The 75-g glucose tolerance test in pregnancy: a reference range determined on a low-risk population and related to selected pregnancy outcomes

OBJECTIVE: To determine a reference range for the 75-g glucose tolerance test (GTT) in pregnancy using a group of women at low risk for gestational diabetes mellitus (GDM) and to determine the validity of this reference range by examining selected pregnancy outcomes for glucose-tolerant women with a 2-h result on the GTT up to 1.0 mmol/l below the diagnostic level for GDM compared with treated women with GDM. RESEARCH DESIGN AND METHODS: The reference range for the GTT was determined in 573 Caucasian women with an age <25 years and a BMI of <25 kg/m2. Selected pregnancy outcomes were compared between 272 treated women with GDM (diagnosed on the basis of a 2-h glucose level > or =8.0 mmol/l) and 308 women with a 2-h glucose level of 7.0-7.9 mmol/l. RESULTS: There was 95% confidence that at least 95% of all the fasting glucose levels are < or =5.1 mmol/l(92 mg/dl) and 95% confidence that at least 95% of all the 2-h glucose levels were < or =7.8 mmol/l (140 mg/dl). Treated women with GDM had a significantly reduced rate of large-for-gestational-age infants compared with glucose-tolerant women, without any increase in the rate of small-for-gestational-age infants or obstetric interventions. CONCLUSIONS: The reference range for the GTT in pregnancy should be determined on a low-risk population rather than on a total population. Consideration should be given to lowering the fasting glucose level to 5.0 mmol/l (90 mg/dl) and the 2-h level to 7.8 mmol/ (140 mg/dl). Glucose-tolerant women below this relatively low reference range have an increased rate of large-for-gestational-age infants and may benefit from treatment.     

Thyroid autoimmunity in pregnant women at risk for GDM

Presence of antithyroid autoantibodies (ThyAb) during pregnancy is strictly related to the risk of developing post partum thyroiditis (PPT) and this risk is increased in IDDM pregnant women. Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance of variable severity that begins, or is first diagnosed, during pregnancy. GDM is considered a risk factor for both type 1 and type 2 diabetes and various non-organ specific autoantibodies have been found to be associated with GDM, although there is little information on the association of GDM with thyroid autoimmunity. In this study oral glucose tolerance and prevalence of ThyAb were evaluated in a group of 41 pregnant women at increased risk of developing GDM and in a healthy control group. Our results showed that 22% of GDM risk group had impaired glucose gestational tolerance (IGGT) or GDM at the time of oral glucose tolerance test (OGTT). Moreover, ThyAb prevalence found in the women at increased risk of GDM (14.6%) was similar to that observed in healthy pregnant controls (12.5%). Nevertheless ThyAb frequency was higher in those GDM risk women with family history of diabetes (30.7%).     

A protocol of screening of gestational diabetes mellitus

We evaluated GDM frequency in the Padua area. 490 non-diabetic pregnant women were divided into group A (234), with at least one GDM risk factor, and group B (256), with no risk factors. Group A underwent this screening program with oral glucose challenge test (OGCT) and OGTT when OGCT was positive at 10-14th gestational week (gw), at 24-28th gw and at 30-34th gw. Group B underwent the same screening starting at 24-28th gw. 46.9% of the pregnant women had positive OGCT with higher frequency in group A (group A vs group B p < 0.01). GDM prevalence in all women was 10.8% with higher frequency in group A women (group A vs group B p < 0.01). The anticipation of the screening at the first trimester of pregnancy in group A women allowed early diagnosis of 11.6% of GDM. Regarding maternal and fetal outcome the only significative differences between GDM and non-GDM were prevalence of macrosomia and of cesarean sections.     

Large-scale screening for early diagnosis of gestational diabetes mellitus (GDM)

The aim of study was to evaluate incidence of GDM in Poland. All 1500 pregnant women between 24-28 week's gestation consulted in 4 centers were offered a 50 g oral glucose test (screening test). Capillary blood glucose was measured at 60 min after glucose ingestion. When blood glucose > 140 mg/dl, 75 g OGTT according to WHO criteria was performed. 241 women have abnormal screening test and in 181 cases blood glucose were at range 140-160 mg/dl, in 39 at range 160-180 and 21 were > 180 mg/dl. Only 14 women in the first group (140-160 mg/dl) have diagnosed GDM (7.7%). In second group 24 pregnant women have GDM (61.5%). Overall GDM incidence is shown to be 3.7% (57 women). The mean age for the GDM was 28.8 +/- 0.9 years compared with 26.4 +/- 0.4 years (p < 0.05) uncomplicated pregnancy.     

Decreased stature in gestational diabetes mellitus

Short stature has been associated with various degrees of abnormal glucose tolerance in middle-aged people, where the effects of age and metabolic control would be difficult to exclude. We chose to examine body stature in women with gestational diabetes mellitus (GDM), a prediabetic state affecting a young group of people. A sample of 2772 Greek pregnant women, referred for GDM screening was examined. After a 100-g oral glucose tolerance test, 1787 women were classified as normal (N), 300 women were found with one abnormal glucose value (OAV) and 685 women with GDM. Basal insulin resistance was calculated in 640 women by homeostasis model assessment. In addition, 51 pregnant women with pre-existing Type II (non-insulin-dependent) diabetes mellitus and 109 with pre-existing Type I (insulin-dependent) diabetes mellitus were included in the study. There was a gradual decrease in mean height (cm) as glucose intolerance became more severe: N: 161.0 +/- 6.2, OAV:160.2 +/- 6.1, GDM:158.7 +/- 6.3, Type II diabetes 158.2 +/- 7.0 (p < 0.001, analysis of variance]. Height in Type I diabetes (160.1 +/- 5.9) did not differ from the normal group. The difference in height between the normal and GDM groups remained (p < 0.001) when body weight, age, birth before or after 1960 and educational status were also taken into account. An independent correlation was also found between height and insulin resistance (n = 640) adjusted for the above mentioned variables. In conclusion, short stature appears to be associated with glucose intolerance as an independent variable, even when this intolerance is both mild and temporary. The previously unrecognised independent association of stature with basal insulin resistance merits further investigation.     

Gestational diabetes: antepartum characteristics that predict postpartum glucose intolerance and type 2 diabetes in Latino women

We examined antepartum clinical characteristics along with measures of glucose tolerance, insulin sensitivity, pancreatic beta-cell function, and body composition in Latino women with gestational diabetes mellitus (GDM) for their ability to predict type 2 diabetes or impaired glucose tolerance (IGT) within 6 months after delivery. A total of 122 islet cell antibody-negative women underwent oral and intravenous glucose tolerance tests (OGTT; IVGTT), hyperinsulinemic-euglycemic clamps, and measurement of body fat between 29 and 36 weeks' gestation and returned between 1 and 6 months postpartum for a 75-g OGTT. Logistic regression analysis was used to examine the relationship between antepartum variables and glucose tolerance status postpartum. At postpartum testing, 40% of the cohort had normal glucose tolerance, 50% had IGT, and 10% had diabetes by American Diabetes Association criteria. Independent antepartum predictors of postpartum diabetes were the 30-min incremental insulin:glucose ratio during a 75-g OGTT (P = 0.0002) and the total area under the diagnostic 100-g glucose tolerance curve (P = 0.003). Independent predictors of postpartum IGT were a low first-phase IVGTT insulin response (P = 0.0001), a diagnosis of GDM before 22 weeks' gestation (P = 0.003), and weight gain between prepregnancy and the postpartum examination (P = 0.03). All subjects had low insulin sensitivity during late pregnancy, but neither glucose clamp nor minimal model measures of insulin sensitivity in the 3rd trimester were associated with the risk of IGT or diabetes within 6 months' postpartum. These results highlight the importance of pancreatic beta-cell dysfunction, detectable under conditions of marked insulin resistance in late pregnancy, to predict abnormalities of glucose tolerance soon after delivery in pregnancies complicated by GDM. Moreover, the association of postpartum IGT with weight gain and an early gestational age at diagnosis of GDM suggests a role for chronic insulin resistance in mediating hyperglycemia outside the 3rd trimester in women with such a beta-cell defect.     

Impaired endothelium-dependent vasodilatation in women with previous gestational diabetes

OBJECTIVE: To assess whether otherwise healthy women with a history of gestational diabetes mellitus (GDM) may have abnormalities in endothelial function at a very early stage, before glucose intolerance occurs. RESEARCH DESIGN AND METHODS: A total of 33 women with previous GDM (17 nonobese [BMI < 27] and 16 obese [BMI > or = 27]) and 19 healthy nonobese women were examined. A 75-g oral glucose tolerance test was performed, and insulin levels and biochemical parameters were also measured. Using high-resolution ultrasound, we measured vasodilatory responses of the brachial artery during reactive hyperemia (endothelium-dependent vasodilatation), and after nitroglycerin administration, an endothelium-independent vasodilator. RESULTS: Flow-mediated dilatation (FMD) was significantly and equally decreased in both groups of women with previous GDM, compared with control subjects (1.6 +/- 3.7% in the nonobese GDM group and 1.6 +/- 2.5% in the obese GDM group vs. 10.3 +/- 4.4% in control subjects, P < 0.001). FMD correlated inversely with serum uric acid levels, BMI, serum total cholesterol, and basal insulin resistance (homeostasis model assessment). Nitrate-induced dilatation was significantly decreased only in the obese GDM group compared with control subjects, (21.4 +/- 5.1 vs. 27.9 +/- 9.5, P < 0.05). CONCLUSIONS: Endothelial dysfunction, which is considered as a very early index of atherogenesis, is already present in both obese and nonobese women with a history of GDM, even when they have normal glucose tolerance.     

Incidence of diabetes mellitus in women following impaired glucose tolerance in pregnancy is lower than following impaired glucose tolerance in the non-pregnant state

Impaired glucose tolerance (IGT), which is asymptomatic and requires a glucose tolerance test for detection, is a well-known risk factor for diabetes mellitus. Outside the research setting it is rarely identified in people who lack specific risk factors for diabetes except during pregnancy, at which time screening with an oral glucose challenge is a routine procedure. A 75-g oral glucose tolerance test was performed during the latter part of pregnancy or during a routine epidemiology survey in 15-39-year-old Pima Indian women with no history of abnormal glucose tolerance. Those with IGT by World Health Organization criteria were included in this study. Diabetes incidence in women was compared between those whose IGT was first detected during pregnancy and those who were not pregnant when IGT was first recognized. Seventeen of 73 pregnant women and 114 of 244 non-pregnant women developed diabetes within 10 years. When controlled for plasma glucose concentration, age, body mass index, parity and duration of follow-up, those who were not pregnant were at higher risk of developing diabetes than those who were pregnant (hazard rate ratio = 1.71, 95% confidence interval = 1.01-2.91). Previous studies had reported that women with IGT during pregnancy are at higher risk of diabetes than women with normal glucose tolerance. This study suggests that women with IGT during pregnancy are at lower risk than non-pregnant women with a similar plasma glucose concentration who, in the clinical setting, are likely to remain unrecognized.     

Gestational diabetes: a challenge for the future

It is well established that pregnancy is associated with temporary changes in maternal metabolism which include a decrease in maternal insulin sensitivity to values similar to those associated with Type 2 diabetes. Fasting glucose concentrations fall throughout pregnancy, postprandial values rise. The maintenance of glucose tolerance in pregnancy requires a two- to three-fold increase in postprandial maternal insulin secretion. Glucose intolerance develops in women unable to compensate for the metabolic changes incurred by pregnancy. Increasing maternal hyperglycaemia is associated with increasing pregnancy morbidity and an increased likelihood of subsequent diabetes in the mother. In addition, maternal hyperglycaemia has a direct effect on the development of the fetal pancreas and is associated with an increased susceptibility to future diabetes in the infant, an effect which is independent of genetic factors. Gestational diabetes mellitus (GDM) is defined as glucose intolerance first recognized in pregnancy, and by definition includes a small number of women with previously unrecognized diabetes or impaired glucose tolerance (IGT). Figures on the prevalence of GDM vary between maternity units, depending on screening methods and the ethnic distribution of the populations. However, in a comprehensive study of a multi-ethnic antenatal population in inner London, UK it was found that only 2% of pregnant women develop significant glucose intolerance. Obstetricians and physicians debate the importance of identifying this 2% of women. The lack of agreed criteria for diagnosing gestational diabetes and the questionable obstetric benefits of treating all women with mild disturbances of glucose tolerance in pregnancy has resulted in few UK centres undertaking universal screening for GDM.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cesarean delivery in relation to birth weight and gestational glucose tolerance: pathophysiology or practice style? Toronto Trihospital Gestational Diabetes Investigators

OBJECTIVES: To examine the relationship between birth weight and mode of delivery among women with untreated borderline gestational diabetes mellitus (GDM), treated overt GDM, and normoglycemia. DESIGN: Prospective cohort study. SETTING: Three Toronto, Ontario teaching hospitals. PATIENTS: A total of 3778 volunteers aged 24 years or older. INTERVENTIONS: Subjects underwent a 3-hour long, 100-g oral glucose tolerance test at 28 weeks' gestation, regardless of screening test results. Usual care was provided to 143 women who met the National Diabetes Data Group criteria for GDM. Physicians were blinded to glucose tolerance test results for all others, including 115 untreated women with borderline GDM by the broader criteria of Carpenter and Coustan. MAIN OUTCOME MEASURES: Crude and adjusted rates of cesarean delivery and neonatal macrosomia (birth weight >4000 g). RESULTS: Compared with normoglycemic controls, the untreated borderline GDM group had increased rates of macrosomia (28.7% vs 13.7%, P<.001) and cesarean delivery (29.6% vs 20.2%, P=.02). Cesarean delivery in this subgroup was associated with macrosomia (45.5% vs 23.5%, P=.03). Usual care of known GDM normalized birth weights, but the cesarean delivery rate was about 33% whether macrosomia was present or absent. A clearly increased risk of cesarean delivery among treated patients compared with normoglycemic controls persisted after adjustment for multiple maternal risk factors (adjusted odds ratio, 2.1; 95% confidence interval, 1.3 to 3.6). CONCLUSIONS: Infant macrosomia was a mediating factor in high cesarean delivery rates for women with untreated borderline GDM. While detection and treatment of GDM normalized birth weights, rates of cesarean delivery remained inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment.     

Gestational diabetes mellitus and subsequent development of overt diabetes mellitus

GDM develops in 1-3% of all pregnancies. Women with GDM are characterized by a relatively diminished insulin secretion coupled with a pregnancy-induced insulin resistance primary located in skeletal muscle tissue. The cellular background for this insulin resistance is not known. The binding of insulin to its receptor and the subsequent activation of the insulin receptor tyrosine kinase have significant importance for the cellular effect of insulin. Thus, the pathogenesis to the insulin resistance was studied by investigating insulin receptor binding and tyrosine kinase activity in skeletal muscle biopsies from women with GDM and pregnant controls. No major abnormalities were found in GDM wherefore it is likely that the insulin resistance is caused by intracellular defects distal to the activation of the tyrosine kinase. Glucose tolerance returns to normal postpartum in the majority of women with GDM. However, previous studies, in populations quite different from a Danish population, have shown that women with previous GDM have a high risk of developing overt diabetes mellitus later in life. Hence, we aimed to investigate the prognosis of women with previous GDM with respect to subsequent development of diabetes and also to identify predictive factors for the development of overt diabets in these women. A follow-up study of diet treated GDM women diagnosed during 1978 to 1985 at the Rigshospital, Copenhagen was performed. Glucose tolerance was evaluated in 241 women (81% of the GDM population) 2-11 years after pregnancy. Abnormal glucose tolerance was found in 34.4% of the women (3.7% IDDM, 13.7% NIDDM, 17% IGT) in contrast to a control group where none had diabetes and 5.3% had IGT. Logistic regression analysis identified the following independent risk factors for later development of diabetes: a high fasting glucose level at diagnosis of GDM, a delivery more than 3 weeks before term, and an abnormal OGTT 2 months postpartum. Low insulin secretion at diagnosis of GDM was also an independent risk factor. The presence of ICA and GAD-autoantibodies in pregnancy was associated with later development of IDDM. In another study the following techniques: hyperinsulinaemic euglycaemic clamp, indirect calorimetry and tritiated glucose infusion were used to evaluate insulin sensitivity in glucose tolerant nonobese women with previous GDM and controls. A decreased insulin sensitivity due to a decreased non-oxidative glucose metabolism in skeletal muscle was found in women with previous GDM. Hence, the activity of three key enzymes in intracellular glucose metabolism (GS, HK and PFK) was studied in skeletal muscle biopsies obtained in the basal state and after 3 h hyperinsulinaemia, with the aim to identify the cellular defects causing the decreased insulin sensitivity. However, no abnormalities in enzyme activity was found. The same group of previous GDM women had a relatively reduced insulin secretion evaluated by the IVGTT. A longitudinal study of 91 GDM women showed a relatively reduced insulin secretion to oral glucose in pregnancy, postpartum as well as 5-11 years later. Thus the present review has shown that even nonobese glucose tolerant women with previous GDM are characterized by the metabolic profile of NIDDM i.e. insulin resistance and impaired insulin secretion. Hence, the combination of this finding together with the significantly increased risk for development of diabetes indicates that all women with previous GDM should have a regular assessment of their glucose tolerance in the years after pregnancy. The first OGTT should be performed around 2 months postpartum in order to diagnose women already diabetic and to identify women with the highest risk for later development of overt diabetes. Women with previous GDM comprise a target group for future intervention trials with the aim to prevent or delay development of NIDDM and IDDM.     

High prevalence of polycystic ovaries and associated clinical, endocrine, and metabolic features in women with previous gestational diabetes mellitus

The prevalence of polycystic ovaries, according to ultrasonography, and associated clinical, endocrine, and metabolic features were investigated in women with previous gestational diabetes mellitus (GDM). Thirty-four women with GDM 3-5 yr before the investigation and 36 controls with uncomplicated pregnancies, selected for similar age, parity, and date of delivery, were investigated. The women with previous GDM showed a higher prevalence of polycystic ovaries [14 of 34 (41%) vs. 1 of 36 (3%); P < 0.0001], hirsutism (P < 0.01), irregular menstrual cycles (P < 0.01), and a higher body mass index (BMI; P < 0.001) than the controls. Five women (15%) with previous GDM had developed manifest diabetes (excluded in comparisons of metabolic variables). After dividing the women with previous GDM into subgroups according to ovarian appearance, the 2 subgroups showed similar glucose tolerance and prevalence of diabetes, whereas the women with polycystic ovaries were younger (mean +/- SD, 33.3 +/- 1.4 vs. 38.2 +/- 1.1; P < 0.01), had higher truncal-abdominal/femoral fat ratio according to skin folds (P < 0.05), had higher concentrations of androstenedione (P < 0.01) and testosterone (P < 0.01), and had a higher LH/FSH ratio (P < 0.01), lower levels of GH (P < 0.01), higher levels of triglycerides (P < 0.05) and cholesterol (P < 0.05) in very low density lipoprotein, all independent of age and BMI, and had a higher prevalence of pregnancy-induced hypertension (50% vs. 15%; P < 0.05) during the index pregnancy compared with the women with normal ovaries. The group of women with GDM showed a lower early insulin release after glucose (i.v. glucose tolerance test) for their degree of insulin resistance (euglycemic hyperinsulinemic clamp) compared with controls (P < 0.05). In the two subgroups, insulin sensitivity was lower in the polycystic ovaries group, independent of BMI (P < 0.05), than in the group with normal ovaries. In conclusion, ultrasonographic, clinical and endocrine signs of polycystic ovary syndrome were much increased in women with a history of GDM. Compared with the women with normal ovaries and previous GDM, those with polycystic ovaries formed a distinct subgroup that may be more prone to develop various features of the insulin resistance syndrome. Both groups showed a similarly disturbed balance between beta-cell activity and insulin sensitivity, but in women with polycystic ovaries, insulin resistance may be the dominant component.     

Need for systematic HIV serological study during pregnancy

BACKGROUND: To evaluate human immunodeficiency virus (HIV) screening usefulness in pregnancy and to know the prevalence of this infection in an urban area of Spain. PATIENTS AND METHOD: Routine prenatal screening for antibodies to HIV was offered to pregnant women from Fuenlabrada-Leganés Health Care Area (Madrid) from 1992 to 1995. Unlinked anonymous screening of HIV was done with the sera from women refusing the assay or if it had not been offered. RESULTS: HIV prevalence was 0.28% (CI: 95%; 0.19 to 0.40) in the 11.021 pregnant women group studied. 87.1% pregnant seropositive women were detected by consented screening. 55.6% of them recognized risk behavior (73.33% by intravenous drug use) and 44.4% did not do it. With a second anamnesis in this group 75% admitted risk conducts and 25% confirmed their ignorance about them. CONCLUSIONS: HIV seropositive screening in pregnant women selected only by risk behavior may be unsuccessful. For that reason, it is more convenient the perform a routine test for detection of HIV antibodies after informed consent in high prevalence areas of HIV infection.     

Glucose and amino acid turnover in untreated gestational diabetes

OBJECTIVE: Although gestational diabetes affects as many as 3% of all pregnant women, specific aspects of glucose and protein metabolism in this population have not been clearly delineated. We tested the hypothesis that gestational diabetes mellitus (GDM) results in increased glucose production and proteolysis during fasting. RESEARCH DESIGN AND METHODS: Using tracer isotope infusions, the rate of appearance (Ra) of glucose, leucine, phenylalanine and tyrosine, phenylalanine hydroxylation, leucine oxidation, and urea nitrogen excretion were determined after an overnight fast in 10 GDM subjects, within 2 weeks of diagnosis and before initiation of treatment, and in a matched control group of nine healthy nondiabetic pregnant women. RESULTS: Fasting glucose Ra was similar in GDM patients and control subjects (GDM, 12.8 +/- 1.1 vs. control subjects, 12.8 +/- 0.9 mumol . kg-1 . min-1). Leucine and phenylalanine Ra (reflecting proteolysis) also were not different between GDM patients and control subjects (GDM leucine Ra, 128 +/- 14 vs. control subjects, 124 +/- 5; phenylalanine Ra GDM, 35 +/- 4 vs. control subjects, 40 +/- 2 mumol . kg-1 . h-1). Furthermore, leucine oxidation and phenylalanine hydroxylation were not increased in GDM subjects, urea nitrogen excretion was actually lower in GDM patients. However, fasting insulin concentrations were significantly elevated in GDM subjects (GDM, 165 +/- 35 vs. control subjects, 30 +/- 5 pmol/l; P < 0.01). CONCLUSIONS: Hepatic glucose release and whole-body proteolysis in GDM patients were remarkably similar to matched pregnant control subjects. This was achieved with insulin concentrations three- to fivefold higher than normal, suggesting significant insulin resistance for both glucose and protein metabolism in GDM.     

A follow-up program for women with previous gestational diabetes mellitus

OBJECTIVE: To analyse the patterns of attendance in a gestational diabetes mellitus (GDM) follow-up program for detection of impaired glucose tolerance and diabetes mellitus. DESIGN: Retrospective cohort study using computerised data from the GDM follow-up program. PARTICIPANTS AND SETTING: All women with GDM who delivered at the Mercy Hospital for Women in Victoria between 1 January 1981 and 31 December 1995. OUTCOME MEASURES: Enrollment and maintenance in the follow-up program. Predictors of attendance analysed were attendance for the postnatal oral glucose tolerance test (OGTT), severity of GDM, insulin requirement in pregnancy, age at index pregnancy, country of birth, patient booking status and year of index pregnancy. RESULTS: There were 3524 women with GDM delivered during the study period. Attendance for postnatal OGTT was 71% and increased from 43.7% to 69.5% to 84.4% during the three five-year periods of the study (P < 0.00001). Entry into the follow-up program was 58% (1743 of 2986 eligible). A further 538 women (15.3%) were awaiting the postnatal OGTT or first follow-up OGTT. By December 1995, 45% of women who had entered the program had been lost to follow-up. Enrollment in the follow-up program was significantly predicted by insulin requirement in pregnancy (odds ratio [OR], 2.22; 95% confidence interval [95% CI], 1.57-3.13), attendance for postnatal OGTT (OR, 1.94; 95% CI, 1.64-2.29), private patient status (OR, 1.31; 95% CI, 1.12-1.54), severity of GDM (OR, 1.50; 95% CI, 1.24-1.82) and age 30 years or more (OR, 1.37; 95% CI, 1.17-1.60). Maintenance in the follow-up program was significantly associated with attendance for postnatal OGTT (OR, 2.67; 95% CI, 2.19-3.24), insulin requirement in pregnancy (OR, 2.56; 95% CI, 1.87-3.50), age 30 years or more (OR, 1.59; 95% CI, 1.34-1.88) and severity of GDM (OR, 1.55; 95% CI, 1.28-1.89). CONCLUSIONS: There are major difficulties with both recruiting women with GDM into a follow-up program and ensuring their continued attendance. However, a postnatal OGTT and consultation is the most important remediable factor for continuation in a follow-up program. The dedication of the follow-up team administrators rather than the clinical variables of the patients was probably the main determinant of compliance with the follow-up program.     

Insulin sensitivity and insulin response in women with gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is associated with much increased risk of developing diabetes later on in life. Using the frequently sampled intravenous glucose tolerance test and the minimal model analyses we have therefore determined the early insulin response to glucose (EIR) and insulin sensitivity (Si), in women with GDM of different severity (n = 14) and in normal women (n = 10). During the last trimester of pregnancy. GDMs compared to controls had significantly lower EIR (p < 0.001) and Si (p < 0.01). The reduction in EIR was less marked in GDM patients treated with diet alone (n = 6) as compared to GMD patients (n = 8) who subsequently during pregnancy needed treatment also with insulin. The insulin treated GDM group only had higher fasting glucose level than controls (5.2 vs 4.2 mmol/l, p < 0.001). Both GDM subgroups had slightly elevated basal levels of FFA and 3-hydroxybutyrate. Si and EIR were inversely correlated in control women and their fasting glucose correlated both to EIR (r = 0.63, p < 0.05) and to Si (r = 0.59, p < 0.05). In the GDM subgroups Si and EIR were unrelated and there were no correlations between fasting glucose and Si or EIR. These results suggest that glucose intolerance in GDM patients in the last trimester of pregnancy is characterized by both an impaired insulin secretion and an increased resistance to insulin. The impairment of insulin secretion and action increases with the severity of hyperglycemia, and the relative insulin deficiency characterizing GDM patients is associated with a selected defect in insulin action mainly affecting gluco-regulation.     

Prevalence of heart disease diagnosed de novo in pregnancy in a West London population

OBJECTIVES: To determine the prevalence of heart disease diagnosed de novo in pregnancy in a West London population and to re-examine the current role of routine cardiovascular examination in antenatal care in the UK. DESIGN: Retrospective study. SETTING: Obstetric medical clinics at Queen Charlotte's and Chelsea Hospital, University College Hospital and Northwick Park Hospital. POPULATION: Three hundred and twenty women referred for cardiac evaluation during pregnancy. RESULTS: The majority of the 139 women referred specifically for evaluation of murmurs during pregnancy were found to have physiological murmurs (97%). Only four women (3%) were found to have significant cardiac lesions de novo in their pregnancy. Three of these four women were immigrants who had no previous history of heart disease. The only woman from the UK was already known to have a murmur from childhood. CONCLUSIONS: Our study shows that heart disease diagnosed de novo in pregnancy in a West London population is an uncommon problem with low prevalence. It also appears to be a problem seen mainly in the immigrant population. The results emphasise the importance of taking a thorough medical history in all pregnant women. However, our results if they are confirmed, would suggest that only immigrants and those with significant symptoms or a known history of heart murmur or heart disease need undergo cardiovascular examination during pregnancy. These findings need to be confirmed in a larger group in other parts of the UK before further recommendations on selective cardiovascular examination can be made. This will have significant implications for midwifery-led care.     

Glycosylated hemoglobin and fetal growth in normal, gestational and insulin dependent diabetes mellitus pregnancies

Aims of the study were: evaluation of HbA1c levels in the peripheral blood of pregnant women with insulin dependent diabetes, gestational diabetes, glucose intolerance, and healthy pregnant controls; implications of HbA1c concentration on detection and the control of women with impaired carbohydrate metabolism in pregnancy; comparison of HbA1c levels with appearance of miscarriages, and premature deliveries; comparison of weight gain during pregnancy to HbA1c levels; comparison of difference from ideal body weight with HbA1c in diabetic pregnant women; comparison of neonatal birth weight and HbA1c levels. 290 pregnant women were enrolled to the study. The highest value of HbA1c was in the group IDDM pregnant women (7.7% +/- 1.8%), and the lowest value of HbA1c was in the control group (4.1% +/- 0.5%). Statistically significant coefficients were found between HbA1c and weight gain during pregnancy, between weight deviation from ideal body weight and HbA1c (r = 0.54 and r = 0.48 respectively); and between newborns weight and HbA1c (r = 0.51). Well regulated glycemia and intensive pregnancy follow-up of diabetic women reduces stillbirths, neonatal complications and neonatal macrosomia incidence.     

Neurophysiologic signal recording. New technical and general practice aspects of EEG recording electrodes

BACKGROUND: The most serious complication of diabetes is the progressive development of vascular changes in which impaired hemocoagulation and fibrinolysis participate. The latter were investigated in diabetes type 1 and 2, but les is known about them in gestational diabetes (GDM). The objective of the submitted work was to assess wither these disorders occur also during GDM and to compare the assessed changes of haemostasis and fibrinolysis with findings in a) non-pregnant healthy controls (n = 58), b) healthy pregnant women (n = 41) and c) groups of pregnant women with impaired haemostasis during gestation/gestational hemorrhage (n = 15), preeclampsia (n = 22), varicosities (n = 15) and dead foetus syndrome (n = 16), but normal carbohydrate metabolism. The changes in GDM were moreover compared with changes found in diabetes type 1 and 2. METHODS AND RESULTS: In pregnant women with GDM (n = 29) which was diagnosed according to WHO criteria the following parameters were examined: number of thrombocytes, APTT, fibrinogen-Fbg (according to Clauss), euglobulin fibrinolysis-ECLT, t-PA concentration, PAI-I (Coaliza, Kabi) and by microturbidimetry the concentration of plasma proteins/orosomucoid (ORM), alpha-1-antitrypsin (A1AT), prealbumin (PREA), transferrin (TRF) and alpha-2-macroglobulin (A2M). In patients with GDM a high Fbg level was found (4.51 +/- 0.98 g/l, p<0.01) not only as compared with Fbg in non-pregnant women (2.42 +/- 0.40 g/l), Fbg in healthy pregnant women (3.63 +/- 0.70 g/l) but also Fg in other patient groups with a pathological pregnancy. In pregnant women with GDM a reduced fibrinolytic activity - ECLT (464 +/- 98 min., p<0.01) was observed as compared with the finding in non-pregnant women (273 +/- 98 min.) but also in healthy pregnant women (303 +/- 106 min.). Another important deviation as compared with findings in healthy pregnant women in GDM is the reduced value of two proteinase inhibitors: A2M (2.04 +/- 0.59 g/l vs. 2.89 +/- 0.90 g/l, p < 0.01) and A1AT (2.98 +/- 0.80 g/l vs. 3.96 +/- 0.85 g/l, p < 0.01). The rise of t-PA (Ag), PAI-1 (Ag), fibrinogen and reduction of fibrinolytic activity (longer ECLT) made the changes the haemostasis and fibrinolysis in GDM closer to findings in DM type 2 than type 1. CONCLUSIONS: In GDM a higher thrombophilia was found (higher Fbg, longer ECLT) than in other groups of pregnant women. Another pathological finding is the reduced A2M level (proteinase inhibitor but also of PDGF and interleukins) and A1AT (inhibitor of leucocytic proteinases). The authors assume that these deviations favour the development of possible vascular changes in GDM and possibly also diabetic foetopathy (reduced A2M).     

An illustrative comparison of the event-size distributions for gamma-rays and alpha-particles in the whole mammalian cell nucleus

Postnatal depression is a significant problem affecting 10-15% of mothers in many countries and has been the subject of an increasing number of publications. Prenatal depression has been studied less. The aims of the present investigation were: 1) to obtain information on the prevalence of prenatal and postnatal depression in low income Brazilian women by using an instrument already employed in several countries, i.e., the Edinburgh Postnatal Depression Scale (EPDS); 2) to evaluate the risk factors involved in prenatal and postnatal depression in Brazil. The study groups included 33 pregnant women interviewed at home during the second and third trimesters of pregnancy, and once a month during the first six months after delivery. Questions on life events and the mother's relationship with the baby were posed during each visit. Depressed pregnant women received less support from their partners than non-depressed pregnant women (36.4 vs 72.2%, P < 0.05; Fisher exact test). Black women predominated among pre- and postnatally depressed subjects. Postnatal depression was associated with lower parity (0.4 +/- 0.5 vs 1.1 +/- 1.0, P < 0.05; Student t-test). Thus, the period of pregnancy may be susceptible to socio-environmental factors that induce depression, such as the lack of affective support from the partner. The prevalence rate of 12% observed for depression in the third month postpartum is comparable to that of studies from other countries.