Maternal Blood Glucose Values Research Articles

Fetal biometry for guiding the medical management of women with gestational diabetes mellitus for improving maternal and perinatal health.

Gestational diabetes mellitus (GDM) is a common medical condition that complicates pregnancy and causes adverse maternal and fetal outcomes. At present, most treatment strategies focus on normalisation of maternal blood glucose values with use of diet, lifestyle modification, exercise, oral anti-hyperglycaemics and insulin. This has been shown to reduce the incidence of adverse outcomes, such as birth trauma and macrosomia. However, this involves intensive monitoring and treatment of all women with GDM. We propose that using medical imaging to identify pregnancies displaying signs of being affected by GDM could help to target management, allowing low-risk women to be spared excessive intervention, and facilitating better resource allocation. We wanted to address the following question: in women with gestational diabetes, does the use of fetal imaging plus maternal blood glucose concentration to indicate the need for medical management compared with glucose concentration alone reduce the risk of adverse perinatal outcomes? We searched Cochrane Pregnancy and Childbirth's Trials Register (29 January 2019), ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (both on 29 January 2019), and reference lists of retrieved studies. Randomised controlled trials, including those published in abstract form only. Studies using a cluster-randomised design and quasi-randomised controlled trials were both eligible for inclusion, but we didn't identify any. Cross-over trials were not eligible for inclusion in our review.We included women carrying singleton pregnancies who were diagnosed with GDM, as defined by the trials' authors. The intervention of interest was the use of fetal biometry on imaging methods in addition to maternal glycaemic values for indicating the use of medical therapy for GDM. The control group was the use of maternal glycaemic values alone for indicating the use of such therapy. Two review authors independently assessed trials for inclusion and assessed risk of bias. Two review authors extracted data and checked them for accuracy. Three randomised controlled trials met the inclusion criteria for our systematic review - the studies randomised a total of 524 women.We assessed the three included studies as being at a low to moderate risk of bias; the nature of the intervention made it difficult to achieve blinding of participants and personnel and none of the trial reports contained information about methods of allocation concealment (and were therefore assessed as being at an unclear risk of selection bias).In all studies, the intervention was the use of fetal biometry on ultrasound to identify fetuses displaying signs of fetal macrosomia, and the use of this information to indicate the use of medical anti-hyperglycaemic treatments. Those pregnancies were subject to more stringent blood glucose targets than those without signs of fetal macrosomia.Maternal outcomesThe use of fetal biometry in addition to maternal blood glucose concentration (compared with maternal blood glucose concentration alone) may make little or no difference to the incidence of caesarean delivery (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.10; 2 trials, 428 women; low-certainty evidence). We are unclear about the results for hypertensive disorders of pregnancy (RR 0.80, 95% CI 0.34 to 1.89; 2 trials, 325 women) due to very low-certainty evidence. The included trials did not report on development of type 2 diabetes in the mother or maternal hypoglycaemia.Fetal and neonatal outcomesThe use of fetal biometry may make little or no difference to the incidence of neonatal hypoglycaemia (RR 0.90, 95% CI 0.57 to 1.42; 3 trials, 524 women; low-certainty evidence). Very low-certainty evidence means that we are unclear about the results for large-for-gestational age (RR 0.81, 95% CI 0.38 to 1.74; 3 trials, 524 women); shoulder dystocia (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women); a composite measure of perinatal morbidity or mortality (RR 1.00, 95% CI 0.21 to 4.71; 1 study, 96 women); or perinatal mortality (RR 0.33, 95% CI 0.01 to 7.98; 1 trial, 96 women). This review is based on evidence from three trials involving 524 women. The trials did not report some important outcomes of interest to this review, and the majority of our secondary outcomes were also unreported. The available evidence ranged from low- to very low-certainty, with downgrading decisions based on limitations in study design, imprecision and inconsistency.There is insufficient evidence to evaluate the use of fetal biometry (in addition to maternal blood glucose concentration values) to assist in guiding the medical management of GDM, on either maternal or perinatal health outcomes, or the associated costs.More research is required, ideally larger randomised studies which report the maternal and infant short- and long-term outcomes listed in this review, as well as those outcomes relating to financial and resource implications.

Evaluation of Treatment Strategies to Manage Diabetes Mellitus in Pregnancy: Use of Fetal Sonography Compared to Monitoring of Maternal Blood Glucose Alone

Introduction When planning the treatment of women with gestational diabetes, the current standard approach also takes fetal growth development into account. The treatment of pregnant women with type 1 diabetes mellitus (DM) used to be based exclusively on maternal blood glucose values. This study investigated the impact of including fetal growth parameters in the monitoring of pregnant women with type 1 diabetes mellitus. Patients/Method 199 pregnant women with type 1 DM were included in a cohort study. The patient population was divided into two study cohorts. In the mBG cohort (n = 94; investigation period: 1994 – 2005) treatment was monitored using only maternal blood glucose (mBG) values; the aim was to achieve standard target glucose values (mean BG < 5.5 mmol/l, postprandial: at 1 h < 7.7 mmol/l, at 2 h < 6.6 mmol/l). In the fUS collective (n = 101, investigation period: 2006 – 2014) fetal growth parameters were additionally included when monitoring treatment from the 22nd week of gestation, and maternal target glucose values were then individually adjusted to take account of fetal growth. This study aimed to investigate the impact of these two different ways of monitoring treatment on perinatal and peripartum outcomes. Results 91.4% of all patients were normoglycemic at the time of delivery (HbA 1c < 6.7%); 58.9% of patients achieved strict normoglycemia (HbA 1c < 5.7%). No differences were found between the two study cohorts (fUS vs. mBG: HbA 1c < 6.7%: 93.9 vs. 88.4%, n. s.; mean blood glucose (BG): 5.4 ± 0.6 to 6.6 ± 1.1 vs. 5.9 ± 0.7 to 7.4 ± 1.9 mmol/l, n. s.). Patients from the fUS cohort required significantly lower weight-adjusted maximum insulin doses (0.9 ± 0.3 vs. 1.0 ± 0.4 IE/kg bodyweight, p < 0.05). Pregnancy complications occurred significantly less often in the fUS cohort (preeclampsia: 7.1 vs. 20.9%, p = 0.01; premature labor: 4.0 vs. 23.3%, p < 0.001; cervical insufficiency: 0.0 vs. 11.6%, p = 0.001), and there were significantly fewer cases with neonatal hyperbilirubinemia (19.2 vs. 40.7%, p = 0.001). There was no difference in the rates of LGA infants between the two cohorts (21.2 vs. 24.4%, n. s.). Conclusion Using maternal blood glucose values combined with fetal growth parameters to monitor DM treatment allows therapeutic interventions to be individualized and reduces the risk of maternal and infant morbidity. The metabolism of patients in the fUS cohort was significantly more stable and there were fewer variations in glucose values. It is possible that the detected benefits are due to this metabolic stabilization.

Comparison of the effectivity of two internationally recommended screening methods for the recognition of gestational diabetes

Introduction: Early diagnosis and adequate care of gestational diabetes is of great importance for both the mother and her fetus. Although several national and international guidelines are known on the methodology for screening gestational diabetes, a not negligible part of the cases remain unrecognized when applying even the most widely used criteria recommended by the World Health Organization (1st recommendation). A connection has been found between the maternal blood glucose values and the prevalence of still-birth, preeclampsia and large for gestational age neonates in several studies, from which the Hyperglycaemia and Adverse Pregnancy Outcomes study has come into prominence. According to conclusions of this study the International Association of Diabetic Pregnancy Study Groups suggested new numeric criteria for the evaluation of the 75-gramm oral glucose tolerance test (2nd rercommendation), which differs from the evaluation used in the afore mentioned screening system. Aims: The aim of the study was to compare the effectiveness of the two screening systems by evaluation of the pregnancy outcomes. Methods: By following non-twin pregnancies of 1107 pregnant mothers (831 with normal glucose tolerance, 276 with gestational diabetes based on any of the applied screening methods) the maternal (pre- and postterminal birth, caesarean section, toxaemia) and newborns pregnancy outcomes (infants small and large for gestational age, hypoglycaemia) were analysed. Results: With the exception of the prevalence of large for gestational age infants – which was higher among women screened by the new evaluation – no substantial difference in the efficacy of the two investigated methods was found. Conclusion: The decision whether the screening of gestational diabetes using the new criteria results in safer recognition of the disturbances of glucose metabolism during pregnancy requires further investigations including a large number of cases. Orv. Hetil., 2013, 154, 776–783.

Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus.

Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus (GDM). We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data. Women with GDM were randomized to either the telemedicine group (n=40) or the control group (n=40) and asked to monitor their blood glucose levels four times a day. Women in the intervention group transmitted those values via the telemedicine system, whereas women in the control group maintained paper logbooks, which were reviewed at prenatal visits. Primary outcomes were infant birth weight and maternal glucose control. Data collection included blood glucose records, transmission rates for the intervention group, and chart review. There were no significant differences between the two groups (telemedicine vs. controls) in regard to maternal blood glucose values or infant birth weight. However, adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study (35.6±32.3 sets of data vs.17.4±16.9 sets of data; P<0.01). Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes.

Long-Term Breast-Feeding in Women With Type 1 Diabetes

Breast-feeding may be more difficult in women with diabetes because of neonatal morbidity and fluctuating maternal blood glucose values. The frequency of long-term breast-feeding and the possible predictors for successful breast-feeding were investigated. One hundred two consecutive women with type 1 diabetes were interviewed about breast-feeding using a semistructured questionnaire 5 days and 4 months after delivery. Clinical data were collected from the medical records. Five days after delivery, 86% of the women were breast-feeding. Four months after delivery, 55 (54%) women were exclusively, 14 (14%) were partly, and 33 (32%) were not breast-feeding compared with 50, 26, and 24% in the background population (NS). Mothers exclusively breast-feeding at 4 months were characterized by previous experience with breast-feeding, a higher educational level, and vaginal delivery and included a high proportion of nonsmokers, whereas there were no associations with diabetes-related parameters such as white classes, duration of diabetes, HbA(1c), and insulin dose at conception. Breast-fed offspring had a significantly higher birth weight and gestational age and were less often receiving glucose intravenously compared with the remaining offspring. Independent predictors of exclusive breast-feeding at 4 months were previous experience with breast-feeding (odds ratio 6.3 [95% CI 2.4-17]) and higher educational level (7.1 [2.4-21]). Cessation of breast-feeding was mainly due to common nursing problems, such as perceived milk supply, and not related to maternal diabetes status. The majority of the women with type 1 diabetes initiated breast-feeding, and the prevalence of breast-feeding at 4 months was comparable to that in the background population. Independent predictors of exclusive breast-feeding at 4 months were previous experience with breast-feeding and higher educational level.

Levels of amniotic fluid insulin and profiles of maternal blood glucose in pregnant women with diabetes type-I.

The aim of this study was to investigate the relationship between amniotic fluid insulin (AF-insulin) measurements and maternal blood glucose levels in pregnancies complicated by insulin-dependent maternal diabetes mellitus (IDDM). Twenty-five patients with IDDM underwent amniocentesis (AC) in the third trimester. Twelve patients had a second amniocentesis after 2-3 weeks. The maternal blood glucose values (MBG) 2 weeks before amniocentesis were correlated with AF-insulin. Mean (+/-S.D.) MBG in the group with AF-insulin > 97th centile (n = 7) was 6.1 +/- 1 mmol/l. MBG in the group with AF-insulin < 97th centile (n = 18) was 5.3 +/- 1.2 mmol/l (r = 0.2948; P-value 0.162). In the group with repeated AC and AF-insulin > 97th centile (n = 6) the correlation coefficient was 0.722 (P = 0.043), whereas in the group with normal AF-insulin (n = 6) no correlation was found (r = -0.213; P = 0.686). These results indicate that no significant correlation exists between MBG values and concentration of AF-insulin. MBG is not appropriate for the diagnosis of fetal hyperinsulinism in well-controlled women with IDDM. In individual cases with AF-insulin > 97th centile a decrease of MBG causes lower AF-insulin levels. These results indicate that there seems to be an individual threshold for maternal MBG which causes hyperinsulinism. Fetal hyperinsulinism not only depends on blood glucose levels. Different fetal sensitivity to maternal glucose stimuli or a different glucose transport across the placenta in the individual fetus could be responsible for these results.

Oxygen consumption and guanosine diphosphate binding by fetal brown adipose tissue in diabetic pregnancy

Oxygen consumption and 3H-guanosine diphosphate (GDP) binding were determined in brown adipocytes and mitochondria from 28-day gestation fetuses of alloxan-diabetic rabbit does and saline-injected controls. Maternal diabetes was classified as severe or mild determined by whether maternal blood glucose values were greater or less than 200 mg/dL, respectively, at death. Basal oxygen consumption and adipocyte diameters did not vary among groups. A significant reduction in maximal norepinephrine (NE) stimulated O 2 consumption by fetal brown adipose tissue (BAT) cells was seen in offspring of severely diabetic pregnancies when compared with control values ( 248 ± 53 ± v 482 ± 32 μ L O 2 10 6 cells/h ; P < .005 ). In contrast, a significant increase in maximal NE-stimulated O 2 consumption by fetal BAT cells occurred in offspring of mild diabetic pregnacies (807 ± 60, P < .001 v controls). A highly significant inverse correlation between serum glucose levels and maximal O 2 consumption by fetal BAT was observed in fetuses from mild and severe diabetic pregnancies ( r = −.98, P < .005), and there was no correlation between these two parameters in offspring of normal pregnancies. A significant inverse correlation was observed between maximal O 2 consumption by fetal BAT cells and serum insulin levels in offspring of both control and diabetic pregnancy ( r = −.74; P < .02). Tissue cytochrome oxidase activity was lower in offspring of severely affected diabetic does, indicating a reduction in BAT mitochondrial content compared with controls. BAT mitochondria from fetuses of severely diabetic does exhibited reduced 3H-GDP capacity, which was 2.5-fold lower than controls. These studies show that brown adipocytes obtained from offspring of severely diabetic pregnancies exhibit reduced NE-stimulated oxygen consumption. Reduced thermogenin content, indicated by lower GDP binding, is the most likely cause of the impaired oxygen consumption offspring of severely affected diabetic pregnancies.

RITODRINE EXPOSURE IN UTERO: EFFECTS ON FETAL RATS

Beta-sympathomimetics used for tocolysis have been shown to cause changes in fetuses and neonates. Ritodrine (R) (5mg/kg, sc, q12h) was given to rats on days 10-19 of pregnancy. Control (C) rats received saline alone. On day 20 the animals were anesthesized and the fetuses were delivered via abdominal incision. (R) and (C) exhibited no significant differences in fetal or placental weight, placental glycogen content, or fetal and maternal blood glucose values. The following significant fetal results were obtained:Our findings that (R) causes cardiac muscle hypertrophy without affecting cardiac glycogen deposition are in agreement with reports of cardiovascular effects of the drug. The increase in liver glycogen content may indicate a hyperglycemic state which has also been linked to (R) therapy. Maternal heart weights and liver glycogen also increased in the (R) group, similar to the fetal changes. Unlike the fetuses, maternal cardiac glycogen content and pituitary weights were increased in the (R) group. These results suggest that cardiovascular and metabolic side effects be considered in infants born to mothers on (R).

Monocyte insulin receptors in infants of strictly controlled diabetic mothers.

Infants of diabetic mothers have hyperinsulinism at birth, presumably resulting from maternal hyperglycemia or some other derangement of maternal metabolism, and are extremely sensitive to insulin. Such infants have significantly greater numbers of insulin receptors on cord blood monocytes compared to normal infants. To assess the role of maternal diabetic control, nine infants of insulin-dependent diabetic mothers, who were intensively treated during pregnancy, were studied. Maternal blood glucose values were measured during weekly out-patient visits throughout pregnancy, and insulin therapy was given to maintain fasting blood glucose values below 100mg/dl. When necessary, the patients were hospitalized early in pregnancy in order to achieve glucose control, and all patients were hospitalized for up to 2 weeks before delivery for strict glucose control. The mean birth weight (+/- SD) of these infants (3.23 +/- 0.23 kg) was lower than that of nine infants of mothers with gestational diabetes not receiving insulin or intensive efforts at maintenance of normoglycemia (3.99 +/- 0.12; P less than 0.01) and was not significantly different from that of normal infants (3.51 +/- 0.37 kg). Mean cord blood C-peptide levels (+/- SD), determined by RIA, were 1.6 +/- 0.78 ng/ml for infants of these strictly controlled diabetic mothers and 1.4 0.1 ng/ml for normal infants. Scatchard analysis of [125]insulin binding to cord blood monocytes yielded mean receptor numbers for infants of diabetic mothers of 22,500 vs. 105,000 sites/cell for infants of diabetic mothers (P less than 0.001) and 26,600 sites/cell for normal infants. We conclude that the strict control of maternal diabetes during the last trimester of pregnancy prevents fetal hyperinsulinemia and is associated with the development of normal numbers of insulin receptors on the infants' monocytes.