Accelerated starvation in late pregnancy: a comparison between obese women with and without gestational diabetes mellitus

The effect of bedtime snacks on fasting blood glucose levels in gestational diabetes mellitus

AIM

To investigate the effect of different bedtime snacks (higher carbohydrate versus lower carbohydrate versus no snack) on first morning fasting blood glucose levels (BGLs) in women with diet-controlled gestational diabetes mellitus (GDM) and borderline fasting glucose levels.

METHODS

This prospective randomised crossover trial enrolled women with diet controlled GDM between 24 and 34 weeks gestation who had two or more first morning fasting BGLs between 4.7 and 5.4 mmol/L in the week prior to recruitment. The women were randomly allocated to 6 different orders of 5 days each of a standardised higher carbohydrate bedtime snack, a lower carbohydrate bedtime snack and no bedtime snack. The primary outcome was fasting capillary BGL as measured with a home glucometer, and the secondary outcome was requirement for insulin as assessed by a physician.

RESULTS

A total of 68 women with GDM were enrolled in and completed the study at a median gestation of 30.8 weeks. Compared with no bedtime snack, the higher carbohydrate snack (4.96 vs 4.87 mmol/L, mean difference: 0.09 mmol/L, 95% CI 0.05-0.13, p < 0.001) and the lower carbohydrate snack (5.01 vs 4.87 mmol/L, mean difference: 0.14 mmol/L, 95% CI 0.09-0.18, p < 0.001) were both associated with a slightly higher fasting BGL the following morning.

CONCLUSIONS

Taking a bedtime snack was associated with slightly higher fasting BGLs in women with diet-controlled GDM compared with no bedtime snack (Clinical trial registration: ACTRN12617000659303).

Plasma Levels of Free Fatty Acids in Women with Gestational Diabetes and Its Intrinsic and Extrinsic Determinants: Systematic Review and Meta-Analysis

BACKGROUND

Free fatty acids, also known as nonesterified fatty acids, are proinflammatory molecules that induce insulin resistance in nonpregnant individuals. Nevertheless, the concentration of these molecules has not been systematically addressed in pregnant women.

OBJECTIVE

This meta-analysis is aimed at evaluating the difference in free fatty acid plasma levels between women with gestational diabetes and healthy pregnant controls and their intrinsic and extrinsic determinants.

METHODS

We performed a systematic search to find relevant studies published in English and Spanish using PubMed, SCOPUS, and ISI Web of Knowledge. We included observational studies measuring the mean plasma levels of free fatty acids among gestational diabetes and healthy pregnant women, with at least ten subjects being analyzed in each group. The standardized mean difference (SMD) by random effects modeling was used. Heterogeneity was assessed using Cochran's Q, H, and I ² statistics.

RESULTS

Among the 290 identified studies, twelve were selected for analysis. A total of 2426 women were included, from which 21% were diagnosed as having gestational diabetes. There were significantly higher levels of free fatty acids among women with gestational diabetes (SMD: 0.86; 0.54-1.18; p < 0.001) when compared to healthy pregnant controls and between-study heterogeneity (I ² = 91%). The metaregression analysis showed that the gestational age at inclusion was the only cofactor influencing the mean levels of free fatty acids, indicating a trend towards lower plasma levels of free fatty acids later in gestation (estimate: -0.074; -0.143 to -0.004; p = 0.036). No significant publication bias was found nor a trend towards greater results in small studies.

CONCLUSIONS

Women with gestational diabetes have higher levels of free fatty acids when compared to healthy pregnant controls. More investigation is needed to assess the potential role of free fatty acids in the prediction of gestational diabetes earlier in pregnancy.

Prevalence of maternal urinary ketones in pregnancy in overweight and obese women

Background

Ketonuria may be associated with adverse fetal outcomes. This study aimed to determine the prevalence of ketonuria at three time points in pregnancy and to assess whether ketonuria correlates with a clinical indication for performing a urine test.

Methods

Women had fasting urinary ketone levels measured at 16 and 28 weeks gestation and random ketone levels measured close to 36 weeks gestation. All ketone levels in the third trimester were recorded along with the clinical indication for the test.

Results

One hundred and eighty-seven women were included in the study. Twenty-two per cent of women had ketonuria at either 16 or 28 weeks gestation and 8% at 36 weeks gestation. Ketonuria was significantly more likely if a test was performed for a clinical indication (p = 0.0002).

Conclusion

Ketonuria in pregnancy is common affecting at least one in five women. Ketonuria is more common in women who have a clinical indication for performing a urine test.

Masked hypoglycemia in pregnancy

BACKGROUND

Hypoglycemia is a major hindrance for optimal glycemic control in women with gestational diabetes mellitus (GDM) on insulin. In the present study, masked hypoglycemia (glucose <2.77mmol/L for ≥30 min) was estimated in pregnant women using a continuous glucose monitoring (CGM) system.

METHODS

Twenty pregnant women with GDM on insulin (cases) and 10 age-matched euglycemic pregnant women (controls) between 24 and 36 weeks gestation were recruited. Both groups performed self-monitoring of blood glucose (SMBG) and underwent CGM for 72 h to assess masked hypoglycemia. Masked hypoglycemic episodes were further stratified into two groups based on interstitial glucose (2.28-2.77 and ≤2.22 mmol/L).

RESULTS

Masked hypoglycemia was recorded in 35% (7/20) of cases and 40% (4/10) of controls using CGM, with an average of 1.28 and 1.25 episodes per subject, respectively. Time spent at glucose levels between 2.28 and 2.77 mmol/L did not differ between the two groups (mean 114 vs 90 min; P = 0.617), but cases spent a longer time with glucose ≤2.2 mmol/L. Babies born to women with GDM were significantly lighter than those born to controls (2860 vs 3290 g; P = 0.012). There was no significant difference in birth weight within the groups among babies born to women with or without hypoglycemia.

CONCLUSION

Euglycemic pregnant women and those with GDM on insulin had masked hypoglycemia. Masked hypoglycemia was not associated with adverse maternal or fetal outcomes. Therefore, low glucose levels in the hypoglycemic range may represent a physiologic adaptation in pregnancy. This response is exaggerated in women with GDM on insulin.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY 2016 OUTPATIENT GLUCOSE MONITORING CONSENSUS STATEMENT

This document represents the official position of the American Association of Clinical Endocrinologists and American College of Endocrinology. Where there were no randomized controlled trials or specific U.S. FDA labeling for issues in clinical practice, the participating clinical experts utilized their judgment and experience. Every effort was made to achieve consensus among the committee members. Position statements are meant to provide guidance, but they are not to be considered prescriptive for any individual patient and cannot replace the judgment of a clinician.

Turning the tide: type 2 diabetes trends in offspring of mothers with gestational diabetes mellitus

In this review, the thesis is presented that maternal hyperglycemia produces an overnourished, fat fetus. If the fetus has a predisposition for type 2 diabetes, then the fat deposition in the fetus is predominantly in the fetal visceral cavity. Visceral fat deposition is the origin of insulin resistance. The fat fetus begins life with its pancreatic output of insulin compromised. Thus, the stage is set for developing type 2 diabetes in its lifetime. This review supports the hypothesis that normalization of maternal nutrition and fucose will decrease the risk of type 2 diabetes.

Measurement of fasting ketonuria and capillary blood glucose after main meals in women with gestational diabetes mellitus: How well is the metabolic picture captured?

AIM

Metabolic monitoring of women with gestational diabetes mellitus (GDM) usually consists of measuring fasting ketonuria and postprandial capillary blood glucose (CBG) after main meals. We aimed to evaluate how this monitoring system captures the metabolic picture as compared to a scheme with a greater number of time points.

METHODS

Thirty-five women with GDM were recommended to follow a fractionated diet and trained in CBG and ketonuria monitoring. They were asked to monitor ketonuria before a main meal, and to monitor CBG at fasting and 1 h postprandial after any two of the six daily meals. Participants were requested to monitor different meals each day. The goal for 1 h postprandial CBG was <135 mg/dL (7.5 mmol/L). Ketonuria was defined as significant before a certain meal when ≥30% of measurements at that point were positive. Similarly, postprandial CBG was defined as abnormal after a meal when ≥30% measurements exceeded the goal.

RESULTS

Ketonuria was significant in 22.5% of the time points and 41.2% of women had significant ketonuria at one or more time points; 61% of the time points and 35.7% of the women with significant ketonuria would have been undetected with monitoring restricted to breakfast. Postprandial CBG was abnormal in 17.6% of meals and 57% of women had abnormal postprandial CBG at one or more meals; 37.8% of points and 15% of women with abnormal postprandial CBG would have been undetected with monitoring restricted to main meals.

CONCLUSION

A substantial proportion of metabolic abnormalities in GDM women are not detected with a monitoring program that measures only fasting ketonuria and postprandial CBG after main meals.

Rationale for prevention and treatment of glucose-mediated macrosomia: a protocol for gestational diabetes

OBJECTIVE

To formulate a rationale for preventing and treating hyperglycemia during pregnancy and the concomitant risk of macrosomia.

METHODS

We reviewed pertinent studies in the literature and personal experience with patients who had gestational diabetes. In addition, dietary and exercise interventions in the management of such patients were assessed.

RESULTS

During pregnancy, sequential hormonal increases occur to provide glucose substrate to the fetus. When a pregnant woman has a limited insulin secretory capacity and cannot produce enough insulin to compensate for the effect of diabetogenic hormones, gestational diabetes occurs (usually during the second trimester). Maternal hyperglycemia reportedly increases fetal secretion of insulin, and fetal hyperinsulinemia may predispose the fetus to macrosomia. Thus, metabolic abnormalities associated with diabetes during pregnancy result in long-term effects on the offspring, including insulin resistance, obesity, and diabetes, which in turn may contribute to transmission of risk for development of the same problems in subsequent generations. Insulin therapy, dietary measures, and exercise have helped to achieve euglycemia in patients with gestational diabetes.

CONCLUSION

Universal screening for gestational diabetes is optimally performed at 26 weeks of gestation. Treatment of diagnosed cases, by insulin, diet, and exercise regimens, will decrease the occurrence of glucose-related macrosomia, improve the outcome of the pregnancy, and reduce the risks for obesity, hypertension, and diabetes in future progeny.

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.

Nutrition and pregnancy: the link between dietary intake and diabetes

Pregnancy is a time when serial metabolic changes in the mother are carefully regulated to provide optimum substrate to both mother and fetus. Subtle perturbations in maternal metabolism can have implications not only for the index pregnancy, but also for future generations. The literature provides evidence that maternal nutrition plays a major role in the destiny of the offspring. Both maternal malnutrition and overnutrition are associated with subsequent diabetes in the offspring. Pregnancy represents a window of opportunity for health care providers to change dietary patterns toward habits that will be healthier for the individual now, as well as impacting on the future. The challenge for clinicians is to provide nutritional information based on scientific evidence that facilitates the normalization of fetal nutrition, and thus minimize the risk that the child will develop diabetes.

Achieving Euglycaemia in Women with Gestational Diabetes Mellitus

Gestational diabetes mellitus is one of the major medical complications of pregnancy. Untreated, the mother and the unborn child may experience morbidity and fetal death may even occur. It is important to diagnose and treat all hyperglycaemia appearing during pregnancy. Ideally, a screening and diagnostic test that identified all women at risk for hyperglycaemia-associated complications would be employed in all pregnant women. Unfortunately, there is no such test available currently. The best alternative is to administer an oral glucose challenge test to all pregnant women and then apply the best strategies for interpretation. This article discusses the limitations of our present diagnostic tools and suggests an option for the clinician until the definitive test has been elucidated. In addition, this article outlines one dietary and management strategy that has been associated with an outcome of pregnancy that is similar to the outcome of pregnancies in healthy women. This strategy includes starting with a "euglycaemic" diet (comprising < 40% carbohydrates and > or =40% fat), which can then be individualised according to the patient's glucose levels. Appropriate exercise, such as arm ergometer training, may enhance the benefits of diet control. For patients who require insulin, if the fasting glucose level is >90 mg/dL or 5 mmol/L (whole blood capillary) then NPH insulin (insulin suspension isophane) should be given before bed, beginning with dosages of 0.2 U/kg/day. If the postprandial glucose level is elevated, pre-meal rapid-acting insulin should be prescribed, beginning with a dose of 1U per 10g of carbohydrates in the meal. If both the fasting and postprandial glucose levels are elevated, or if a woman's postprandial glucose levels can only be blunted if starvation ketosis occurs, a four-injections-per-day regimen should be prescribed. The latter can be based on combinations of NPH insulin and regular human insulin, timed to provide basal and meal-related insulin boluses. The total daily insulin dose for the four-injection regimen should be adjusted according to pregnant bodyweight and gestational week (0.7-1 U/kg/day); doses may need to be increased for the morbidly obese or when there is twin gestation. There is now some evidence that insulin lispro, other insulin analogues and oral antihyperglycaemic drugs may be beneficial in gestational diabetes, and more data on these agents are awaited with interest.

The principles of dietary management of gestational diabetes: reflection on current evidence

BACKGROUND

Gestational diabetes (GDM) is the commonest metabolic disorder of pregnancy. Most women with GDM are treated with nutritional management alone. There are conflicting guidelines surrounding its dietary management and this has resulted in a lack of conformity to the dietary advice currently prescribed. There is also conflicting opinions to the effectiveness of dietary management of GDM on pregnancy outcomes. The aim of this review was to examine the scientific evidence for the optimal nutritional management of GDM.

METHODS

A Medline search of all English papers published between 1995 and 2001 that cross-referenced GDM with diet was under taken. Because of the poor quality of many of these papers, literature prior to 1995 known to the authors and considered relevant to the review were also included.

RESULTS

The evidence base in this area is of poor quality. One systematic review based on randomized control trials failed to show any benefit from dietary intervention in GDM. However, that review did not include informative clinical and observational studies that are not classified as randomized controlled trials. Overall current evidence points to the effectiveness of dietary advice as a means of improving maternal hyperglycaemia and reducing the risk of accelerated foetal growth. The evidence surrounding energy restriction, carbohydrate and fat manipulation in GDM remains controversial.

CONCLUSIONS

Current but limited evidence supports dietary alterations to reduce rates of accelerated foetal growth. There is a clear need for good quality randomized control trials in this area.

Effect of a high monounsaturated fatty acid diet on blood pressure and glucose metabolism in women with gestational diabetes mellitus

OBJECTIVE

The effect of a diet rich in monounsaturated fatty acids (MUFA) on blood pressure, glycemic control, lipids and insulin sensitivity was evaluated in women with gestational diabetes mellitus.

DESIGN AND METHODS

A randomized, unpaired diet intervention was performed in 27 women with gestational diabetes mellitus in an outpatient clinic. After randomization the women received either a high-carbohydrate diet (H-CHO) or a high-MUFA diet (H-MUFA) from the 33rd gestational week of pregnancy. Outcome measures were 24 h ambulatory blood pressure, blood lipids, glycemic control and insulin sensitivity estimated by an intravenous glucose tolerance test.

RESULTS

The 24 h diastolic blood pressure increased more in the H-CHO group than in the H-MUFA group (P<0.04).

CONCLUSIONS

After 5 weeks of treatment with a MUFA-enriched diet, no increase in 24 h diastolic blood pressure and no adverse effects on blood lipids were seen. The favorable effect on the blood pressure by the MUFA diet is a possible non-medication treatment. The H-MUFA diet had no advantage to the H-CHO diet in ameliorating the decline of insulin sensitivity in third term of pregnancy in GDM.

The impact of maternal ketonuria on fetal test results in the setting of postterm pregnancy

OBJECTIVE

The aim of this study was to determine whether ketonuria, a commonly assessed urinary marker of maternal starvation and dehydration, is associated with abnormal fetal test results in the setting of postterm pregnancy.

STUDY DESIGN

During a 4-year period (January 1993-December 1996), a total of 3655 visits for antepartum maternal-fetal testing of postterm pregnancies (> or =41 weeks' gestation) occurred at our institution. Maternal assessment included vital signs and urinalysis. The presence and degree of maternal ketonuria was correlated against abnormal results of fetal heart rate tests, nonstress tests, amniotic fluid index measurements, and biophysical profile scores performed on the same day.

RESULTS

There were 3601 encounters suitable for inclusion in the study. Clinically detectable ketonuria occurred in 10.9% of the patients studied. Patients with clinically detectable ketonuria were at increased risk relative to patients without ketonuria for abnormal outcomes during postterm testing, including the presence of oligohydramnios (24% vs. 9.3%; P<.0001 ), nonreactive nonstress tests (6.2% vs. 2.15%; P<.0001), and fetal heart rate decelerations (14% vs 9.2%; P =.0039 ).

CONCLUSION

Maternal ketonuria among patients with postterm pregnancy was associated with a >2-fold increase in the occurrence of oligohydramnios, a 3-fold increase in nonreactive nonstress tests, and a significant increase in fetal heart rate decelerations. Further studies are required to evaluate the potential benefits of treating ketonuria before fetal testing.

Nutritional origins of insulin resistance: a rat model for diabetes-prone human populations

While there has been little success identifying the genetic bases of noninsulin-dependent (type-2) diabetes, current epidemiological data and animal models implicate fetal undernutrition in the development of type-2 diabetes. We examined the effects of fetal undernutrition on insulin responses and glucose tolerance in adulthood in genetically normal rats. Control rats were adequately nourished in utero and consumed nutritionally adequate (N) diets throughout life. Experimental rats (F1 generation) were undernourished in utero and consumed either N or high-energy, high-fat (HF) diets postweaning. The offspring of the experimental rats (F2 generation) received the respective diets of their parent. Body weights of experimental F1 rats at d 4 were 40% less than that of control pups, and they remained significantly smaller than controls throughout adulthood. The experimental F1 rats consuming N diets postweaning had a reduced insulin response (-30%) at 30-min postglucose challenge in adulthood (P > 0.05). However, their offspring (F2 generation) displayed a markedly elevated insulin response [+80% at 30 min (P < 0.05) and + 230% at 120 min (P < 0.001) postglucose challenge]. The insulin response of the F2 generation rats fed the high-energy, HF diet was even more pronounced [+130% at 30 min (P < 0.003) and + 250% at 120 min (P < 0.001) postglucose challenge]. Thus, undernourishment in utero produces striking insulin resistance in genetically normal, well-nourished second-generation rats.

Medical nutritional therapy in pregnant women with pregestational diabetes mellitus

OBJECTIVE

Diabetic women now can have the same chances as nondiabetic women to have a healthy infant. The reduction of risk associated with pregnancies complicated by diabetes can only be assured if normoglycemia is achieved before and during pregnancy. This review is intended to provide guidelines and scientific evidence for the optimal diet for the Type 1 or Type 2 diabetic woman.

METHODS

The literature over the past 10 years is presented. Those diets which achieved the best outcome of pregnancies complicated by diabetes (as evidenced by term delivery of a healthy, normal weight infant) are then outlined.

RESULTS

Diets which provide adequate calories without causing postprandial hyperglycemia or premeal ketosis are found to be based on body weight and gestational week of the pregnancy. Quantity of carbohydrate in the meal plan emerges as the most important component in achieving and maintaining glucose control.

CONCLUSIONS

The medical nutritional therapy for the Type 1 and Type 2 diabetic woman is a necessary component of the overall strategy to achieve and maintain normoglycemia and thus achieve the best outcome of pregnancy.

When is fasting really fasting? The influence of time of day, interval after a meal, and maternal body mass on maternal glycemia in gestational diabetes

OBJECTIVE

The object of the study was to determine whether time of day, interval after a standard meal, and maternal body mass influence plasma glucose concentrations in women with gestational diabetes mellitus.

STUDY DESIGN

Identical mixed meals were administered on 2 separate occasions 1 week apart to 30 women with dietarily treated gestational diabetes and pregnancies between 28 and 38 weeks' gestation. One meal was administered at 7 AM (morning meal) and the other was administered at 9 PM (evening meal), each after a fast of >/=5 hours. The order of the meals (morning first versus evening first) was assigned randomly. Sixteen of the women had a body mass index >/=27 kg/m(2) (overweight) and 14 women had a body mass index <27 kg/m(2) (lean). Venous plasma concentrations of glucose, insulin, free fatty acids, beta-hydroxybutyrate, and bound and free cortisol were measured hourly for 9 hours after each of the test meals.

RESULTS

When all women were considered together glucose concentrations after the morning meal were significantly greater at 1 hour, were not different at 2 hours, and were significantly lower from 3 through 9 hours postprandially than those at corresponding times after the evening meal. Plasma beta-hydroxybutyrate and free fatty acid concentrations were higher between 5 and 9 hours after the morning meal than at the same times after the evening meal. Total and free cortisol levels were higher for the first 7 hours after the morning feeding, reflecting known diurnal variation in cortisol concentrations. Overweight patients' glucose values were significantly greater than those of lean subjects during the last 4 hours of the overnight fast.

CONCLUSIONS

Among women with dietarily treated gestational diabetes the glucose concentrations were significantly higher from 3 to 9 hours after an evening meal, whereas suppression of free fatty acids and beta-hydroxybutyrate was less sustained after a morning feeding. The mechanisms underlying these differences remain to be determined but may involve diurnal influences of counterregulatory hormones. The relationships between measurements of maternal glycemia and maternal and perinatal outcomes in pregnancies complicated by gestational diabetes may be clarified by establishing a uniform duration of a fast and by developing meal-specific preprandial and postprandial maternal glucose targets for these patients.

Exercise and the nutritional management of diabetes during pregnancy

Although exercise is widely accepted as an important component in programs of maintaining a healthy lifestyle, the question of safety and utility of an exercise program for pregnant diabetic women is still controversial. Pregnant women who have diabetes want some direction as to what their possibilities are regarding exercise programs, as there is accumulating evidence that exercise during pregnancy has some advantages for them. In addition, there is now a consensus of thought that the ideal nutritional therapy for the gestational diabetic woman is a diet that facilitates normoglycemia. This article outlines a program that not only improves metabolic control through dietary principles and exercise prescriptions to achieve and maintain normoglycemia, but also will be safe for the mother and her baby, is enjoyable, and also has physical benefits for the mother.

Metabolic interactions of diabetes and pregnancy

Many of the embryonic and fetal abnormalities that occur in pregnancies complicated by maternal diabetes are the result of development in a metabolically abnormal environment. Diabetic embryopathy (birth defects and spontaneous abortions) results from maternal metabolic abnormalities during the first 6-7 weeks of gestation. The embryopathy appears to be multifactorial in origin, and the resulting defects remain important causes of morbidity and mortality in diabetic pregnancies. Diabetic fetopathy (predominantly macrosomia and neonatal hypoglycemia) results from fetal overnutrition and hyperinsulinemia during the second and third trimesters. Fetopathy may cause significant morbidity not only in the perinatal period, but also in later life as overweight infants grow up to be overweight children and young adults. Careful regulation of maternal metabolism from the preconceptional period onward can reduce greatly or even eliminate the excess risks that have been incurred by infants of diabetic mothers in the past. Successful management of maternal diabetes requires knowledge of the alterations in intermediary metabolism that normally occur during pregnancy, as discussed in this chapter.

The pathogenesis of eclampsia: the 'magnesium ischaemia' hypothesis

'Magnesium ischaemia' is a term used to denote the functional impairment of the ATP-dependent sodium/potassium and calcium pumps in the cell membranes and within the cell itself. The production of ATP and the functioning of these pumps is magnesium-dependent and is critically sensitive to acidosis. Zinc and iron deficiencies may secondarily impair these pumps and thus contribute to 'magnesium ischaemia' (as does acidosis). This term is two-dimensional at its simplest; it refers to a functional magnesium deficiency, whether actual or induced. It is argued that chronic acidosis is the most common inducing factor. This simple hypothesis can begin to unify diverse pathophysiologies: some spontaneous abortions, aspects of Type II and gestational diabetes and the curious observation that heroin addicts become diabetic. It can also unify clinical thinking about pregnancy-induced hypertension, pre-eclampsia/eclampsia and acute fatty liver of pregnancy, as well as the coagulopathy of pregnancy. It makes important predictions about perinatal morbidity and suggests that early supplementation might prevent much pregnancy-induced disease.