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Abnormal glucose tolerance tests and infant outcome
878
July
Correspondence
two distinct groups can be defined according to basal LH levels and LH response following LH-KH. Group 1 patients have elevated basal LH levels and an exaggerated delayed response to LH-RH, while Group 2 patients have normal basal LH levels and a quantitatively normal LH response.” All of the above investigators, with the exception of Zarate and associates,’ administered 100 pg of LH-RH which might explain the discrepancy in results. On the other hand, it may be that all six of the patients of Zarate and associates belong to our PC0 Group 2. The detection of two groups of patients with polycystic ovaries is important. It mzay be that they represent different pathophysiologic conditions or, alternatively, that Group 1 is merely a more adweed stage of the same condition existing in Group 2. Either way, the detection of two groups is exciting, as 40 years since the original description of the Stein-Leventhal syndrome’ controversy still exists regarding its etiology. Maurice K;ntz, F.C.P.(S.A.), M.R.C.P. (LOW!.) Gyaecological Endocrine Laboraty Department of Obstetrics and G~~tuzecolo~ University of Cape Town Medical School Observatory Cape, South Africa 7900 REFERENCES
1. Zarate, A., Canales, E. F., De La Cruz, A., Soria, J., and Schally, A. V.: Obstet. Gynecol. 41: 803, 1973. 2. Aono, T., Minagawa, J., Kinugasa, T., Miyake A., and Kurachi, K.: AM. 1. OBSTET. GYNECOL. 119: 740, 1974. 3. Patton, W. C., ThGmpson, I. E., Berger, M. J., Chong, A. P.. and Tavmor. M. L.: Obstet. Gvnecol. 44: 823. 1975. 4. Duignan, I(r. M,‘, Shaw, R. W., R;dd, B. T., H&er, G., Williams, J. W., Butt, W. R., Logan-Edwards, R., and London, D. R.: Clin. Endocrinol. 4: 287, 1975. 5. Katz, M., and Carr, P. J.: S. Afr. Med. J. 49: 473, 1975. 6. Stein, I. F., and Leventhal, M. L.: AM. J. OBSTET. GYNECOL. 29: 181. 1935.
Abnormal glucose tokrwtce tests and i&ant outcome To the Editors: In the article by Drs. Haworth and Dilling on abnormal glucose tolerance in pregnancy and infant mortality and morbidity rates (Ahf. J. OBSTET. 122: 555, 1976), they conclude that GYNECOL. ‘6 .documentation of the degree of glucose intolerance. . .is of little value in assessing fetal outcome.” They also note that neither the oral nor intravenous glucose tolerance test is of value in assessing Fetal outcome. The two mothers having stillbirths in their study also had abnormal intravenous glucose tolerance tests. Since the frequency of abnormal intravenous tests is not given, the questions raised are: 1. How many abnormal intravenous tests occurred? 2. How were the abnormal intravenous tests related to the abnormal oral tests?
15, 1976
;\m. ,J.Obstet. Gynecol.
3. Was the fetal death rate higher in WOIINXI with abnormal intravenous tests than in either the control population or those with normal intravenous tests? 4. Are the authors recommending on page 560 and in the abstract that glucose tolerance tests on pregnant women be abandoned if the fasting blood glucose value is normal? Finally, one woman was treated with tolbutamide and, since it affects fetal insulin secretion and survival,
was that caseexcluded from the cord insulin calculations and what was the outcome
of that gestation? W. N. Spellacy, M.D.
Professor und Chairman Department of Obstetrics and Gynecology The University of Florida College of Medicitw Gainesville, Florida 32610
Reply to Qr. spellscy 7’0 the Editors: The answers to Dr. Spellacy’s questions about our article are as follows: 1. Of the 84 intravenous glucose tolerance tests, 47 were normal, and 37 were abnormal. 2. Eight of the 16 women with diabetic oral glucose tolerance tests also had intravenous tests; seven of these intravenous tests were abnormal, and one was normal. Both oral and intravenous tests were normal in 46 women. Thirty women had abnormal intravenous tests but normal oral tests. Dyck and Moorhouse,’ whose method for the intravenous test was used, have discussed the usefulness and sensitivity of the intravenous test as an indicator of abnormal carbohydrate metabolism as compared to the oral test. 3. We do not have information about the total fetal wastage among the women in our small series. There were two stillbirths, both in women with abnormal intravenous tests but with normal oral tests. The stillbirth rate among women with abnormal intravenous tests was not significantly different from that in women with normal intravenous tests or from that in our over-all hospital group. However, numbers of observations were small. t. We did not recommend that glucose tolerance tests should be abandoned in pregnant women if the fasting blood glucose value is normal. What we said was that our study suggested that the results of glucose tolerance tests were of little value in predicting fetal outcome, although they may indicate infants at risk of hypoglycemia and hypocalcemia. Recently we2 have shown that the probability of neonatal hypoglycemia can be predicted from the mother’s glucose level two hours following the oral glucose tolerance test. We recognize that there may be several reasons for an obstetrician to perform a glucose tolerance test on a pregnant woman who is at risk for diabetes. The infant of the mother who was treated with tolbutamide was normal at birth and did not have
July
Correspondence
two distinct groups can be defined according to basal LH levels and LH response following LH-KH. Group 1 patients have elevated basal LH levels and an exaggerated delayed response to LH-RH, while Group 2 patients have normal basal LH levels and a quantitatively normal LH response.” All of the above investigators, with the exception of Zarate and associates,’ administered 100 pg of LH-RH which might explain the discrepancy in results. On the other hand, it may be that all six of the patients of Zarate and associates belong to our PC0 Group 2. The detection of two groups of patients with polycystic ovaries is important. It mzay be that they represent different pathophysiologic conditions or, alternatively, that Group 1 is merely a more adweed stage of the same condition existing in Group 2. Either way, the detection of two groups is exciting, as 40 years since the original description of the Stein-Leventhal syndrome’ controversy still exists regarding its etiology. Maurice K;ntz, F.C.P.(S.A.), M.R.C.P. (LOW!.) Gyaecological Endocrine Laboraty Department of Obstetrics and G~~tuzecolo~ University of Cape Town Medical School Observatory Cape, South Africa 7900 REFERENCES
1. Zarate, A., Canales, E. F., De La Cruz, A., Soria, J., and Schally, A. V.: Obstet. Gynecol. 41: 803, 1973. 2. Aono, T., Minagawa, J., Kinugasa, T., Miyake A., and Kurachi, K.: AM. 1. OBSTET. GYNECOL. 119: 740, 1974. 3. Patton, W. C., ThGmpson, I. E., Berger, M. J., Chong, A. P.. and Tavmor. M. L.: Obstet. Gvnecol. 44: 823. 1975. 4. Duignan, I(r. M,‘, Shaw, R. W., R;dd, B. T., H&er, G., Williams, J. W., Butt, W. R., Logan-Edwards, R., and London, D. R.: Clin. Endocrinol. 4: 287, 1975. 5. Katz, M., and Carr, P. J.: S. Afr. Med. J. 49: 473, 1975. 6. Stein, I. F., and Leventhal, M. L.: AM. J. OBSTET. GYNECOL. 29: 181. 1935.
Abnormal glucose tokrwtce tests and i&ant outcome To the Editors: In the article by Drs. Haworth and Dilling on abnormal glucose tolerance in pregnancy and infant mortality and morbidity rates (Ahf. J. OBSTET. 122: 555, 1976), they conclude that GYNECOL. ‘6 .documentation of the degree of glucose intolerance. . .is of little value in assessing fetal outcome.” They also note that neither the oral nor intravenous glucose tolerance test is of value in assessing Fetal outcome. The two mothers having stillbirths in their study also had abnormal intravenous glucose tolerance tests. Since the frequency of abnormal intravenous tests is not given, the questions raised are: 1. How many abnormal intravenous tests occurred? 2. How were the abnormal intravenous tests related to the abnormal oral tests?
15, 1976
;\m. ,J.Obstet. Gynecol.
3. Was the fetal death rate higher in WOIINXI with abnormal intravenous tests than in either the control population or those with normal intravenous tests? 4. Are the authors recommending on page 560 and in the abstract that glucose tolerance tests on pregnant women be abandoned if the fasting blood glucose value is normal? Finally, one woman was treated with tolbutamide and, since it affects fetal insulin secretion and survival,
was that caseexcluded from the cord insulin calculations and what was the outcome
of that gestation? W. N. Spellacy, M.D.
Professor und Chairman Department of Obstetrics and Gynecology The University of Florida College of Medicitw Gainesville, Florida 32610
Reply to Qr. spellscy 7’0 the Editors: The answers to Dr. Spellacy’s questions about our article are as follows: 1. Of the 84 intravenous glucose tolerance tests, 47 were normal, and 37 were abnormal. 2. Eight of the 16 women with diabetic oral glucose tolerance tests also had intravenous tests; seven of these intravenous tests were abnormal, and one was normal. Both oral and intravenous tests were normal in 46 women. Thirty women had abnormal intravenous tests but normal oral tests. Dyck and Moorhouse,’ whose method for the intravenous test was used, have discussed the usefulness and sensitivity of the intravenous test as an indicator of abnormal carbohydrate metabolism as compared to the oral test. 3. We do not have information about the total fetal wastage among the women in our small series. There were two stillbirths, both in women with abnormal intravenous tests but with normal oral tests. The stillbirth rate among women with abnormal intravenous tests was not significantly different from that in women with normal intravenous tests or from that in our over-all hospital group. However, numbers of observations were small. t. We did not recommend that glucose tolerance tests should be abandoned in pregnant women if the fasting blood glucose value is normal. What we said was that our study suggested that the results of glucose tolerance tests were of little value in predicting fetal outcome, although they may indicate infants at risk of hypoglycemia and hypocalcemia. Recently we2 have shown that the probability of neonatal hypoglycemia can be predicted from the mother’s glucose level two hours following the oral glucose tolerance test. We recognize that there may be several reasons for an obstetrician to perform a glucose tolerance test on a pregnant woman who is at risk for diabetes. The infant of the mother who was treated with tolbutamide was normal at birth and did not have