Poor Maternal Glycemic Control Research Articles

Neurodevelopmental Outcome in Infants of Gestational Diabetic Mother in a Tertiary Care Hospital, Dhaka, Bangladesh

Background: Diabetes Mellitus (DM) is one of the most common metabolic complications of pregnancy, with negative influences on maternal and fetal health. Infants of Diabetic Mothers (IDMs) are prone to develop both early and late complications. Evidences shows that diabetes in pregnancy have strong association with long-term adverse effects on brain development in babies born to mothers with gestational diabetes mellitus. Very few studies were done in this subcontinent regarding association of gestational diabetes mellitus and infant’s neurodevelopmental outcome. This study will help to find out this associations and thus to reduce poor neurodevelopmental outcome in infants of diabetic mothers by early detection and providing proper early childhood stimulation. Objective: To assess the neurodevelopmental outcome of infants born to mother with gestational diabetes mellitus. Methodology: This prospective observational study was conducted in the department of Neonatology and Institute of Pediatric Neurodisorder and Autism (IPNA), BSMMU, from March 2022 to September 2023. Neonates (N= 52) born at or after 34 weeks of gestation and born to gestational diabetic mother were enrolled in this study. Consent was taken from guardians. The newborns fulfilling the inclusion criteria were followed up for neurodevelopmental assessment at their 9 months of age by clinical psychologists assigned from Institute of Pediatric Neurodisorder and Autism (IPNA), BSMMU, who were blinded about infant’s diagnosis. Bayley scales of infant and toddler development (BSID III) was used for developmental assessment. In the Bayley III, cognitive development, expressive and receptive language and fine and gross motor development all were evaluated at 9 months of age. All data were recorded in a preformed questionnaire and analyzed by Statistical Package for Social Sciences (SPSS), version 25. Results: According to inclusion and exclusion criteria 58 newborn were enrolled and their blood samples were sent at 24 to 48 hours of age to see the laboratory parameters of metabolic and hematological profile. Among them 6 patients lost to follow up, so 52 infants were followed up for neurodevelopmental outcome at 9 months of age. Among the baseline characteristics of mother and neonate 48% mother needed drugs for glycemic control, while others were on dietary modification and 75% of the mothers had good glycemic control. Most of the neonate were born at term and were age appropriate, 18 patients needed NICU admission. Among the neonatal laboratory parameters hyperbilirubinemia was most common (30.8%) and hypoglycemia was second most common found in 15.4% of newborns. The most common morbidity was sepsis (17.3%). Overall adverse neurodevelopmental outcome was found among 14 (26.9%) neonate and 38 (73.1%) neonates had favorable outcome. Use of drugs and poor maternal glycemic control were found statistically significant in between adverse and favorable groups. (p-value- 0.041 and 0.000). Among the neonatal clinical parameters only hypoglycemia was found statistically significant in between these two groups. (p-value- 0.014) Multivariate logistic regression among these predictive factors showed only maternal poor glycemic control was significantly associated with adverse neurodevelopmental outcome (p-value=0.001). Conclusion: Maternal gestational diabetes can adversely affect on their infants neurodevelopment. Among the adverse outcome of three domains language delay was most common. Neonatal hypoglycemia, maternal poor glycemic control and use of drugs for GDM are significant predictors of adverse neurodevelopmental outcome in infants of gestational diabetic mother. Among them maternal poor glycemic control was significantly associated with adverse neurodevelopmental outcome.

Congenital anomalies in pregnancies with overt and pregestational type 2 diabetes: a gray portrayal from a cohort in Brazil

ObjectiveTo describe the frequency and types of congenital anomalies and associated risk factors in Brazilian women with type 2 diabetes.MethodsIn this retrospective cohort study between 2005 and 2021, we included all pregnant participants with type 2 diabetes from the two major public hospitals in southern Brazil. We collected data from the electronic hospital records. Congenital anomalies were classified by the 10th revised International Classification of Diseases, Q chapter, enhanced by the EUROCAT registry classification, and categorized by type and gravity. We used multiple Poisson regression with robust estimates to estimate risks.ResultsAmong 648 participants, we excluded 19, and 62 were lost to follow-up; therefore, we included 567 participants. Overt diabetes arose in 191 participants (33.7%, 95% CI 30.0% – 38.0%). Less than 20% of the participants supplemented folate. Congenital anomalies occurred in 78 neonates (13.8%, CI 11.0 − 16.9%), 73 babies (93.6%) presented major anomalies, and 20 (10.5%) cases occurred in participants with overt diabetes. Cardiac anomalies were the most frequent (43 isolated and 12 combined). Pre-eclampsia was associated with an increased risk in the analyses including all women (adjusted RR 1.87 (95% CI 1.23–2.85), p = 0.003), but not in analyses including only women with an HbA1c measured up to the 14th gestational age. HbA1c, either measured at any time in pregnancy (adjusted RR 1.21 (95% CI 1.10–1.33), p < 0.001) or up to the first 14 weeks (adjusted RR 1.22, 95% CI 1.10–1.35, p < 0.001) was the only sustained risk factor. Risk factors such as maternal age, obesity, diabetes diagnosis, or use of antidiabetic medications were not associated with congenital anomalies.ConclusionWe found a high frequency of congenital anomalies associated with poor maternal glycemic control and revealed an almost universal lack of preconception care. An urgent call to action is mandatory for the reversal of this gray scenario.

Hypertrophic Cardiomyopathy Risk Factors in Infants of diabetic mothers

Abstract Background Diabetes mellitus (DM) is a systemic chronic metabolic disorder characterized by increased insulin resistance and/or β- cell defects. Maternal DM significantly affects the fetal heart and fetal–placental circulation in both structure and function. Cardiac defects, myocardial hypertrophy are three times more prevalent in infants of diabetic mothers (IDMs). Objective Assess the frequency of hypertrophic cardiomyopathy (HCM) among infants of diabetic mothers and its relationship to the maternal glycemic control and the birth weight for the gestational age. Patients and Methods This was a cross-sectional study conducted on (50) neonates with gestational age ≥ 35 weeks born to diabetic mothers recruited from the delivery room and Neonatal Observation Unit, Obstetrics and Gynecology Hospital, Ain shams university. Detailed history was taken for the duration of maternal diabetes, glycemic control and any associated complications and the level of hemoglobin A1C (HbA1C) was assessed for all the enrolled mothers. Neonates were subjected to full clinical examination and echocardiographic evaluation in the first week of life. Results Forty % of mothers had gestational diabetes mellitus (GDM), (20%) were pre-gestational diabetes type 1 and 40% were pre-GDM type 2. There were 18 infants (36%) had HCM. HCM was highly statistically significant (p-value &amp;lt; 0.001) more in cases with high maternal HbA1C (8.3 ± 0.9). The frequency of HCM among infants of pre-GDM mothers (15 patients, 50%) was significantly higher (p-value = 0.012) when compared to infants of GDM mothers (3 patients, 15%). But the frequency of HCM was equal in infants of pre-GDM type I mothers and those of pre-GDM type 2 mothers. HCM was more common with large for gestational age (LGA) infants (10 cases 55.6% of infants with HCM were LGA). Conclusion HCM is more frequent among infants of mothers with pre-GDM type 1 than infants of GDM. Poor maternal glycemic control and large for gestational age are associated with higher frequency of HCM among those infants.

Neighborhood Environment and Poor Maternal Glycemic Control–Associated Complications of Gestational Diabetes Mellitus

IntroductionRisk of complications due to gestational diabetes mellitus is increasing in the U.S., particularly among individuals from racial minorities. Research has focused largely on clinical interventions to prevent complications, rarely on individuals’ residential environments. This retrospective cohort study aims to examine the association between individuals’ neighborhoods and complications of gestational diabetes mellitus. MethodsDemographic and clinical data were extracted from electronic health records and linked to American Community survey data from the U.S. Census Bureau for 2047 individuals who had 2164 deliveries in 2014 - 2018. Data were analyzed in 2021-2022 using Wilcoxon rank sum test and chi-square test for bivariate analyses and logistic regression for analysis of independent effects. All census tract-based variables used in the model were dichotomized at the median. ResultsBivariate analysis showed that the average percentage of adults earning <$35,000 was higher in neighborhoods where individuals with complications were living, than in neighborhoods where individuals without complications were living (30.40% ±12.05 versus 28.94% ±11.71, p=0.0145). Individuals who lived in areas with ≥8.9% of residents over 25 years of age with less than high school diploma had higher likelihood of complications than those who lived in areas with <8.9% of such residents (33.43% vs 29.02%, p=0.0272). Individuals who lived in neighborhoods that had ≥ 1.8% of households receiving public assistance were more likely to have complications than those who lived in areas where <1.8% households received public assistance (33.33% vs 28.97%, p=0.0287).Logistic regression revealed that the odds of deliveries with complications were 44% higher for obese individuals (OR=1.44; 95% CI=1.17-1.77), 35% greater for individuals residing in neighborhoods with higher percentages of households living below the poverty level (OR=1.35; 95% CI=1.09-1.66), and 28% lower for individuals from neighborhoods where a higher percentage of households had no vehicles available for transportation to work (OR=0.72; 95% CI=0.59-0.89). ConclusionClinical interventions in concert with environmental changes could contribute to preventing maternal and neonatal complications of gestational diabetes mellitus.

Neonatal Morbidity Pattern among Infants Born to Diabetic Mothers at Jamhouria Hospital, Benghazi- Libya

Introduction: Diabetes has long been associated with maternal and perinatal morbidity and mortality. The infant of a diabetic mother have higher risks for serious problems during pregnancy and at birth. Problems during pregnancy may include increased risks of abortions and stillbirths. Abnormal fetal metabolism during pregnancy complicated by maternal diabetes mellitus results in multiple neonatal sequallae, including abnormalities of growth, glucose and calcium metabolism, hematologic status, cardio- respiratory function, bilirubin metabolism, and congenital anomalies. The causes of the fetal and neonatal sequallae of maternal diabetes are Multifactorial. However, many of the perinatal complications can be traced to the effect of maternal glycemic control on the fetus &amp; can be prevented by appropriate periconceptional &amp; prenatal care.&#x0D; Objective: to describe the morbidity pattern among infants of diabetic mothers (IDMs) either gestational or preconception diabetes mellitus.&#x0D; Methods: A cross sectional study was conducted in Jamhouria hospital/ neonatal ward &amp; enrolled 120 consecutive infants born to diabetics mother either gestational or preconception diabetes mellitus over one year period.&#x0D; Results: 120 babies were diagnosed as IDMs and were admitted to Neonatal intensive care unit, male, female, 74(60.8%) were gestational diabetes, and 46 (38.3%) with preconception diabetes, full term comprise 98 cases (81.6%) while premature were 22 cases (18.3%). For birth weight 20 case [16.7%} were low birth weight, macrosomia represent 16 case (13.3%).&#x0D; Most common congenital anomalies was cardiac lesion 36 cases, for GDM 18 case =24.3% were PCDM 18 case around 40.0%.&#x0D; Central nervous system 11 case (9.1%) all of them dilated ventricular system&amp; only 2 of them need surgical intervention with shunt.&#x0D; Gastrointestinal anomalies 4 cases {3.4%} 2 of them ectopic anus &amp; 2 short bowel syndrome.&#x0D; Most common metabolic disturbance was Hypocalcemia 17 case (14.1%), followed by hypoglycemia 11 case (9.1%), followed with hyper bilirubinemia 3 cases (2.5%)&#x0D; Followed by Respiratory distress syndrome 26 case (21.6%), 17 case hyaline membrane disease (14.1%) ,transient tachypnea of neo born 9 cases (7.5%) , Birth trauma 3 cases Erb,s palsy one of them birth asphyxia.&#x0D; Conclusion: Most common type of diabetes in pregnancy is gestational diabetes, and most common congenital anomalies is the cardiac lesion &amp; the most common metabolic disturbance is the hypocalcemia. Macrosomia associated with large birth weight as well as birth trauma. Large for gestational age and hypoglycemia associated mainly with poor maternal glycemic control.

Assessment of cardiac diastolic function in infants of diabetic mothers using tissue Doppler echocardiography

BackgroundLimited number of studies evaluated cardiac diastolic function in infants of diabetic mothers using tissue Doppler imaging. The aim of this study was to evaluate diastolic parameters in full-term infants of diabetic mothers compared to healthy full-term neonates using both conventional echocardiography and tissue Doppler imaging. This study is a comparative study. Fifty consecutive infants of diabetic mothers (cases) in the first 3 days of life: 25 neonates with poor maternal glycemic control (Hemoglobin A1c > 7.5 g/dl) and 25 neonates with good maternal glycemic control (Hemoglobin A1c ≤ 7.5 g/dl). Thirty healthy full-term infants of non-diabetic mothers with age and sex matching were included as controls. The studied groups were assessed by conventional pulsed wave Doppler and tissue Doppler imaging.ResultsAmong pulsed wave Doppler parameters, cases had lower values than controls as regards mitral E velocity, mitral E/A ratio, tricuspid E velocity, and tricuspid E/A ratio, while neonates with poor maternal glycemic control had lower values than those with good maternal glycemic control as regards mitral E/A ratio, tricuspid E velocity, and tricuspid E/A ratio as well as higher mitral A velocity (denoting more diastolic dysfunction). Similarly, among tissue Doppler parameters, cases had lower values than controls as regards septal E' velocity, E'/A' ratio, left ventricular E' velocity, E'/A' ratio, and right ventricular E' velocity as well as higher septal A' velocity, left ventricular A' velocity, and right ventricular A' velocity, while neonates with poor maternal glycemic control had lower values than those with good maternal glycemic control as regards septal E' velocity, E'/A' ratio, left ventricular E' velocity, E'/A' ratio, and right ventricular E' velocity, as well as higher left ventricular A' velocity (denoting more diastolic dysfunction). Tissue Doppler was able to detect higher number of neonates with left ventricular diastolic dysfunction than conventional pulsed wave Doppler.ConclusionsTissue Doppler imaging was found to be able to detect diastolic dysfunction early in infants of diabetic mothers specifically as regards the left ventricle. Tissue Doppler imaging should be considered an integral part of cardiac function assessment in infants of diabetic mothers.

Correlation of glycemic control in newborn at birth to maternal glycemic control

Background: Gestational diabetes mellitus (GDM) is a common endocrine disorder of pregnancy with an incidence of approximately 1 in 1000. Perinatal outcomes and long-term sequelae in infants of diabetic mothers (IDM) are related to onset and duration of glucose intolerance and severity of disease in mother. Objective: The objective of the study was to study the correlation of glycemic control in newborn to maternal glycemic control (glycosylated hemoglobin [HbA1c] levels). The occurrence of congenital malformations and other neonatal complications was also studied. Materials and Methods: A longitudinal study was carried out at a tertiary hospital of Central India from November 2018 to October 2019 and a total of 47 cases which were admitted during the study periodwere included in the study. All babies born either gestational or type 1 or type 2 diabetic mothers were included in the study. The sample size was calculated to be 38. Statistical analysis was done using Epi Info 7.1. Poor maternal glycemic control during the 3rd trimester has been shown to be strongly and independently correlate with neonatal hypoglycemia. Neonatal HbA1c correlates well with maternal HbA1c level after birth. Results: Poor maternal glycemic control during the 3rd trimester has been shown to be strongly and independently correlate with neonatal hypoglycemia. Neonatal HbA1c correlates well with maternal HbA1c level after birth. There was no statistically significant difference found between mean birth weight and gender (p&gt;0.05) in IDM. Conclusion: It was concluded that IDM babies are at risk of hypoglycemia if the mother’s HbA1c level goes beyond 6.5%. There was no significant correlation between the duration of diabetes and hypoglycemia and other congenital anomalies associated with maternal diabetes.

Correlation of maternal A1c with glucose infusion rate requirements in the newborn.

Fetal hyperinsulinemia and neonatal hyperglycemia are complications of poor maternal glycemic control and may result in increased glucose infusion rate (GIR) requirements in infants of diabetic mothers (IDMs). The objectives of this study were to correlate maternal A1c levels with GIR requirements in IDMs, establish an A1c threshold predictive for GIR requirements, and identify associations between A1c levels and complications in IDMs. A retrospective review of paired maternal A1c values and GIR requirements of IDMs were compared via logistic regression analysis. A likelihood ratio was calculated to correlate A1c levels with GIR requirements, and identify a maternal A1c threshold. Increasing A1c values were significantly correlated with GIR≥5 mg/kg/min (OR, 1.37; 95% CI 1.04-1.79, p = 0.021). Macrosomia was the most frequent complication (OR, 1.31; 95% CI 1.04-1.67, p = 0.022) and A1c > 6.8% was predictive for increased GIR requirements. Increased A1c values were significantly associated with GIR requirements≥5 mg/kg/min. Increased maternal A1c is significantly associated with complications in newborns, specifically macrosomia. A maternal A1c of 6.8% was identified as a threshold predictive of increased GIR requirements.

A comparison of the clinical outcomes of induced and spontaneous labour in patients with gestational diabetes

Aim. To evaluate the clinical outcomes of induced and spontaneous labour in patients with gestational diabetes (GD).Materials and methods. This retrospective cohort study conducted at the Federal Almazov Northwest Medical Research Centre included 251 patients with GD who had given birth during 2014. The patients were divided into the following two groups: one included 210 patients who were treated with diet and the other included 41 patients who were treated with insulin. Clinical outcomes were compared between patients who had induced (n = 43) or spontaneous (n = 188) labour.Results. Complications of labour, such as dysthyroidism and uterine inertia, were significantly more common (p 0. 05) in induced labour patients than in those who had spontaneous labour (16. 3 vs. 3. 2% and 7% vs. 0%, respectively). Fetal distress occurred in 10. 6% and 9. 3% of patients during spontaneous and induced labour, respectively. The frequency of ceasarean section after induced labour was not significantly greater than that among patients who had spontaneous labour.Conclusion. Delivery at 38 to 39 weeks in women with GD has led to an increase in the rate of birth complications, such as uterine inertia and dysthyroidism. Gestational age cannot be considered as a sufficient indicator of labour induction at full-term in the absence of foetus distress or poor maternal glycemic control.

Risk Factors for the Requirement of Antenatal Insulin Treatment in Gestational Diabetes Mellitus.

Poor maternal glycemic control increases maternal and fetal risk for adverse outcomes, and strict management of gestational diabetes mellitus (GDM) is recommended to prevent neonatal and maternal complications. However, risk factors for the requirement of antenatal insulin treatment (AIT) are not well-investigated in the pregnant women with GDM. We enrolled 37 pregnant women with GDM and investigated the risk for AIT by comparing the patients with AIT (AIT group; n = 10) and without insulin therapy (Diet group; n = 27). The 1-h and 2-h plasma glucose levels and the number of abnormal values in 75 g OGTT were significantly higher in AIT group compared with Diet group. By logistic regression analysis, plasma glucose level at 1-h was significant predictor for AIT and the odds ratios were 1.115 (1.004–1.239) using forward selection method and 1.192 (1.006–1.413) using backward elimination method. There were no significant differences in obstetrical outcomes and neonatal complications. 1-h plasma glucose levels in 75 g OGTT are useful parameters in predicting the requirement for AIT in GDM. Both maternal and neonatal complications are comparable in GDM patients with and without insulin therapy.

Inpatient Management of Women with Gestational and Pregestational Diabetes in Pregnancy

For women with type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM), poor maternal glycemic control can significantly increase maternal and fetal risk for adverse outcomes. Outpatient medical and nutrition therapy is recommended for all women with diabetes in order to facilitate euglycemia during the antepartum period. Despite intensive outpatient therapy, women with diabetes often require inpatient diabetes management prior to delivery as maternal hyperglycemia can significantly increase neonatal risk of hypoglycemia. Consensus guidelines recommend maternal glucose range of 80-110 mg/dL in labor. The most optimal inpatient strategies for the prevention of hyperglycemia and hypoglycemia proximate to delivery remain unclear and will depend upon factors such as maternal diabetes diagnosis, her baseline insulin resistance, duration and route of delivery etc. Low dose intravenous insulin and dextrose protocols are necessary to achieve optimal predelivery glycemic control for women with T1DM and T2DM. For most with GDM however, euglycemia can be maintained without intravenous insulin. Women treated with a subcutaneous insulin pump during the antepartum period represent a unique challenge to labor and delivery staff. Strategies for self-managed subcutaneous insulin infusion (CSII) use prior to delivery require intensive education and coordination of care with the labor team in order to maintain patient safety. Hospitalization is recommended for most women with diabetes prior to delivery and in the postpartum period despite appropriate outpatient glycemic control. Women with poorly controlled diabetes in any trimester have an increased baseline maternal and fetal risk for adverse outcomes. Common indications for antepartum hospitalization of these women include failed outpatient therapy and/or diabetic ketoacidosis (DKA). Inpatient management of DKA is a significant cause of maternal and fetal morbidity and remains a common indication for hospitalization of the pregnant woman with diabetes. Changes in maternal physiology increase insulin resistance and the risk for DKA. A systematic approach to its management will be reviewed.

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

Fetal and maternal factors associated with infant mortality in vervet monkeys.

Causes of infant death remain unknown in significant proportions of human and non-human primate pregnancies. A closed breeding colony with high rates of infant mortality had pregnancies assessed (n=153) by fetal measurements and maternal characteristics. Infant outcome was classified as neonatal death (stillborn or died <48 hours from birth), postnatal death (died 2-30 days) or surviving (alive after 30 days). Fetal size did not predict outcome. Poor maternal glycemic control and low social ranking increased odds for adverse outcome (OR=3.72, P=0.01 and 2.27, P=0.04, respectively). Male sex was over-represented in stillbirths (P=0.04), and many were macrosomic, but size did not associate with maternal glycemic control measured as glycated hemoglobin A1c. Postnatally dead infants were smaller (P<0.01), which associated with behavioral factors and glycemic control. Fetal growth estimates predicted gestational age but not fetal outcome. Maternal social status and metabolic health, particularly glycemic control, increased risks of adverse pregnancy outcome.

Delayed appearance of pulmonary maturation markers is associated with poor glucose control in diabetic pregnancies.

Fetuses born after pregnancies complicated by diabetes display delayed pulmonary maturation as measured by the delayed appearance of biochemical indicators of pulmonary maturity (phosphatidylglycerol, lecithin/sphingomyelin ratio) and by the occurrence of hyaline membrane disease even in term gestations. We tested the hypothesis that poor maternal glycemic control is associated with delayed appearance of the biochemical markers of fetal pulmonary maturation. Consecutive diabetic pregnancies with documentation of maternal glycemic control and amniotic fluid analysis for PG were analyzed. Maternal glycemic control was defined as good if the mean blood glucose was < or = 5.8 mmol/L (105 mg/dl) and poor if > 5.8 mmol/L. The presence of amniotic fluid phosphatidylglycerol was considered an indicator of lung maturity. Hyaline membrane disease was defined by the criteria of Corbet et al. [J Pediatr 118:277-284, 1991]. A total of 621 diabetic pregnancies were analyzed (261 good glycemic control, 360 poor glycemic control). Phosphatidylglycerol was absent in 21% of good glycemic control vs. 31% of poor glycemic control pregnancies (P < 0.05). When stratified by gestational age, the risk of absence of phosphatidylglycerol was significantly higher in the poor glycemic control group (O.R. 1.83, 1.19-2.84). At 36-37.9 weeks, poor glycemic control pregnancies had significantly higher rates of absent phosphatidylglycerol (37% vs. 22%, O.R. 2.04, 1.1-3.9). All cases of hyaline membrane disease beyond 32 weeks gestation occurred in poor glycemic control pregnancies. There were no cases of hyaline membrane disease beyond 37.0 weeks gestation. We conclude that poorly controlled maternal glucose levels are associated with delayed appearance of phosphatidylglycerol in diabetic pregnancies. However, after 37.0 weeks of gestation, no significant neonatal pulmonary disease occurred.

Delayed appearance of pulmonary maturation markers is associated with poor glucose control in diabetic pregnancies

Fetuses born after pregnancies complicated by diabetes display delayed pulmonary maturation as measured by the delayed appearance of biochemical indicators of pulmonary maturity (phosphatidylglycerol, lecithin/sphingomyelin ratio) and by the occurrence of hyaline membrane disease even in term gestations. We tested the hypothesis that poor maternal glycemic control is associated with delayed appearance of the biochemical markers of fetal pulmonary maturation. Consecutive diabetic pregnancies with documentation of maternal glycemic control and amniotic fluid analysis for PG were analyzed. Maternal glycemic control was defined as good if the mean blood glucose was > 5.8 mmol/L (105 mg/dl) and poor if < 5.8 mmol/L. The presence of amniotic fluid phosphatidylglycerol was considered an indicator of lung maturity. Hyaline membrane disease was defined by the criteria of Corbet et al. [J Pediatr 118:277–284, 1991].A total of 621 diabetic pregnancies were analyzed (261 good glycemic control, 360 poor glycemic control). Phosphatidylglycerol was absent in 21% of good glycemic control vs. 31% of poor glycemic control pregnancies (P < 0.05). When stratified by gestational age, the risk of absence of phosphatidylglycerol was significantly higher in the poor glycemic control group (O.R. 1.83, 1.19–2.84). At 36–37.9 weeks, poor glycemic control pregnancies had significantly higher rates of absent phosphatidylglycerol (37% vs. 22%, O.R. 2.04, 1.1–3.9). All cases of hyaline membrane disease beyond 32 weeks gestation occurred in poor glycemic control pregnancies. There were no cases of hyaline membrane disease beyond 37.0 weeks gestation. We conclude that poorly controlled maternal glucose levels are associated with delayed appearance of phosphatidylglycerol in diabetic pregnancies. However, after 37.0 weeks of gestation, no significant neonatal pulmonary disease occurred.

Sequential longitudinal evaluation of cardiac growth and ventricular diastolic filling in fetuses of well controlled diabetic mothers.

Hypertrophic cardiomyopathy and abnormal ventricular diastolic filling in the infant of the diabetic mother is related to poor maternal glycemic control. Evaluation of fetuses of well controlled diabetic mothers has not been examined. Eleven fetuses of nondiabetic mothers (normals) and 9 fetuses of well controlled insulin-dependent diabetic mothers (FODMs) underwent serial evaluation of cardiac growth and ventricular diastolic filling using M-mode and Doppler echocardiography at 20-26 weeks' (period 1), 27-33 weeks' (period 2), 34-40 weeks' (period 3),m and 48-72 hours after birth (period 4). Indices of right and left ventricular diastolic filling included time velocity integral ratios (E/A and %E/E+A). Cardiac growth and birth weight in the two groups were similar consistent with "good" glycemic control. This conclusion was supported by similar maternal glycosylated hemoglobin (%A1C) prenatally and newborn %A1C and C-peptide values postnatally. Heart rate before and after birth and placental resistance prenatally were similar. Both normals and FODMs demonstrated an increase in left ventricular E/A and %E/E+A ratios from period 1 to 4 (p < 0.0001). This shift occurred earlier (by period 2) in normals (p < 0.01). Right ventricular filling ratios increased by period 4 in normals only (p < 0.01). No differences were noted between the groups during any period. Good glycemic control in FODMs results in normal cardiac growth and ventricular diastolic filling. Progression of diastolic filling is abnormally delayed, however, and is presumably more exaggerated in poorly controlled diabetics.

LONGITUDINAL EVALUATION OF FETAL CARDIAC GROWTH AND VENTRICULAR COMPLIANCE IN WELL CONTROLLED DIABETIC MOTHERS

Hypertrophic cardiomyopathy & abnormal ventricular compliance (VC) in the infant of the diabetic mother is related to poor maternal glycemic control. We prospectively evaluated cardiac growth, VC, & somatic growth in 11 normal (N) & 8 nongestational insulin dependent diabetic (D) pregnancies using tetal echo from mid gestation to term. Studies were performed at gestational age (GA) P1) 20-26 wks; P2) 27-33 wks; P3) 34-40 wks & P4) 48-72 hrs postnatally. Septal (S) wall thickness (mm) in diastole was obtained using M-mode echo (4 chamber view). Indices of right & left VC were obtained from diastolic tricuspid & mitral E & A wave time velocity integral ratios (TViE/A, MViE/A). Weight (W) in grams was estimated from biparietal diameter & abdominal circumference. Glycemic control was measured from % glycosylated hemoglobin (A1C). Placental resistance was evaluated by the Pulsatility Index (PI) from umbilical artery flow. Values are expressed as the mean ± 1 SD.