kg, and one and one half times greater in women with insulin dosages more than 80 units/day. We conclude that several maternal factors in addition to glucose concentration play important roles in the development of fetal macrosomia among diabetic women and that the glucose concentration threshold for macrosomia may exceed 130 mg/dl.     

Randomized trial of human versus animal species insulin in diabetic pregnant women: improved glycemic control, not fewer antibodies to insulin, influences birth weight.

OBJECTIVE: Macrosomia occurs in infants of diabetic mothers in spite of "nearly normal maternal blood glucose levels" with insulin treatment. Insulin antibodies may carry bound insulin into the fetal blood and thus may be associated with fetal hyperinsulinemia and macrosomia in these infants. Our objective was to test the hypothesis that human insulin is associated with lower insulin antibody levels and less macrosomia than is animal species insulin. STUDY DESIGN: Forty-three insulin-requiring pregnant (< 20 weeks' gestation) women, previously treated with animal insulin, were randomized to human and animal insulins and studied at weeks 10 through 20, 24, 28, 32, 36, and 38, at delivery, and at 3 months post partum. Infant blood was drawn at delivery (cord) and at 1 day and 3 months post partum 1 hour after a glucose-amino acid challenge. RESULTS: Women receiving human insulin required significantly less insulin per kilogram of body weight and showed significant dampening of glucose excursions (p < 0.05 for each comparison). Infants born to mothers receiving human insulin weighed 2880 +/- 877 gm compared with 3340 +/- 598 gm for infants of women treated with animal insulin (p < 0.05). There was no difference in insulin antibody levels between groups for either mothers or infants. Infants born to mothers receiving human insulin had a 1 hour C-peptide level after the glucose-amino acid challenge at 3 months of age of 0.21 +/- 0.13 pmol/ml compared with 0.32 +/- 0.13 pmol/ml (p = 0.01). CONCLUSION: Administration of human insulin to pregnant diabetic women has a therapeutic advantage over animal insulin, with less maternal hyperglycemia or hypoglycemia, fewer larger-for-gestational-age infants, and less neonatal hyperinsulinemia. Our data do not support the hypothesis that maternal antibodies to insulin influence infant birth weight.     

Perinatal complications in women with gestational diabetes mellitus

BACKGROUND: The aim of the study was to examine the outcome of the pregnancy and neonatal period in 1) women with gestational diabetes mellitus and non-diabetic pregnant women, and 2) in women with early and late diagnosis of gestational diabetes mellitus. METHODS: Included were 327 women with gestational diabetes mellitus and 295 non-diabetic women, who were screened with a 75 g oral glucose tolerance test because of risk factors for gestational diabetes. Women with gestational diabetes mellitus were treated with low-caloric diet and insulin when appropriate, while women in the control group received routine antenatal care. RESULTS: Gestational age at delivery was significantly lower in the group with gestational diabetes mellitus, both when considering all deliveries (39.1+/-1.7 weeks versus 39.8+/-2.0 weeks, p<0.05) and only those with spontaneous onset of labor (38.8+/-2.0 weeks versus 40.0+/-1.6 weeks, p<0.05). The frequency of macrosomia was increased, although not statistically significant (8% vs. 2%, p=0.07), and the rate of admission to the neonatal ward was significantly increased (18% vs. 9%, p<0.05) in the group with gestational diabetes. Women with early diagnosis of gestational diabetes mellitus had a significantly increased need for insulin treatment during pregnancy (36% vs. 9% p<0.05) and a significantly higher occurrence of diabetes mellitus at follow-up from two months until three years postpartum. CONCLUSIONS: This study of women with gestational diabetes mellitus and non-diabetic pregnant women showed that gestational diabetes mellitus was associated with a significantly lower gestational age at delivery and an increased rate of admission to the neonatal ward. Women diagnosed with GDM before 20 weeks of gestation had an increased need for insulin treatment during pregnancy and a high risk of subsequent overt DM, compared with women diagnosed with GDM later in pregnancy.     

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.     

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.     

Maternal obesity is a major risk factor for large-for-gestational-infants in pregnancies complicated by gestational diabetes

Objectives  Our aim was to evaluate the relative contribution of maternal weight, GDM severity and glycemic control in women with gestational diabetes (GDM) on the prevalence of LGA infants. Methods  A total of 233 women with GDM were classified according to the fasting and/or postprandial glucose levels as in “good” or “poor” glycemic control. Severity of GDM was categorized using fasting plasma glucose on the 3-h 100 g oral glucose tolerance test (OGTT). Results  The incidence of LGA infants was significantly higher in obese women than in those with lower BMI. There was no significant correlation between GDM severity or level of glycemic control and birth weight or proportion of LGA infants. On multivariate regression analyses, only maternal weight at delivery and fasting glucose level on OGTT were found to be independently and significantly associated with the birth weight, and only maternal weight at delivery was a significant and independent predictor of LGA infants. Conclusions  Both the GDM severity and maternal weight are independent predictors of infants’ birth weights. Maternal weight at delivery is a major risk factor for LGA infants. The study was presented at the SMFM 27th annual meeting on February, 2007.     

One hour versus two hours postprandial glucose measurement in gestational diabetes: a prospective study.

OBJECTIVE: To compare the rate of adverse perinatal outcomes among women with gestational diabetes mellitus (GDM), monitored by 1 versus 2 hour-postprandial glucose (PPG) measurements. METHODS: A total of 112 women diagnosed with GDM, by the criteria of Carpenter-Coustan, were included in the study population. Women were recruited from two different treatment settings, but were managed by the same team of health-care professionals using a standardized protocol. Allocation to treatment group was based on treatment setting. Glucose levels were measured fasting, and either 1 hour (1-hour monitoring group-target values <140 mg/dl) or 2 hours (2-hour monitoring group-target values <120 mg/dl) postprandially. Demographic data and perinatal outcomes were collected from their medical records. RESULTS: In all, 66 women were assigned to 1-hour monitoring group (1 h-PPG) and 46 women to 2-hour monitoring group (2 h-PPG). There were no differences in parity, family history of diabetes, rate of GDM in previous pregnancies, weight gain, pregestational BMI and 50-g-glucose challenge test (GCT) and 100-g oral glucose challenge test (OGTT) results. As expected, there was a significant difference in mean blood glucose levels between the two groups (108.1+/-19.2 and 94.9+/-21.2 mg/dl, 1- and 2 hours, respectively, p<0.0001); however, HbA1C levels were similar in the two groups. Perinatal outcomes were defined as gestational week at delivery; fetal weight (3325+/-471 vs 3309+/-608 g, respectively) and percentile (47.2+/-27 vs 49.6+/-30, respectively), and were similar for both groups. Insulin therapy was initiated more frequently in 2-hour monitoring group (28 and 40% of women in groups 1 and 2, respectively; p<0.05). Rates of macrosomia (7.5 versus 10.6%), large for gestational age (7.4 versus 15.2%), and delivery by cesarean section (24 versus 30%) were increased in group 2 (2 h-PPG) but these differences did not reach statistical significance. CONCLUSION: These data suggest that diet control in women with GDM managed by 1-hour PPG measurements is associated with a decreased rate of insulin therapy. However, neonatal and obstetrical outcomes are not determined by the timing of their glucose determinations.     

超声测量胎儿腹围预测新生儿出生体重的研究

目的探讨超声测量胎儿腹围在预测新生儿出生体重和诊断巨大儿中的价值。方法在孕妇分娩前1周超声测量胎儿腹围,追踪胎儿的出生体重,分析胎儿腹围与出生体重的关系。结果(1)共检测1475例单胎孕妇胎儿,胎儿腹围与出生体重呈直线正相关关系,r为0.85(P<0.01)。(2)胎儿腹围<34cm者中无一例巨大儿;胎儿腹围<35cm有1007例,99.7%的新生儿平均出生体重<4000g;胎儿腹围在35～35.9cm有206例,新生儿平均出生体重为(3691±277)g,其中14.6%(30例)的新生儿出生体重≥4000g;胎儿腹围在36～36.9cm有149例,其中51.0%(76例)的新生儿出生体重≥4000g,新生儿平均出生体重为(3957±256)g;胎儿腹围在37～37.9cm有64例,其中84.4%(54例)的新生儿出生体重≥4000g,平均出生体重(4205±250)g;胎儿腹围≥38cm有44例,新生儿平均出生体重≥4000g者为100%(44例),平均出生体重为(4489±267)g。(3)1475例中有811例孕妇行剖宫产术(55.0%),新生儿出生体重为4000～4500g者,剖宫产率为71.4%(125/175),出生体重≥4500g者,剖宫产率为93.8%(30/32),均显著高于新生儿出生体重<4000g的剖宫产率(P<0.01)。结论超声测量胎儿腹围可以预测新生儿出生体重。胎儿腹围与胎儿体重呈高度直线正相关。胎儿腹围<35cm提示发生巨大儿的可能性极低;≥37cm提示巨大儿的可能性大。     

Metformin and insulin in the management of gestational diabetes mellitus: preliminary results of a comparison

OBJECTIVE: To compare glycemic control and neonatal outcomes in women with gestational diabetes mellitus (GDM) treated with metformin vs. insulin. STUDY DESIGN: Women with GDM not controlled with diet and exercise were randomized to metformin (n = 32) or insulin (n = 31). The levels of glycemic control as well as maternal/neonatal complications were evaluated. RESULTS: The mean (+/- SD) fasting and 2-hour postprandial blood glucose did not differ statistically between the 2 treatment groups. No patient failed metformin and required insulin. The majority (27/32) were easily controlled on the initial dosage (500 mg twice a day). Gestational age at entry and delivery (p = 0.077, 0.412) were similar. The difference in the rate of cesarean delivery was not statistically significant between the 2 groups (p = 0.102). Neonatal statistics were also not different between the metformin and insulin groups: birth weight, Apgar score at 5 minutes, respiratory distress syndrome, hyperbilirubinemia, neonatal hypoglycemia and neonatal intensive care unit admission (p = 0.144-0.373). CONCLUSION: Based on these preliminary data, metformin appears to be an effective alternative to insulin in the treatment of GDM.     

烟台市30年巨大胎儿发生率及其相关因素的变化

目的　探讨巨大胎儿发生率的变化趋势以及发生的相关因素。方法　以 1970年 1月至 1999年 12月分娩的 84 883例新生儿为研究对象 ,分别统计巨大胎儿 (体重≥ 4 0 0 0g)的发生率、平均出生体重、特大胎儿 (体重≥ 4 5 0 0g)所占比例 ,孕龄分布、剖宫产及阴道手术助产率、发生巨大胎儿的相关因素。结果　 1970年至 1979年、1980年至 1989年及 1990年至 1999年 3个阶段的巨大胎儿发生率分别为 2 6 %、6 9%和 13 2 % (P <0 0 1) ;剖宫产率分别为 2 3%、2 8 9%和 4 5 3% (P <0 0 1) ;阴道手术助产率分别为 14 7%、35 6 %、4 8% ,经阴道分娩肩难产发生率为 4 3%、5 0 %、1 7% ,而剖宫产孕妇无此并发症发生。特大胎儿所占比例分别为 9 4 %、11 2 %、16 2 % (P <0 0 1)。 3个阶段巨大胎儿平均出生体重分别为 (42 2 0± 2 5 0 )g、(42 2 3± 14 6 )g和 (42 5 3± 2 5 0 )g。孕妇的身高、体重、腹围、糖尿病性巨大胎儿的变化均有统计学意义。结论　 30年来 ,烟台市区的巨大胎儿发生率、平均出生体重、特大胎儿所占比例及剖宫产率呈增加趋势。巨大胎儿的发生与孕妇的身高、营养状况、体重、妊娠期糖尿病、孕周等因素有关。巨大胎儿的分娩方式以剖宫产为相对安全     

孕鼠营养异常对子鼠成年后激素抵抗影响的实验研究

目的 探讨孕鼠营养异常对子鼠成年后胰岛素、瘦素抵抗的影响。方法 36只孕鼠随机分成低蛋白组（低蛋白饲料喂养）、高营养组（高营养饲料喂养）及正常营养组（普通饲料喂养）,每组12只,各组孕鼠均足月自然分娩。正常营养组子鼠为正常体重组,低蛋白组子鼠体重小于孕龄（SGA）为SGA组（体重小于正常体重组子鼠平均体重2s以下）,高营养组子鼠体重大于孕龄（LGA）为LGA组（体重高于正常营养组子鼠平均体重2s以上）,每组子鼠36只。于子鼠出生后4周、12周龄时采用酶联免疫吸附试验测定其胰岛素、瘦素水平及胰岛素敏感指数（ISI）。结果 （1）低蛋白组子鼠体重明显低于正常体重组（P〈0．01）,69％的子鼠为SGA。高营养组子鼠体重明显高于正常体重组（P〈0．01）,38％的子鼠为LGA。（2）子鼠出生4周时,SGA组子鼠与正常体重组比较,体重已无显著差异,肾脏周围脂肪重量（FW）、Fw与体重（BW）比值分别为（0．36±0．14）g．6．5±0．3,显著高于正常体重组的（0．19±0．13）g,3．4±0．3（P〈0．01,P〈0．05）;LGA组子鼠FW／BW比值与正常体重组比较,差异无统计学意义（P〉0．05）。子鼠出生12周时,SGA组子鼠体重为（222±19）g,LGA组子鼠体重为（257±24）g,均明显高于正常体重组的（215±25）g（P〈0．05,P〈0．01）。SGA组子鼠FW／BW比值为10．5±5．1,LGA组子鼠为11．8±3．6,均明显高于正常体重组的7．2±3．6（P〈0．01）。（3）SGA组子鼠在出生4周时,胰岛素、瘦素水平分别为（5．5±0．9）μg/L、（6．1±0．7）μg／L,ISI为3．4±0．3,与正常体重组比较,差异有统计学意义（P〈0．05）;出生12周时,胰岛素、瘦素水平及ISI的变化与正常体重组比较,差异有统计学意义（P〈0．01）。LGA组子鼠在出生4周时,胰岛素、瘦素水平及ISI分别为（4．0±1．0）μg／L、（5．0±0．3）μg／L及4．1±0．5,与正常体重组比较,差异无统计学意义（P〉0．05）;出生12周时的胰岛素、瘦素水平及ISI与正常体重组比较,差异有统计学意义（P〈0．01）。结论 孕鼠营养异常将导致子鼠出生体重异常,体重异常子鼠在成年后可发生腹型肥胖以及胰岛素、瘦素抵抗。     

Increased risk of macrosomia among overweight women with high gestational rise in fasting glucose

Objectives.?Maternal overweight is a risk factor for gestational diabetes (GDM) and for newborn macrosomia. Among women without GDM, it is not well understood why some women with high body mass index (BMI) give birth to macrosomic newborns while others do not. We wanted to explore the effect of BMI and fasting plasma glucose (FPG), fasting plasma insulin (FPI) and insulin resistance (HOMA-IR) on the risk of newborn macrosomia.

Methods.?A cohort of 553 Caucasian women was followed throughout pregnancy. The dependent variable was high birth weight (≥4200?g). Independent variables included gestational age, intake of macronutrients and energy, maternal BMI, weight gain, FPG, FPI and HOMA-IR.

Results.?FPG in late pregnancy (30–32 weeks) remained a significant determinant of newborn macrosomia in multiple regression analysis (OR: 1.9, 95% CI: [1.1, 3.4]), whereas FPI and HOMA-IR did not. The women in the highest BMI quartile (≥27?kg/m²) who gave birth to macrosomic newborns had higher increase in FPG and HOMA-IR from early to late pregnancy. Among women in this BMI category, the risk for delivering a macrosomic infant was higher among those with an increase in FPG above 0.60?mmol/l (upper quartile) (OR?=?4.5, 95% CI: [1.7, 12.5]).

Conclusion.?Fasting plasma glucose at week 30–32, but not fasting plasma insulin or insulin resistance, is a determinant of newborn macrosomia. Overweight women with high increase in fasting plasma glucose from early to late pregnancy had a 4.5-fold increase in risk of newborn macrosomia compared to the remaining group with high BMI.