Glycemic Control In Pregnancy Research Articles

Systematic Literature Review of Basal Bolus Insulin Analogue Therapy during Pregnancy

Currently standard insulin therapy for pregnancies complicated by diabetes mellitus (DM) is a combination of intermediate Neutral Protamine Hagedorn (NPH) and regular human insulin. In contrast, for non-pregnant individuals with diabetes, standard insulin therapy is basal bolus therapy (BBT) using a combination of rapid- and long-acting insulin analogues designed to mimic physiologic biphasic insulin secretion by the pancreatic beta cells. Although there are published reports describing use of BBT during pregnancy, due to the lack of strong clinical evidence regarding safety and efficacy of BBT during pregnancy, its use has not been adopted as standard insulin administration during pregnancies complicated by diabetes mellitus. To evaluate the evidence for this discrepant clinical management, we conducted a systematic review. Search strategy and selection criteria: PubMed, Medline, Cochrane Database of Systematic Reviews for publications between 1996 and 2014. Search terms: lispro, apart, glargine, detemir, glulisine, Humalog, NovoLog, Lantus, Levemir, Apidra, pregnancy, and diabetes. Included: randomized clinical trials, prospective and retrospective cohort analyses, case-control studies and case series and reports. Search limited to human studies and English language. Excluded: review articles. Nineteen studies were identified that assessed safety/efficacy of rapid-acting insulin analogues, lispro and aspart, and 23 studies that assessed the long-acting insulin analogues, glargine and detemir, in pregnant patients complicated with pregestational (PGDM) and gestational diabetes mellitus (GDM). The principal efficacy endpoint examined in the selected studies was glycated hemoglobin levels. Other study outcome variables to assess maternal glycemic control included fasting and postprandial glucose levels, large for gestational age (LGA) infants, mean birth weight, congenital malformations, and incidence of hypoglycemic events. Compared to conventional insulin therapy, insulin analogue use provided similar overall glycemic control in pregnancy. In addition, they contributed to greater postprandial glucose control. There was no compelling evidence that insulin analogue use was associated with any significant differences in maternal and neonatal outcomes, particularly in terms of incidences in maternal and neonatal hypoglycemia, LGA, and congenital malformations. Given the documented benefits of physiological insulin replacement, we found no reason that BBT should not be standard prenatal care for pregnancies complicated by DM.

1,5-Anhydroglucitol: a new predictor of neonatal birth weight in diabetic pregnancies

ObjectiveTo determine whether 1,5-anhydroglucitol is predictive of neonatal birth weight. Study designA retrospective cohort study including 85 pregnancies complicated by diabetes (Type 1=37, Type 2=24, gestational=24). Women had simultaneous hemoglobin A1c and 1,5-anhydroglucitol measurements every 4–8 weeks throughout pregnancy until delivery. Neonatal birth weight was evaluated by standardized z-scores. Linear regression analysis was performed to determine an association of 1,5-anhydroglucitol with neonatal birth weight z-score. ResultsType 1 diabetic patients had the lowest mean 1,5-anhydroglucitol of 3.5mcg/mL (SD=1.6mcg/mL) and highest mean hemoglobin A1c of 6.5% (SD=0.74%) compared to gestational diabetic patients who had the highest mean 1,5-anhydroglucitol of 6.7mcg/mL (SD=3.8mcg/mL) and lowest mean hemoglobin A1c of 6.0% (SD=0.94%). Mean 1,5-anhydroglucitol values were significantly different between diabetes types (p<0.01). Mean neonatal birth weight was above population averages for all diabetes classifications, although mean birth weight z-scores did not differ significantly between diabetic types (p=0.38). Multivariate linear regression showed a negative association between log-transformed 1,5-anhydroglucitol and birth weight (coefficient −0.82, 95% CI −1.19, −0.46). ConclusionIn pregnancies complicated by diabetes, low 1,5-anhydroglucitol was associated with increased neonatal birth weight. 1,5-Anhydroglucitol may be useful in the assessment of glycemic control in pregnancy in addition to A1c.

Glycemic targets in pregnancies affected by diabetes: historical perspective and future directions.

The definition of optimal glycemic control in pregnancies affected by diabetes remains enigmatic. Diabetes phenotypes are heterogeneous. Moreover, fetal macrosomia insidiously occurs even with excellent glycemic control. Current blood glucose (BG) targets (FBG ≤95, 1-h post-prandial <140, 2 h <120 mg/dL) have improved perinatal outcomes, but arguably they have not normalized. The conventional management approach has been to replicate a pattern of glycemia in normal pregnancy. Although these patterns are lower than previously appreciated, a randomized controlled trial (RCT) has never compared current vs. lower glucose targets powered on maternal/fetal outcomes. This paper provides historical context to the current targets by reviewing evidence supporting their evolution. Using lower targets (FBG <90, 1 h <122, 2 h <110, mean BG ≤95 mg/dL) may help normalize outcomes, but phenotypic differences (type 1 vs. type 2 vs. gestational diabetes) might require different glycemic goals. There remains a critical need for well-designed RCTs to confirm optimal glycemic control that minimizes both small for and large for gestational age across pregnancies affected by diabetes.

Exploring the Relationship Between Increased Arterial Stiffness and Myocardial Hypertrophy in Infants of Diabetic Mothers

We have previously shown that infants of diabetic mothers (IDM) have increased aortic stiffness in the first 6 months of life, and aortic stiffness is related to poor maternal glycemic control in pregnancy. Increased left ventricular (LV) posterior (LVPW) and interventricular septal (IVS) wall thickness is observed in IDM in late gestation and early infancy, predominantly in mothers with worse glycemic control. Although it is generally believed that the LV hypertrophy in IDM regresses after the first 3 months, we have recently shown that hypertrophy persists even in late infancy. In this study we sought to explore the relationship between aortic stiffness and LV hypertrophy in IDM. We hypothesized that LVPW and IVS wall thickness would be greater in infants with greater aortic stiffness.

Prevalence and Significance of Late Gadolinium Enhancement in Children and Adolescents With Hypertrophic Cardiomyopathy

s S97 BACKGROUND: We have previously shown that infants of diabetic mothers (IDM) have increased aortic stiffness in the first 6 months of life, and aortic stiffness is related to poor maternal glycemic control in pregnancy. Increased left ventricular (LV) posterior (LVPW) and interventricular septal (IVS) wall thickness is observed in IDM in late gestation and early infancy, predominantly in mothers with worse glycemic control. Although it is generally believed that the LV hypertrophy in IDM regresses after the first 3 months, we have recently shown that hypertrophy persists even in late infancy. In this study we sought to explore the relationship between aortic stiffness and LV hypertrophy in IDM. We hypothesized that LVPW and IVS wall thickness would be greater in infants with greater aortic stiffness. METHODS: Diabetic pregnancies were prospectively recruited in the mid trimester. Their infants were evaluated in infancy by echocardiography. LVPW and IVS wall thickness was measured by m mode and measurements were compared to normative data for the calculation of z scores based on body surface area. Aortic wall stiffness was assessed with echocardiography, using 2D and pulsed Doppler interrogation of the ascending aorta and distal arch. Aortic pulse wave velocity (PWV) was calculated as the distance from the ascending aorta to distal arch, divided by the time interval from the QRS to the onset of flow for the two interrogated sites (m/s). RESULTS: Twenty-one IDM were investigated at a median age of 7 weeks (range 2-48 weeks). Mean aortic PWV was 4.7 1.7m/s, and the mean IVS and LVPW z scores were 1.3 1.2 and LVPW 1.4 1.1, respectively. Although no relationship was observed between PWV and IVS, there was a weak but positive correlation between aortic PWV and LVPW z score (r1⁄40.50, p1⁄40.027). CONCLUSION: Our study suggests that a potential relationship exists between the degree of stiffness of the aorta and LV wall thickness. This could be due to a common prenatal exposure (hyperglycemia) or to a causal relationship (greater aortic stiffness leading to evolution or persistence of LV hypertrophy). Further studies are underway to determine the etiology of increased aortic stiffness and LV hypertrophy and the natural course of these changes. 025 PREVALENCE AND SIGNIFICANCE OF LATE GADOLINIUM ENHANCEMENT IN CHILDREN AND ADOLESCENTS WITH HYPERTROPHIC CARDIOMYOPATHY L Grosse-Wortmann, J Windram, D Andreea, S Yoo, L Mertens, D Wong, L Benson

Three-Dimensional Echocardiographic Assessment of the Longitudinal Tricuspid Valve Changes Associated With Tricuspid Regurgitation in Hypoplastic Left Heart Syndrome

s S97 BACKGROUND: We have previously shown that infants of diabetic mothers (IDM) have increased aortic stiffness in the first 6 months of life, and aortic stiffness is related to poor maternal glycemic control in pregnancy. Increased left ventricular (LV) posterior (LVPW) and interventricular septal (IVS) wall thickness is observed in IDM in late gestation and early infancy, predominantly in mothers with worse glycemic control. Although it is generally believed that the LV hypertrophy in IDM regresses after the first 3 months, we have recently shown that hypertrophy persists even in late infancy. In this study we sought to explore the relationship between aortic stiffness and LV hypertrophy in IDM. We hypothesized that LVPW and IVS wall thickness would be greater in infants with greater aortic stiffness. METHODS: Diabetic pregnancies were prospectively recruited in the mid trimester. Their infants were evaluated in infancy by echocardiography. LVPW and IVS wall thickness was measured by m mode and measurements were compared to normative data for the calculation of z scores based on body surface area. Aortic wall stiffness was assessed with echocardiography, using 2D and pulsed Doppler interrogation of the ascending aorta and distal arch. Aortic pulse wave velocity (PWV) was calculated as the distance from the ascending aorta to distal arch, divided by the time interval from the QRS to the onset of flow for the two interrogated sites (m/s). RESULTS: Twenty-one IDM were investigated at a median age of 7 weeks (range 2-48 weeks). Mean aortic PWV was 4.7 1.7m/s, and the mean IVS and LVPW z scores were 1.3 1.2 and LVPW 1.4 1.1, respectively. Although no relationship was observed between PWV and IVS, there was a weak but positive correlation between aortic PWV and LVPW z score (r1⁄40.50, p1⁄40.027). CONCLUSION: Our study suggests that a potential relationship exists between the degree of stiffness of the aorta and LV wall thickness. This could be due to a common prenatal exposure (hyperglycemia) or to a causal relationship (greater aortic stiffness leading to evolution or persistence of LV hypertrophy). Further studies are underway to determine the etiology of increased aortic stiffness and LV hypertrophy and the natural course of these changes. 025 PREVALENCE AND SIGNIFICANCE OF LATE GADOLINIUM ENHANCEMENT IN CHILDREN AND ADOLESCENTS WITH HYPERTROPHIC CARDIOMYOPATHY L Grosse-Wortmann, J Windram, D Andreea, S Yoo, L Mertens, D Wong, L Benson

Effect of Home Blood Glucose Telemonitoring with Self-Care Support on Glycemic Control in Pregnancy

Effect of Home Blood Glucose Telemonitoring with Self-Care Support on Glycemic Control in Pregnancy

Effect of Home Blood Glucose Telemonitoring with Self-Care Support on Glycemic Control in Pregnancy

Effect of Home Blood Glucose Telemonitoring with Self-Care Support on Glycemic Control in Pregnancy

Effect of Home Blood Glucose Telemonitoring with Self-Care Support on Glycemic Control in Pregnancy

Effect of Home Blood Glucose Telemonitoring with Self-Care Support on Glycemic Control in Pregnancy

Fetal Macrosomia and Shoulder Dystocia in Women with Gestational Diabetes: Risks Amenable to Treatment?

Fetal macrosomia and maternal diabetes are independent risk factors for shoulder dystocia, an obstetrical emergency that may cause permanent neonatal injury. Randomized trials of glycemic control in pregnancies complicated by gestational diabetes reveal decreased rates of macrosomia and shoulder dystocia among those treated. However, definitions of gestational diabetes vary and a specific glycemic threshold for clinically significant risk reduction remains to be delineated. This review discusses risks associated with gestational diabetes including macrosomia (birth weight above 4000-4500 g) and delivery-related morbidity, specifically, shoulder dystocia. Subsequently, we will review recent randomized trials assessing the impact of glycemic control on these delivery-related morbidities. Finally, we will examine a large observational study that found associations with delivery-related morbidity and hyperglycemia below current diabetic thresholds, observations which may suggest reexamination of current diagnosis guidelines for gestational diabetes.

Role of glycemic variability in gestational diabetes mellitus (GDM): still an uphill climb

Insulin resistance tends to increase in physiological pregnancy because of the gradually rising levels of feto-placental hormones such as progesterone, cortisol, growth hormone, prolactin, and human placental lactogen. In response to this imbalance, the pancreas normally compensates with a higher insulin secretion. When this compensatory mechanism fails, glucose intolerance develops and, in pregnancy, this is called gestational diabetes mellitus (GDM) [1]. The resulting maternal hyperglycemia gives rise to a concomitant fetal hyperinsulinemia via the placenta, leading primarily to fetal macrosomia, which is the main cause of well-known complications relating to the fetus’s development (e.g., shoulder dystocia, Erb’s paralysis, hypoxia, and acidosis) and to the course of labor (e.g., perineal laceration, cesarean section) [2]. Clinical evidence has confirmed that the main goal of glycemic management in GDM is to keep the mother’s blood glucose levels as close as possible to the normal range. A number of studies have demonstrated that macrosomia correlate with glycemic control in pregnancy complicated by diabetes [3]. It has recently been suggested that glucose variability, characterized by significant glucose excursions, may overlap with HbA1c levels in determining the risk of diabetes-related complications [4]. Oscillating blood sugar levels have been shown to increase free radicals and endothelial dysfunction, which are the links between hyperglycemia and the activation of pathological pathways that lead to tissue damage [5], and it has been reported that containing these hyperglycemic spikes coincides with a reduction in some markers of oxidative stress. In pregnancy complicated by diabetes even transient periods of hyperglycemia may lead to accelerated fetal growth, resulting in macrosomic infants. These peaks are difficult to capture using common glucose monitoring methods based on six to eight glucose measurements a day, whereas continuous glucose monitoring (CGM) systems are more revealing because they enable glucose levels to be monitored constantly throughout the day [6]. Despite recent opportunities to shed further light on the subject, glucose variability is still a poorly understood factor in GDM patients, especially its link with maternal and fetal complications. In one study, 48-h CGM was performed in all three trimesters in 31 women with GDM, and showed a close relationship between babies’ ponderal index and their mothers’ glucose variability indicators and mean glycemia in the 2nd trimester, irrespective of their HbA1c levels. This study emphasized that fetal growth in the early stages of gestation could be affected even in patients whose glycemic variability indices were only slightly higher than in controls [7]. In this issue of Endocrine, Su et al. [8] set out to use 72-h CGM to analyze several glycemic variability parameters in 30 patients with GDM, as compared with 20 healthy pregnant women and 20 healthy non-pregnant women, seeking a possible association with markers of beta-cell function. As indicators of glucose variability, they took into account the mean amplitude of glycemic excursion (MAGE), the mean of daily differences (MODD), and the standard deviation of blood glucose (SDBG); the HOMA-IR index was calculated to assess insulin resistance. The early insulinogenic index (DI30/DG30) and the area under the curve of insulin (AUCI 180) derived from 75 g oral glucose tolerance test (OGTT) were calculated to A. Lapolla (&) N. C. Chilelli Department of Medicine (DIMED), University of Padua, Via Giustiniani n 2, 35128 Padua, Italy e-mail: annunziata.lapolla@unipd.it

Timing of screening for gestational diabetes mellitus in women with moderate and severe obesity

We evaluated screening with a diagnostic oral glucose tolerance test earlier than 20 weeks gestation in women with moderate to severe obesity. Prospective observational study. Large university teaching hospital. We enrolled 100 women booking for antenatal care in the first trimester at their convenience. Height and weight were measured and body mass index calculated. Only women with a body mass index > 34.9 kg/m(2) were included. Women were booked for a 100 g oral glucose tolerance test before 20 weeks and, if normal, another test at 28 weeks gestation. Impaired glucose tolerance and gestational diabetes mellitus. Of the 100 women given an appointment for an oral glucose tolerance test before 20 weeks gestation, 92 attended. Of these, 10 (10.8%) women had an abnormal result, with impaired glucose tolerance in five (5.4%) cases and gestational diabetes mellitus in five (5.4%) cases. Of those with a normal result at 20 weeks, 81 attended for a repeat test at 28 weeks gestation. A further four (4.9%) had impaired glucose tolerance and four (4.9%) had gestational diabetes mellitus. A total of 18 (20.5%) of the 88 women who complied with screening had an abnormal test. Women who have moderate/severe obesity have a one in five chance of having an abnormal diagnostic oral glucose tolerance test when screened for gestational diabetes mellitus. To optimize maternal glycemic control in pregnancy, we suggest that women with a body mass index > 34.9 kg/m(2) may need to be screened early in pregnancy and, if the test is normal, again at 28 weeks gestation.

Associação entre perfil glicêmico materno e o índice de líquido amniótico em gestações complicadas pelo Diabetes mellituspré-gestacional

to study the relation between amniotic fluid volume and glycemic control in pregnancies complicated by diabetes mellitus type 1 and 2, followed in a specialized multidisciplinary prenatal care service. This descriptive study was performed between January 2001 and December 2004. Inclusion criteria were: simple pregnancy, diagnosis of pregestational diabetes, beginning of prenatal care before the 26th week and absence of fetal anomaly. Cases with newborns small for gestational age were excluded. The amniotic fluid index (AFI) was measured weekly, beginning at the 27th week of gestation and continued until delivery and the maternal glycemic profile was obtained a week before ultrasound assessment. This profile consisted of the glycemic level averages and percentages of the abnormal high values. Correlation between the glycemic profile and the AFI was shown by the Spearman correlation test. Sixty pregnant women were assessed and 659 correlations between the AFI and glycemic profile were obtained. No correlation was observed in any of the gestational weeks studied. The mean glycemic value was 103.69 mg/dl (SD=13.69) in the group with AFI pound18 cm, and the 103.67 mg/dl (SD=11.46) in the group with AFI < 18 cm and no significant difference was detected. This study showed no correlation between AFI and maternal glycemic profile during the third trimester in type 1 and 2 diabetic pregnant women, undergoing standardized treatment and rigorous metabolic control.

A1C but Not Serum Glycated Albumin Is Elevated in Late Pregnancy Owing to Iron Deficiency

OBJECTIVE—A1C levels have been shown to be elevated in relation to glycemia in late pregnancy, although the precise mechanisms remain undetermined. We hypothesized that iron deficiency is involved in the A1C increase in late pregnancy.RESEARCH DESIGN AND METHODS—In study 1, A1C, serum glycated albumin, erythrocyte indexes, and iron metabolism indexes were determined in 47 nondiabetic pregnant women not receiving iron supplementation who were divided into four groups according to gestational period (group I, 21–24 weeks; group II, 25–28 weeks; group III, 29–32 weeks; and group IV, 33–36 weeks). In study 2, these determinants were obtained at two gestational periods (20–23 weeks and 32–33 weeks) in 17 nondiabetic pregnant women.RESULTS—In study 1, A1C levels were higher in groups III and IV than those in groups I and II, whereas serum glycated albumin levels were not different among these four groups. Hemoglobin, mean corpuscular hemoglobin (MCH), serum transferrin saturation, and serum ferritin were lower in groups III and IV. A1C levels were negatively correlated with MCH, serum transferrin saturation, and serum ferritin. In study 2, A1C levels were significantly increased at gestational weeks 32–33 from those at weeks 20–23, whereas serum glycated albumin levels did not differ between the two gestational periods. MCH, serum transferrin saturation, and serum ferritin were decreased at gestational weeks 32–33. A1C levels showed a negative correlation with MCH, serum transferrin saturation, and serum ferritin.CONCLUSIONS—A1C levels were elevated in late pregnancy owing to iron deficiency. Serum glycated albumin may offer a better index for monitoring glycemic control in pregnancy.

The Clinical Significance of IGF-I in Maternal Serum During Pregnancy in Type 1 Diabetes

Insulin-like growth factors (IGFs) constitute a system of peptides that promote mitosis, growth, and organ development by both paracrine and endocrine pathways, their bioavailability being modulated by at least six specific IGF-binding proteins (IGFBP). In type 1 diabetic pregnancies IGF-I and -II in maternal serum are associated with birth weight and their action modulated by IGFBP-3 and phosphorylated isoforms of IGFBP-1. Pregnancy-associated plasma protein-A (PAPP-A), a proteolytic substance of IGFBPs, is probably a modulator in early diabetic pregnancy while human placental growth hormone (hPGH) regulates the effect of IGF-I in pregnancy of diabetic and non-diabetic pregnancies. IGF-I in maternal serum increases concomitantly with progression of diabetic retinopathy despite good glycemic control in pregnancy. The role of the new insulin analogues in improving this effect has yet to be established. Retinopathy in pregnancy is associated with an elevated level of fibroblast growth factor-2 (FGF-2) and highly-phosphorylated IGFBP-1, the latter further increasing the level of free IGF-I and FGF-2. Thus, the effect on development of retinopathy may be directly mediated by IGF-I or indirectly by a modifying effect of IGFBP-3 and phosphorylated isoforms of IGFBP-1 with FGF-2 as a mediator.

Diurnal glycemic profile in obese and normal weight nondiabetic pregnant women

A paucity of data exists concerning the normal glycemic profile in nondiabetic pregnancies. Using a novel approach that provides continuous measurement of blood glucose, we sought to evaluate the ambulatory daily glycemic profile in the second half of pregnancy in nondiabetic women. Fifty-seven obese and normal weight nondiabetic subjects were evaluated for 72 consecutive hours with continuous glucose monitoring by measurement interstitial glucose levels in subcutaneous tissue every 5 minutes. Subjects were instructed not to modify their lifestyle or to follow any dietary restriction. For each woman, mean and fasting blood glucose values were determined; for each meal during the study period, the first 180 minutes were analyzed. For the study group, the fasting blood glucose level was 75 +/- 12 mg/dL; the mean blood glucose level was 83.7 +/- 18 mg/dL; the postprandial peak glucose value level was 110 +/- 16 mg/dL, and the time interval that was needed to reach peak postprandial glucose level was 70 +/- 13 minutes. A similar postprandial glycemic profile was obtained for breakfast, lunch, and dinner. Obese women were characterized by a significantly higher postprandial glucose peak value, increased 1- and 2-hour postprandial glucose levels, increased time interval for glucose peak, and significantly lower mean blood glucose during the night. No difference was found in fasting and mean blood glucose between obese and nonobese subjects. Glycemic profile characterization in both obese and normal weight nondiabetic subjects provide a measure for the desired level of glycemic control in pregnancy that is complicated with diabetes mellitus.

Use of insulin pumps in pregnancies complicated by type 2 diabetes and gestational diabetes in a multiethnic community.

To describe the use of insulin pump therapy in women with gestational diabetes mellitus (GDM) or type 2 diabetes in pregnancy and persistent hyperglycemia despite multiple injections of subcutaneous insulin. As part of a service audit, deliveries to women with diabetes at a single South Auckland hospital were reviewed from 1991 through 1994. Glycemic control was estimated by the mean of self-recorded and laboratory postprandial glucose concentrations. In a nested case-control study, pregnancies complicated by GDM/type 2 diabetes with use of an insulin pump were compared with those without insulin pump therapy and peak insulin requirements of 100-199 units/ day, matched for ethnicity and type of diabetes. A total of 30 of 251 Polynesian, European, and South Asian women with singleton pregnancies complicated by insulin-requiring GDM/type 2 diabetes used an insulin pump. An additional two women with high insulin requirements discontinued pump therapy. None of the women with GDM/type 2 diabetes experienced severe hypoglycemia, whereas 79% of the women had improved glycemic control within 1-4 weeks. Mothers using a pump had greater insulin requirements (median maximum 246 vs. 130 units per day) and greater weight gain (10.6 vs. 5.0 kg). Their babies were more likely to be admitted to the Special Care Baby Unit but were neither significantly heavier nor experienced greater hypoglycemia than control subjects. Insulin pump therapy seems to be safe and effective for maintaining glycemic control in pregnancies complicated by GDM/type 2 diabetes and requiring large doses of insulin.

Metabolic Changes in Diabetic and Nondiabetic Subjects During Pregnancy

Diabetes mellitus with its resulting derangement of various metabolic fuels, carbohydrates, amino acids, lipids, and ketones has the potential to adversely affect the developing fetus. Therefore, strict glycemic control in pregnancy has become the standard of care in modern obstetrics. A considerable amount of research has been undertaken into the metabolic changes that occur during pregnancy in both women with insulin-dependent diabetes and gestational diabetes. This paper will review current research in normal and diabetic pregnancies both in the fasting and fed states as well as during episodes of hypoglycemia. In normal pregnancy insulin secretion increases throughout gestation whereas peripheral insulin sensitivity is decreased. Fasting levels of plasma glucose are reduced by approximately 10 per cent during the first trimester. Maternal amino acid levels are also reduced in normal pregnancy, although cholesterol and triglyceride levels are increased, most dramatically in the second trimester. As gestation advances, progressively increasing amounts of insulin antagonistic hormones are secreted by the placenta. This leads to gestational diabetes in 2 to 3 per cent of women who exhibit hyperglycemia despite an increased insulin response to oral glucose as well as an increased insulin/glucagon ratio. In insulin dependent diabetes mellitus, the insulin-deficient state results in fasting and postprandial hyperaminoacidemia, hyperlipidemia, and hyperglycemia. These metabolic changes and the resulting hyperglycemic milieu can lead to fetal macrosomia that will result in maternal and fetal morbidity. Therefore, normalization of these fuels with the use of intensive insulin regimens is the goal of therapy during pregnancy.

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

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

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

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