Management of diabetes mellitus complicating pregnancy

Dietary restraint and gestational weight gain

OBJECTIVE

To determine whether a history of preconceptional dieting and restrained eating was related to higher weight gains in pregnancy.

DESIGN

Dieting practices were assessed among a prospective cohort of pregnant women using the Revised Restraint Scale. Women were classified on three separate subscales as restrained eaters, dieters, and weight cyclers.

SUBJECTS

Participants included 1,223 women in the Pregnancy, Infection, and Nutrition Study.

MAIN OUTCOME MEASURES

Total gestational weight gain and adequacy of weight gain (ratio of observed/expected weight gain based on Institute of Medicine recommendations).

STATISTICAL ANALYSES PERFORMED

Multiple linear regression was used to model the two weight-gain outcomes, while controlling for potential confounders including physical activity and weight-gain attitudes.

RESULTS

There was a positive association between each subscale and total weight gain, as well as adequacy of weight gain. Women classified as cyclers gained an average of 2 kg more than noncyclers and showed higher observed/expected ratios by 0.2 units. Among restrained eaters and dieters, there was a differential effect by body mass index. With the exception of underweight women, all other weight status women with a history of dieting or restrained eating gained more weight during pregnancy and had higher adequacy of weight gain ratios. In contrast, underweight women with a history of restrained eating behaviors gained less weight compared to underweight women without those behaviors.

CONCLUSIONS

Restrained eating behaviors were associated with weight gains above the Institute of Medicine's recommendations for normal, overweight, and obese women, and weight gains below the recommendations for underweight women. Excessive gestational weight gain is of concern because of its association with postpartum weight retention. The dietary restraint tool is useful for identifying women who would benefit from nutritional counseling prior to or during pregnancy with regard to achieving targeted weight-gain recommendations.

Macrosomia in well controlled CSII treated Type I diabetic pregnancy

OBJECTIVE

To survey the effect of tight glycemic control by insulin pumps, of pre-gestational Type 1 diabetic women on pregnancy outcome.

METHODS

Twelve consecutive Type 1, insulin pump treated, diabetic patients followed in the high risk maternal - fetal clinic were ascertained. Data regarding glucose control was assessed and correlated with pregnancy outcome.

RESULTS

A total of 14 deliveries (10 singleton) were assessed. There were no miscarriages, one baby that was born with a ventricular septal defect (VSD). Glycemic control was within the acceptable guidelines. HbA1c (%) by trimesters: 6.5 +/- 0.9, 5.9 +/- 0.7, 5.8 +/- 0.6 and average glucose (mg/dL) 121.0 +/- 15.2, 114.8 +/- 13.2, 116.0 +/- 21.1. Average birth weight was 3312.1 +/- 750.2 g with five babies (35%) weighting over 4.0 kg at birth. Birth weight was significantly correlated with HbA1c at the first trimester, mean glucose at trimester 1 and 2, and maternal weight at delivery (r = 0.74, p = 0.045; r = 0.72, p = 0.051; r = 0.74, p = 0.046; r = 0.74, p = 0.04, respectively).

CONCLUSIONS

Our study of a limited number of patients suggest that women with pre-gestational diabetes obtaining acceptable glycemic goals with insulin pump therapy have increased risk of macrosomia. Current glycemic goals and therapies in treating pre-gestational diabetic patients therefore might not be sufficient to normalise pregnancy outcomes in of women with pre-gestational diabetes.

Insulin and carbohydrate metabolism

Fetal glucose exposure and consequent fetal insulin secretion is normally tightly regulated by glucose delivery from the mother during pregnancy. Maternal hyperglycaemia and gestational diabetes (GDM) are known to be detrimental to offspring, although defining the criteria for diagnosis of GDM is controversial. Recent data suggest that the risk of poor fetal outcome appears to be a continuous variable across the range of glucose control, and that the level of maternal blood glucose for a diagnosis of gestational diabetes needs to be reviewed. After birth, rapid adaptation is necessary for infants to be able to maintain independent glucose homeostasis. This adaptation is compromised in infants who are small for gestational age (SGA), premature, or large for gestational age (LGA). Interestingly, the infants who are born at the extremes of birth weight are also at increased risk of impaired glucose tolerance and diabetes in later life.

Labor and delivery management for women with diabetes

Diabetes in pregnancy confers a number of risks for both the mother and her baby, and many of these risks are encountered in the labor and delivery unit. The obstetric provider caring for women with diabetes should be alert to the risk of hypertension and the potential for difficult delivery due to an overgrown fetus. Women with preexisting diabetes or poor glycemic control are at increased risk for poor obstetrical outcomes such as stillbirth or delivery of a malformed infant. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia.

Can plasma glucose and HbA1c predict fetal growth in mothers with different glucose tolerance levels?

To assess whether HbA1c and plasma glucose predicts abnormal fetal growth, 758 pregnant women attending 5 Diabetic Centers were screened for gestational diabetes mellitus (GDM). On glucose challenge (GCT) at 24-27 weeks of gestation (g.w.), negative cases formed the normal control group (N1). Positive cases took an oral glucose tolerance test (OGTT): those found negative were classed as false positives screening test (N2); if they had an OGTT result at least as high as their normal glucose levels, they were classed as having one abnormal glucose value (OAV) at OGTT; two values as GDM. HbA1c was assayed on the day of GCT. We considered fetal macrosomia, large for gestational age (LGA), ponderal index and mean growth percentile. Mean age, pre-pregnancy BMI, fasting plasma glucose (FPG) and HbA1c were progressively higher from N1 to GDM patients. The newborn of N2 mothers were heavier than those with N1 or GDM. The mean growth percentile was significantly higher in N2 than in N1. More LGA babies were born to OAV than to N1 or N2 women. Macrosomia and ponderal index did not differ significantly in the four groups. At logistic regression only plasma glucose at GCT could predict LGA babies and a ponderal index above 2.85. At risk analysis, GDM and OAV significantly predicted LGA babies, and GDM a ponderal index >2.85. In conclusion, FPG at GCT could predict fetal overgrowth and plasma glucose >85mg/dl doubles the risk of LGA infants. HbA1c at 24-27g.w. does not predict fetal overgrowth. Mild alterations in glucose tolerance correlate with fetal overgrowth and needs monitoring and treatment.

[Neonatal outcome in pregnancies complicated with pregestational diabetes mellitus]

BACKGROUND/AIM

Pregestational diabetes mellitus (PGDM) represents glucose intolerance that begins before pregnancy and is followed by the increased risk of neonatal and maternal complications. The aim of this study was to establish neonatal outcome in pregnancies with pregestational diabetes mellitus and the factors that had influence on it.

METHODS

This study included 27 pregnant women with insulin-dependant PGDM hospitalized during 2004 in the Institute for Obstretics and Gynecology, Clinical Center of Serbia, Belgrade. The control group consisted of 2 292 healthy pregnant women presented to the Institute within 2004.

RESULTS

Twenty-three (85%) infants of the women with PGDM had complications in comparison with 356 (15.5%) infants of the women in the control group, that was statistically significant difference (p < 0.001). Macrosomia was present in 8 (29.6%/0) and birth injuries in 6 (22.2%) infants of women with PGDM that was statistically significant difference (p < 0.001) in comparisom with the women in the control group who had 194 (8.5%) infants with macrosomia and 156 (6.8%) infants with birth injuries. The women with PGDM had 3 (11.1%) neonatal deaths and 3 (11.1%) infants were born with congenital malformations in comparison with the women in the control group without these complications. We established statisticaly significant correlation (p < 0.001) between glicoregulation before and during pregnancy in the women with PGDM and neonatal outcome.

CONCLUSION

The incidence of neonatal morbidity and mortality in the women with PGDM was significantely more frequent as compared with the normal population. Achieving optimal maternal glucose levels in women with PGDM both preconceptionally and during pregnancy is associated with significant reduction of neonatal complications.

Weight loss programs for urban-based, postpartum African-American women: perceived barriers and preferred components

OBJECTIVES

There are currently 1.85 million reproductive-aged women in the United States with diabetes or glucose intolerance. While it is known that postpartum weight retention can lead to obesity and diabetes, particularly among African-American women, little is known about African-American women's preferences for postpartum weight loss programs. Our objective was to explore urban-based African-American women's attitudes toward weight gain, perceived barriers to postpartum weight loss, and preferences for weight intervention strategies.

METHODS

Focus groups of pregnant African-American women (n = 22) were conducted by a race-concordant moderator. Open-ended questions were posed to stimulate discussions which were audio taped and transcribed verbatim. Transcriptions were independently reviewed by two investigators who extracted quotations and coded each statement to identify major themes.

RESULTS

The median age of participants was 26 years. Median pre-pregnancy or first trimester body-mass index was 31 kg/m(2). Fifty-seven percent of the women were multiparous and 68% were Medicaid recipients. We identified 16 themes with the majority of participant comments focused on: (1) effect of postpartum depression on motivation to lose weight; (2) strong desire to lose weight; (3) knowledge of adverse effects of obesity; (4) costs of weight loss programs; (5) negative impact of media coverage of successful celebrity postpartum weight loss; (6) limitations of childcare on ability to exercise; and (7) family-centered lifestyle behaviors that promote unhealthy eating.

CONCLUSIONS

Weight loss interventions for African-American women with postpartum obesity should address psychological effects of childbearing, affordability, and perceptions of body image. Interventions should incorporate family-centered approaches and weight loss maintenance strategies.

Management of gestational diabetes from the patient's perspective ? a comparison of Swedish and Middle-Eastern born women

AIM

To explore patients' evaluation of a specialized diabetes clinic for management of women with gestational diabetes born in Sweden and the Middle East and its contribution to a decreased level of stress and improved coping capability to promote health in patients receiving care.

BACKGROUND

No studies comparing patients' perceptions of healthcare in women of different origin with gestational diabetes have been found. A perceived clinical problem in specialized diabetes care is of lower activity level in self-care in foreign- than Swedish-born women and the question is whether the healthcare organization is optimal in meeting different individuals' needs.

DESIGN

Explorative study.

METHOD

Semi-structured individual interviews by external evaluators.

PARTICIPANTS

Consecutive sample. Females with gestational diabetes, 13 born in Sweden and 14 born in the Middle East.

RESULTS

The healthcare model was perceived as functioning well. Swedish women were problem focused and information seeking. Frustration and stress were increased due to perceived delay in information concerning gestational diabetes, limited access to telephone service and lack of confidence in staff because they lacked the expected competence. Control of gestational diabetes and pregnancy by different persons led to perceived lack of holistic care. Women from the Middle East felt cared, had been given the necessary information and claimed to follow advice. Adequate information reduced respondents' anxiety and increased their control over the situation.

CONCLUSIONS

The clinic needs to be further improved by adapting programmes to persons to become problem focused by giving adequate information immediately.

RELEVANCE TO CLINICAL PRACTICE

Cultural differences in coping strategies and attitudes to gestational diabetes need to be considered. Training of staff working with gestational diabetes patients is urgently needed.

The validity of oral glucose tolerance test after 36 weeks’ gestation

OBJECTIVE

Secretion of anti-insulin hormones plateaus near term, questioning the validity of OGTT (oral glucose tolerance test) during that period. We aimed at assessing the feasibility of OGTT near term as compared to OGTT at 26-32 weeks.

PATIENTS AND METHODS

One thousand four hundred and eighty seven pregnant women were screened by GCT (glucose challenge test), and 282 (19%) of them performed an OGTT at 26th-32nd weeks ("early" OGTT) after meeting the threshold value for GCT. Forty-one women with abnormal and 16 with normal early OGTT underwent a repeated OGTT at 36-40 weeks' gestation ("late" OGTT). Blood glucose levels during GCT and OGTT were compared between women with early and late abnormal OGTT and women who converted from early abnormal to late normal OGTT.

RESULTS

Thirty-six out of 41 participants (88%) with early abnormal OGTT had abnormal test near term as well (Group I). Five women with an early abnormal OGTT converted to normal according to a late OGTT (Group II). These women had lower glucose levels on both late and early OGTT as compared with Group I. All 16 women who tested normal on early OGTT had a consistently normal late OGTT. Glucose levels for all 57 women did not significantly differ between early and late OGTT. The sensitivity, specificity, and positive and negative predictive values of late OGTT were 88%, 100%, 100%, and 76%, respectively.

CONCLUSION

The positive predictive value of late OGTT performed at 36-40 weeks' gestation is 100%. This test may be used to detect gestational diabetes in women near term.

Audit of Pregnancies Complicated by Diabetes from One Center Five Years Apart with Selective versus Universal Screening

The article compares the effect of selective and universal screening on detection rate and outcomes of pregnancies complicated by diabetes mellitus (DM) in a multiethnic population. The method used was to review the pregnancy and delivery of two 18-month periods, 5 years apart. In the year 1996-1997 when selective screening was used 315 (5.7%) of 5506 delivered women had diabetes during pregnancy. The rates of diabetes in the different ethnic groups were: UAE (4.4%), Peninsula Arabs (4.0%), Chami Arabs (4.5%), North African Arabs (6.7%), Indian subcontinent (7.5%), and Somalis and Sudanese (9.7%). The rate of diabetes among the different ethnic groups for the year 2001-2002 when screening was universal but diagnosis made by the same criteria were 590 (9.7%) of 6232 delivered women, UAE (9.2%), Peninsula Arabs (8.4%), Chami Arabs (8.2%), North African Arabs (9.6%), Indian Subcontinent (11.0%), Somalis and Sudanese (11.3%). The outcome indicators and their rates in the years 1996-1997 and 2001-2002 were respectively: gestational diabetes, 86.3%, 89.0%; requirement of insulin treatment, 74.3% 82.5%; vaginal delivery, 68.2%, 75.3%; cesarean section, 30.3%, 19.8%; macrosomia, 22.2%, 6.7%; intrauterine fetal death, 2.9%, 1.1%; and preterm delivery, 22.5%, 17.5%. This article confirms the influence of ethnic background on the prevalence of gestational diabetes in a multiethnic and multicultural society. Over a period of 5 years, there was a 66.7% increase in the incidence of gestational diabetes, which was probably due to a combination of increased detection by change in screening policy and an increase in the incidence of gestational diabetes. The indicators of disease severity and control, such as insulin requirement, rates of abdominal delivery, macrosomia, and structural congenital malformations, were significantly better in a cohort identified by universal screening compared with that identified by selective screening. Universal screening seems to be a more appropriate strategy for screening in this environment.

Maternal race, procedures, and infant birth weight in type 2 and gestational diabetes

OBJECTIVE

To examine the relation between race and cesarean delivery, episiotomy, and low birth weight infants in pregnancies with type 2 and gestational diabetes mellitus and to identify factors that might explain racial differences.

METHODS

Population-based, cross-sectional study of 1999-2004 Maryland hospital discharge data. Hospitalizations for delivery of pregnancies with type 2 and gestational diabetes mellitus were identified and matched to infants. The independent variable was maternal race. Dependent variables were cesarean delivery, episiotomy, and low infant birth weight. Stepwise logistic regression models were developed to estimate the independent effect of race on use of each procedure and infant birth weight, after adjusting for sociodemographic, hospital, and clinical factors.

RESULTS

We examined 6,310 deliveries for pregnancies with type 2 (15%) and gestational (85%) diabetes. Before adjustment, black race was associated with a higher odds of cesarean delivery (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.24-1.58) and low birth weight infants (OR 1.94, 95% CI 1.57-2.40) compared with white race. Adjustment for racial differences in preeclampsia and fetal heart rate abnormalities accounted for a modest degree of the racial variation in outcomes. With full adjustment, black race was still associated with a higher odds of cesarean delivery (OR 1.38, 95% CI 1.20-1.60) and low birth weight (OR 1.81, 95% CI 1.41-2.34) and a lower odds of episiotomy (OR 0.45, 95% CI 0.36-0.57).

CONCLUSION

In pregnancies with diabetes, adjustment for sociodemographic, hospital, and clinical factors only partially explains racial differences in procedure use and infant low birth weight.

The mean platelet volume in gestational diabetes

OBJECTIVE

To compare the platelet count and mean platelet volume (MPV) values of pregnancies diagnosed with gestational diabetes with those of healthy pregnancies.

MATERIAL-METHOD

Between June 2003 and September 2004, 100 healthy pregnancies and 100 pregnancies with gestational diabetes were studied at Gazi University, Department of Obstetrics and Gynecology.

RESULTS

While no statistically significant difference was observed in the platelet count between the two groups, the MPV of the gestational diabetes group (9.4 +/- 1.6 fl) was evaluated to be significantly higher than the MPV of the healthy pregnancy group (8.3 +/- 1.1 fl). Additionally, when linear regression analysis was performed an inverse relationship was observed between platelet number and MPV.

CONCLUSION

There is a need for further research focusing on the platelet function in the observation and treatment of gestational diabetes, which can pose the risk of developing Type 2 diabetes for the mother and has negative consequences for the fetus.

[Use of continuous subcutaneous insulin infusion by a portable insulin pump during pregnancy in women with type 1 diabetes mellitus]

BACKGROUND/AIM

Diabetes mellitus is associated with an increased risk for neonatal morbidity and mortality. One of the most important goals in treating pregnancies complicated with diabetes is keeping glucose level within the normal range, especially in the first trimester. A portable insulin pump for continuous subcutaneous insulin infusion (CSII) represents the best form of therapy for patients with type 1 diabetes mellitus during pregnancy. The aim of our study was to evaluate the effects of therapy with a portable insulin pump for continuous subcutaneous insulin infusion during the first trimester of pregnancy on the quality of glycoregulation and pregnancy outcome in women with type 1 diabetes mellitus.

METHODS

A total of 17 newly diagnosed pregnant women with type 1 diabetes mellitus were treated with CSII therapy for three months. The parameters of glycoregulation (hemoglobin A, glycosylated--HbAlc, mean blood glucose value in daily profiles--MBG, daily requirement for insulin--IJ/kg BM), lipid levels, blood preassure and renal function were estimated before and after the therapy. These parameters were correlated with parameters of pregnancy outcome: fetal weight, APGAR score, duration of pregnancy.

RESULTS

There was a significant improvement in HbA1c (8.94 +/- 1.62 vs. 6.90 +/- 1.22 %,p < 0.05), MBG (9.23 +/- 2.22 vs. 6.41 +/- 1.72 mmol/l, p < 0.01), and daily requirement for insulin (0.66 +/- 0.22 vs. 0.55 +/- 0.13 IJ/kg BM, p < 0.05) during the CSII therapy. There were significant correlations between fetal weight and HbAlc (r = -0.60, p < 0.05), triglyceride levels (r = -0.63, p < 0.01), and the number of pregnancies (r = -0.62, p < 0.01), as well as between APGAR score and MBG (r = -0.52, p < 0.05) and cholesterol levels (r = -0.65, p < 0,01) before a portable insulin pump was applicated.

CONCLUSIONS

There was a significant improvement in the quality of glycoregulation during CSII therapy in the pregnant women with type 1 diabetes mellitus. The quality of glycoregulation in the moment of conception was the important factor for pregnancy outcome.

Pregnancy and Obesity: A Review and Agenda for Future Research

At present, more than 60% of American women of childbearing age are either overweight or obese. As the obesity epidemic in the United States and many other countries continues to grow unchecked, there is greater interest in the relationship between obesity and other major health issues. This paper reviews the literature on the relationship between obesity and pregnancy. We begin with a discussion of the relationship between excess body weight and fertility and then turn to the relationship between maternal body weight and pregnancy-related complications. The role of pregnancy as a possible risk factor for the development of obesity is noted. The studies investigating the efficacy of behavioral interventions to control excessive weight gain during pregnancy or help women lose weight after childbirth are then reviewed. The paper concludes with an agenda for future research examining the relationship between obesity and pregnancy.

Prevalence of postpartum thyroid dysfunction: a quantitative review

Estimates of the prevalence of postpartum thyroid dysfunction (PPTD) vary widely because of variations in study design, populations, and duration of screening. Our objective was to estimate the prevalence of PPTD among general and high-risk women, across geographical regions and in women with antithyroid peroxidase antibodies (TPOAbs). We conducted a systematic review and pooled analysis of the published literature (1975-2004), simultaneously accounting for sample size, study quality, percentage follow-up, and duration of screening. Data sources were MEDLINE and the bibliography of candidate studies. Two reviewers independently extracted data. Of 587 studies identified, 21 articles (8081 subjects) met the study criteria. The pooled prevalence of PPTD, defined as an abnormal thyroid-stimulating hormone (TSH) level, for the general population was 8.1% (95% confidence interval [CI] 6.6%-10.0%). The risk ratios for the development of PPTD among women with TPOAbs compared to women without TPOAbs ranged between 4 and 97 with a pooled risk ratio of 5.7 (95% CI: 5.3-6.1). Global prevalence varied from 4.4% in Asia to 5.7% in the United States. Prevalence among women with type 1 diabetes mellitus was 19.6% (95% CI 19.5%-19.7%). PPTD occurs in 1 of 12 women in the general population worldwide, 1 of 17 women in the United States and is 5.7 times more likely to occur in women with TPOAbs. The high prevalence may warrant routine screening TPOAbs, but the benefits, cost, and risks related to subsequent therapy must be weighed.

Nanoscale analysis of protein and peptide absorption: insulin absorption using complexation and pH-sensitive hydrogels as delivery vehicles

Recent advances in the discovery and delivery of drugs to cure chronic diseases are achieved by combination of intelligent material design with advances in nanotechnology. Since many drugs act as protagonists or antagonists to different chemicals in the body, a delivery system that can respond to the concentrations of certain molecules in the body is invaluable. For this purpose, intelligent therapeutics or "smart drug delivery" calls for the design of the newest generation of sensitive materials based on molecular recognition. Biomimetic polymeric networks can be prepared by designing interactions between the building blocks of biocompatible networks and the desired specific ligands and by stabilizing these interactions by a three-dimensional structure. These structures are at the same time flexible enough to allow for diffusion of solvent and ligand into and out of the networks. Synthetic networks that can be designed to recognize and bind biologically significant molecules are of great importance and influence a number of emerging technologies. These synthetic materials can be used as unique systems or incorporated into existing drug delivery technologies that can aid in the removal or delivery of biomolecules and restore the natural profiles of compounds in the body.

Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization

OBJECTIVE

This study was undertaken to compare the use of glyburide with insulin for the treatment of gestational diabetes mellitus (GDM) unresponsive to diet therapy.

STUDY DESIGN

A retrospective study was performed among women with singleton pregnancies who had GDM diagnosed, with fasting plasma glucose 140 mg/dL or less on glucose tolerance testing, between 12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified 584 women and compared those treated with insulin between 1999 and 2000 with women treated with glyburide between 2001 and 2002. Maternal and neonatal outcomes and complications were assessed. Statistical methods included univariate analyses and multivariable logistic regression.

RESULTS

In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide. The 2 groups were similar with regard to age, nulliparity, and historical GDM risk factors; however, women in the insulin group had a higher mean body mass index (31.9 vs 30.6 kg/m 2 , P=.04), a greater proportion identified themselves as white (43%, 28%, P<.001) and fewer as Asian (24%, 37%, P=.001), and they had a significantly higher mean fasting on glucose tolerance test (105.4 vs 102.4 mg/dL , P=.005) compared with the glyburide group. There were no significant differences in birth weight (3599+/-650 g vs 3661+/-629 g, P=.3), macrosomia (24%, 25%, P=.7), or cesarean delivery (35%, 39 %, P=.4). Women in the glyburide group had a higher incidence of preeclampsia (12%, 6%, P=.02), and neonates in the glyburide group were more likely to receive phototherapy (9%, 5%, P<.05), and less likely to be admitted to the neonatal intensive care unit (NICU) (15%, 24%, P=.008) though they had a longer NICU length of stay (4.3+/-9.6 vs 8.0+/-10.1, P=.002). Posttreatment glycemic control data were available for 122 women treated with insulin and 137 women treated with glyburide. More women in the glyburide group achieved mean fasting and postprandial goals (86%, 63%, P<.001). These findings remained significant in logistic regression analysis.

CONCLUSION

In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study.

Swedish and Middle-Eastern-born women's beliefs about gestational diabetes

OBJECTIVE

to compare beliefs about health and illness between women born in Sweden and the Middle East who developed gestational diabetes (GD).

DESIGN

a qualitative, explorative study using semi-structured interviews.

SETTING

in-hospital diabetes specialist clinic in Sweden.

PARTICIPANTS

consecutive sample of women with GD; 13 born in Sweden and 14 born in the Middle East.

MEASUREMENT AND FINDINGS

all the women described health as freedom from disease, and expressed worries for the baby's health and well-being. Women from the Middle East did not know the cause of GD, discussed the influence of social factors, such as being an immigrant, and supernatural factors, tried to adapt to the disease and thought it would disappear after birth, felt they had more pregnancy-related complications but had not received any treatment. Swedish women attributed GD to inheritance, environment and hormonal change, feared developing Type 2 diabetes, found work-related stress harmful to their health, more often sought help, used medications against pregnancy-related complications, and were more often on sick-leave from work.

KEY CONCLUSIONS

Swedish women initiated a battle against GD, demanded medical treatment for pregnancy-related complications because of gainful employment and viewed pregnancy as a disease. Women from the Middle East temporarily adapted to the disease and perceived pregnancy and related problems as a natural part of life.

IMPLICATIONS FOR PRACTICE

it is important to assess individual beliefs, risk awareness and to meet individual needs for information.

Diabetes mellitus in pregnancy

This article reviews normal and abnormal carbohydrate metabolism in pregnancy, with an emphasis on the challenges that are faced by those who care for the pregnant woman who has hyperglycemia. The growing problem of type 2 diabetes in pregnancy, the controversial use of oral antihyperglycemic agents for the treatment of gestational diabetes, and the long-term issue of diabetes prevention in those whose hyperglycemia resolves postpartum are also addressed.

Gestational diabetes and nutritional recommendations

The goals of medical nutrition therapy for gestational diabetes mellitus (GDM) are to meet the maternal and fetal nutritional needs, as well as to achieve and maintain optimal glycemic control. Nutrition requirements during pregnancy are similar for women with and without GDM. The American Diabetes Association and the American College of Obstetrics and Gynecology recommend nutrition therapy for GDM that emphasizes food choices to promote appropriate weight gain and normoglycemia without ketonuria, and moderate energy restriction for obese women. Current controversies in GDM nutrition therapy involve manipulation of dietary composition (amounts and types of carbohydrates and fats), gestational weight gain, and energy and carbohydrate restriction. Randomized controlled trials are needed to determine which dietary compositions and patterns promote normoglycemia as well as optimal maternal and infant outcomes. Until better evidence is available, nutrition therapy will remain a cornerstone of GDM management with potential benefits that cannot be fully realized in clinical practice.