Pregnancy outcome and placental pathology differences in term gestational diabetes with and without hypertensive disorders

Objective: To compare pregnancy outcome and placental pathology in pregnancies complicated by gestational diabetes mellitus (GDM A1 and A2), with and without hypertensive disorders.

Methods: Pregnancy outcome and placental pathology from term deliveries of women complicated with GDM with (GDM?+?H) and without (GDM???H) hypertensive disorders were compared. Results of the GDM?+?H group were compared also with the non-diabetic patients but with hypertensive disorders (non-GDM?+?H). Composite neonatal outcome was defined as one or more of early complications: respiratory distress or need of ventilation support, sepsis, phototherapy, transfusion, seizure, hypoxic-ischemic encephalopathy. Placental lesions were categorized to lesions related to maternal and fetal vascular supply abnormalities, and maternal and fetal inflammatory responses.

Results: Of the 192 women with GDM, the GDM?+?H group (n?=?41) were more obese, p?<?0.001, with higher rate of placental maternal and fetal vascular supply lesions, p?=?0.008, p?=?0.03, respectively, but similar neonatal outcome, compared to the GDM???H (n?=?151) group. Compared to the non-GDM?+?H group (n?=?41), the GDM?+?H group had higher birth weights, similar neonatal outcome and similar rate of placental vascular lesions.

Conclusions: Higher rate of placental maternal and fetal vascular supply lesions express underlying placental pathology in women with diabetes and hypertensive disorders, similar to women without DM and with hypertensive complications.     

The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes

Objective.?To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM).

Methods.?Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI?≥?30?kg/m²) and non-obese (pre-pregnancy BMI?<?30?kg/m²) women and for women across five increasing pre-pregnancy BMI categories.

Results.?A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes.

Conclusion.?In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.     

How much weight are women gaining during pregnancy? An Italian cohort study

Abstract

Introduction: The 2009 Institute of Medicine (IOM) guidelines define adequate gestational weight gain (GWG) in the attempt to prevent maternal and neonatal adverse outcomes. The aim of this study was to assess whether the IOM guidelines are met in pregnant women with different pre-gestational body mass index (BMI).

Methods: The study included 230 pregnant women recruited at the University Hospital of Pisa (Italy) at their screening visit (24–28 weeks of gestation) for gestational diabetes (GDM). GWG was determined at screening time and before delivery to be compared with GWG recommended by IOM for each pre-pregnancy BMI category.

Results: A total of 48% of women had a GWG exceeding IOM recommendations. The prevalence of GWG excess was higher in over-weight (OW, 63.2%) and obese (OB, 63.8%) women as compared to normal-weight (NW, 27.7%; p?<?0.0001) women. The upper limit of the recommended IOM weight gain range was already exceeded at screening time in 15.5% of women. The percentage increased 27% and 18% in OW and OB, respectively, compared with 1.5% in NW (p?<?0.001).

Conclusion: About half of pregnant women had a GWG greater than the IOM recommended. GWG excess is particularly evident in OW and OB women.     

Weight gain in gestational diabetes: the effect of treatment modality

Objective: To evaluate treatment effectiveness (diet alone, insulin or glyburide) on maternal weight gain in gestational diabetes (GDM).

Methods: GDM patients were treated with diet alone, insulin or glyburide. Weight gain was stratified into: prior to GDM diagnosis, from diagnosis to delivery and total pregnancy weight gain. Good glycemic control was defined as mean blood glucose ≤105?mg/dl and obesity as Body Mass Index (BMI)?≥?30?kg/m², overweight BMI 25–29?kg/m² and normal <?25?kg/m².

Results: Total weight gain was similar in all the treatment groups. Two-thirds of weight gain occurred prior to diagnosis (diet 85%, insulin 67% and glyburide 78%). Post-diagnosis, patients on diet alone gained less weight than those on insulin or glyburide (p?<?0.001); insulin-treated patients showed greater weight gain than glyburide-treated patients (p?<?0.001). Patients on diet with good glycemic control showed less weight gain after diagnosis than patients on insulin or glyburide (2.8?±?13, 6.6?±?10, 5.2?±?7.9 lbs, respectively, p?<?0.02). Poorly-controlled patients, regardless of treatment, had similar patterns of weight gain throughout pregnancy.

Conclusion: Patterns of maternal weight gain in GDM pregnancies are associated with treatment modality and level of glycemic control.     

Insulin detemir versus glyburide in women with gestational diabetes mellitus

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

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

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

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

The mutual effect of pregestational body mass index,maternal hyperglycemia and gestational weight gain on adverse pregnancy outcomes

Objective: To investigate the mutual effect of obesity, gestational diabetes (GDM) and gestational weight gain (GWG) on adverse pregnancy outcomes.

Methods: Charts of patients who delivered in our hospital between June 2001 and June 2006 singleton, live births >24 weeks gestation were reviewed. Univariate and multivariate logistic regression were used to assess pregnancy outcomes defined as large for gestational age (LGA), primary cesarean section (PCS) and a composite outcome of LGA and/or PCS.

Results: A total of 8595 women were included. Frequency of composite outcome increased with increasing body mass index (BMI), increasing hyperglycemia and above-recommended GWG. In the multivariate logistic regression analysis compared to women with normal BMI, odds ratio (OR) for composite outcome was 1.23 (95% confidence interval [CI] 1.06–1.44) in overweight women, OR?=?1.86 (1.51–2.31) in obese women and in severe obesity OR?=?2.97 (2.15–4.11).

Compared to normoglycemic women, odds for composite outcome in women with abnormal glucose challenge test OR?=?1.46 (1.20–1.79), impaired glucose tolerance OR?=?1.65 (1.14–2.4) and GDM OR?=?1.56 (1.16–2.10). Women with GWG above recommended had OR?=?1.58, (1.37–1.81) for composite outcome.

Conclusions: Higher pregestational BMI, maternal hyperglycemia and above-recommended GWG independently contribute to adverse pregnancy outcomes. Furthermore, there is mutual effect between these three factors and adverse outcomes. Appropriate pregestational weight and adequate GWG might reduce risk of adverse pregnancy outcomes.     

Homeostatic indices of insulin resistance among gestational diabetics in anticipating pregnancy complications

Abstract

Objective: This was to determine HOMA-IR score as well as to assess its association in fetal and maternal outcomes among pregnant women with diabetes risks.

Methods: A prospective cohort study of pregnant women with diabetes risks was done. GDM was diagnosed using modified glucose tolerance test. Serum insulin was taken and measured by an electrochemiluminescence immunoassay method. Plasma glucose was measured by enzymatic reference method with hexokinase. HOMA-IR score was calculated for each patient. Maternal and fetal outcomes were analyzed.

Results: From 279 women recruited, 22.6% had GDM with higher HOMA-IR score (4.07?±?2.44 versus 2.08?±?1.12; p?=?0.001) and fasting insulin (16.76?±?8.63?µIU/L versus 10.15?±?5.07?µIU/L; p?=?0.001). Area under ROC curve for HOMA-IR score was 0.79 (95% confidence interval, 0.74–0.84) with optimum cut-off value of 2.92 (sensitivity?=?63.5%; specificity?=?89.8%), higher than recommended by IDF (2.38). This point showed significant association with neonatal hypoglycemia (p?=?0.02) and Cesarean section (p?=?0.04) in GDM mothers.

Conclusions: HOMA-IR score and insulin resistance levels were higher in GDM women in our population. With the cut-off HOMA-IR value of 2.92, neonatal hypoglycemia and Cesarean section were significant complications in GDM mothers. This can be used in anticipation of maternal and fetal morbidities.     

Maternal and umbilical resistin levels do not correlate with infant birth weight either in normal pregnancies and or in pregnancies complicated with gestational diabetes

Objective.?To evaluate the role of resistin in the pathophysiology of insulin resistance during pregnancy and on the birth weight of infants born from women with gestational diabetes (GDM).

Material and methods.?Thirty women diagnosed with GDM were compared to 30 normal pregnant controls. Maternal serum resistin and insulin levels were measured at the time of the oral glucose tolerance test screening. In addition, umbilical levels of resistin and insulin were measured at the time of delivery.

Results.?There was no difference in maternal serum resistin levels in women with GDM as compared to normal controls at 24–26 weeks. There was no difference in umbilical resistin levels between the infants born in the two groups. There was no correlation between infant weight and either maternal resistin at 24–26 week or umbilical resistin levels.

Conclusion.?There were no significant differences in umbilical resistin levels between infants born of women with GDM as compared to normal pregnant women. In addition, there was no correlation between resistin levels during pregnancy, as well as between umbilical resistin levels and neonatal birth weight. In conclusion, resistin seems to play a rather minor role in the pathophysiology of GDM and the energy metabolism during fetal life.     

Haemostatic and cytokine changes in gestational diabetes mellitus

Background.?Limited data indicate the existence of a hypercoagulable state and the possible involvement of pro-inflammatory cytokines in the pathogenesis of gestational diabetes mellitus (GDM).

Aim.?To characterise the coagulation inhibitor and cytokine profiles in women with GDM.

Methods.?Two groups of women in the third trimester of pregnancy were studied: GDM (n?=?150) and controls: women with normal pregnancy (n?=?100); GDM in their first post-delivery day (n?=?52).

Laboratory assays.?Plasma fibrinogen, antithrombin (AT), protein C, total and free protein S, interleukins-2, 6 and 8 (IL-2, 6, 8).

Results.?During pregnancy, the only significant alterations noted were higher levels of body mass index, fibrinogen and total protein S in women with GDM when compared to normal pregnancy. In the post-delivery group, there was further elevation in the levels of plasma fibrinogen and significant drop in the level of total protein S, protein C and AT. Significant elevation of IL-2 and IL-6 levels was recorded only in post-delivery group.

Conclusion.?In GDM, the only indicator of a tendency towards hypercoagulability is the higher fibrinogen levels as compared to normal pregnancy. This feature along with the higher body mass index and presumed associated insulin resistance suggests that GDM may be a mild form of the metabolic syndrome. The lack of significant change in the levels of pro-inflammatory cytokines do not support the existence of an inflammatory state in GDM.     

Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal gestational diabetes mellitus and fetal outcomes: a randomized controlled trial

Abstract

Objective: To test the hypothesis that dietary myo-inositol may improve insulin resistance and the development of gestational diabetes mellitus (GDM) in women at high risk of this disorder.

Design: A prospective, randomized, double-blind, placebo controlled clinical trial, pilot study.

Participants: Non-obese singleton pregnant women with an elevated fasting glucose in the first or early second trimester were studied throughout pregnancy.

Intervention: Supplementation with myo-inositol or placebo during pregnancy.

Main outcome measure: Development of GDM on a 75?g oral glucose tolerance test at 24–28 weeks’ gestation. Secondary outcome measures were increased in BMI, need for maternal insulin therapy, macrosomia, polyhydramnios, neonatal birthweight and hypoglycemia.

Results: Thirty-six women were allocated to receive myo-inositol and 39 placebo. The incidence of GDM in mid-pregnancy was significantly reduced (p?=?0.001) in women randomized to receive myo-inositol compared to placebo (relative risk 0.127). Women randomized to receive myo-inositol also required less insulin therapy, delivered at a later gestational age, had significantly smaller babies with fewer episodes of neonatal hypoglycemia.

Conclusions: Myo-inositol supplementation in pregnancy reduced the incidence of GDM in women at high risk of this disorder. The reduction in incidence of GDM in the treatment arm was accompanied by improved outcomes.     

Serum chemerin level during the first trimester of pregnancy and the risk of gestational diabetes mellitus

Objective: To investigate the association between chemerin level in the first trimester of pregnancy and the risk of gestational diabetes mellitus.

Methods: The blood samples of 212 women at 8–12?weeks of gestation were collected. After screening for gestational diabetes mellitus (GDM), 19 women with GDM and 20 women randomly selected from 144 women with normal glucose tolerance (NGT) were included in the study. Blood samples were collected from these women. Triglycerides, glucose, total cholesterol, and HDL cholesterol, LDL cholesterol, insulin and chemerin were measured. Gestational weight gain and body mass index was assessed.

Results: Serum levels of chemerin were significantly elevated during late gestation, and the risk of GDM was positively associated with maternal serum chemerin in the first trimester.

Conclusion: Serum chemerin level during the first trimester of pregnancy has the potential to predict risk of GDM.     

Neopterin and hsCRP are not correlated in gestational diabetes mellitus

Objective: To determine serum neopterin and high sensitive C-reactive protein (hsCRP) levels in patients with and without gestational diabetes mellitus (GDM).

Methods: Neopterin and hsCRP levels were quantified in 28 women with GDM and 20 pregnant women with normal glucose tolerance (NGT). Postpartum neopterin and hsCRP levels were measured in a follow-up study.

Results: Neopterin levels were significantly higher in women with GDM than in women with NGT (15.89?±?8.19?nmol/L versus 10.4?±?3.8?nmol/L, p?p?p?=?0.9, respectively). In contrast, hsCRP levels decreased after delivery in patients with GDM (5.74?±?3.91 versus 3.78?±?2.78, p?r?=?0.3, p?=?0.02) and fasting glucose (r?=?0.4, p?=?0.004), postprandial glucose (r?=?0.3, p?=?0.01), HbA1c (r?=?0.3, p?=?0.02), whereas hsCRP levels were correlated with pre-pregnancy (r?=?0.3, p?=?0.04) and pregnancy body mass index (r?=?0.4, p?=?0.008). No correlation between serum neopterin and hsCRP levels was found (p?=?0.9).

Conclusion: Neopterin levels increased in patients with GDM; hence, it may be related to inflammation. However, the lack of correlation between neopterin and hsCRP suggests the role of different attitudes of these two parameters in the course of pregnancy and GDM.     

Effect of second trimester and third trimester weight gain on immediate outcomes in neonates born to mothers with gestational diabetes: a retrospective observational study from India

Abstract

Aim: To evaluate the effect of second trimester and third trimester rate of weight gain on immediate outcomes in neonates born to mothers with Gestational Diabetes Mellitus (GDM).

Method and material: This retrospective observational study enrolled 593 eligible mothers. The records of all pregnant women booked before 24?weeks and screened for diabetes were eligible if they were diagnosed with Gestational Diabetes Mellitus (GDM) anytime during pregnancy. All the necessary maternal and neonatal details were collected from hospital database. The rate of weight gain was calculated at 18–24?weeks, 28–30?weeks, and that before delivery. The enrolled women were categorized into: poor weight gain, normal weight gain, and increased weight.

Results and discussion: The mean birth weight, length, and head circumference of neonates were significantly lower in women who had poor rate of weight gain in comparison with normal weight gain group. The mean prepregnancy BMI was significantly high in women with increased rate of weight gain when compared to normal weight gain women in second and third trimester. Regression analysis done to evaluate the independent effect of weight gain on C section and neonatal complications, showed that the independent predictors for cesarean section were previous cesarean section or 12.5 (95% CI 6.7–23) and conception by assisted reproductive technologies or 1.75 (95% CI 1.01–4.3), and the neonatal complications were influenced by birth weight or 1.5 (95% CI 1.1–2.2) and weight gain during second trimester or 1.26 (95% CI 1–1.6).

Conclusion: In women with GDM, reduced weight gain during pregnancy is associated with small for gestational age neonates. Caesarean section is predicted by previous C-section, and mode of conception whereas neonatal complications were predicted by birth weight and maternal weight gain during second trimester.     

Clinical significance of neuregulin 4 (NRG4) in gestational diabetes mellitus

Objective: Gestational diabetes mellitus (GDM) is defined as glucose intolerance detected during pregnancy. GDM is increasing worldwide and is associated with adverse maternal and fetal outcomes. Neuregulin 4 (NGR4) is epidermal growth factor like signaling molecule. It plays an important role in cell to cell communication furthermore recent studies indicate that NRG4 may work as a novel adipokine with a possible role in maintaining energy and metabolic homeostasis. The aim of the present study was to assess serum NRG4 levels along with several metabolic parameters in patients diagnosed with gestational diabetic mellitus.

Materials and methods: In this prospective cross-sectional study, the study group was composed of 63 women with GDM and 64 healthy pregnant women matched for age, body mass index (BMI) and gestational age. Blood samples were collected at the 24–28th gestational weeks. Serum NRG4, total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides, glucose levels during 75-gr OGTT, fasting insulin, glycosylated hemoglobin A1c (HbA1c), alanine aminotransferase (ALT) and creatinine levels were measured. Homeostasis model assessment of insulin resistance (HOMA-IR) values were calculated.

Results: Serum NRG4 values were significantly elevated in the GDM group compared to the control group (p?β?=?0.910, p?β?=?0.866, p?β?=?0.222, p?Conclusions: Serum NRG4 levels were associated with metabolic parameters of GDM. The present study can be considered to be a guide for future studies to clarify the pathophysiology of NGR4 in GDM patients.     

Effects of smoking and preeclampsia on birth weight for gestational age

Objective: A counterintuitive interaction between smoking during pregnancy and preeclampsia on birth weight for gestational age (BWGA) outcomes was recently reported. In this report, we examine the relationship between these factors in a well-documented study population with exposure data on trimester of maternal smoking.

Methods: Preeclamptic (n?=?238), gestational hypertensive (n?=?219), and normotensive women (n?=?342) were selected from live-births to nulliparous Iowa women. Disease status was verified by medical chart review, and smoking exposure was assessed by self-report. Fetal growth was assessed as z-score of BWGA. Multiple linear regression was used to test for the association of maternal smoking and preeclampsia with BWGA z-score.

Results: There was no interaction between smoking with preeclampsia or gestational hypertension on fetal growth. BWGA z-scores were significantly lower among women with preeclampsia and those who smoked any time during pregnancy (β?=??0.33, p?=?<0.0001 and β?=??0.25, p?=?0.05) compared to normotensive and non-smoking women, respectively. Infants of women with gestational hypertension were comparable in size to infants born to normotensive women.

Conclusions: Women who developed preeclampsia and those who smoked during pregnancy delivered infants that were significantly smaller than infants of women who did not develop preeclampsia and non-smoking women, respectively.     

Obstetric outcomes and placental findings in gestational diabetes patients according to maternal prepregnancy weight and weight gain

Objective: We assessed clinical outcomes and placental pathology among pregnancies complicated with gestational diabetes mellitus (GDM) according to their pregestational body mass index (BMI) and weight gain during pregnancy.

Study design: Pregnancy outcome and placental pathological reports of all GDM deliveries, during 2009–2015, were reviewed. We compared women with pregestational BMI?>?30 and or gestational weight gain >20?kg (high-BMI group), and women with pregestational BMI?Results: Out of the 429 women with GDM, 221 (51.5%) were in the high-BMI group and 208 (48.3%) were in the normal BMI group. As compared to the normal BMI group, the high-BMI group displayed a higher rate of GDMA2 41.6 versus 30.2%, p?=?.01, higher birth weight, 3475?±?508?g versus 3242?±?503?g, p?p?p?=?.07, respectively. By logistic regression analysis, past CD and high BMI were independently associated with CD, while GDM type and birth weight were nonsignificant. Pathological reports were available for 143 of these patients. Placental weight was increased among the high-BMI group, but did not retain significance after adjustment for birth weight, and GDM type. No differences were demonstrated in other placental histological findings.

Conclusions: GDM pregnancies accompanied by increased weight gain or elevated pregestational BMI are associated with adverse obstetric outcomes, despite similar placental findings. Patient should be advised accordingly, as gestational weight gain may determine delivery mode.     

Circulating galanin and IL-6 concentrations in gestational diabetes mellitus

Objective: The aim of this study is to compare galanin and IL-6 levels in pregnant women with gestational diabetes mellitus (GDM) and normal glucose tolerance (NGT). Also association of insulin resistance markers, galanin and IL-6 was investigated.

Materials and Methods: The study registered 30 pregnant women with GDM and 30 pregnant women with NGT. Fasting venous blood samples were collected from all patients. Galanin and IL-6 levels were measured by an enzyme-linked immunosorbent assay.

Results: Galanin and IL-6 levels were found higher in pregnant women with GDM (p?r?=?0.240, p?=?0.065), insulin (r?=?0.681, p?r?=??0.644, p?r?=?0.783, p?r?=?0.745, p?r?=?0.058, p?=?0.662), body mass index (r?=??0.019, p?=?0.886).

Conclusion: Galanin and IL-6 were found to be significantly associated with insulin resistance markers in GDM, thus may play important roles in regulation of glucose hemostasis.     

Serum levels of nesfatin-1 are increased in gestational diabetes mellitus

Objective: To analyze the concentrations of nesfatin-1 in maternal and cord serum, to evaluate the expression of nesfatin-1 in subcutaneous adipose tissue (SAT) from pregnant women with gestational diabetes mellitus (GDM) and those with normal glucose tolerance (NGT).

Methods: We studied a total of 50 GDM and 50 NGT subjects. The clinical features, serum nesfatin-1, homeostasis model assessment of insulin resistance (HOMA-IR), lipid profiles were measured at the third trimester of pregnancy. The expression of nesfatin-1 in the SAT was determined by western blot.

Results: Compared with the NGT group, the GDM group showed greater levels of serum nesfatin-1, adipocyte fatty acid binding protein (AFABP), and leptin; a greater level of cord blood nesfatin-1; and a higher level of expression in SAT (p?p?b?=?0.317, p=?0.022) and body mass index (BMI) before delivery (b?=?0.367, p=0.008) were independently associated with serum nesfatin-1. Nesfatin-1 was the independent risk factor for GDM.

Conclusions: The GDM group had higher levels of maternal serum and cord blood nesfatin-1, and greater nesfatin-1 expression in SAT. Nesfatin-1 is closely related to obesity and IR in pregnancy.     

Can first trimester maternal serum follistatin like 3 levels predict developing gestational diabetes mellitus?

Purpose: The purpose of this study is to determine whether the first trimester maternal serum levels of follistatin like 3 (FSTL3) are altered in patients who develop gestational diabetes mellitus (GDM).

Methods: This is a prospective nested case-control study that included 170 singleton pregnant women recruited in their first trimester. All women were followed up until the delivery and 144 of them completed the study. The maternal serum levels of FSTL3 were measured at 11–14 weeks of gestation. The GDM-affected women (n?=?19) were compared with the GDM-free control women (n?=?125) for potential serum biomarkers including the FSTL3 levels.

Results: There were no significant differences in maternal age, maternal pre-pregnancy body mass index, and neonatal birth weight between the GDM group and the GDM-free control group. Women with GDM had significantly greater weight gain during pregnancy than the women without GDM. Serum concentration of glycosylated hemoglobin was significantly higher in women with GDM. There were no significant differences in serum FSTL3 levels (p?=?0.578) between the GDM group and the GDM-free control group.

Conclusions: Our results suggest that the first trimester maternal serum FSTL3 levels are not altered in women who develop GDM and thus do not support the use of serum FSTL3 levels for early prediction of GDM.     

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.