Gestational diabetes-perinatal outcome with a policy of liberal and intensive insulin therapy

Clinical Recommendations for the Use of Islet Cell Autoantibodies to Distinguish Autoimmune and Non-Autoimmune Gestational Diabetes

Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. The prevalence of GDM is highly variable, depending on the population studied, and reflects the underlying pattern of diabetes in the population. GDM manifests by the second half of pregnancy and disappears following delivery in most cases, but is associated with the risk of subsequent diabetes development. Normal pregnancy induces carbohydrate intolerance to favor the availability of nutrients for the fetus, which is compensated by increased insulin secretion from the maternal pancreas. Pregnancy shares similarities with adiposity in metabolism to save energy, and both conditions favor the development of insulin resistance (IR) and low-grade inflammation. A highly complicated network of modified regulatory mechanisms may primarily affect carbohydrate metabolism by promoting autoimmune reactions to pancreatic β cells and affecting insulin function. As a result, diabetes development during pregnancy is facilitated. Depending on a pregnant woman's genetic susceptibility to diabetes, autoimmune mechanisms or IR are fundamental to the development autoimmune or non-autoimmune GDM, respectively. Pregnancy may facilitate the identification of women at risk of developing diabetes later in life; autoimmune and non-autoimmune GDM may be early markers of the risk of future type 1 and type 2 diabetes, respectively. The most convenient and efficient way to discriminate GDM types is to assess pancreatic β-cell autoantibodies along with diagnosing diabetes in pregnancy.

Gestational diabetes: maternal weight gain in relation to fetal growth, treatment modality, BMI and glycemic control

OBJECTIVES

We sought to determine the impact of maternal weight gain on fetal growth in gestational diabetes (GDM) in relation to treatment modality, body mass index (BMI) and glycemic control.

STUDY DESIGN

Two thousand four hundred fifty-four GDMs were evaluated. Obesity was defined as BMI >29; good glycemic control ≤ 100 mg/dl; maternal age < and >30 years; parity ± 1; large for gestational age (LGA) >90th percentile and small for gestational age (SGA) <10th percentile.

RESULTS

SGA rates were similar in all groups. Obese/overweight diet-treated women in glycemic control showed a four-fold higher rate of LGA compared to insulin-treated women. A 36-lb weight gain in insulin-treated patients had a six-fold higher risk. In poor glycemic control, LGA rates were higher in all BMI/weight gain categories. Logistic regressions for LGA/SGA revealed that level of glycemia, weight gain, parity, obesity and treatment (for LGA only) were significant.

CONCLUSION

Different thresholds used for different maternal BMI categories in addition to the achievement of glycemic control and pharmacological therapy will enhance pregnancy outcome.

Different HLA-DR-DQ and MHC class I chain-related gene A (MICA) genotypes in autoimmune and nonautoimmune gestational diabetes in a Swedish population

The genetic susceptibility for gestational diabetes (GDM) was estimated by comparisons of genotypes within human leukocyte antigen (HLA) and major histocompatibility complex class I chain-related gene A (MICA) in 199 women with GDM and 213 healthy women. At least one of ICA, glutamic acid decarboxylase antibodies, or islet cell antigen-2 antibodies/tyrosine phosphatase antibodies was found in 6.0% (12/199) of women with GDM and were considered as autoimmune GDM, whereas the remaining 187 were considered as nonautoimmune GDM. HLA genotyping was done with polymerase chain reaction and sequence-specific oligonucleotides. MICA polymorphism was determined with polymerase chain reaction and fragment size determination. HLA-DR3-DQ2/x or DR4-DQ8/x and MICA5.0/5.1 were more frequent in autoimmune GDM compared with controls; 92% versus 46% and 42% versus 13% and conferred increased risk (odds ratio [OR] = 13; 95% confidence interval [CI] 1.7-104) and (OR = 4.7; 95%CI 1.4-16). Four other genotypes were more frequent in nonautoimmune GDM compared with controls: HLA-DR7-DQ2/y, 24% versus 14%; DR9-DQ9/y, 9.6% versus 1.9%; DR14-DQ5/y, 7.5% versus 0.94%; and MICA5.0/z, 24% versus 13% and gave increased risk: OR = 2.0; 95%CI 1.2-3.4, OR = 5.6; 95%CI 1.8-17, OR = 8.5; 95%CI 1.9-38, and OR = 2.0; 95%CI 1.2-3.4, respectively. We concluded that autoimmune diabetes with onset during pregnancy is associated with the type 1 diabetes-associated genotypes and also with MICA5.0/5.1, whereas DR7-DQ2/y, DR9-DQ9/y, DR14-DQ5/y, and MICA5.0/z are risk factors for nonautoimmune GDM.

Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome

AIMS

Gestational diabetes mellitus (GDM) is associated with adverse maternal and fetal outcome. Screening for GDM is therefore recommended but the best screening method remains controversial. This prospective, randomized study compared a risk factor-based screening programme with a universally based one.

METHODS

Subjects were randomized at booking to one of two groups: the risk factor group had a 3-h 100-g oral glucose tolerance test (OGTT) at 32 weeks if any risk factor for GDM was present; the universal group had a 50-g glucose challenge test performed and if their plasma glucose at 1 h was > or = 7.8 mmol/l, a formal 3-h 100-g OGTT was then performed.

RESULTS

Universal screening detected a prevalence of GDM of 2.7%, significantly more than the 1.45% detected in the risk factor screened group (P<0.03). Universal screening facilitated earlier diagnosis than risk factor screening - mean gestation 30 +/- 2.6 weeks vs. 33 +/- 3.7 weeks (P<0.05). A higher rate of spontaneous vaginal delivery at term, and lower rates of macrosomia, Caesarean section, prematurity, pre-eclampsia and admission to neonatal intensive care unit were observed in the universally screened, early diagnosis group.

CONCLUSIONS

Universal screening for GDM is superior to risk factor based screening-detecting more cases, facilitating early diagnosis and is associated with improved pregnancy outcome.

Attenuated hepatic glucose production but unimpaired lipolysis in newborn infants of mothers with diabetes

In infants of diabetic mothers, maternal-fetal hyperglycemia induces fetal hyperinsulinemia, which may be sustained for several hours after birth. The inhibitory effect of insulin on glycogenolysis, gluconeogenesis, and lipolysis increases the risk of hypoglycemia in these infants. Eight term infants of diabetic mothers were studied between 3.9 and 8.5 h postnatally. The maternal diabetes was considered well controlled as judged by self-monitoring of blood glucose and Hb Alc. Neonatal plasma concentrations of glucose, glycerol, and insulin were monitored and averaged 2.7 +/- 0.7 mM, 371 +/- 116 microM, and 15.9 +/- 2.8 microU.mL-1, respectively. Stable isotope-gas chromatography/ mass spectrometry techniques were used to determine glucose and glycerol turnover rates and gluconeogenesis from glycerol in the infants. The appearance rates of glucose and glycerol averaged 20.0 +/- 5.4 mumol.kg-1.min-1 (3.6 +/- 1.0 mg.kg-1.min-1), and 8.9 +/- 2.3 mumol.kg-1.min-1, respectively. The fraction of glycerol appearance rate converted to glucose was 68.2 +/- 17.3%, which accounted for 15.5 +/- 4.6% of glucose production. Thus, compared with healthy term infants studied previously under identical conditions, the infants of diabetic mothers had higher insulin concentrations and attenuated glucose production. Despite increased insulin concentrations, lipolysis was unimpaired, and the gluconeogenic contribution from glycerol was higher than in the healthy newborns.

Relationships between the perceived impact of gestational diabetes mellitus and treatment adherence

OBJECTIVE

To examine the relationship between women's perceptions of the impact of the diagnosis and treatment of gestational diabetes mellitus and treatment adherence.

DESIGN

Longitudinal and prospective, extending from the time of diagnosis of gestational diabetes mellitus through delivery.

SETTING

An urban university-based tertiary perinatal center in Philadelphia.

PARTICIPANTS

A subsample of women enrolled in a larger study of early discharge and nurse specialist transitional care. The 29 women in the sample met the study criteria of diagnosis with gestational diabetes mellitus, English speaking, less than 36 weeks gestation, and telephone access at home.

MAIN OUTCOME MEASURE

Perceived impact of gestational diabetes mellitus was measured with the Impact of Event Scale. Treatment adherence included the percentage of recommended blood glucose self-monitoring, incidence of hypo- and hyperglycemia, obstetric visits kept, and dietary adherence.

RESULTS

Descriptive and correlational analyses were used. Negative correlations between impact and blood glucose self-monitoring (r = -.38, p = .04) and impact and hypoglycemia (r = -.31, p = .10) were found. Positive correlation between obstetric visits and blood glucose self-monitoring (r = .34, p = .07) was found.

CONCLUSIONS

Women who perceive gestational diabetes mellitus to have a great impact on their lives may be less adherent to the behavioral tasks that can influence blood glucose control, potentially increasing risk.