Normoglycemic diabetic ketoacidosis in pregnancy.

The clinical presentation of diabetic ketoacidosis in pregnancy is usually the same as in nonpregnant women, although the blood glucose may not be as high as in the nongravid state. We report a case of a pregnant woman who developed diabetic ketoacidosis with a normal blood glucose and review the pertinent medical literature. A 29-year-old woman with type I diabetes developed diabetic ketoacidosis during induction of labor. She had a glucose level of 87 mg per 100 ml with ketonuria, a metabolic acidosis, and an anion gap of 20 mmol l(-1). Normoglycemic diabetic ketoacidosis during pregnancy is truly unusual but can occur with relatively low, or even normal, blood sugars and necessitates prompt recognition and treatment. In this case, the combination of an initial episode of hypoglycemia and subsequent blood glucose levels below 95 mg per 100 ml led to a prolonged delay in the initiation of a planned insulin infusion for insulin coverage during the induction of labor. A significant ketoacidosis consequently developed, despite the absence of even a single elevated blood glucose measurement. This case illustrated the importance of not withholding insulin in a patient with type I diabetes for more than a few hours even if the blood glucose is normal.     

Management of third-trimester diabetic pregnancies with the use of continuous subcutaneous insulin infusion therapy: A pilot study

Six women with juvenile-onset diabetes were managed as outpatients during the third trimester of pregnancy with continuous subcutaneous insulin infusion therapy. Twenty-four-hour metabolic profiles for plasma glucose, β-hydroxybutyrate, and triglycerides were monitored prior to, 1 week, 5 weeks, and 10 weeks after initiation of continuous subcutaneous insulin infusion therapy and compared with the metabolic profiles of 10 normal (nondiabetic) pregnant women. Near-normal metabolic profiles were achieved in these patients after 5 weeks of therapy in this pilot study. Patient motivation, compliance, and understanding of their illness were crucial in achieving the therapeutic goals of normoglycemia.     

Continuous subcutaneous insulin therapy during early pregnancy

Intensive metabolic control of diabetes is probably important during formation of the embryo early in pregnancy. The purpose of this study was to determine the efficacy and complications of continuous subcutaneous insulin infusion therapy during the fifth to the tenth week of gestation. Twenty-four insulin-dependent subjects were trained to use blood glucose self-monitoring and the Auto Syringe portable insulin infusion pump (AS6C). Regular insulin was administered as a basal infusion of 18 +/- 8 U/24 hours (+/- SD) (12.2 +/- 3.9 mU . kg-1 . h-1) and as bolus injections of 6 +/- 3 U before meals and 1.2 +/- 1 U before snacks. Reasonable control of fasting (119 +/- 30 mg/dL) and postprandial (133 +/- 34 mg/dL) hyperglycemia was achieved, accompanied by an average of 2.2 +/- 1.5 symptomatic hypoglycemic episodes per week. The frequency of complications with this new therapy declined as the authors gained experience in teaching the system. The persistence of good diabetic control in many of the subjects after they returned to conventional insulin therapy points to the need for a controlled trial of continuous subcutaneous insulin infusion therapy versus intensive conventional therapy in pregnancy.     

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.     

Fetal and maternal blood glucose, insulin and acid base observations following maternal glucose infusion.

The aim of the present investigation was to examine the fetal and maternal blood glucose and insulin response following glucose infusion to the mother. The studies were performed on 11 primigravid patients with a gestational age of 38-40 weeks during the first stage of labor. Glucose was given intravenously by a bolus injection of 330 mg/kg body weight, followed by a glucose infusion of 27.5 mg/kg/min for 60 min. Glucose concentration, immuno-reactive insulin (IRI), pH and base excess of the maternal and fetal blood were measured before and during maternal glucose load. Maternal blood glucose rose within 10 min. up to 280.0 mg% (SD 25.9). This level could be fairly maintained throughout the experiment. The maternal glucose was after 60 min. infusion 326.5 mg% (SD 46.9). Fetal glucose concentration rose continuously from 65.8 mg% (SD 5.8) at control to 249.2 mg% (SD 23.3) after 60 min. The increase of maternal and fetal glucose was associated with an elevation of immuno-reactive insulin (IRI). The maternal insulin was 24.0 micronU/ml (SD 8.0). It was scattered over a wide range (55.4 micronU/ml-217.1 micronU/ml) after 60 min. glucose infusion. The fetal insulin was 17.0 micronU/ml (SD 5.2) at control and rose by 86.5% (SD 80.5) after 60 min. glucose load. One case of a mother with a subclinical diabetes mellitus deviated where the fetal insulin rose from 26.0 micronU/ml at control to 215.6 micronU/ml after 60 min. infusion. The increase of insulin per glucose rise was correlated to fetal body weight. During glucose infusion to the mother of both, fetal and maternal, acid base parameters remained unchanged. From these observations it may be concluded that in the human fetus insulin secretion following a single glucose load is generally low, however, it increases in cases where the maternal insulin response to glucose load is abnormal. This might be related to a chronic stimulation by glucose of the fetal pancreatic islet cells in poorly controlled diabetic and possibly prediabetic patients.     

New technologies for the management of pregestational diabetes mellitus

Purpose of the Review: The purpose of this review is to understand new modalities available to treat and manage type 1 and type 2 diabetes during pregnancy. Recent Findings: The use of new insulin analogs and oral agents, as well as new technologies to deliver insulin and monitor glucose during pregnancy remains controversial. This review will outline the advantages and disadvantages, as well as the safety profiles of these new medications and therapeutic options. Summary: There are many effective treatments for diabetes during pregnancy. New insulin analogs seem to be safe to use in pregnancy and offer the potential for better glycemic control compared with older agents. Oral hypoglycemic medications also seem to be safe and may be an option for a select group of pregnant patients with type 2 diabetes. Insulin pumps and continuous glucose monitoring systems may be beneficial in certain patients, but adequate data are not yet available in terms of outcomes and cost-effectiveness to support widespread use. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After participating in this CME activity, physicians should be better able to revise glycemic goals for pregnant patients with pregestational diabetes to be in line with our current understanding of glycemic profiles in normal pregnant women. Use new insulin analogs to treat pregnant women with abnormalities in glucose homeostasis and choose which patients will benefit from advanced technologies for diabetes management, such as insulin pumps and continuous glucose monitoring systems.     

Betamethasone-dixyrazine versus betamethasone-metoclopramide as antiemetic treatment of cisplatin-doxorubicin-induced nausea in ovarian carcinoma patients

In a prospective and randomized pilot study two antiemetic regimens comprising dixyrazine (240 mg) and metoclopramide (10 mg/kg) in high doses and given by continuous i.v. infusion were compared as means of preventing cisplatin-doxorubicin-induced nausead and vomiting. Twenty chemotherapy-naive women with the diagnosis of ovarian carcinoma stages III-IV (FIGO) were included in the study. Medium doses (50 mg/m2) of cisplatin and doxorubicin were used. The antiemetic drugs (the above-mentioned ones plus betamethasone 20 mg, and biperiden 5 mg) were administered by small portable infusion pumps during 24 hours. The effects and adverse reactions were evaluated during the course of chemotherapy and the first week thereafter. Complete protection from nausea during the first 24 hours was achieved in 80% by the metoclopramide cocktail and in 50% by the dixyrazine combination. During days 2-7 there were no significant differences between the two regimens. Vomiting was not satisfactorily prevented by either treatment. Sedation was significantly more common after dixyrazine than after metoclopramide but other recorded side effects were similar for the two antiemetic regimens. Serum concentrations of dixyrazine and metoclopramide were determined.     

Prognostic factors in platinum-resistant ovarian carcinoma treated with ifosfamide-etoposide

One hundred and seven patients (median age 56) with cisplatin-resistant ovarian carcinomas were included in a phase II study with ifosfamide (5 g/m2) and etoposide (300 mg/m2) every three weeks. The first 30 patients received a 5-day regimen: 100 mg/m2 etoposide (i.v.) repeated in three days followed by 1 g/m2 ifosfamide as a bolus dose in five days. Mesna 200 mg/m2 was given 0.4 and 8 hours after each ifosfamide infusion. The next 77 patients received a 1-day regimen: 300 mg/m2 etoposide for two hours and then 5 g/m2 ifosfamide together with 5 g/mg2 mesna in 3.000 ml Ringer solution for 24 hours followed by 1 g/m2 mesna i.v. in 100 ml Ringer solution for eight hours. Overall the objective response rate was 6.5% (all PR) and SD in 42% of patients with a median duration of six and four months, respectively. Median survival of the total group was seven and 12 months for the responders. One- and two-year overall survival was 32% and 6%, respectively. Toxicity was similar in both regimens except for significantly more nausea and vomiting (gr 3 and 4) in groups with the 1-day regimen. There were few serious effects and they were manageable. Multivariate analysis identified degree of differentiation and response to ifosfamide/etoposide as the two most powerful prognostic factors of overall survival (p=0.0004 and p=0.0018, respectively). In conclusion, the therapeutic index of ifosfamide/etoposide treatment was very low and in this subset of ovarian cancer patients with platinum resistance and should be abandoned.     

New concepts and applications in the use of the insulin pump during pregnancy

Subcutaneous insulin infusion or insulin pump therapy has been advocated as an alternative to multiple dose insulin injections for nearly two decades. These devices provide insulin administration in a pattern which more closely resembles that of physiologic insulin release, a basal insulin infusion during the day and throughout the night with boluses given prior to meals. Because the number of patients using an insulin pump is increasing, it is likely the perinatologist will encounter women who are being treated with an insulin infusion pump or are considering this therapy. Insulin pump therapy requires that the patient be highly motivated and compliant. One of the most important criteria in selecting patients for this treatment is their willingness to test their capillary glucose levels 6 to 8 times each day. Interruption of the insulin infusion can produce hyperglycemia in any pump user. Should this occur in the pregnant patient, the likelihood of ketoacidosis developing is significantly greater. Ideally, insulin pump therapy should be initiated prior to pregnancy so that glucose control can be normalized, thereby reducing the risk for spontaneous abortion and fetal malformations. Gradually improving glucose control prior to pregnancy can reduce the likelihood of deterioration of retinopathy, which has been observed when poorly controlled pregnant patients rapidly become euglycemic. The published experience with the insulin pump has demonstrated that this therapy can achieve glucose control and perinatal outcomes comparable to that obtained with multiple-dose insulin injection therapy.     

Continuous glucose monitoring for the evaluation of gravid women with type 1 diabetes mellitus

OBJECTIVE: To compare the daily glycemic profile reflected by continuous and intermittent blood glucose monitoring in pregnant women with type 1 diabetes and to compare the treatment protocols based on the two monitoring methods. METHODS: The study sample consisted of 34 gravid patients at gestational weeks 16-32, with type 1 diabetes being treated by multiple insulin injections. Data derived from the continuous glucose monitoring system for 72 hours were compared with finger stick glucose measurements performed 6-8 times per day. During the study period, patients documented the time of food intake, insulin injections, and hypoglycemic events. Data on demographics, gravidity, parity, body mass index, hemoglobin A1c, and fructosamine levels were collected for each patient. RESULTS: An average (+/- standard deviation) of 780 +/- 54 glucose measurements was recorded for each patient with continuous glucose monitoring. The mean total time of hyperglycemia (glucose level greater than 140 mg/dL) undetected by the finger stick method was 192 +/- 28 minutes per day. Nocturnal hypoglycemic events (glucose level less than 50 mg/dL) were recorded in 26 patients; in all cases, there was an interval of 1-4 hours before clinical manifestations appeared or the event was revealed by random blood glucose examination. Based on the additional information obtained by continuous monitoring, the insulin therapeutic regimen was adjusted in 24 patients (70%). CONCLUSION: Continuous glucose monitoring can diagnose high postprandial blood glucose levels and nocturnal hypoglycemic events that are unrecognized by intermittent blood glucose monitoring and may serve as a basis for determining treatment regimens. A large, prospective study on maternal and neonatal outcome is needed to evaluate the clinical implications of this new monitoring technique.     

Metabolic effects of constant hypertonic glucose infusion in well-oxygenated fetuses.

In order to investigate the metabolic effects of a constant hypertonic glucose infusion in well-oxygenated fetuses, ten experiments were carried out in nine long-term experiments in fetal lambs. It appeared that a constant hypertonic glucose infusion did not significantly affect the fetal blood gases, pH, and plasma lactate levels when fetal glucose was kept below 150 mg. per 100 ml. It was also demonstrated that glucose infusions significantly increased the fetal lactate levels and decreased the blood pH when fetal plasma glucose was over 150 mg. per 100 ml. However, there was no decrease in fetal PO2 and pco2 until fetal glucose reached values over 300 mg. per 100 ml. These studies suggest that constant hypertonic glucose infusion does not improve fetal blood gases or pH and that fetal hyperglycemia over 300 mg. per 100 ml. produces severe metabolic acidosis.     

Methotrexate infusion and folinic acid as primary therapy for nonmetastatic and low-risk metastatic gestational trophoblastic tumors. 15 years of experience

OBJECTIVE: To investigate the efficacy and toxicity of methotrexate (MTX) given intravenously (i.v.) at a dose of 100 mg/m2 i.v. bolus and 200 mg/m2 infusion over 12 hours followed by folinic acid in the primary treatment of gestational trophoblastic tumors (GTTs). STUDY DESIGN: We reviewed the records of patients at the New England Trophoblastic Disease Center who had received MTX infusion at a dose of 100 mg/m2 i.v. bolus and 200 mg/m2 infusion over 12 hours followed by folinic acid as primary therapy for GTTs that did not resolve with uterine evacuation alone. Data on the patients' age, gravity and parity, disease stage (by FIGO and WHO criteria), antecedent pregnancy, presenting level of hCG, metastatic status, courses of chemotherapy required to achieve remission, toxicity related to chemotherapy treatments and time to normalization of hCG were recorded. RESULTS: One hundred ninety-two patients with persistent GTTs were treated with the MTX infusion protocol between December 1985 and December 2000. One hundred twenty-four patients (64.6%) achieved complete remission with the MTX infusion protocol. Complete remission was induced in 108 (87.1%) with a single course of chemotherapy; 12 others achieved remission with a single additional course of MTX. All patients found to be resistant to MTX therapy later achieved remission with other chemotherapy. Minimal toxicity was experienced during MTX treatment. CONCLUSION: MTX infusion with folinic acid is effective and well tolerated as primary single-agent therapy for nonmetastatic and low-risk metastatic GTT.     

Evaluation of serum ischemia-modified albumin levels in pregnant women with and without gestational diabetes mellitus

Objective. To investigate serum ischemia-modified albumin (IMA) levels in gestational diabetes mellitus and the effect of treatment with continuous subcutaneous insulin infusion on the biomarker. Methods. The gestational diabetes mellitus women in the second trimester were evaluated before and after the two kinds of treatments with continuous subcutaneous insulin infusion and medical nutrition therapy for 6 weeks. Maternal serum ischemia-modified albumin and metabolic parameters were measured at baseline and at the 6th week. Results.Serum ischemia-modified albumin levels and metabolic parameters were higher in patients with gestational diabetes mellitus at baseline than in controls. Ischemia-modified albumin levels were correlated with plasma glucose (p < 0.05). Variables of glycemic control and ischemia-modified albumin levels were significantly reduced at the 6th week. The effect of insulin treatment was generally better than diet therapy. Linear regression analysis showed that fasting plasma glucose was an independent determinant for IMA levels (β = 0.611, p = 0.035).Fetal outcome was similar except for macrosomia and Apgar score at 5 min. Conclusion.Serum ischemia-modified albumin levels were higher in gestational diabetes mellitus compared to normal pregnancy. Continuous subcutaneous insulin infusion consistently improved metabolic disorder control. Gestational diabetes mellitus women were associated to a higher risk of oxidative stress and pregnancy complications.     

Significance of amniotic fluid glucose in pregnancy

Amniotic fluid glucose values were measured in 285 women with normal and abnormal pregnancies. A progressive decrease in glucose values was observed with advancing gestation. Complications in pregnancy did not influence the amniotic fluid glucose value for the given gestational age. In patients with diabetes, very high levels were found, but these progressively decreased with advancing gestation. Since abnormal conditions in pregnancy, other than diabetes, do not affect the amniotic fluid glucose level, it seems to be a reliable tool in assessing fetal maturity. Values above 15 mg/100 ml rule out term pregnancies and those below 5 mg/100 ml, prematurity.     

Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis

Perinatal glucose, insulin, and sodium homeostases were assessed in relation to antepartum intravenous infusions administered to 59 normal mothers undergoing cesarean section at term without labor under epidural anesthesia. Group A (N = 20) received 1 L of Ringer's lactate without dextrose during one hour; group B (N = 20), 1 L of 5% dextrose in water during one hour; and group C (N = 19), 1 L of 5% dextrose in water during two and one half hours. Mean maternal and fetal serum glucose and insulin and sodium concentrations at delivery differed among all groups in direct relationship to the rate of glucose infusion. Neonatal hypoglycemia (30 mg/dL or less) correlated with the presence of a glucose infusion, a maternal glucose concentration of 117 mg/dL or greater, and an umbilical venous insulin concentration of 26 microU/mL or greater. Among group A patients who received sodium, and group B and C patients who did not, fetal hyponatremia (umbilical venous sodium 130 mEq/L or less) correlated with the absence of sodium in the prepartum infusion. The results suggest that the antepartum administration of a balanced electrolyte solution without excess glucose infusion can minimize the incidence of fetal hyperglycemia and hyponatremia and neonatal hypoglycemia.     

Defibrination syndrome after intra-amniotic infusion of hypertonic saline

To determine the role of changes in coagulation factors in hermorrhagic complications after intraamniotic infusion of hypertonic saline for therapeutic abortion, 21 women undergoing this operation, ranging 15-38 years in age with an average gestation of 18 weeks, were studied for coagulation factors, fibrinogen survival, and plasma volume. Blood tests were taken before, immediately after, and at 3-hour intervals after infusion of hypertonic saline. Significant changes were found in the following factors: Thrombin clotting time was consistently prolonged from the third hour after infusion. The platelet count dropped significantly from 310,000/cu. mm before infusion to 223,000/cu. mm 18 hours later. Fibrinogen levels dropped significantly from a mean preinfusion level of 393 mg/100 ml to 297 mg/100 ml at 18 hours. Factor VIII levels also fell significantly from 131% of normal at preinfusion to 85% of normal at 6 hours. Factor V levels declined significantly from a preinfusion mean of 104% of normal to 91% at 6 hours, though the rate of decrease varied widely among the patients. Fibrinogan/fibrin, degradation products, negative at preinfusion, appeared in all patients serums. Euglobulin lysis time was not accelerated. Fibrinogen survival studies were conducted in only 5 patients, 4 of whom showed a significant decrease, notably immediately preceding abortion, with a highly significant correlation to the time from infusion. Plasma volume increased significantly with a corresponding decrease in hematocrit. It is concluded that a mild form of diffuse intravascular coagulation develops after the intraamniotic infusion of hypertonic saline, but further research is necessary to pinpoint the cause of serious coagulopathy and hemorrhage.     

羟苄羟麻黄碱用于前置胎盘的期待治疗

目的探讨β２肾上腺素能受体兴奋剂羟苄羟麻黄碱期待治疗前置胎盘的效果。方法将５０例未足月前置胎盘患者随机分为两组,对照组２６例,采用硫酸镁治疗;治疗组２４例,采用羟苄羟麻黄碱治疗,将羟苄羟麻黄碱１００ｍｇ加５％葡萄糖５００ｍｌ静脉滴注,从每分钟８滴开始,根据疗效调节药物用量,待阴道流血停止、无宫缩后,继续维持１２小时,以后改口服,病情反复者可重复用药。结果治疗组延长孕期平均２８．２４天,新生儿出生体重平均２９１３．６８ｇ,与对照组比较,差异有显著性（Ｐ值均＜０．０５）。结论羟苄羟麻黄碱用于前置胎盘期待治疗效果显著、安全。     

Ambroxol in comparison with betamethasone for the stimulation of antepartal lung maturity. A clinical double-blind study

Stimulation of the surfactant production in fetal cells by ambroxol (metabolite VIII of bromhexine) has been investigated in human and animal experiments. There are no contraindications for the prenatal use of ambroxol, which is also well tolerated in high dose. Therefore the 1st Department of Obstetrics and Gynecology in Vienna took part in a multicentric clinical trial, where the allocation between cortisone and ambroxol was randomised in a double blind fashion. The 1st Department included 34 women between 30 and 36 weeks of pregnancy with premature labour or indicated premature induction. Amniotic fluid samples were taken by amniocentesis before therapy to prove lung immaturity by measurement of the L/S ratio and the dynamic surface tension. Following doses were used for this clinical trial group A: 1,000 mg ambroxol in 500 ml 5% glucose infusion i.v. daily from day 1 to day 5 and 2 ml placebo-injection i.m. on day 1 and day 2, group B: 8 mg Betamethasone i.m. on day 1 and day 2 and 500 ml 5% glucose infusion with a placebo daily from day 1 to day 5. The patients were treated at least 3 days; in all cases amniotic fluid samples were taken after therapy, to examine the L/S ratio and the dynamic surface tension. 29 women of the 34 fulfilled the above criteria, 15 in group A and 14 in group B (1 twin pregnancy). With the pretreatment parameters of lung maturity being similar in both groups ambroxol was found to lead to a marked but not significant improvement of the L/S ratio and the surface tension.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relationship between maternal and fetal plasma glucose and insulin concentrations during graded maternal hyperglycemic states in primates

Our goal was to conduct a controlled study using an established timed-pregnant baboon model to describe the maternal and fetal plasma glucose and insulin concentrations during graded increases in maternal circulating glucose levels. Timed-pregnant baboons were operated on during the second half of pregnancy, and after recovery from surgery, maternal glucose infusions were started. To determine changes in plasma glucose and insulin concentrations, maternal and fetal blood samples were obtained before glucose infusion and at 30-minute intervals to include 30 minutes postinfusion. Maternal plasma glucose concentrations ranged from 97 to 392 mg/dL and fetal plasma glucose concentrations from 78 to 278 mg/dL. Maternal plasma insulin concentrations ranged from 123 to 1384 U/mL, and the fetal plasma insulin concentrations from 76 to 260 U/mL. Significant correlations were noted between maternal plasma glucose and insulin concentrations (N = 10; R(2), 80%; P < 0.001), as well as maternal and fetal plasma glucose concentrations (N = 10; R(2), 97%; P < 0.001). Maternal-to-fetal glucose gradient ranged from 16 to 34% (mean, 23%) and did not correlate with maternal plasma glucose concentration. No correlation was found between fetal plasma glucose and insulin concentration. Maternal-to-fetal insulin gradient ranged from 31 to 87% (mean, 70.7%) and was significantly different from the glucose gradient ( P < 0.0001). Results from this study suggests that (1) there is a relatively steady transplacental glucose transfer during the second half of pregnancy at maternal plasma glucose concentrations ranging from 97 to 392 mg/dL; and (2) there is also a relative incapacity of the fetal pancreas, compared with the maternal pancreas, to respond to graded increases of hyperglycemia. Studies aimed at determining whether particular thresholds of maternal hyperglycemia at different gestational ages can lead to transitory hyperosmolar and polyuric fetal states could provide further insights into the mechanisms leading to idiopathic polyhydramnios.     

C-peptide and insulin levels at 24-30 weeks' gestation: an increased risk of adverse pregnancy outcomes?

OBJECTIVE: The hypothesis was that fasting C-peptide and insulin values, during an oral glucose tolerance test (OGTT), might allow an estimation of the increased risk for gestational hypertension (GH) and fetal macrosomia. STUDY DESIGN: Two-hundred and six consecutive patients were submitted to an OGTT. Thirty-five developed gestational hypertension and 29 delivered large-for-gestational-age (LGA) newborns. Plasma glucose levels (mg/dl) and insulin levels (microU/ml) were measured fasting and after 60, 120 and 180 min C-peptide fasting levels (ng/ml) were also measured. RESULTS: Twenty-five patients were excluded, 181 were enrolled. According to the OGTT, 143 patients were classified as normal, 26 were found affected by gestational diabetes (GD) mellitus, and 12 had impaired gestational glucose tolerance (IGGT). Hypertensive women exhibited higher 60 and 120 min insulin values than the normotensive group (128.3+/-69.9 microU/ml versus 86.2+/-58.3 microU/ml, P<0.05; 104.9+/-66.4 microU/ml versus 78.7+/-56.5 microU/ml, P<0.05).C-peptide cut-off at 2.9 ng/ml resulted predictive for patients delivering large-for-gestational-age newborns (OR=3.42, 95% CI=1.59-7.39). CONCLUSIONS: C-peptide and insulin may be used as indicators of risk for the development of complications in late pregnancy.