Gestational diabetes mellitus (GDM) poses health risks due to hyperglycaemia, which can lead to clinical complications for mother and child. While dietary therapy serves as first-line treatment, approximately one-third of women with GDM require insulin to obtain glycaemic control. However, insulin therapy amplifies hospital care expenses and personal burdens. Intensive nutrition education, training and support may improve dietary intake leading to glycaemic control and reducing the need for insulin therapy. This study investigates the effectiveness of intensified dietary therapy versus standard dietary therapy in reducing the need for insulin and consequently lowering hospital care costs among women with GDM at high risk of requiring insulin therapy. Responses to the dietary interventions will also be examined within ethnic subgroups.

This study is a randomised controlled parallel-group trial involving women with GDM randomised in a 1:1 ratio to receive either intensive dietary therapy (intensive group) or standard dietary therapy with only one educational consultation (control group). The educational content of the first consultation is according to routine care and similar in both groups. The intensive group receives two additional dietitian consultations and two additional consultations on request to facilitate training and support in addition to education. Assessments are conducted at baseline and 2-3 weeks before planned delivery, with additional data gathered from medical records. The primary outcome is the difference in the proportion of women requiring insulin therapy. Maternal outcomes, neonatal outcomes, patient-reported outcomes, health behaviour and cost-saving aspects of hospital care will also be assessed. Recruitment began in January 2024 and ends in December 2025, with a target enrolment of 214 women.

The study received approval from the Ethics Committee of the Capital Region of Denmark (H-23055674). Results will be disseminated through peer-reviewed journals, and detailed presentations to key stakeholders.

NCT06127823.

There is little evidence concerning the need to treat gestational diabetes (GDM) in the same way as pregestational diabetes. We evaluated the efficacy of the simple insulin injection (SII) regimen for achieving the target glucose goal without increasing adverse perinatal outcomes in singleton pregnant women with GDM. All subjects underwent self-monitoring of blood glucose (SMBG), and insulin therapy was indicated according to the SMBG profile. Insulin was initially started with the SII regimen, in which one daily injection of NPH insulin before breakfast was used, and another NPH injection was added at bedtime, if necessary. We used the target glucose as <95 mg/dL at fasting and <120 mg/dL postprandial and accepted <130 mg/dL for the latter. If the target glucose did not reach with the regimen, we switched to the multiple daily injection (MDI) with additional prandial insulin aspart. We compared the SMBG profile before delivery as well as the perinatal outcomes between the SII and MDI groups. Among 361 women (age 33.7 years, nullipara 41%, prepregnancy body mass index 23.2 kg/m²) with GDM, 59%, 18%, and 23% were in the diet-alone, SII, and MDI groups, respectively. Consequently, regarding women requiring insulin therapy, 43% were treated with the SII regimen throughout pregnancy. The severity of baseline hyperglycemia according to the SMBG data at baseline was the MDI>the SII>the diet group. The rate of achieving target glucose levels before delivery in the SII group at fasting, postprandial < 120 mg/dL and <130 mg/dL were 93%, 54% and 87%, respectively, which were similar to that in the MDI group (93%, 57%, and 93%, respectively), with no significant differences in perinatal outcomes. In conclusion, more than 40% of women with GDM requiring insulin therapy achieved the target glucose goal with this simple insulin regimen without any increase in adverse effects.

In Vitro Fertilization (IVF) is increasingly becoming a necessary mode of reproduction. This high risk group is prone to Gestational Diabetes Mellitus (GDM) which further exposes these pregnancies to an increased risk of adverse outcomes. In light of the limited data in the current literature, further investigation is needed regarding the time of GDM diagnosis in IVF pregnancies as well as the outcome of IVF pregnancies complicated by GDM.

In this three center pilot cross sectional study, the data of 101 singleton IVF pregnancies complicated by GDM were analyzed. Prompt GDM diagnosis in IVF pregnancies was accomplished by self-blood glucose monitoring (SMBG) from the first antenatal visit and confirmed by an OGTT. To evaluate pregnancy outcome, maternal and fetal complications in the 101 GDM IVF group was compared to 101 IVF as well as 101 spontaneous conceptions (SC). The three groups were matched by age. The effect of demographic and glycemic parameters on the outcome of GDM IVF pregnancies was investigated.

GDM diagnosis was made before the 24th week in 37.6% of the GDM IVF group. The week of delivery was earlier for the GDM IVF group (37 ± 1.7) relative to the IVF (37.9 ± 0.9, p < 0.001) and the SC group (38.1 ± 0.8, p < 0.001). GDM IVF pregnancies exhibited greater preeclampsia rates and 84.8% underwent caesarian section. No significant difference regarding LGA and SGA birth weights was found. Complications of GDM IVF pregnancies were associated with the 1-h postprandial BG (r = 0.267, p = 0.007).

GDM screening in IVF pregnancies may be considered earlier than the 24th week. IVF pregnancies affected by GDM are prone to increased maternal and fetal complications which are associated with 1-h postprandial BG.

Gestational diabetes mellitus (GDM) is a common complication during pregnancy. Evaluation of the quantitative physical activity in diabetic pregnant women is critical. The aim of this study was to test the reliability and validity of the Pregnancy Physical Activity Questionnaire (PPAQ) in Turkish patients with GDM. A total of 120 pregnant women between the ages of 18 and 44 years with GDM were included. The reliability of the questionnaire was measured by internal consistency and analysis of 2-week test-retest reliability. Of the patients, 74 completed the test-retest procedure. Concurrent validity was examined by comparing the PPAQ with the Short Form of the International Physical Activity Questionnaire (IPAQ) in 36 patients. Test-retest intraclass correlation coefficient scores varied between 0.72 and 0.95. The Spearman rank correlation analysis showed that the PPAQ total activity values were statistically significantly correlated with the total values of IPAQ-Short Form (r = 0.410 and p = .030). In conclusion, the Turkish version of the PPAQ is a valid and reliable tool for the measurement of the physical activity level of pregnant women with GDM.Impact statementWhat is already known on this subject? The pregnancy physical activity questionnaire (PPAQ) developed in 2004 by Chasan-Taber et al.; is a simple and short questionnaire measuring the frequency, duration, and intensity of physical activity in pregnant women. To date, this questionnaire has been translated into many languages and has been used in a number of studies.What do the results of this study add? The aim of this study was to test the reliability and validity of the PPAQ in Turkish pregnant women with GDM. On the basis of our study results, we suggest that the Turkish version of the PPAQ is a valid and reliable tool for the measurement of the physical activity level of pregnant women with GDM.What are the implications of these findings for clinical practice and/or further research? Evaluation of the quantitative physical activity in diabetic pregnant women may contribute to gain a better understanding of the role of physical activity during treatment and may be useful to compare the results of different studies carried out in different places more effectively.

Exercise has been proved to be safe during pregnancy and to offer benefits for both mother and fetus; moreover, physical activity may represent a useful tool for gestational diabetes prevention and treatment. Therefore, all women in uncomplicated pregnancy should be encouraged to engage in physical activity as part of a healthy lifestyle. However, exercise in pregnancy needs a careful medical evaluation to exclude medical or obstetric contraindications to exercise, and an appropriate prescription considering frequency, intensity, type and duration of exercise, to carefully balance between potential benefits and potential harmful effects. Moreover, some precautions related to anatomical and functional adaptations observed during pregnancy should be taken into consideration. This review summarized the suggested recommendations for physical activity among pregnant women with focus on gestational diabetes.

To compare the existing maternal and fetal outcomes in Asian Indian women with or without gestational diabetes mellitus (GDM) before the development of the Women in India with GDM Strategy (WINGS) GDM model of care (MOC).

Records of pregnant women were extracted retrospectively from three maternity centers in Chennai. GDM was diagnosed using the International Association for Pregnancy Study Groups criteria or the Carpenter and Coustan criteria. Demographic details, obstetric history, antenatal follow-up, treatment for GDM, and outcomes of delivery were collected from the electronic medical records.

Of the 3642 records analyzed, 799 (21.9%) had GDM, of whom 456 (57.1%) were treated with insulin and medical nutrition therapy (MNT), 339 (42.4%) with MNT alone, and 4 (0.5%) with metformin. Women with GDM were older than those without (28.5 ± 4.5 vs. 27.1 ± 4.5 years; P < 0.001) and had higher mean body mass index at first booking (26.4 ± 5.2 kg/m(2) vs. 25.2 ± 5.1 kg/m(2); P < 0.001). Rates of cesarean section (26.2% vs. 18.7%; P < 0.001), preeclampsia (1.8% vs. 0.8%; P = 0.04), and macrosomia (13.9% vs. 10.8%; P = 0.02) were significantly higher among women with GDM. In women with GDM treated with insulin and MNT, emergency cesarean section (16.2% vs. 36.6%; P < 0.0001), preeclampsia (0.7% vs. 3.2%; P = 0.015), and macrosomia (9.9% vs. 18.6%; P = 0.0006) were significantly lesser compared to those treated with MNT alone.

Pregnancy outcomes were in general worse in GDM women. Treatment with insulin was associated with a significantly lower risk of complications. However, in countries with limited access to insulin and other medicines may lead to poor follow-up and management of GDM. Data from this retrospective study will form the basis for the development of the WINGS GDM MOC, which will address these gaps in GDM care in low-resource settings.

The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. This disease has many detrimental consequences for the woman, the unborn foetus and child. The management of GDM aims to mediate the effects of hyperglycaemia by controlling blood glucose levels. Along with pharmacology and dietary interventions, exercise has a powerful potential to assist with blood glucose control. Due to the uncertainty of risks and benefits of exercise during pregnancy, women tend to avoid exercise. However, under adequate supervision exercise is both safe and beneficial in the treatment of GDM. Therefore it is vital that exercise is incorporated into the continuum of care for women with GDM. Medical doctors should be able to refer to competently informed exercise professionals to aid in GDM treatment. It is important that exercise treatment is informed by research. Hence, the development of evidence-based guidelines is important to inform practice. Currently there are no guidelines for exercise in GDM. This review aims to assess the efficacy of exercise for the management of GDM in order to establish an exercise prescription guideline specific to the condition. It is recommended that women with GDM should do both aerobic and resistance exercise at a moderate intensity, a minimum of three times a week for 30-60 min each time.

Glucose challenge test (GCT) has been used as an effective screening test for gestational diabetes mellitus (GDM), though it has its own limitations. Hence, we assessed the effectiveness of fasting plasma glucose (FPG) as a simpler alternative procedure. A prospective study was done in 500 pregnant women with gestational age between 22 and 37 weeks. FPG, GCT and GTT were performed in all patients using the glucose oxidase/peroxidase method. The overall sensitivity and specificity of GCT were 75.0% and 92.0%, respectively and the corresponding values for FPG were 88.8% and 95.2%. The positive predictive value and negative predictive value were 42.2% and 97.9% for GCT and 59.2% and 99.1% for FPG, respectively. We conclude that FPG can be used as an effective screening tool for gestational diabetes mellitus.

To evaluate the accuracy of gestation-adjusted birth-weight estimation using a three-dimensional (3D) fractional thigh volume (TVol) method in pregnant women with gestational diabetes mellitus (GDM), and to compare it with the conventional two-dimensional method of Hadlock et al.

Pregnant women with GDM were referred at 34 to 36 + 6 weeks' gestation for ultrasound examination. Estimated fetal weight (EFW) was obtained using both the Hadlock and the TVol methods. Using a gestation-adjusted projection method, predicted birth weight was compared to actual birth weight at delivery.

Based on 125 pregnancies, the TVol method with gestation-adjusted projection had a mean (± SD) percentage error in estimating birth weight of -0.01 ± 5.0 (95% CI, -0.96 to 0.98)% while the method of Hadlock with gestation-adjusted projection had an error of 1.28 ± 9.1 (95% CI, -0.33 to 2.87)%. The mean percentage error of the two methods was significantly different (P = 0.039), while the random error was not (P = 1.0). For the prediction of macrosomia (birth weight ≥ 4000 g, n = 19), sensitivity was 84 and 63% for the TVol and Hadlock methods, respectively (95% CI for difference -2 to 44%, P = 0.22) and specificity was 96 and 89% for the TVol and Hadlock methods, respectively (95% CI for difference 5-9%, P = 0.01).

In women with GDM, a new method of estimating birth weight based on 3D-TVol measurements performed at 34 + 0 to 36 + 6 weeks' gestation and gestation-adjusted projection of estimated fetal weight, is more accurate than the standard method based on Hadlock's formula in predicting birth weight. The TVol method has comparable sensitivity but higher specificity than the Hadlock method in predicting neonatal macrosomia.

The objective of the study was to evaluate the effect of a resistance exercise program with an elastic band on insulin requirement and glycemic control in patients with gestational diabetes mellitus (GDM).

Sixty-four patients with gestational diabetes mellitus were randomly assigned into 2 groups: an exercise group (EG; n = 32) and a control group not submitted to the exercise program (CG; n = 32).

A significant reduction in the number of patients who required insulin was observed in the EG (7/32) compared with the CG group (18/32) (P = .005). The percentage of time spent within the proposed target glucose range (of at least 80% of weekly measurements below the limits preestablished for the disease) was significantly higher in EG compared with the CG group (EG = 0.63 ± 0.30; CG = 0.41 ± 0.31; P = .006).

The resistance exercise program was effective in reducing the number of patients with GDM who required insulin and in improving capillary glycemic control in this population.

The objective of this study was to test the hypothesis that maternal blood glucose excursions correlate with deviation from optimized birth weight.

Patients were recruited for 3-day continuous glucose monitoring (CGM) plus self-blood glucose monitoring followed by routine diabetes screening at 26-28 weeks gestation. Patients and caregivers were blinded to CGM results. The magnitude and duration of blood glucose (BG) excursions were measured as a "glycemia index." A customized birth weight centile was calculated.

Twenty-three patients consented, 21 completed the study: 5 diabetic and 16 nondiabetic individuals. The duration of CGM was 72 (+/-7.2) hours, and each patient performed self-BG monitoring >/=3 times per day. All diabetic and 10 nondiabetic patients had several measured BG excursions above 130 mg/dl. A positive correlation was observed between birth weight centile and glycemia index above 130 (p < 0.03); the trend persisted for nondiabetic patients alone (p < 0.05). No significant correlation was noted between birth weight centile and average 3-day CGM values, 3-day fasting BG, average 3-day self-BG monitoring values, or diabetes screening BG value.

The glycemia index has a better correlation with birth weight centile than BG measured by conventional methods in a mixed diabetic and nondiabetic population. Fetal exposure to maternal blood glucose excursions correlates positively with fetal growth, even in nondiabetic patients with apparently normal glucose tolerance.

The purpose of this study was to compare pregnancy outcomes in women with diet-treated gestational diabetes mellitus (GDM) that was diagnosed at < 24 weeks of gestation to those women who received the diagnosis at > or = 24 weeks of gestation.

This was a retrospective cohort study of 2596 women with diet-treated GDM who delivered between December 1999 and June 2005 at Parkland Hospital. Women with risk factors for GDM underwent immediate glucose screening; women without risk factors underwent universal glucose screening between 24 and 28 weeks of gestation. Women with diet-treated GDM that was diagnosed at < 24 weeks of gestation (n = 339; 13.1%) were compared with those women who received the diagnosis at > or = 24 weeks of gestation.

Women with an earlier diagnosis of diet-treated GDM were at increased risk of preeclampsia and the delivery of large infants. Even after adjustment for differences in maternal characteristics and glycemic control, the risk of preeclampsia persisted (odds ratio, 2.4; 95% CI, 1.5, 3.8).

Women with an early diagnosis of diet-treated GDM have a 2-fold increased risk of preeclampsia.

Diabetes in pregnancy confers a number of risks for both the mother and her baby, and many of these risks are encountered in the labor and delivery unit. The obstetric provider caring for women with diabetes should be alert to the risk of hypertension and the potential for difficult delivery due to an overgrown fetus. Women with preexisting diabetes or poor glycemic control are at increased risk for poor obstetrical outcomes such as stillbirth or delivery of a malformed infant. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia.

Intrauterine growth restriction (IUGR) and preeclampsia differ in their association with maternal disease but share a similar placental pathology. Moreover, mothers who have had pregnancies complicated by preeclampsia or IUGR are at elevated later-life cardiovascular risk. Why, then, do some women develop IUGR and others develop preeclampsia? In this clinical opinion, based on a review of the literature, we hypothesize that both women experiencing preeclampsia and IUGR enter pregnancy with some degree of endothelial dysfunction, a lesion that predisposes to shallow placentation. In our opinion, preeclampsia develops when abnormal placentation, through the mediator of elevated circulating cytokines, interacts with maternal metabolic syndrome, comprised of adiposity, insulin resistance/hyperglycemia, hyperlipidemia, and coagulopathy. IUGR develops in the absence of antenatal metabolic syndrome. Among these women, the baby is affected by shallow placentation but the mother does not develop clinically apparent disease. This conceptualization provides a testable framework for future etiologic studies of preeclampsia and IUGR.

To determine whether women with gestational diabetes mellitus (GDM) and their offspring have pregnancy outcomes and complications of pregnancy that are different from those in the general obstetric population.

Through medical record coding, we identified women with GDM and a singleton pregnancy with cephalic presentation who delivered at St. Paul's Hospital between January 1, 1995, and December 31, 2001. In total, 394 births were analyzed and their outcomes compared with those of a control group of 100 non-diabetic women with the same gestational age (38 weeks) at delivery.

Women with gestational diabetes were of lesser parity (P 0.05), appreciably older (P 0.05), and less likely to be Caucasian (P 0.005) than the general obstetric population. Women with GDM also had a higher risk of Caesarean section (P 0.05), gestational hypertension (P 0.05), and large for gestational age (LGA) deliveries (P 0.005). Of women with GDM, those treated with insulin had a higher incidence of LGA deliveries than those on diet therapy alone. The incidence of respiratory distress syndrome and of need for phototherapy was similar in babies whose mothers had GDM and in those whose mothers did not.

Although the rate of complications remains low, GDM creates a predisposition to increased maternal and neonatal complications.

To determine whether an initial fasting blood glucose determination will predict which pregnant women will need insulin in addition to dietary measures to maintain fasting glucose levels during gestation.

All women referred for management of gestational diabetes received dietary counseling and instructions for self-monitoring of blood glucose levels during fasting and at 2 hours after each meal. Insulin therapy was initiated if the fasting blood glucose value exceeded 5.8 mmol/L (105 mg/dL) on more than one occasion, the 2-hour postprandial glucose exceeded 8.3 mmol/L (150 mg/dL), or the 2-hour postprandial glucose exceeded 6.7 mmol/L (120 mg/dL) three times in a week. The use of diet alone or diet plus insulin therapy was determined by review of medical records.

Fifty-two pregnant women with fasting blood glucose levels of less than 5.8 mmol/L (105 mg/dL) and with two or more elevated blood glucose values on a 3-hour glucose tolerance test underwent follow-up at least through the 36th week of gestation. In 21 patients, insulin therapy was initiated in addition to diet. Two of five women with an initial fasting glucose level of less than 4.4 mmol/L (80 mg/dL) required insulin, and 8 of 24 women with fasting levels of 5.3 to 5.8 mmol/L (96 to 105 mg/dL) eventually needed insulin.

The height of the fasting blood glucose level in women with gestational diabetes does not separate those who will maintain blood glucose levels in the targeted therapeutic range on diet alone from those who will need insulin. Therefore, all women with gestational diabetes need to participate in self-monitoring of blood glucose levels.

There is still no consensus on screening, threshold levels and treatment of gestational diabetes mellitus. Furthermore, the importance of a positive 50-g glucose screening test in patients who had a negative 100-g oral glucose tolerance test remains controversial. We investigated the impact of the 50-g glucose screening test results on neonatal outcome in pregnant women with uncomplicated pregnancies, who had no risk factors according to ACOG criteria.

Three hundred eighty-six pregnant women with singleton pregnancies were prospectively screened with 50-g glucose challenge test between 24 and 28 weeks. If the test result was >140 mg/dl, a 100-g 3-hour oral glucose tolerance test was performed. Patients with a positive screening test, but not diagnosed as gestational diabetes mellitus constituted the study group, and patients with a negative screening test constituted the control group. Cesarean rates, neonatal birth weights and complications were compared between these groups.

The cesarean delivery rates were not statistically different between the study and control groups (8.3% vs. 6.4%, P>0.05). The rates of macrosomic births were 10.0% in the study group, and 6.4% in the control group (P>0.05), but the mean birth weight (3451.67 +/- 355.70 g) in the study group was significantly higher than the mean birth weight (3296.29 +/- 365.14 g) in the control group (P=0.003). Neonatal hypoglycemia and hyperbilirubinemia was also encountered more often in babies of pregnant women with a positive 50-g glucose challenge test but negative 100-g glucose tolerance test.

Because of similarities with gestational diabetes mellitus on the basis of perinatal outcomes, the non-diabetic pregnant women with 50-g glucose screen test result over 140 mg/dl but a negative 100-g OGTT should be followed closely.

To evaluate oxidative and antioxidative status in pregnant diabetic women between 26 and 32 weeks of gestation.

Free and total malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPX), and vitamins A and E were determined in plasma and erythrocytes of 54 pregnant women. Among these, 27 were diabetics with either gestational diabetes mellitus (GDM), sub-group I, or previous insulin-dependent diabetes mellitus (type 1 diabetes), sub-group II. The other 27 patients were controls. Fasting plasma glucose and HbA(1c) levels were determined in all women.

HbA(1c) levels, plasma-, and erythrocyte-free MDA levels were significantly higher in all diabetic women and in both sub-groups than in controls. Plasma vitamin E and erythrocyte vitamin A levels were significantly lower in all diabetic women than in controls. Moreover, GPX and SOD activities were significantly reduced in all diabetic women, GPX in both sub-groups and SOD only in type 1 diabetes.

The increased oxidative stress we demonstrated in pregnant women with previous type 1 diabetes or with GDM should be monitored by strictly controlling blood glucose during pregnancy with stringent recommendations and perhaps antioxidant supplementation.

To compare the management of Caucasian women with gestational diabetes (GDM) based predominantly on monthly fetal growth ultrasound examinations with an approach based solely on maternal glycemia.

Women with GDM who attained fasting capillary glucose (FCG) <120 mg/dl and 2-h postprandial capillary glucose (2h-CG) <200 mg/dl after 1 week of diet were randomized to management based on maternal glycemia alone (standard) or glycemia plus ultrasound. In the standard group, insulin was initiated if FCG was repeatedly >90 mg/dl or 2h-CG was >120 mg/dl. In the ultrasound group, thresholds were 120 and 200 mg/dl, respectively, or a fetal abdominal circumference >75th percentile (AC>p75). Outcome criteria were rates of C-section, small-for-gestational-age (SGA) or large-for-gestational-age (LGA) infants, neonatal hypoglycemia (<40 mg/dl), and neonatal care admission.

Maternal characteristics and fetal AC>p75 (36.0 vs. 38.4%) at entry did not differ between the standard (n = 100) and ultrasound groups (n = 99). Assignment to (30.0 vs. 40.4%) and mean duration of insulin treatment (8.3 vs. 8.1 weeks) did not differ between groups. In the ultrasound group, AC>p75 was the sole indication for insulin. The ultrasound-based strategy, as compared with the maternal glycemia-only strategy, resulted in a different treatment assignment in 34% of women. Rates of C-section (19.0 vs. 18.2%), LGA (10.0 vs. 12.1%), SGA (13.0 vs. 12.1%), hypoglycemia (16.0 vs. 17.0%), and admission (15.0 vs. 14.1%) did not differ significantly.

GDM management based on fetal growth combined with high glycemic criteria provides outcomes equivalent to management based on strict glycemic criteria alone. Inclusion of fetal growth might provide the opportunity to reduce glucose testing in low-risk pregnancies.

This study examines the effects of circuit-type resistance training on the need for insulin in women with gestational diabetes mellitus.

Thirty-two patients with gestational diabetes mellitus were randomly assigned either to a group that was treated with diet alone or to a group that was treated with diet plus resistance exercise.

The number of women whose condition required insulin therapy was the same, regardless of treatment. However, a subgroup analysis that examined only overweight women (prepregnant body mass index, >25 kg/m(2)) showed a lower incidence of insulin use in the diet-plus-exercise group (P<.05). Women in the diet-plus-exercise group were prescribed less insulin (P<.05) and showed a longer delay from diagnosis to the initiation of insulin therapy (P<.05), compared with the diet-alone group.

Resistance exercise training may help to avoid insulin therapy for overweight women with gestational diabetes mellitus.

With respect to the feto-maternal outcome of pregnancy both appropriate screening and treatment of gestational diabetes mellitus (GDM) remain a matter of debate. Furthermore, the importance of only one abnormal glucose value at the glucose tolerance test (GTT) is still discussed, including the term "gestational impaired glucose tolerance" with normal fasting but an increased 2h postprandial glucose value.

We have evaluated the feto-maternal outcome of pregnancy in 152 women with abnormal glucose values during the oral 100g GTT. The data were analysed with respect to the number of abnormal GTT values and compared to age- and body mass index (BMI)-matched control groups including 304 women with normal GTT values.

A positive family history of diabetes was found in 24.4% of the GDM women and in 16.4% of the control group. In 45.9% of the women with abnormal GTT values glucose target levels could be obtained by dietary management, 54.1% required additional insulin therapy. Insulin therapy was administered in 32.8% of the women with one abnormal GTT value, in 65.0% of the women with two abnormal values and in 83.3% of the women with three abnormal values. Compared to the age- and BMI-matched control group the percentage of women with hypertension was increased in women with one, two and three abnormal GTT values. The percentage of LGA and macrosomic infants was significantly increased only in women with three abnormal GTT values. Women with one, two or three abnormal GTT values revealed an increased percentage of caesarean section compared to the control group.

Our results show that women with three abnormal GTT values are at an overall increased risk with respect to the feto-maternal outcome of pregnancy. Compared to the control group also women with only one abnormal GTT value revealed an increased risk indicating a need for further control and therapy.

Fetal hyperinsulinism is a strong predictor for excessive growth and fetopathy in pregnancies complicated by diabetes. We examined (i). the relationship between measurements of amniotic fluid insulin (AF insulin) and fetal abdominal circumference (AC) at the time of amniocentesis, and (ii). whether there is a threshold for fetal AC percentiles which can identify low vs. high-risk levels of AF insulin without performing an amniocentesis.

In a retrospective study, AF insulin from 121 pregnant diabetic women (32 pregestational; 89 gestational) was measured during the 3rd trimester as part of a diabetes management protocol. AC measurements were transformed into a continuous variable of percentile growth for gestational age (Hadlock). Division of the cohort according to deciles or quartiles of AC percentiles was performed to identify a threshold AC with a significant increase in elevated AF insulin, previously defined as AF insulin >or= 7 microU/ml. A receiver operator characteristic (ROC) curve was created and the negative predictive value (NPV) of the determined threshold was calculated.

AF insulin levels were significantly correlated with the AC percentiles (r = 0.3, P = 0.0005) by linear regression. No AC threshold could reliably identify a moderate elevated AF insulin >or= 7 microU/ml (NPV 77.2%), but an AC threshold >or= 75th percentile could identify with fetal hyperinsulinism with an AF insulin >or= 16 microU/ml. All 10 cases of AF insulin >or= 16 microU/ml were identified with a NPV of 100% (74/74).

Our data indicate that an AC >or= 75th percentile determined by a 3rd trimester ultrasound examination may discriminate between pregnancies at low vs. high risk for AF insulin >or= 16 microU/ml. This AF insulin concentration corresponds to a level of hyperinsulinism reported to be associated with considerable neonatal and long term morbidity.

The current therapeutic strategies to reduce macrosomia rates in gestational diabetes (GDM) have focused on the normalizing of maternal glucose levels. The aim of our study was 1.) to compare maternal glycemic values with the presence of fetal macrosomia at different gestational ages (GA) and with LGA at birth in a cohort of women with glucose intolerance and standard diabetic therapy.

306 women with GDM and 97 with impaired glucose tolerance underwent ultrasound examinations at entry and, after initiation of therapy, monthly in addition to standard diabetic therapy. Measurements from the entry diagnostic oGTT, glucose profile and HbA1c and from subsequent glucose profiles obtained within 3 days of the ultrasound at 5 categories of GA age (20-23, 24-27 etc) were retrospectively compared between pregnancies with and without fetal macrosomia, defined as an abdominal circumference (AC) > or = 90th percentile. Maternal prepregnancy BMI was adjusted for and BMI > or = 30 kg/m2 was defined as obesity.

At entry, neither the hourly oGTT values, HbA1c, nor the entry glucose profile differed significantly between pregnancies with and without fetal macrosomia. In a total of 919 pairs of ultrasound/glucose profiles there was no significant difference in glucose levels at every GA category neither in lean nor in obese woman except for the fasting glucose of 32-35 GA. The fetal macrosomia rate in each GA category and the rate of LGA were significantly higher in obese women: e.g. 14.5 vs 28% at diagnosis, 15.7 vs 26.7% at 32-35 weeks, 15.5 vs 25.0% at birth (p < 0.05 for each comparison).

The association of maternal glucose values and fetal macrosomia was limited to the fasting glucose values between 32-35 weeks while maternal obesity appeared to be a strong risk factor for macrosomia throughout pregnancies with GDM. In obese women the high fetal macrosomia rate did not appear be normalized by therapy based on maternal euglycemia.

Alterations in placental transport may contribute to accelerated fetal growth in pregnancies complicated by diabetes. We studied the activity of the syncytiotrophoblast amino acid transporter system A and the transport of the essential amino acids leucine, lysine, and taurine. Syncytiotrophoblast microvillous plasma membranes (MVMs) and basal plasma membranes (BMs) were isolated from placentas obtained from normal pregnancies and pregnancies complicated by gestational diabetes mellitus (GDM) and type 1 diabetes, with and without large-for-gestational-age (LGA) fetuses. Amino acid transport was assessed using radio-labeled substrates and rapid filtration techniques. System A activity in MVM was increased (65-80%, P < 0.05) in all groups with diabetes independent of fetal overgrowth. However, MVM system A activity was unaffected in placentas of normal pregnancies with LGA fetuses. MVM leucine transport was increased in the GDM/LGA group. In BMs, amino acid transport was unaffected by diabetes. In conclusion, diabetes in pregnancy is associated with an increased system A activity in MVM, and MVM leucine transport is increased in the GDM/LGA group. We suggest that these changes result in an increased uptake of neutral amino acids across MVM, which may be used in placental metabolism or be delivered to the fetus. The increased MVM leucine uptake in the GDM/LGA group may contribute to accelerated fetal growth in these patients.

This is a retrospective study to compare the criteria for diagnosis of gestational diabetes mellitus (GDM) by the National Diabetes Data Group (NDDG), and Carpenter and Coustan criteria, and to study the outcome of GDM when diagnosed by the more sensitive criteria. Six hundred and sixty-two pregnant women were included in this study from the medical records between September 1998 and April 2001. GDM was positive in 6.50% of patients according to Carpenter and Coustan and in 4.08% of patients according to NDDG criteria. Women with GDM were older, had higher fasting and glucose challenge test (GCT) glucose levels, and fetal weight than the normal women. Hypoglycemia was observed only in one infant. Regarding pre-term delivery and pre-eclampsia, there was no significant difference between the groups. Age, delivery week and fetal weight of patients who had caesarian delivery were significantly higher than spontaneous vaginal delivery. Prevalence of macrosomia in GDM group was higher than in the normal group. There was a significant correlation between the macrosomia and number of positive blood glucose values during OGTT. In multivariate analyses, fasting, GCT and second hour OGTT blood glucose levels, mean parity, and delivery week were independent risk factors for fetal weight. Carpenter and Coustan criteria is more sensitive than the NDDG criteria and women with GDM had a higher frequency of macrosomia and the frequency of macrosomia increases by the number of positive blood glucose levels during OGTT. Tight glycemic control might decrease the prevalence of caesarian delivery, pre-eclampsia, pre-term delivery and hypoglycemia of the infant.

Intrauterine tissues (placenta, amnion, chorion, decidua) express hormones and cytokines that play a decisive role in maternal-fetal physiological interactions. The excessive or deficient release of some placental hormones in association with gestational diseases may reflect an abnormal differentiation of the placenta, an impaired fetal metabolism, or an adaptive response of the feto-placental unit to adverse conditions. This review is focused on the applicability of hormone measurements in the risk assessment, early diagnosis, and management of pregnancies complicated by Down's syndrome, fetal growth restriction, preeclampsia, preterm delivery, and diabetes mellitus. Combined hormonal tests or the combination of hormones and ultrasound may achieve reasonable sensitivity, but research continues to simplify the screening programs without sacrificing their accuracy. Only in a few instances is there sufficient evidence to firmly recommend the routine use of hormone tests to predict maternal and fetal complications, but the judicious use of selected tests may enhance the sensitivity of the risk assessment based solely on clinical and ultrasound examination.

Gestational diabetes mellitus, however currently defined, is relatively rare in a UK Caucasian population, but is much more common in other ethnic groups. There is likely soon to be better agreement on diagnostic levels of hyperglycaemia in pregnancy, but there is still considerable reluctance to start insulin therapy. There is now good evidence that insulin administered twice daily during the third trimester to mothers who have even a mild degree of hyperglycaemia will reduce fetal size, and in particular fetal adiposity. In relation to recent concepts of the transgenerational passage of Type 2 diabetes and obesity, further epidemiological investigation is required. Insulin treatment in pregnancy may also prove to have a role in prevention of Type 2 diabetes in the next generation.

The aim of the study was to examine the outcome of the pregnancy and neonatal period in 1) women with gestational diabetes mellitus and non-diabetic pregnant women, and 2) in women with early and late diagnosis of gestational diabetes mellitus.

Included were 327 women with gestational diabetes mellitus and 295 non-diabetic women, who were screened with a 75 g oral glucose tolerance test because of risk factors for gestational diabetes. Women with gestational diabetes mellitus were treated with low-caloric diet and insulin when appropriate, while women in the control group received routine antenatal care.

Gestational age at delivery was significantly lower in the group with gestational diabetes mellitus, both when considering all deliveries (39.1+/-1.7 weeks versus 39.8+/-2.0 weeks, p<0.05) and only those with spontaneous onset of labor (38.8+/-2.0 weeks versus 40.0+/-1.6 weeks, p<0.05). The frequency of macrosomia was increased, although not statistically significant (8% vs. 2%, p=0.07), and the rate of admission to the neonatal ward was significantly increased (18% vs. 9%, p<0.05) in the group with gestational diabetes. Women with early diagnosis of gestational diabetes mellitus had a significantly increased need for insulin treatment during pregnancy (36% vs. 9% p<0.05) and a significantly higher occurrence of diabetes mellitus at follow-up from two months until three years postpartum.

This study of women with gestational diabetes mellitus and non-diabetic pregnant women showed that gestational diabetes mellitus was associated with a significantly lower gestational age at delivery and an increased rate of admission to the neonatal ward. Women diagnosed with GDM before 20 weeks of gestation had an increased need for insulin treatment during pregnancy and a high risk of subsequent overt DM, compared with women diagnosed with GDM later in pregnancy.

We conducted a population-based study of maternal and neonatal characteristics and delivery complications in relation to the outcome of a 75-g, 2-hour oral glucose tolerance test at 25 to 30 weeks' gestation.

An oral glucose tolerance test was offered to pregnant women in a geographically defined population. Pregnancy outcome was analyzed according to the test result.

Among women delivered at Lund Hospital, we identified 4526 women with an oral glucose tolerance value of <7.8 mmol/L (<140 mg/dL), 131 women with a value of 7.8 to 8.9 mmol/L (140-162 mg/dL), and 116 women with gestational diabetes (> or =9.0 mmol/L [> or =162 mg/dL]). A further 28 cases of gestational diabetes were identified, giving a prevalence of 1.2%. An increased rate of cesarean delivery and infant macrosomia was observed in the group with a glucose tolerance value of 7.8 to 8.9 mmol/L (140-162 mg/dL) and in the gestational diabetes group. Advanced maternal age and high body mass index were risk factors for increased oral glucose tolerance values in 12,657 screened women in the area.

The study stresses the significance of moderately increased oral glucose tolerance values.

We have previously reported that type 1 diabetes mellitus with hyperglycemia during the first trimester is associated with an up-regulation of placental glucose transport at term. We speculated that glucose concentrations regulate placental glucose transporters only during early pregnancy. To test this hypothesis we studied placental glucose transport in gestational diabetes mellitus, which is associated with hyperglycemia mainly during the second half of pregnancy.

Syncytiotrophoblast microvillous membrane vesicles and basal membrane vesicles were isolated from uneventful pregnancies (control group, n = 32) and pregnancies complicated by gestational diabetes mellitus (n = 18). Glucose uptake and glucose transporter 1 expression were studied by means of radiolabeled tracers and Western blotting, respectively.

Gestational diabetes mellitus was not associated with alterations in placental glucose transport. Separate analysis of 6 patients in the gestational diabetes mellitus group with large-for-gestational-age babies did not affect these results.

These findings are consistent with the hypothesis that the sensitivity of placental glucose transporters to regulation by nutrient availability is limited to early pregnancy.

Glucose monitoring is essential for the successful management of gestational diabetes. The accuracy of glucose meters is typically determined over a much wider range of glucose values than that commonly encountered in gestational diabetes. The objective of our study was to look at the accuracy of self-monitoring glucose meters in a clinic setting over a range of glucose values seen in gestational diabetes. We retrospectively analyzed 107 case records of subjects with gestational diabetes, each of whom had three simultaneous laboratory and glucose meter glucose tests. The results were compared using the performance goals that (1) all of glucose meters should have readings within 10% of the reference value and (2) the error grid analysis in the standard format and a modified version suitable for gestational diabetes. We also examined the range of the differences from the reference value. Nearly half of the values (47%) were in excess of 10% of the reference range (either above or below). Close to 15% were in excess of 20% difference from the reference range. Standard error grid analysis showed that 96% of the values fell within sections A of the error grid which are considered acceptable, and 100% fell within sections A and B, differences which are generally considered to have no major impact on care. The modified version of the error grid analysis demonstrated that 39% of the values were outside the acceptable range. Within subjects, a substantial number (26%) had a range of differences that exceeded 20% difference between each other. Although the meters give reasonable results that might be acceptable for general diabetes care, the results provide some cause for concern in the management of gestational diabetes. Given the need for precision in the setting of pregnancy particularly in making the decision of whether to start or withhold insulin therapy, caregivers need to be cognizant of these inaccuracies.

To investigate whether 2-hour postprandial blood glucose levels up to 8.0 mmol/L affect maternal or neonatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM).

Retrospective analysis of data collated by the Victorian Perinatal Data Collection Unit.

394 GDM women and 394 control women matched for age and country of birth who gave birth at a university teaching hospital, 1991-1997.

Maternal--hypertension/pre-eclampsia, obstetric intervention, gestation at delivery, length of hospital stay; neonatal--Apgar scores, time to establish respiration, birthweight, macrosomia, large or small for gestational age (LGA or SGA), fetopelvic disproportion, jaundice, hypoglycaemia.

For most outcome measures there were no statistically significant differences between the GDM and control groups. However, in the GDM group, gestation was shorter, hospital stays longer and delivery interventions more common.

Our study suggests that maternal and neonatal outcomes in GDM women are comparable with those of women without GDM when 2-hour postprandial glucose levels of up to 8mmol/L are maintained. This is 1.0 mmol/L higher than the current Australian Diabetes in Pregnancy Society recommendation.

The Cree of James Bay have the highest ever reported mean birth weight and a high prevalence of infant macrosomia. This study was designed to examine independent risk factors for infant macrosomia among the Cree, to compare these to risk factors among non-Native Canadians and to determine if ethnic differences persist after adjusting for differences in the distribution of other risk factors. Macrosomia was defined as birth weight >90(th) percentile for gestational age of a reference population. Independent determinants of macrosomia were examined in 385 Cree and 5644 non-Native women. The potential effect of ethnicity (Cree vs. non-Native) was determined after statistically adjusting for age, parity, pregravid weight, height, net rate of weight gain, gestational diabetes mellitus (GDM) and smoking status. The prevalence of macrosomia among the Cree was 34.3% vs. 11.1% among non-Natives. Although GDM significantly increased the risk for macrosomia among the Cree (odds ratio: 4.46, 95% CI: 2.24-9.26), it was not a significant risk factor among non-Natives (odds ratio: 1.15, 95% CI: 0.79-1.65). The risk for infant macrosomia remained elevated among the Cree compared with non-Natives after adjusting for other risk factors (odds ratio: 3.64, 95% CI: 2.69-4.90). In conclusion, the Cree have a high prevalence of macrosomia despite controlling for important differences in pregravid weight and GDM. Some of this variation may be due to genetic differences in fetal growth. The differential impact of GDM on macrosomia in the two ethnic groups may be due to differences in treatment strategies for GDM.

Gestational diabetes mellitus (GDM) is associated with adverse maternal and fetal outcome. Screening for GDM is therefore recommended but the best screening method remains controversial. This prospective, randomized study compared a risk factor-based screening programme with a universally based one.

Subjects were randomized at booking to one of two groups: the risk factor group had a 3-h 100-g oral glucose tolerance test (OGTT) at 32 weeks if any risk factor for GDM was present; the universal group had a 50-g glucose challenge test performed and if their plasma glucose at 1 h was > or = 7.8 mmol/l, a formal 3-h 100-g OGTT was then performed.

Universal screening detected a prevalence of GDM of 2.7%, significantly more than the 1.45% detected in the risk factor screened group (P<0.03). Universal screening facilitated earlier diagnosis than risk factor screening - mean gestation 30 +/- 2.6 weeks vs. 33 +/- 3.7 weeks (P<0.05). A higher rate of spontaneous vaginal delivery at term, and lower rates of macrosomia, Caesarean section, prematurity, pre-eclampsia and admission to neonatal intensive care unit were observed in the universally screened, early diagnosis group.

Universal screening for GDM is superior to risk factor based screening-detecting more cases, facilitating early diagnosis and is associated with improved pregnancy outcome.

To evaluate whether measuring fasting plasma glucose concentration is an easier screening procedure for gestational diabetes mellitus than the 1 hour 50 g glucose challenge test.

Prospective population based study.

Outpatient clinic in a university hospital.

520 pregnant women (328 (63%) white, 99 (19%) Asian, 31 (6%) African, 62 (12%) others) with mean age 28.4 (SD 0.2; range 17-45) years. All underwent a glucose challenge test between the 24th and 28th gestational week, followed by a diagnostic 3 hour 100 g oral glucose tolerance test within one week. This was done irrespective of the result of the challenge test.

Receiver operating curves were used to determine the best cut off values for screening with fasting plasma glucose concentrations.

Fasting plasma glucose concentration at a threshold value of 4.8 mmol/l and the glucose challenge test with a threshold value of 7.8 mmol/l yielded sensitivities of 81% and 59% respectively and specificities of 76% and 91% respectively. Measuring fasting plasma glucose concentration as a screening procedure required a diagnostic test in 30%, compared with 14% when the challenge test was used.

Measuring fasting plasma glucose concentrations using a cut off value of >/=4. 8 mmol/l is an easier screening procedure for gestational diabetes than the 50 g glucose challenge test and allows 70% of women to avoid the challenge test.

We analyzed the safety and patient acceptance of amniotic fluid insulin measurements by third-trimester amniocentesis in women with gestational diabetes mellitus.

We studied the rate of early uterine contractions, need for tocolysis, premature rupture of membranes, mode of delivery, length of gestation, and fetal weight and length at birth in 194 women with gestational diabetes mellitus who underwent third-trimester amniocentesis and 268 controls. Patient acceptance of amniocentesis was assessed prospectively with a visual rating scale and a semistructured interview comparing 50 women with gestational diabetes mellitus to 50 women undergoing second-trimester amniocentesis for fetal karyotyping.

Only the length of gestation differed significantly but without clinical relevance (39.5 +/- 1.9 vs 40.0 +/- 2.0, P = .006) between women with gestational diabetes mellitus who had amniocentesis and controls. Patient acceptance was equally high both for second-trimester and third-trimester amniocentesis.

Third-trimester amniocentesis for measuring amniotic fluid insulin is safe and well accepted by the patients. This is important information both for treating and counseling women with gestational diabetes mellitus.

Ambulatory management of multiple gestation requires careful and continuing care by the obstetrician. The initial evaluation should include a comprehensive history, including use of fertility enhancing drugs and ART, family history, social history; a general physical examination, including a pelvic examination; laboratory evaluation, including complete blood cell count, dipstick urinalysis for protein and glucose, urine culture, blood type, Rh factor and irregular blood antibody determination, serology for rubella, syphilis, hepatitis B surface antigen and varicella (if there is no history). A Papanicolaou smear should be done at the time of the pelvic examination, as should evaluation for bacterial vaginosis. Ultrasound assessment of placentation should be done at 14 weeks' gestation, but vaginal or perineal ultrasound of cervical length should be done at the initial visit. Other testing procedures should include repeat ultrasound evaluation for fetal growth every 4 weeks in a dichorionic placentation and every 3 weeks if monochorionic placentation is present. Triple screen MSAFP at 16-18 weeks' gestation and blood sugar screening at 22-26 weeks should be performed. After the first trimester, the patient should schedule physician visits every 2 weeks or less. Routine medications should include one prenatal vitamin per day, additional folic acid supplementation of 1.0 mg per fetus, supplemental iron preparation, and additional calcium to equal 1500 mg/day. The use of low-dose aspirin to prevent preeclampsia in twin gestations has not been adequately studied. Continuing vigilance by the knowledgeable obstetrician should occur. Multiple gestations should not be cared for by non-physician providers or by family physicians. Referral to a maternal-fetal medicine unit is recommended.

For patients with preconception diabetes, the most important aspect is the need for good glycemic control pre conception to lessen the risk of congenital malformations. Careful assessment of diabetes complications is essential prepregnancy. In the absence of major complications, good glycemic control gives the pregnant diabetic patient the same chance for a healthy baby as the rest of the population. Pregnancy alters carbohydrate tolerance, and thus gestational diabetes should be screened for and, when found, treated aggressively with dietary intervention, glucose monitoring, and insulin if good glycemic control has not been attained. These patients are at greatly increased risk for diabetes in the long term.

Prior studies have suggested that macrosomia is the only morbid condition associated with gestational diabetes and that this association is the result of confounding by maternal obesity rather than a result of gestational diabetes itself. We sought to determine whether unrecognized gestational diabetes is an independent predictor of macrosomia and other perinatal morbid conditions after controlling for confounding variables.

A retrospective analysis of 472 consecutive cases of gestational diabetes diagnosed between 24 and 30 weeks' gestation was undertaken including 16 prospectively identified but clinically unrecognized cases, 297 cases treated with diet alone, and 76 treated with diet plus insulin. Unrecognized cases were matched to 64 nondiabetic controls for race, age, body mass index, parity, pregnancy weight gain, and gestational age at delivery.

In the unrecognized gestational diabetes group versus the nondiabetic control versus gestational diabetes diet groups rates of large for gestational age infants (44% vs 5% vs 9%, p < 0.0005), macrosomia (44% vs 8% vs 15%, p < 0.01), shoulder dystocia (19% vs 3% vs 3%, p < 0.05), and birth trauma (25% vs 0% vs 0.3%, p < 0.001) were all significantly increased. These differences remained significant after controlling for maternal age, race, parity, body mass index, pregnancy weight gain, and gestational age at delivery.

This study suggests that unrecognized gestational diabetes increases risks of large for gestational age infants, macrosomia, shoulder dystocia, and birth trauma independent of maternal obesity and other confounding variables. Clinical recognition and dietary control of gestational diabetes are associated with a reduction in these perinatal morbid conditions.

The usual approach to detecting gestational diabetes mellitus is to screen all pregnant women by measuring their plasma glucose after a 50-g oral glucose load at 24 to 28 weeks' gestation. Women are referred for an oral glucose-tolerance test if the plasma glucose concentration one hour later is > or = 140 mg per deciliter (7.8 mmol per liter). We hypothesized that the efficiency of screening could be enhanced by considering women's risks of gestational diabetes on the basis of their clinical characteristics.

We studied 3131 pregnant women who underwent both the screening and the diagnostic tests. We randomly selected data on half the women and used them to derive new screening strategies. We categorized each woman's risk of gestational diabetes mellitus on the basis of her age, body-mass index before pregnancy, and race. We developed strategies that entailed no screening for low-risk women, usual care for intermediate-risk women, and universal screening with lower thresholds -- plasma glucose values of 130 mg per deciliter (7.2 mmol per liter) or 128 mg per deciliter (7.1 mmol per liter) -- for high-risk women. The strategies were validated with data on the other half of the women.

The new strategies allowed a 34.6 percent reduction in the number of screening tests performed (95 percent confidence interval, 32.3 to 37.0) and detected 81.2 to 82.6 percent of the women with gestational diabetes as compared with the 78.3 percent detected through usual care. The percentage of false positive screening tests was significantly reduced, from 17.9 percent with usual care to 16.0 per cent (P=0.02) or 15.4 percent (P<0.001) with the new strategies, depending on the threshold values for high-risk women.

Consideration of women's clinical characteristics allows efficient selective screening for gestational diabetes.