Pregnancy outcome of diabetic women 15 years after the St. Vincent declaration: success or failure?

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Severe diabetic fetopathy despite strict metabolic control.

In pregnant women, diabetes mellitus (DM) can cause severe complications for both mother and child during pregnancy and delivery; for example, hypertension, pre-eclampsia, macrosomia or intrauterine fetal death. It is therefore essential to achieve good metabolic control in the mother from before conception to the postpartum period. A 35-year-old primipara with type 2 DM presented herself at our outpatient department at 21 weeks of gestation. Until this time her DM had been treated with oral antidiabetic drugs; these were withdrawn and conventional insulin therapy was initiated. Except for the first two weeks after insulin adjustment, blood glucose values were within the required range. Biometric tests performed until week 30 of gestation showed discreet fetal growth. In the week 31, fetal abdominal girth near the 95% limit was observed for the first time; this was soon followed by an explosion-like enlargement of the abdomen along with glycemic values at the lower limit. A cesarean section was performed in week 35 of gestation because of the excessive macrosomia. The female newborn had a birth weight of 4920 g and, one hour after delivery, a blood glucose of 10 mg/dl requiring an intravenous glucose bolus. In addition, the child needed oxygen and also needed both an enteral and a parenteral supply of glucose until day 7 after delivery. Mother and child were discharged from the clinic 19 days postpartum in good general condition. This case illustrates the complexity of treatment of glucose-tolerance disturbances during pregnancy and underlines the importance of fetal monitoring by ultrasound, given that measurement of maternal blood glucose does not always provide sufficient information on the metabolic situation of the fetus.

Hearing screening outcomes in infants of pregestational diabetic mothers.

PURPOSE: Hearing screening results for newborns of diabetic mothers were compared with those of nondiabetic controls. METHOD: This study was a retrospective chart review of mothers with pregestational diabetes mellitus and their neonates (n=73) who received newborn hearing screening between January 1, 2000, and May 1, 2002. A group of nondiabetic mothers and their infants (n=73), with birth dates that matched the diabetic group, served as controls. A 2-tiered hearing screening protocol, employing distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (A-ABR) screening techniques, was used. RESULTS: The DPOAE screening failure rate was 5.5% (4/73) for babies in the nondiabetic control group and 11.0% (8/73) for infants of diabetic mothers; this difference was not statistically significant. The A-ABR failure rate was 9.1% (1/11) for the diabetic group compared with 0% (0/4) for the controls, but the A-ABR was measured for only a small number of participants in each group. The frequency of premature birth and abnormal birth weight was significantly greater for the infants of diabetic mothers compared with controls. CONCLUSIONS: Given the greater frequency of prematurity and abnormal birth weight in the population of neonates born to diabetics, additional research using A-ABR is recommended.

Absent or reversed end-diastolic flow in the umbilical artery: outcome at a community hospital.

OBJECTIVE: To describe the peripartum outcome and risk factors for neonatal death among pregnancies complicated with umbilical arterial absent end diastolic or reverse flow (AREDF UA), in a community hospital. STUDY DESIGN: The inclusion criteria of this retrospective analysis were: AREDF UA detected and managed at a community hospital. RESULTS: During the 46 months, 50 cases of AREDF UA were detected and the pregnancies were complicated by hypertensive disease in 52%, twins in 26%, and diabetes mellitus in 14%. Excluding four (8%) stillbirths of non-anomalous fetuses, nine newborns died and the significant differences between those who died and lived (n = 36) were: oligohydramnios (odds ratio [OR] 34.00, 95% confidence intervals [CI] 4.65, 248.50), non-immune hydrops (OR 24.33, 95% CI 1.01, 560.60) and respiratory distress syndrome (OR 7.00, 95% CI 1.27, 38.59). CONCLUSIONS: The risk factors for neonatal mortality with AREDF UA are oligohydramnios, non-immune hydrops, or respiratory distress syndrome.

Suspicion and treatment of the macrosomic fetus: a review.

OBJECTIVE: To review the prevalence of and our ability to identify macrosomic (birthweight >4000 g) fetuses. Additionally, based on the current evidence, propose an algorithm for treatment of suspected macrosomia. STUDY DESIGN: A review. RESULTS: According to the National Vital Statistics, in the United States, the prevalence of newborns weighing at least 4000 g has decreased by 10% in seven years (10.2% in 1996 and 9.2% in 2002) and 19% for newborns with weights >5000 g (0.16% and 0.13%, respectively). Bayesian calculations indicates that the posttest probability of detecting a macrosomic fetus in an uncomplicated pregnancy is variable, ranging from 15% to 79% with sonographic estimates of birth weight, and 40 to 52% with clinical estimates. Among diabetic patients the post-test probability of identifying a newborn weighing >4000 g clinically and sonographically is over 60%. Among uncomplicated pregnancies, there is sufficient evidence that suspected macrosomia is not an indication for induction or for primary cesarean delivery. For pregnancies complicated by diabetes, with a prior cesarean delivery or shoulder dystocia, delivery of a macrosomic fetus increases the rate of complications, but there is insufficient evidence about the threshold of estimated fetal weight that should prompt cesarean delivery. CONCLUSION: Due to the inaccuracies, among uncomplicated pregnancies suspicion of macrosomia is not an indication for induction or for primary cesarean delivery.

[Maternal diabetes and congenital malformations]. / Maternel diabetes og medfødte misdannelser.

Maternal diabetes is a known risk factor for congenital malformations. Maternal hyperglycemia is a non-specific teratogen. The risk of congenital malformations, even with optimal metabolic control, is considerably elevated compared with non-diabetic pregnancies. The relationship between maternal hyperglycemia in early pregnancy and the risk of congenital malformations seems to be linear without any threshold level. To diminish the risk of congenital malformations, close preconceptional and first-trimester diabetic control and folic acid supplementation of 5 mg/day are recommended.

DiGeorge anomaly in a patient with isochromosome 18p born to a diabetic mother.

The DiGeorge anomaly (DGA) is an etiologically heterogeneous developmental field defect in which cardiovascular malformations, hypocalcemia, thymic hypoplasia, and characteristic dysmorphisms are major clinical features. The 22q11.2 deletion is the most common single etiology of DGA, although a number of other chromosomal abnormalities and teratogens, including maternal diabetes, have been implicated as well. We present a patient, born to a diabetic mother, with interrupted aortic arch type B (IAA-B), neonatal hypocalcemia, thymic hypoplasia, and dysmorphic features including microcephaly, thick, overfolded helices, and anteriorly-placed anus. Cytogenetic studies showed the presence of a marker chromosome, identified by fluorescence in-situ hybridization (FISH) as an isochromosome 18p [i(18p)]. We did not detect a 22q11.2 deletion by FISH using a cosmid probe corresponding to locus D22S75. The patient is the first example of either DGA or IAA-B in a patient with i(18p). We review the genetic abnormalities associated with DGA, and discuss the potential contributions of maternal diabetes and i(18p) in our patient.

[Pregnancy in a diabetic woman: practical recommendations to prevent complications]. / Grossesse chez une femme diabétique: recommandations pratiques pour une prévention des complications.

Pregnancy in a diabetic woman should be considered as a high risk pregnancy. Indeed, it may lead to complications in both the mother and the baby. A careful management can significantly reduce the risk of complications. Some practical recommendations are given in order to optimize the overall management of diabetic women (mainly type 1) who would like to be successful in giving birth to a child.

[Glucooxidative stress and spontaneous abortion in pregnant women with diabetes mellitus type 1].

UNLABELLED: The pregnancies in women with Diabetes mellitus are in condition of increased glucooxidative stress, which could be toxic for the developing embryo. END-POINTS: To evaluate the levels of selenium and glutation peroxidase in pregnant women with Diabetes mellitus type 1 in the first trimester of pregnancy and to establish whether there is a correlation between the diabetic glycemic control and occurrence of spontaneous abortions. STUDY DESIGN: Prospective study of 75 women for 1 year period. he pregnant women were divided in 3 groups as follows: 1st group--30 pregnant women with Diabetes mellitus type 1 with normal outcome; 2nd group--16 pregnant women with Diabetes mellitus type 1 with spontaneous abortion; 3rd group--29 healthy pregnant controls. The activity of GI-Px in red blood cells was measured in hemolysat of EDTA plasma in Germany. The levels of glucosylated haemoglobin were also evaluated. RESULTS: 1. In all pregnant women the levels of selenium were lower without significant difference between them 1st group--0.12 +/- 0.6 mmol/l, 2ndd group 0.13 +/- 0.1 mmol/l, 3rd group 0.13 +/- 0.7 mmol/l (P > 0.05). 2. There is an increase in the activity of GI-Px, which is statistically significant in the healthy pregnant women 47.8 +/- 13.3 U/g Hb and diabetic pregnant women with normal outcome 48. 6 +/- 8.4 U/g Hb. There is no statistically significant difference in the activity of GI-Px in diabetic pregnant women with spontaneous abortions and the healthy controls (P > 0. 05). 3. Negative correlation between the levels of selenium and the activity of GI-Px was proved in healthy pregnant women (r = - 0.4; P < 0.05). No correlation was found between the level of the selenium and the activity of GI-Px into the two groups of diabetic pregnant women. 4. There is a correlation in the levels of diabetic pregnant women with spontaneous abortions (r = -0.38; P < 0.001). CONCLUSIONS: The increased activity of GI-Px in diabetic pregnant women with spontaneous abortions is a result of increased antioxidative defense of the cell. Probably the ineffective antioxidant defense, leading to a spontaneous abortion is due to the low levels of selenium and high level of pre-prandial glycaemia.

[Upper extremity gangrene in an infant of a diabetic mother, presenting at birth].

In utero gangrene of an extremity because of an arterial thrombosis is rare. More than 20% of the reported cases concern infants of diabetic mothers (IDM) with poor control of diabetes. Changes in coagulation related to deviation of clotting factors and low plasminogen activity may be the cause. We report a case of an IDM who presented at birth with upper extremity gangrene. The Dopplersonography has shown missing pulsations and thrombosis of a.brachialis sin, which was confirmed after amputation of the arm on the 5th day. The postoperative period was complicated by septicaemia, necrotising enterocolitis and disseminated intravasal coagulation resulting in the baby's death 10 days after birth.

[The frequency of mild and severe fetal malformations in diabetic women with high values of glycosilated hemoglobin in early pregnancy].

PURPOSE: To evaluate the correlation between maternal hyperglycemia in early pregnancy and the risk of fetal abnormalities in pregnant women with type 1 diabetes mellitus. STUDY DESIGN: A retrospective study over 124 pregnant women with diabetes mellitus type 1 hospitalized in High Risk Pregnancy Department--SHATOG "Maichin dom" has been done from January. 1998 to January 2004. The diabetic pregnant women were divided in two groups: first group pregnant women without malformations n = 105 and second group pregnant women with malformations n = 19. The pregnant women with fetal malformations were divided into two subgroups: with major malformations n = 13 and with minor malformations n = 6. The diabetic pregnant women were divided in classes according to Whites Classification: Class B - 38, Class C - 35; Class D - 39 and Class R/F - 12. The values of preprandial glucose, postprandial glucose and glycosilated hemoglobin has been measured at 13 week of gestation. RESULTS: 104 pregnancies of total 124 pregnancies were without abnormalities. The fetal malformations were observed in 19 (15.3%) of total 124 pregnancies. The rate of major abnormalities were - 13 (10.4%) and minor abnormalities were - 7 (5.6%). The highest rate of abnormalities there has been within the complicated diabetic women of class D - n = 7 (17.9 %) and class R/F n = 3 (25%). The initial values of preprandial glucose 9.54 (SD +/- 3.59) mmol/l and postprandiai glucose 10.52 (SD +/- 1.81) mmol/l between the women whit pregnancies with abnormalities were significantly higher then those values of preprandial glucose 7.39 (SD +/- 2.82) mmol/l (P - 0.021) and values of postprandial glucose 10.52 (SD +/- 1.81) mmol/l (P = 0.014) between the women without fetal malformations. The mean values of glycosilated hemoglobin were significantly higher HbA 1 c = 9. 01% (SD +/- 1.53) in pregnancies complicated with malformations than those values measured in pregnancies without fetal malformations 8.06% (SD +/- 1.64, P = 0.022). A positive correlation between the observed abnormalities and metabolic control in the early pregnancy exist. The values of Hbeta A1-c is significantly higher Hbeta A1-c - 9.9% (SD +/- 1.2) in pregnancies complicated with fetal malformations than those measured in pregnancies without malformations. Hbeta A1-c 8.2% (SD +/- 1.5) n = 125. Significant differences in the value of Hbeta A1-c between pregnancies with mild and those with severe abnormalities have not been established. A correlation between the levels of Hbeta A1-c in early pregnancy and the rate of the observed abnormalities exist. Within the values of Hbeta A1-c < 7.9%, the rate of malformations is 6.9%, Hbeta A1-c > 8.0% < 10%, the rate of malformations is 19.0% and within the values of Hbeta A1-c > 10%, the rate of the observed abnormalities is 31.5%. A logistic regression between the higher values of postprandial glucose and Hbeta A1-c values and the relative risk of congenital malformations has been observed. The relative risk is evaluated by odds ratio (OR) When the levels of Hbeta A1-c rise with 1% the relative risk of congenital malformations is evaluated by odds ratio OR = 2.02 (limited in 1.46 - 2.81 by 95% conf. interval) and when the levels of postprandial glucose rise with 1 mmol/l the relative risk OR = 1.21 (limited in 1.06 - 1.37: 95% conf. interval). CONCLUSION: Fetal abnormalities are more frequent in pregnant women with long lasting diabetes complicated with vasculopathy. Fetal abnormalities are associated with higher levels of Hbeta A1-c in the first trimester of pregnancy. In diabetic women who planed their pregnancy an optimal metabolic control must been established.

Pregnancy in women with pre-existing diabetes: management issues.

Despite significantly increased input from multidisciplinary teams during the antenatal period, pregnancy outcomes for women with type 1 and type 2 diabetes remain substantially worse than that of the general obstetric population. Regarding fetal congenital malformations, these are likely to be preventable only by strategies introduced prior to pregnancy. The relationship between fetal macrosomia and glycaemic control is complex, and reducing the incidence of macrosomia may be possible only by novel management strategies that address the wide fluctuations in blood glucose over a 24-hour period. Irrespective of pregnancy diabetes control, the complication of neonatal hypoglycaemia can largely be avoided by tight control of glucose values during labour and delivery. The continued lack of understanding of the pathophysiology of late fetal death in diabetic pregnancies and the shortcomings of current methods of antenatal fetal surveillance make it likely that infants of diabetic mothers will continue to be delivered preterm, with the attendant implications of neonatal morbidity and cost.

Controversies around gestational diabetes. Practical information for family doctors.

OBJECTIVE: To summarize some of the issues facing primary care physicians who are seeing increasing numbers of patients with gestational diabetes mellitus (GDM) and to explore new developments in use of oral hypoglycemics during pregnancy. QUALITY OF EVIDENCE: All the literature on screening for GDM offers level III evidence. Much of the literature on treatment is also level III, but newer studies offer level I evidence and are more useful for daily practice. Existing research leaves many important questions unanswered; research findings are inconsistent among studies, and treatment strategies are challenging to implement. MAIN MESSAGE: Recent studies have clarified that rates of neonatal mortality and congenital malformations are not higher among the offspring of mothers with GDM. Treatment might affect birth weight, but whether treatment is associated with reductions in rates of shoulder dystocia and cesarean section is unclear. Several level I studies conclude that the oral hypoglycemic glyburide can be used safely and effectively during the second and third trimesters of pregnancy. CONCLUSION: Management of GDM remains a controversial area in obstetric care. It is a growing area of research, and new developments that might clarify risk and simplify treatment are expected in the coming years.

Echocardiographic measurements in infants of diabetic mothers and macrosomic infants of nondiabetic mothers.

AIM: To compare echocardiographic findings of infants of diabetic mothers (IDMs), macrosomic infants of nondiabetic mothers and healthy full term appropriate-for-gestational-age (AGA) infants. METHODS: Included in this study were 83 infants, admitted to our Neonatology Unit. Thirty-three IDMs, including both macrosomic and nonmacrosomic, comprised Group A, 25 macrosomic infants of nondiabetic mothers comprised group B, and 25 healthy full term AGA infants comprised group C. Echocardiographic measurements were performed in the first three days after birth and compared by using one-way ANOVA, Post Hoc Tukey HSD and Student's t tests. RESULTS: The left ventricular end-systolic/left ventricular end-diastolic diameter ratio of group A was significantly smaller than that of group C (P<0.05). The interventricular septum/posterior wall thickness ratios of groups A and B were greater than those of group C (P<0.05). The left ventricular mass index of group A was greater than those of groups B and C (P<0.05). The shortening fraction and ejection fraction of group A were increased in comparison to group C (P<0.05). When comparing the values of echocardiographic measurements of macrosomic IDMs (n=9) with nonmacrosomic ones (n=24), and infants of pregestational diabetic mothers (n=11) with those of gestational diabetes mothers (n=22), no statistical difference was found. CONCLUSION: The present study suggests that underlying mechanisms common to both macrosomic infants of nondiabetic mothers and IDMs lead to less cardiac alterations in the macrosomic infants of nondiabetic mothers than in IDMs.

Acute myocardial infarction in the first trimester of pregnancy.

Acute myocardial infarction rarely occurs in women during pregnancy. However, when it does occur, it usually carries a high risk of maternal and perinatal mortality. There is a lack of awareness that this condition can occur in pregnancy since coronary artery disease is uncommon in women of childbearing age. In this report, a 43-year-old lady with acute anterior myocardial infarction in her eighth week of pregnancy is presented. The challenges involved in diagnosing this condition in pregnancy are briefly discussed.

Diabetes mellitus y embarazo / Diabetes mellitus and pregnancy

En la práctica clínica la coincidencia de diabetes y embarazo ocurre en 2 circunstancias diferentes: diabetes gestacional y la diabetes pregestacional. La hiperglucemia materna puede tener repercusiones importantes en el feto, que dependen del período de la gestación en el que está presente. La diabetes gestacional identifica a mujeres con un riesgo sustancialmente elevado de presentar diabetes y enfermedades cardiovasculares en el futuro, lo que justifica la necesidad de establecer programas de prevención en el seguimiento posparto. En la diabetes pregestacional el control preconcepcional constituye la mejor oportunidad para prevenir las complicaciones maternas y neonatales. La diabetes (gestacional y pregestacional) no debe suponer un impedimento para la lactancia materna que, de hecho, puede aportar beneficios adicionales sus hijos (AU)

Diabetes mellitus and pregnancy co-occur in two different clinical entities: gestational diabetes and pregestational diabetes. Maternal hyperglycemia may have profound effects on the foetus, which depend on the period of pregnancy in which it is present. Gestational diabetes identifies women at significant risk for developing diabetes and cardiovascular disease in the future, who should undergo preventive programs in the postpartum follow-up. Preconception care in women with pregestational diabetes is the best method of preventing maternal and neonatal complications. Diabetes (gestational and pregestational) should not be an obstacle for breastfeeding, which may, in fact, provide additional benefits to the child (AU)

Current perspectives on the causes of neural tube defects resulting from diabetic pregnancy.

Maternal diabetes increases the risk for neural tube, and other, structural defects. The mother may have either type 1 or type 2 diabetes, but the diabetes must be existing at the earliest stages of pregnancy, during which organogenesis occurs. Abnormally high glucose levels in maternal blood, which leads to increased glucose transport to the embryo, is responsible for the teratogenic effects of maternal diabetes. Consequently, expression of genes that control essential developmental processes is disturbed. In this review, some of the biochemical pathways by which excess glucose metabolism disturbs neural tube formation are discussed. Research from the author's laboratory has shown that expression of Pax3, a gene required for neural tube closure, is significantly reduced by maternal diabetes, and this is associated with significantly increased neural tube defects (NTD). Pax3 encodes a transcription factor that has recently been shown to inhibit p53-dependent apoptosis. Evidence in support of this model, in which excess glucose metabolism inhibits expression of Pax3, thereby derepressing p53-dependent apoptosis of neuroepithelium and leading to NTD will be discussed.

[Upper extremity gangrene in an infant of a diabetic mother, presenting at birth].

In utero gangrene of an extremity because of an arterial thrombosis is rare. More than 20% of the reported cases concern infants of diabetic mothers (IDM) with poor control of diabetes. Changes in coagulation related to deviation of clotting factors and low plasminogen activity may be the cause. We report a case of an IDM who presented at birth with upper extremity gangrene. The Dopplersonography has shown missing pulsations and thrombosis of a. brachialis sin, which was confirmed after amputation of the arm on the 5th day. The postoperative period was complicated by septicaemia, necrotising enterocolitis and disseminated intravasal coagulation resulting in the baby's death 10 days after birth.

[Risk factors for fetal macrosomia].

AIM: To determine the influence of some of the risk factors on fetal macrosomia. MATERIALS AND METHODS: A retrospective study was provided at the Department of Obstetrics and Gynecology, Medical University, Pleven, from January, 1, 2001 to December, 31, 2002 over 625 deliveries: 225 cases of fetal macrosomia--fetal birth weight (FBW) more than 4000 g and/or over 90. percentile (macrosomic group--MG) and 400 cases of singleton term newborns--with FBW between 10. and 90. percentile (nonmacrosomic group--NMG). Analysis included influence of: maternal age, height, prepregnant weight, BMI, weight gain and weight before delivery, previous delivery of macrosomic infant, maternal diabetes mellitus, fetal sex and gestational age. RESULTS: A comparative analysis of data for both of groups was performed. It was found significant correlation (p = 0.001) for influence of maternal age (r = 0.34); height (r = 0.33); prepregnant weight (r = 0.42); BMI (r = 0.32); weight before delivery (r = 0.49); weight gain (r = 0.34); previous delivery of macrosomic infant (r = 0.41); maternal diabetes mellitus (r = 0.54); fetal sex (r = 0.37) and gestational age (r = 0.39). Correlations are different in both of groups. CONCLUSION: Positive correlations between analysed factors and delivering of macrosomic infants and differences in both of groups suggest that analysed factors can't explain completely fetal macrosomia.

Cetoacidosis diabética durante la gestación. Una forma poco habitual de inicio de la diabetes tipo 1 / Diabetic ketoacidosis during pregnancy. an unusual form of onset of type 1 diabetes

La cetoacidosis diabética durante la gestación es infrecuente. Puede ocurrir en pacientes con diabetes mellitus tipo 1 pregestacional, pero también en pacientes con diabetes gestacional complicada con corticoterapia o infecciones, o puede coincidir, como ocurre con el caso que presentamos, con el inicio de una diabetes mellitus tipo 1.Describimos el caso de una mujer de 28 años que, en la semana 27 de gestación, presentó un cuadro de cetoacidosis diabética. Algunos datos clínicos, así como la negatividad inicial en los anticuerpos antiislotes pancreáticos, nos hicieron dudar sobre el tipo de diabetes subyacente tras la cetoacidosis: una diabetes gestacional frente al inicio de una diabetes mellitus tipo 1. Los datos obtenidos en el seguimiento de la paciente confirmaron que presentaba una diabetes mellitus tipo 1, que comenzó en el tercer trimestre de gestación (como cetoacidosis) probablemente debido a la resistencia insulínica típica de este período, seguida de un tiempo de luna de miel en los meses siguientes al parto (AU)

Diabetic ketoacidosis in pregnant womenis comparatively rare. However, it mayoccur in pregestational patients with type 1diabetes mellitus or in cases of gestational diabetes complicated by cortico therapy, infections, etc. It can also coincide with the onset of type 1 diabetes, as in the case presented herein. We describe the case of a 28-year old woman who, in the 27th week of pregnancy, presented symptoms of diabetic ketoacidosis. However, clinical tests together with the initial low value of anti-islet cell antibodies made us doubt on the type of diabetes underlying ketoacidosis: gestational diabetes vs the onset of type 1 diabetes mellitus. Subsequent monitoring and data confirmed that the patient had type 1diabetes. The diabetes appeared (asketoacidosis) in the third trimester of pregnancy and was probably due to the insulin resistance, which is typical at this stage of pregnancy and which was followed in our patient by a honeymoon period in the months following delivery (AU)