Intervention during pregnancy to reduce excessive gestational weight gain­a randomised controlled trial.

OBJECTIVE: To evaluate if a feasible, low-cost intervention could decrease the percentage of women gaining weight above the Institute of Medicine (IOM) recommendations on gestational weight gain (GWG) compared with standard maternity care. DESIGN: A randomised controlled interventional design. SETTING: Antenatal clinics (n = 14) in Örebro county, Sweden, participated. POPULATION: Healthy women with a body mass index (BMI) ≥19 kg/m(2), age ≥18 years and adequate knowledge of Swedish language who signed in for maternity care at ≤16 weeks of gestation. METHODS: Standard care was compared with a composite intervention consisting of education on recommended GWG according to IOM, application of personalised weight graph, formalised prescription of exercise and regular monitoring of GWG at every antenatal visit. OUTCOME: The proportion of women gaining weight above IOM guidelines (1990) and mean GWG (kg) was compared between groups. RESULTS: In all, 445 women were randomised and 374 women remained for analysis after delivery. A majority of the women analysed were normal weight (72%). The intervention reduced the proportion of women who exceeded the IOM guidelines (41.1% versus 50.0%). The reduction was, however, not statistically significant (P = 0.086). Mean GWG was significantly lower among women receiving the intervention, 14.2 kg (SD 4.4) versus 15.3 kg (SD 5.4) in the standard care group (P = 0.029). CONCLUSIONS: The low-cost intervention programme tested did significantly reduce the mean GWG but the proportion of women who exceeded the IOM recommendations for GWG was not significantly lower. ClinicalTrials.gov Id NCT00451425 http://clinicaltrials.gov.

Gestational diabetes mellitus and later cardiovascular disease: a Swedish population based case-control study.

OBJECTIVE: To identify if gestational diabetes mellitus (GDM) is a clinically useful marker of future cardiovascular disease (CVD) risk and if GDM combined with other risks (smoking, hypertension or body mass) identifies high-risk groups. DESIGN: Population-based matched case-control study. SETTING: National Swedish register data from 1991 to 2008. POPULATION: A total of 2639 women with a cardiovascular event and matched controls. METHODS: Conditional logistic regression examined associations with CVD before and after adjustment for conventional risk factors and confounders. Effect modification for the association of GDM with CVD by body mass index (BMI), smoking and chronic hypertension was assessed by stratification and interaction testing. Adjustment for diabetes post-pregnancy evaluated its mediating role. MAIN OUTCOME MEASURES: Inpatient diagnoses or causes of death identifying ischemic heart disease, ischemic stroke, atherosclerosis or peripheral vascular disease. RESULTS: The adjusted odds ratios (and 95% confidence intervals) for the association of CVD with GDM are 1.51 (1.07-2.14), 2.23 (2.01-2.48) for smoking, 1.98 (1.71-2.29) for obesity and 5.10 (3.18-8.18) for chronic hypertension. In stratified analysis the association of CVD with GDM was only seen among women with BMI ≥25, with an odds ratio of 2.39 (1.39-4.10), but only women with a BMI <30 accounted for this increased risk. Adjustment for post-pregnancy diabetes attenuated it somewhat to 1.99 (1.13-3.52). CONCLUSIONS: In the absence of other recognised cardiovascular risk factors, such as smoking, obesity or chronic hypertension, GDM is a useful marker of raised CVD risk among women with BMI between 25 and 29.

Increased fat mass and cardiac septal hypertrophy in newborn infants of mothers with well-controlled diabetes during pregnancy.

BACKGROUND: Improved glycaemic control during pregnancy in mothers with type 1 diabetes (T1DM) and gestational diabetes (GDM) has resulted in a marked reduction of perinatal mortality and morbidity, but the prevalence of macrosomia is usually high. OBJECTIVE: We used non-invasive anthropometric methods to estimate the body composition and the thickness of the interventricular heart septum in 18 infants of mothers with well-controlled T1DM, 10 infants of mothers with GDM and 28 infants of healthy control mothers matched for gestational age and mode of delivery. METHODS: Skinfold measurements were obtained with a Harpenden calliper within 48 h after delivery. Echocardiography was also performed to measure the thickness of the interventricular septum. Cord blood was sampled for assays of C-peptide, leptin and IGF-I. RESULTS: The rates of macrosomia (gestational age-adjusted birth weight >2 standard deviation score, SDS) were 56 and 30% in infants of mothers with T1DM and GDM, respectively, compared to 10% in control infants. The body fat content was 40% (0.2 kg) higher and the interventricular heart septum thickness was increased by 20% in both groups of infants of diabetic mothers. We found no associations between maternal levels of HbA1c during pregnancy and body composition or interventricular heart septum thickness. Cord levels of C-peptide and leptin were significantly higher in infants of T1DM mothers than in control infants. Cord leptin level was associated with birth weight SDS and percent body fat in infants of T1DM mothers. IGF-I was associated with percent body fat in infants of GDM mothers and control mothers. A multiple-regression analysis showed that 50% of the variation in body weight SDS could be determined, with IGF-I, leptin and C-peptide as independent variables. CONCLUSION: Both fat mass and cardiac septal thickness are increased in newborn infants of women with T1DM and GDM in spite of efforts to achieve good glycaemic control during pregnancy.

Maternal and neonatal outcomes and time trends of gestational diabetes mellitus in Sweden from 1991 to 2003.

AIMS: To determine maternal and neonatal outcomes for women with gestational diabetes mellitus (GDM) in Sweden during 1991-2003, and to compare the outcomes in the two time periods. METHODS: This is a population-based cohort study using the Swedish Medical Birth Register data for the period 1991-2003. There were 1,260,297 women with singleton pregnancies registered during this time, of whom 10 525 were diagnosed with GDM, based on a 75 g oral glucose tolerance test. The main diagnostic criteria were fasting capillary whole blood glucose>or=6.1 mmol/l and 2 h blood glucose>or=9.0 mmol/l. RESULTS: Maternal characteristics differed significantly between the GDM and non-GDM group. Adjusted odds ratios (OR) were as follows: for pre-eclampsia, 1.81 (95% confidence interval (CI) 1.64-2.00); for shoulder dystocia, 2.74 (2.04-3.68); and for Caesarean section, 1.46 (1.38-1.54). No difference was seen in perinatal mortality, stillbirth rates, Apgar scores, fetal distress or transient tachypnoea. There was a markedly higher risk of large for gestational age, OR 3.43 (3.21-3.67), and Erb's palsy, OR 2.56 (1.96-3.32), in the GDM group, and statistically significant differences in prematurity<37 weeks, birth weight>4.5 kg, and major malformation, OR 1.19-1.71. No statistically significant improvement in outcomes was seen between the two study periods. CONCLUSIONS: Women with GDM have higher risks of pre-eclampsia, shoulder dystocia and Caesarean section. Their infants are often large for gestational age and have higher risks of prematurity, Erb's palsy and major malformations. These outcomes did not improve over time.

Metabolic acidosis at birth and suboptimal care--illustration of the gap between knowledge and clinical practice.

OBJECTIVE: To evaluate the occurrence and nature of suboptimal intrapartum care in cases with metabolic acidosis in the newborn, and to estimate the degree to which this may be prevented. DESIGN: Case-control study. Clinical audit. Setting Delivery units at two university hospitals in Sweden. POPULATION: Out of 28 486 deliveries, 161 neonates > or =34 weeks of gestational age were born with metabolic acidosis. METHODS: Cases (n = 161): umbilical artery pH < 7.05 and base deficit > or =12 mmol/l. Controls (n = 322): pH > or = 7.05 and Apgar score > or =7 at 5 minutes. Obstetric characteristics and oxytocin administration were recorded. The last 2 hours of electronic fetal monitoring before delivery were evaluated blinded to outcome. Intrapartum management was analysed for suboptimal care by using predefined criteria. MAIN OUTCOME MEASURE: Suboptimal intrapartum care. RESULTS: Case and control comparisons displayed an occurrence of suboptimal care in 49.1% versus 13.0% (P < 0.001), oxytocin misuse in 46.6% versus 13.0% (P < 0.001), a failure to respond to a pathological cardiotocographic pattern in 19.9% versus 1.2% (P < 0.001) and suboptimal care related to vacuum deliveries in 3.1% versus 0.3% (P < 0.01) respectively. CONCLUSION: Metabolic acidosis at birth is often associated with suboptimal intrapartum care. The high rate of suboptimal care with regard to oxytocin use and fetal surveillance illustrate a gap between guidelines and clinical practice. Metabolic acidosis and related neonatal morbidity could potentially be prevented in 40-50% of cases. The adherence to guidelines must be checked.

Continuous Subcutaneous Glucose Monitoring System in diabetic mothers during labour and postnatal glucose adaptation of their infants.

AIMS: To assess a new technique for continuous monitoring of glucose concentration during labour in diabetic mothers. A second objective was to study maternal glucose levels in relation to postnatal glucose adaptation and the need for intravenous (IV) glucose treatment in the newborn infant. METHODS: Fifteen pregnant women with insulin-treated diabetes mellitus participated in this prospective pilot study. To measure their glucose control during labour we used the Continuous Subcutaneous Glucose Monitoring System (CGMS; Medtronic, Minneapolis, MN, USA) to calculate the mean glucose concentration and the area under the curve (AUC) in the last 120 min before delivery. All infants of these women were transferred to the neonatal care unit for early oral feeding and blood glucose measurements up to 14 h after delivery. Infants received IV glucose if blood glucose values were repeatedly < 2.2 mmol/l. RESULTS: All women coped well with the CGMS monitoring. AUC 0-120 min before delivery, mean glucose concentration 0-120 min before delivery and cord plasma insulin level were all significantly associated with the need for IV glucose in the newborn children. CONCLUSIONS: In this study we found an association between maternal glucose concentrations during labour and postnatal glucose adaptation and need for IV glucose treatment in the infants. Online monitoring of glucose levels during delivery might help us to achieve maternal normoglycaemia and further reduce the risk of postnatal hypoglycaemia in the offspring.

Fasting capillary glucose as a screening test for gestational diabetes mellitus.

OBJECTIVE: To evaluate fasting capillary glucose as a screening test for gestational diabetes mellitus (GDM) compared with traditional risk factors and repeated random capillary glucose measurements. DESIGN: Cross-sectional, population-based study. SETTING: Maternal Health Care Clinics in Orebro County, Sweden. POPULATION: An unselected population of women without diabetes. METHODS: Fasting capillary glucose levels were measured at gestational weeks 28-32. Random capillary glucose levels were measured four to six times during pregnancy. Traditional risk factors for GDM were registered. GDM was diagnosed using a 75-g oral glucose tolerance test. MAIN OUTCOME MEASURES: Sensitivity, specificity, likelihood ratios. RESULTS: In 55 of 3616 women participating in the study, GDM was diagnosed before 34 weeks of gestation. For fasting capillary glucose cutoff values between 4.0 and 5.0 mmol/l, sensitivity was in the range between 87 and 47% and specificity between 51 and 96%. Using a combined screening model of traditional risk factors with fasting capillary glucose at various cutoff values increased the sensitivity only slightly compared with using fasting capillary glucose alone. CONCLUSION: In this Swedish, unselected, low-risk population, fasting capillary glucose measurements were found to be an acceptable and useful screening test for GDM.