Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.

BACKGROUND: We conducted a randomized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications. METHODS: We randomly assigned women between 24 and 34 weeks' gestation who had gestational diabetes to receive dietary advice, blood glucose monitoring, and insulin therapy as needed (the intervention group) or routine care. Primary outcomes included serious perinatal complications (defined as death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labor, cesarean birth, and maternal anxiety, depression, and health status. RESULTS: The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group (1 percent vs. 4 percent; relative risk adjusted for maternal age, race or ethnic group, and parity, 0.33; 95 percent confidence interval, 0.14 to 0.75; P=0.01). However, more infants of women in the intervention group were admitted to the neonatal nursery (71 percent vs. 61 percent; adjusted relative risk, 1.13; 95 percent confidence interval, 1.03 to 1.23; P=0.01). Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group (39 percent vs. 29 percent; adjusted relative risk, 1.36; 95 percent confidence interval, 1.15 to 1.62; P<0.001), although the rates of cesarean delivery were similar (31 percent and 32 percent, respectively; adjusted relative risk, 0.97; 95 percent confidence interval, 0.81 to 1.16; P=0.73). At three months post partum, data on the women's mood and quality of life, available for 573 women, revealed lower rates of depression and higher scores, consistent with improved health status, in the intervention group. CONCLUSIONS: Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman's health-related quality of life.

Maternal Bartter's syndrome in pregnancy treated by amiloride.

BACKGROUND: Bartter's syndrome is a rare condition during pregnancy. The prenatal management is difficult to maintain normal potassium serum levels. CASE: We describe a 26-year-old woman with Bartter's syndrome. During pregnancy, she required increasing potassium and magnesium supplementations. Amiloride, a sparing potassium diuretic, was continued. She delivered an unaffected girl at term. CONCLUSION: When Bartter's syndrome is associated with pregnancy, the management must be careful. Amiloride can be used to support potassium supplementation.

Perinatal outcome in large-for-gestational-age infants. Is it influenced by gestational impaired glucose tolerance?

OBJECTIVE: To examine the relationship between the World Health Organization category of impaired glucose tolerance (IGT) (two-hour value of the 75-g oral glucose tolerance test at 8-10.9 mmol/L) and outcome in large-for-gestational age (LGA) infants to determine whether IGT affects perinatal morbidity in addition to affecting infant size. STUDY DESIGN: A retrospective study was performed on 461 LGA newborns (birth weight > 90th percentile) from singleton pregnancies delivering after 36 completed weeks in a 12-month period to determine the difference in perinatal outcome between nondiabetic pregnancies (n = 382) and pregnancies with diet-treated IGT (n = 79). RESULTS: The IGT group had significantly higher mean maternal age, prepregnancy weight and body mass index (BMI) but lower absolute and percent gestational weight gain and no difference in infant gestational age, birth weight, BMI, incidence of macrosomia (birth weight > or = 4,000 g) or obstetric complications. However, the IGT group had an increased incidence of Erb's palsy (OR 7.81, 95% CI 1.76-34.62), meconium aspiration syndrome (OR 5.29, 95% CI 1.27-22.02), phototherapy (OR 2.10, 95% CI 1.03-5.69), sepsis (OR 2.90, 95% CI 1.25-6.74) and shoulder dystocia (OR 5.64, 95% CI 1.06-29.89) after adjusting for confounding factors (maternal age and BMI, postdate pregnancy, mode of delivery and infant sex). CONCLUSION: Despite dietary treatment, maternal IGT is associated with increased perinatal morbidity independent of its effect on fetal size.

Complementary therapy for severe Rh-alloimmunization.

PURPOSE OF INVESTIGATION: This report describes successful treatment, using invasive and noninvasive techniques, of a 36-year-old woman (gravida 10, para 0) referred to our center at 13 weeks' gestation for severe Rh alloimmunization. Pre-pregnancy indirect Coombs titers ranged from 1:1024-2048. All nine past pregnancies (conceived with three different partners) had ended in abortion, intrauterine death or neonatal death METHODS: The patient was treated with a single session of plasmapheresis (week 14) immediately followed by five days of immunoglobulin therapy and immunosuppressive therapy based on azathioprine and prednisone (weeks 15-22). Seven fetal transfusions (one intraperitoneal, six intravascular) were performed beginning at 16 weeks. RESULTS: The pregnancy, which was characterized by insulin-dependent gestational diabetes, spontaneously resolving polyhydramnios and peak indirect Coombs titers of 1:65,536, ended at 27 weeks with cesarean section delivery of a viable female weighing 1,000 g. In spite of numerous neonatal complications, the child is physically well at age 3, with normal intellectual and psychomotor development. CONCLUSION: In light of the negative outcomes of the patient's nine past pregnancies, our experience suggests that the early initiation of an integrated approach based on noninvasive and invasive techniques can play a potentially decisive role in the management of severe Rh-alloimmunization.

High intake of energy, sucrose, and polyunsaturated fatty acids is associated with increased risk of preeclampsia.

OBJECTIVE: Preeclampsia is associated with high body mass index, insulin resistance, and hypertriglyceridemia. Our objective was to investigate prospectively whether diet in the first half of pregnancy is associated with the risk for preeclampsia. STUDY DESIGN: This prospective, population-based, cohort study of pregnant women investigated dietary intake early in the second trimester with a quantitative food frequency questionnaire. RESULTS: The questionnaire was completed by 3133 women (83%). Preeclampsia developed in 85 women. Adjusted odds ratio (95% CI) for preeclampsia was 3.7 (1.5-8.9) for energy intake of >3350 kcal/d compared with < or =2000 kcal/d. Adjusted odds ratio (95% CI) for preeclampsia was 3.6 (1.3-9.8) for sucrose intake (percent of total energy) of >25% compared with < or =8.5% and 2.6 (1.3-5.4) for polyunsaturated fatty acids intake (percent of total energy) of >7.5% compared with < or =5.2%. Other energy-providing nutrients were not associated with the risk for preeclampsia. CONCLUSION: The current study suggests that high intakes of energy, sucrose, and polyunsaturated fatty acids independently increase the risk for preeclampsia.

Thiamin status of gravidas treated for gestational diabetes mellitus compared to their neonates at parturition.

Since thiamin plays a role in glucose metabolism we wanted to know if blood thiamin influx from gravida to neonate was influenced by treatment of gravidas having gestational diabetes mellitus (GDM). In this study we found thiamin hypovitaminemia in 19% of the 77 pregnancies despite vitamin supplementation and treatment for GDM; neonates born to mothers with hypovitaminemia were also thiamin hypovitaminemic. All neonatal blood had significantly higher thiamin concentration than gravidas. Indeed, cord blood from neonates born to mothers treated with insulin for GDM had significantly higher thiamin concentration than other neonates in the study. A significant weight depression was noted in neonates born to treated GDM mothers. Healthy gravidas giving birth to macrosomia neonates, had significant thiamin hypovitaminosis, but only macrosomic neonates of treated diabetic mothers had significantly depressed blood thiamin concentrations. We noted that subclinical thiamin hypovitaminemia is prominent during pregnancy despite vitamin supplementation. Perhaps increased thiamin supplementation during pregnancy seems warranted to avoid metabolic stress in mother and fetus due to thiamin hypovitaminemia.