Recommendations of the AGG (Working Group for Obstetrics, Department of Maternal Diseases) on How to Treat Thyroid Function Disorders in Pregnancy.

Objective These recommendations from the AGG (Committee for Obstetrics, Department of Maternal Diseases) on how to treat thyroid function disorder during pregnancy aim to improve the diagnosis and management of thyroid anomalies during pregnancy. Methods Based on the current literature, the task force members have developed the following recommendations and statements. These recommendations were adopted after a consensus by the members of the working group. Recommendations The following manuscript gives an insight into physiological and pathophysiological thyroid changes during pregnancy, recommendations for clinical and subclinical hypo- and hyperthyroidism, as well as fetal and neonatal diagnostic and management strategies.

Evaluation of Treatment Strategies to Manage Diabetes Mellitus in Pregnancy: Use of Fetal Sonography Compared to Monitoring of Maternal Blood Glucose Alone.

Introduction When planning the treatment of women with gestational diabetes, the current standard approach also takes fetal growth development into account. The treatment of pregnant women with type 1 diabetes mellitus (DM) used to be based exclusively on maternal blood glucose values. This study investigated the impact of including fetal growth parameters in the monitoring of pregnant women with type 1 diabetes mellitus. Patients/Method 199 pregnant women with type 1 DM were included in a cohort study. The patient population was divided into two study cohorts. In the mBG cohort (n = 94; investigation period: 1994 - 2005) treatment was monitored using only maternal blood glucose (mBG) values; the aim was to achieve standard target glucose values (mean BG < 5.5 mmol/l, postprandial: at 1 h < 7.7 mmol/l, at 2 h < 6.6 mmol/l). In the fUS collective (n = 101, investigation period: 2006 - 2014) fetal growth parameters were additionally included when monitoring treatment from the 22nd week of gestation, and maternal target glucose values were then individually adjusted to take account of fetal growth. This study aimed to investigate the impact of these two different ways of monitoring treatment on perinatal and peripartum outcomes. Results 91.4% of all patients were normoglycemic at the time of delivery (HbA 1c < 6.7%); 58.9% of patients achieved strict normoglycemia (HbA 1c < 5.7%). No differences were found between the two study cohorts (fUS vs. mBG: HbA 1c < 6.7%: 93.9 vs. 88.4%, n. s.; mean blood glucose (BG): 5.4 ± 0.6 to 6.6 ± 1.1 vs. 5.9 ± 0.7 to 7.4 ± 1.9 mmol/l, n. s.). Patients from the fUS cohort required significantly lower weight-adjusted maximum insulin doses (0.9 ± 0.3 vs. 1.0 ± 0.4 IE/kg bodyweight, p < 0.05). Pregnancy complications occurred significantly less often in the fUS cohort (preeclampsia: 7.1 vs. 20.9%, p = 0.01; premature labor: 4.0 vs. 23.3%, p < 0.001; cervical insufficiency: 0.0 vs. 11.6%, p = 0.001), and there were significantly fewer cases with neonatal hyperbilirubinemia (19.2 vs. 40.7%, p = 0.001). There was no difference in the rates of LGA infants between the two cohorts (21.2 vs. 24.4%, n. s.). Conclusion Using maternal blood glucose values combined with fetal growth parameters to monitor DM treatment allows therapeutic interventions to be individualized and reduces the risk of maternal and infant morbidity. The metabolism of patients in the fUS cohort was significantly more stable and there were fewer variations in glucose values. It is possible that the detected benefits are due to this metabolic stabilization.

[Posttransplantation diabetes mellitus in patients after kidney transplantation - Incidence and risk factors]. / Posttransplantationsdiabetes mellitus bei Patienten nach Nierentransplantation.

BACKGROUND: Transplantation (NTX) associated ischemia-reperfusion-mechanisms and the predisposition for insulin resistance are discussed as causes of a posttransplantation diabetes mellitus (PTDM). Furthermore, immunosuppressants can have a damaging effect on insulin secretion. METHODS: 55 metabolically healthy patients with an endstage renal disease (age 52 ± 14 years, body mass index 27 ± 5 kg / m(2), blood pressure 137 ± 15/82 ± 11 mmHg) were included in a prospectively cohort study. These patients were transplanted between 2009 and 2011 (82 % of the NTX patients). Baseline examination was performed before NTX. Within the 2nd week as well as 6 and 12 months after transplantation an oral glucose tolerance test (oGGT), 3 and 9 months after NTX a glucagon test took place. In these connections the determination of plasma glucose, C-peptide and insulin was performed. Study endpoints were: graft failure, impaired glucose tolerance (iGT), PTDM, patient's death. RESULTS: Over a follow-up-period of 1 year post NTX iGT / PTDM occurred in 31 % and graft failure in 13 %. In comparison with the healthy control group patients with iGT / PTDM were older (59 ± 8 vs. 48 ± 14ys, p = 0.001), overweight (BMI 29 ± 4 vs. 26 ± 5 kg / m(2), p = 0.038), showed an indication of an insulin resistance before NTX (HOMA 4.0 ± 2.9 vs. 2.4 ± 1.4, p = 0.013; C-peptide 10.1 ± 5.2 vs. 7.1 ± 3.6 ng / ml, p = 0.014; insulin 14.6 ± 9.4 vs. 10.6 ± 5.5mU / l, p = 0.045) and higher HbA1c levels (5.6 ± 0.5 vs. 5.4 ± 0.4 %, p = 0.032). Age (p = 0.001), fasting plasma glucose (p = 0.042), the glucose levels of oGTT immediately after transplantation were shown as prognostically relevant (fasting glucose: p = 0.027; 1 h: p = 0.014; 2 h: p = 0.002). An isolated defective secretion as a result of a toxic damage to the ß-cells by immunosuppressants couldn't be shown in any of the patients with iGT / PTDM. 4 % of the patients died in the first year after NTX. CONCLUSION: In 31 % a disorder of glucose metabolism was found as a frequent complication after NTX. The HOMA index was found to be a meaningful marker for an existing insulin resistance. The fasting glucose before and an oGTT in the first weeks after NTX showed itself as clinically valid laboratory parameters for a risk assessment.

Gestational diabetes mellitus: an evaluation of gynecologists' knowledge of guidelines and counseling behavior.

PURPOSE: Knowledge of risks, adequate pre- and post-partum care, and counseling is essential to reduce short- and long-term consequences for women with gestational diabetes mellitus (GDM) and their offspring. Our study explored the current GDM guideline knowledge and practiced patient counseling of private gynecologists in Germany. METHODS: A survey assessing the GDM guidelines and patient counseling was mailed to 775 practicing gynecologists. We evaluated the knowledge of maternal and offspring disease risks, counseling practice, and guideline awareness. Descriptive statistics were used to analyze the responses and Chi-Square or Fisher exact test to explore differences between groups. RESULTS: Of the 418 private gynecologists (54.1 % response rate) who responded, the majority was aware of obesity and GDM in the previous pregnancy as risk factors for GDM. To a lesser extent, risk factors like recurrent miscarriages and stillbirth were recalled. Eighty percent stated that GDM was associated with a higher risk for the development for hypertension and 96 % with type 2 diabetes in the mother. Respondents with knowledge of the current GDM guidelines were more often aware of the development of chronic diseases, counseled patients more frequently, and performed post-partum glucose screenings more regularly compared with private gynecologists with no knowledge of the guidelines. CONCLUSIONS: The majority of participants incorporated recent recommendations into their practice patterns for GDM. Providing private gynecologists with additional training may further improve care for women with GDM-affected pregnancies.

PP063. Carotid artery stiffness and elasticity in gestational diabetes.

INTRODUCTION: Gestational diabetes (GMD) is gaining in importance in prenatal care due to it's increasing prevalence. These women do have a higher risk for disrupted elasticity and stiffening of the carotid artery. Aim of this study was to assess carotid intima media thickness (IMT) and vessel wall changes during pregnancy and postpartum. METHODS: IMT and vessel wall parameters of the carotid artery were evaluated with high resolution ultrasound during pregnancy and postpartum on 84 women with gestational diabetes and 106 gestational age matched controls. RESULTS: Carotid elasticity (mean (%)±SD) was significantly lower in women with GDM than healthy pregnant women (9.48 (103/kPa)±3.21 vs. 11.01±3.17, p<0.047), whereas blood pressure independent ß-stiffness (mean±SD) was significantly increased in women with GDM (6.08±3.15 vs. 4.68±1.57; p=0.007). Pregnancies complicated by GDM had higher mean arterial pressure then matched controls (93±12 vs. 86±10mmHg, p<0.015). Postpartum, both groups did not show any significant changes. CONCLUSION: Carotid stiffening and rigidity is present in gestational diabetes mellitus during pregnancy and shows postpartal recovery. Therefore GDM dependent vessel wall changes seem to be only temporary and not pre-existing.

[Prevalence of polyglandular autoimmune syndrome in patients with diabetes mellitus type 1]. / Prävalenz eines polyglandulären Autoimmunsyndroms bei Patienten mit Diabetes mellitus Typ 1.

BACKGROUND AND PURPOSE: The aim of this study was to examine the prevalence of autoimmune antibodies (autoimmune hypophysitis, adrenalitis, thyropathy, pernicious anemia, celiac disease) and clinically relevant endocrine autoimmune disease (AIEK) in patients with type 1 diabetes in the course of 1 year. PATIENTS AND METHODS: Antibody screening was performed in 139 diabetic patients (age 44 +/- 14 years; years since diagnosis 26 +/- 15 years; duration of diabetes 18 +/- 12 years; body mass index 26 +/- 4 kg/m(2); HbA(1c) 7.5% +/- 1.1% [normal range 4.4-5.9%]) who completed a routine clinic visit in 2003. Patients with pathologically increased antibody titers were further examined regarding the clinically relevant AIEKs. Reexamination was performed 1 year later. RESULTS: In 2003, 63% of diabetic patients showed at least one pathologically increased antibody titer (2004: 60%). In 32% of the patients, increased antibody titers were clinically inapparent. Apart from diabetes mellitus type 1, in 2003, 31% suffered from other AIEK requiring therapy (2004: +3.6%): 22.3% harbored two additional AIEKs (2004: +2.2%) and 8.6% even > or = 3 AIEKs (2004: +1.5%). The following pathologically increased antibody titers/prevalences of clinically relevant AIEKs were found (in comparison with 2004): increased antithyroid autoantibodies: 47.5% (-0.7%)/autoimmune thyroiditis 24.5% (+2.8%) and Graves' disease 4.3% (+0.7%), respectively; adrenal cortex autoantibodies 0.7% (+1.5%)/Addison's disease 1.4% (+/-0), gliadin peptide antibodies and IgA to tissue transglutaminase, respectively: 18.7% (-5.0%)/celiac disease 1.4% (+0.8%), parietal cell antibodies: 15.8% (+7.2%)/pernicious anemia 7.2% (+1.4%), hypophysitis 0.7% (+/-0), hypogonadism 0.7% (+/-0). All new AIEK manifestations in 2004 had had an at least tenfold increased antibody titer in 2003. Comparing patients with and without polyglandular autoimmune syndrome (PAS), no difference in age (43 +/- 14 vs. 46 +/- 13 years), duration of diabetes (17 +/- 13 vs. 18 +/- 12 years), and HbA1c (7.3% +/- 0.9% vs. 7.6% +/- 1.1%) could be found. CONCLUSION: In this study, more than half of the patients with diabetes mellitus type 1 had at least one pathologically increased antibody titer apart from diabetes without clinical sign of an additional AIEK. 31% of patients with increased antibodies presented with symptoms of another AIEK (increase by 3.6% within 1 year). Patients with diabetes mellitus type 1 should be screened for other AIEKs. Thyropathy had the greatest prevalence and increased by 3.5% within 1 year's time.

Diabetic foot syndrome and renal function in type 1 and 2 diabetes mellitus show close association.

BACKGROUND: Diabetic nephropathy and diabetic foot syndrome (DFS) are two major complications of diabetes. Surprisingly, little is known of a potential relationship between renal function and the development of DFS in patients with preterminal renal insufficiency. A retrospective cohort study at a single tertiary university centre caring for a large collective of patients with type 1 and 2 diabetes was performed. Patients and methods. All patients with type 1 or 2 diabetes from 1989 to 2007 on the electronic patient sheet who had standardized food examination, albuminuria and serum creatinine were analysed. A total number of 899 patients with type 1 and 4007 individuals with type 2 diabetes were studied. Estimated glomerular filtration rate (eGFR) was calculated according to the modified equation 7 MDRD formula. Patients were grouped into the chronic kidney disease (CKD) stages according to the eGFR and presence of albuminuria. DFS was classified according to Wagner as well as Armstrong stages. RESULTS: Forty-six patients (5.1%) of 899 patients with type 1 diabetes have active or a history of DFS. Patients with type 1 diabetes and DSF had significantly higher serum creatinine levels, lower eGFR, higher systolic blood pressure and higher HbA1c levels compared to those without DFS. There was a significant negative correlation between eGFR and the presence of DFS in patients with type 1 diabetes (r = -0.155, P < 0.01). In type 1 diabetes patients, there was a significant negative correlation (Spearman test) between eGFR and Wagner stages (r = -0.218, P = 0.01) as well as Armstrong stages (r = -0.255, P = 0.01). Multiple logistic regression analysis revealed a significant association between the presence of DFS and eGFR (odds ratio 0.696 per 10 ml/min increase, 95% confidence interval 0.627-0.773, P < 0.001). A total of 532 type 2 patients from 4007 patients had DFS (13.7%). Compared with type 2 patients without DFS, those with DFS were significantly older (P < 0.005), exhibited a higher HbA1c, had a longer duration of diabetes (P < 0.005), higher serum creatinine levels (P < 0.005) and a lower eGFR (P < 0.005). There was a significant negative correlation between the Wagner stages and eGFR (r = -0.104, P < 0.01) as well as Armstrong stages and eGFR (r = -0.125, P < 0.01) in all patients with type 2 diabetes (Spearman test). Multiple logistic regression analysis revealed a significant association between the presence of DFS and eGFR (odds ratio 0.873 per 10 ml/min increase, 95% confidence interval 0.842-0.904, P < 0.001). There were also significant associations between DFS and duration of diabetes as well as diastolic blood pressure. In addition, the Jonckheere-Terpstra test confirmed the decrease of eGFR with increasing Wagner and Armstrong stages in patients with type 2 diabetes. Smoking was not associated with a higher prevalence of DFS in type 1 and 2 diabetic patients. CONCLUSION: There was a strong association between the degree of renal function impairment and DFS in this observational study. Data show that diabetics with DFS undergo a higher incidence of amputation; thus, it should be recommended that diabetic patients with renal insufficiency should be regularly screened for the presence of DFS.

Hemoglobin concentrations are closely linked to renal function in patients with type 1 or 2 diabetes mellitus.

BACKGROUND/AIMS: It has been reported that anemia is more common in patients with diabetes mellitus, and that it occurs early in the disease process. METHODS: In this study, we evaluated hemoglobin (Hb) values of patients with diabetes type 1 or 2 from a large collective receiving care from a tertiary center. A total of 751 patients with type 1 diabetes and 3,306 patients with type 2 were studied. Correlations were calculated for Hb with the following parameters: metabolic control (HbA(1c) and blood glucose), renal function [estimated glomerular filtration rate (eGFR), serum creatinine, albuminuria, proteinuria], blood leukocytes, duration of diabetes and use of ACE inhibitors/AT1-receptor antagonists. RESULTS: 17% of patients with type 1 diabetes and 14% of those with type 2 had anemia [defined as an Hb <8.5 mmol/l (<13.68 g/dl) in men and <7.5 mmol/l (<12.07 g/dl) in women). There was a close positive correlation between Hb and eGFR, and a negative correlation with albuminuria and proteinuria. These close associations were also confirmed with linear regression analysis. A significant negative correlation was observed between serum creatinine levels and Hb. There was no negative correlation between actual Hb and mean HbA(1c) in the individual follow-up periods. No correlation was found between blood glucose (morning and postprandial blood glucose) and Hb. Blood leukocyte numbers, as a parameter of systemic inflammation, were not correlated with Hb. The use of ACE inhibitors/AT1-receptor antagonists had no adverse effect on Hb in our study cohort. CONCLUSION: No negative effects of metabolic control on Hb could be demonstrated in this study.