Gestational diabetes diagnosed in third trimester pregnancy and pregnancy outcome.

BACKGROUND: The clinical significance of gestational diabetes diagnosed in the third trimester is unclear. A prospective observational study was performed on a cohort of women without pre-existing gestational diabetes or other medical disorders to examine the effect of gestational diabetes on pregnancy complications and infant outcome. METHODS: Four hundred and eighty-nine consecutive women were assessed at 28-30 weeks by random glucose screening and/or a 75 g oral glucose tolerance test. The subsequent management was according to established departmental protocols. The outcome of pregnancy was compared among the groups with negative screening, positive screening but normal glucose tolerance, and gestational diabetes which was controlled with diet therapy. RESULTS: Women with gestational diabetes (n=67 or 13.7%) had significantly increased maternal age, pre-pregnancy weight and body mass index, hemoglobin levels at booking and at 36-38 weeks, and incidences of parity >1, pre-eclampsia, and female infants, while the gestational age was shorter and there was no significant difference in the birthweight outcome or neonatal morbidity. CONCLUSIONS: Despite diet treatment, gestational diabetes diagnosed in the last trimester is associated with increased risk of pre-eclampsia and shorter length of gestation, and this is likely to reflect a pathological process rather than the physiological effect of pregnancy on maternal glucose tolerance.     

妊娠合并糖尿病的围产期监护

1986年1月至1992年11月期间该院孕产妇中有妊娠合并糖尿病者107例(10.13‰),包括妊娠期糖尿病37例,White分类B～D级70例,平均年龄31岁,初产妇比经产妇为1.23:1,有不良孕产史者占43％,1/3患者并发妊高征,大于孕龄儿占39.25％,胎儿畸形3例(2.8％),剖宫产率82.24％,产母因并发症死亡1例(9.35‰),宫内死胎7例(65.42‰)。本文认为加强孕妇管理是降低母儿并发症和围产儿死亡之关键。     

Pyridoxine treatment of chemical diabetes in pregnancy.

Thirteen women with chemical diabetes diagnosed in late pregnancy were found to excrete excessive amounts of urinary xanthurenic acid after a tryptophan load, indicative of a relative pyridoxine (vitamin B6) deficiency. Treatment with 100 mg pyridoxine daily for 14 to 23 days restored the urinary xanthurenic acid excretion to normal in all patients. Improvement of glucose tolerance was observed in only two of the patients studied, deterioration in six, and no significant change in the remaining five. The insulin response to glucose was unaltered during pyridoxine therapy.     

Glycosylated hemoglobins and diabetes mellitus in pregnancy.

The glycosylated hemoglobins (HA1) were measured in the blood of normal nonpregnant (n = 50) and pregnant (n = 29) volunteers and pregnant diabetic patients (n = 21). HA1 in normal pregnancy (6.7% +/- 1.03%) did not differ significantly from values in nonpregnancy (7.5% +/- 0.73%) and did not vary with the stage of gestation. HA1 was increased in diabetic pregnancy (8.4+ +/- 2.15%) and was positively correlated with serial fasting blood sugar (FBS) mean values in samples drawn up to 16 weeks (r = 0.57) prior to the measurement of HA1, although the highest correlation (r = 0.73, p less than 0.001) was with FBS levels over the prior 8 weeks. A large standard error of the estimate (26.9 mg/100 ml) showed HA1 to be insensitive as an indicator of prior FBS. There was a large overlap of HA1 from known diabetic patients with the normal range for pregnancy. There was no correlation of third-trimester HA1 and newborn birth weight. It was concluded that (1) normal pregnancy does not alter HA1; (2) HA1 is proportional to prior mean FBS; (3) marked elevations of HA1 (greater than 10%) reliably predict poor diabetic control, but HA1 is not useful for fine control of FBS; (4) HA1 is not useful as a screen for diabetes mellitus; (5) HA1 is not predictive of newborn birth weight.     

Noninsulin dependent diabetes mellitus and pregnancy in Mexico.

We analyzed 215 consecutive patients with diabetes mellitus and pregnancy, 118 (54.83%) with noninsulin dependent diabetes mellitus (NIDDM), 90 (41.86%) with gestational diabetes mellitus (GDM) and 7 (3.26%) with insulin dependent diabetes mellitus (IDDM). NIDDM and GDM patients had no significant difference in age and body mass index. There were no maternal deaths, nor episodes of ketoacidosis. Maternal and neonatal complications occurred with a similar frequency in NIDDM and GDM. We concluded that in our population, diabetes associated with insulin-resistance occurred in over 96% of our pregnant diabetic patients and was associated with an increased prevalence of maternal and neonatal complications. Earlier perinatal care has to be established in NIDDM patients, and obese young women should be screened to detect GDM from early gestation and advised to reduce weight before pregnancy ensues.     

Three cases of diabetes insipidus complicating pregnancy.

Diabetes insipidus (DI) is a rare complication of pregnancy. In cases related to pregnancy, the condition is thought to result from enhanced placental clearance of arginine vasopressin secondary to placental vasopressinase production. In such cases careful monitoring of the patient's fluid balance during and after pregnancy is essential. If treatment is necessary, desmopressin is the drug of choice. In the present article, we present three cases of pregnancy complicated by DI.     

Care of diabetes in pregnancy

Diabetes, whether existing before pregnancy or brought on by changes in maternal physiology, poses risks to the mother and developing fetus. Excellent preconceptional and pregnancy care can help to minimize, or even to eliminate, these risks. This article reviews the problems that are associated with diabetes in pregnancy and evidence-based strategies to avoid them.     

Drugs in pregnancy. Endocrine disease (including diabetes).

This chapter reviews the treatment of endocrine disease in pregnancy, including diabetes mellitus, hypo- and hyperthyroidism, adrenal and pituitary disorders, and hyper- and hypoparathyroidism. Pregnancy in some of these disorders is relatively rare, so that management is often based on limited information and clinical judgement rather than on strong evidence-based criteria.     

Type 2 diabetes in pregnancy: exposing deceptive appearances.

Now that we have been forewarned of the growing pandemic of type 2 diabetes and obesity in pregnancy, we need to become forearmed. Over the past few decades there has been no significant improvement in perinatal outcome complicated by diabetes mellitus (type 1 and type 2). The recognition of modifiable risk factors such as maternal glycemic control using self-monitoring blood glucose in combination with pharmacological therapy (intensified therapy) and weight gain in pregnancy should enhance pregnancy outcome. The overemphasis and concentration on the non-modifiable risk factors in pregnancy is a futile pursuit that may generate lively discussion but paucity of results. The focus needs to be in education for the care provider, i.e., enhanced recognition of this growing entity and a heightened awareness of the need for pre-pregnancy counseling about preconception glycemic control. Another center of attention should be the dissemination of information to patients of the impending maternal and fetal risks of type 2 diabetes in pregnancy. This care would include antenatal care for surveillance of maternal diabetes complications as well as careful obstetric surveillance to improve maternal and fetal outcomes.     

Glycosylated hemoglobins in normal pregnancy and gestational diabetes mellitus.

Glycosylated hemoglobins (HbA1) were measured in 23 nonpregnant women, 53 normal pregnant women, and 22 Class A diabetics; the results were 6.1 +/- 0.7%, 5.8 +/- 1.0%, and 7.0 +/- 1.3% in the 3 groups, respectively. The decrease in normal pregnancy was insignificant, whereas the increase in HbA1 in Class A diabetics over the other 2 groups was statistically significant (P less than 0.05). HbA1 did not correlate with maternal age, gravidity, or gestational age at the time of sampling. There was no difference in HbA1 between whites and blacks [patients with sickle hemoglobin (HbS) were excluded] (P = 0.35), nor between primigravidas and multigravidas (P = 0.8). HbA1 levels did not correlate with the birth weight ratios in either normal pregnancies (r = 0.06, P = 0.7) or in Class A diabetics (r = -0.4, P = 0.09). This is probably due to the long interval between HbA1 determination and delivery (9.9 weeks).     

Insulin levels in amniotic fluid. Management of pregnancy in diabetes

A correlation between high insulin levels in amniotic fluid and the appearance of diabetogenic fetal morbidity was found in radioimmunoassays of 487 samples of the fluid. The mean insulin level in metabolically normal pregnancies rose from 9 muU/ml (Week 27) to 15 muU/ml (Week 40). The insulin level in amniotic fluid of diabetic patients was elevated up to 27 times the mean. Insulin levels in the umbilical cord and urine of newborns of diabetic mothers were also elevated, to 29 and 21 times the mean, respectively. Elevation of insulin levels in amniotic fluid portends diabetogenic fetal morbidity. High and rising insulin levels at an early stage (26-28 weeks) may indicate a high risk of preterm onset of labor. Regular adjustment of metabolic compensation on the basis of amniotic fluid insulin made it possible to reduce the level in 12 of 17 pregnant diabetic women by increasing insulin dosage. The 12 women were thereby enabled to carry their pregnancies to term and to await the onset of spontaneous labor without diabetogenic fetal morbidity. Beta-stimulating agents affect glucose management and may cause elevated insulin levels in amniotic fluid.