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Not so intensive treatment of insulin-requiring diabetes in pregnancy
330
249
SPO Abstracts
THE PREVALENCE OF GESTATIONAL DIABETES IN GRAVIDAS WITH SCREENING GLUCOSE VALUE >200 MG/DL.
January 1995 Am J Obstet Gynecol
251
van Dyk,M. Karp,O. Kalter,J. Bar,Y. Peled,A. Erman,G. Boner,J. Ovadia, O. Langer. Bellinson Medical Center, TelAviv University, Israeland UTHSCSan Antonio, TX, OBJECTIVE: To examine the effect of pre-pregnancy treatment of diabetic, nephrotic women with Captopril (angiotensin-converting enzyme inhibitor, [ACE-I]), on maternal renal function throughout pregnancy. STUDY DESIGN: Eight insulin d e p e n d e n t diabetic (IDDM), nephrotic patients planning pregnancy were treated with Captopril for a minimum of six months prior to conception, together with intensive insulin therapy. Conception was allowed when proteinuria was <500 rag/day and euglycemia was achieved. At conception Captopril was discontinued. RESULTS: Prior to Captopril treatment, proteinuria was 1633+666 mg/day. At conception, it dropped to 273+ 146 mg/day (p=0.0000) and increased gradually over the three trimesters (593+ 515, 783 + 813 and 1,000-1-1185 mg/day, respectively; p=0.2); and was 619_+411 three months postpartum. No significant change in other renal functions (CCT, creatinine, uric acid, K+ and blood pressure) was observed. Three casesof preeclampsia (PET) occurred prior to delivery. Glycemic control improved significantly at conception (p=0.0002) and patients remained euglycemic throughout pregnancy. Perinatal outcome was excellent. CONCLUSION: Captopril treatment before pregnancy has a prolonged protective effect on maternal-renal function during pregnancy and may result in a favorable fetal outcome.
J.L. Harris. P. Browl~ M. Bazarga~ B. Kendricksx Dqx,a l r a ~ of OB/GYN, Charles R. Drew University of Medicine and Science, Los Angeles, CA OBJECTIVE: To detmnine the i~waleax:e of Gestational Diabetes in 8ravidas with screening glucose values >200 mg/dl. STUDY DESIGN: Forty-eight of 180 gravidas with a one hour plasma glucose >200 mg/dl had a standard 3 hr GTI'. Perinatal outcome data including frequency of insulin therapy, mean birthweight, frequency of c/s and neonatal hypoglycemia were co~mred between all 180 gravidas in this group and 734 gravidas with 8estational diabetes based onan abnormal 3 hr GTr, by the appropriate statistical analysis. RESULTS: Forty-three of 48 gravidas (89.6%) tested d~lonst~ted an abnormal 3 hr GTT. Gravidas with screening values >200 mg/d had a higher frequency of insulin therapy, 56.9% vs. 44.3%, p<0.05. However, c/s rotes, mean birthweight, and frequency ofnennatal hypoglycemia was the same in both groups. CONCLUSIONS: A plasma glucose screen >200 mg/dl predicts gestational diabetes in 90% of eases. Perinatal outcome is not worsened in this group of patients.
2 5 0 NOT SO INTENSIVE TREATMENT OF INSULINREQUIRING DIABETES IN PREGNANCY. R. Krame~-, G. Gilson, L. lzqoierdo, L Curet. Dept. Ob/Gyn, Univ. of New Mexico, Albuquerque, NM Obieotive: To review the effectof not so intensive insulin t~,atment on the iocidmc~ of matenml and neonatal hypoglycemia and permatal ou~ in mothers with insulin-reqoiringdiabetesrnellitus. Study I)esi~: Charts wexereviewed for 182 consecutive pregnant women requiting insulin.The goal of dietary therapy was to avoid ketosis and to insure optimal weight gain based on BMI. P a ~ were instructed in home glt~ese mnit, mng. The ~ of therapy was to maintain fasting and 2-h(mrpo~prm~dialblood glumxmbetween 61 and 150 mg/dl. The insulin n:~im~ t~iliz©d was rcgula" insulin oao half honr before each meal with a mixtureof regularandNPHat bedtime. Patients ~ delivered at 38-40 weeks tmlass the clinical situation mandated earlier delivery. l/.esults: Mean bir(hweigh for all pregnancies was 316~±847 gin. 45 infants (24.7%) were greater than the 90th % for GA adjusted birthweight. 53 patients (29*/0) were delivered by primary cesarean socti(m. There were four casm of nematal hypoglycemia. There we~ two cases of severe maternal hypoglycemin,both of which were teated with ghcagon. Eleven women were Ueated for nxxlerate hypoglycemiawith IV D I 0. 5.4% of pregnancies were complicated by major c~ngenital anomalies . Eight infants (4.3%) died in the perinatai period. Three had lethal congenital anomalies for a coffected perinatal mortality of 2.'P/,. Contlmion: This degree of not so intensive treatment of insulinrequiring diabetic paamts resulted in neonatal morbidity which was comparable to that reported by other investigators utilizing tighter control (i.e. 2-hoor post prandial glucose < 120). Because our control criteria were less stringent than others have advocated, the incidence of maternal hypoglycemia was low. Not ua~octed~, the congenital ~aomely rate was increased whea companxl widi the gmoral population. This increased rate can be explained by the absence of precmr.epfional g ~ i c control.
ACE-I TREATMENT Of IDDM NEPHROTIC PATIENTS PRIOR TO PREGNANCY: MATERNAL-FETAL OUTCOME. M. Hod,D.J.
252
THE EFFECT OF DIABETES ON CORD BLOOD GAS AT TERM. M. Hod, O. Langer, M. McFarland, E. M-J.
Xenakis,B . ~ t t . Dept. of Ob/Gyn, UTHSC, San Antonio, TX, OBJECTIVE: To determine cord blood gas values (pH) in term n e w b o r n s of g e s t a t i o n a [ (GDM) and pregestational (PGDM) diabetic mothers. STUDY DESIGN: 2,044 consecutive deliveries were studied. Arterial cord pH was obtained at delivery, pH values less than 7.20 were considered as acidotic. Newborns were stratified according to the maternal diabetes category, actual birth w e i g h t and level of glycemic control. RESULTS: A significantly higher incidence of acidosis in PGDM was f o u n d w h e n c o m p a r e d t o GDM n e w b o r n s (28.6% vs 18.8%, p = 0 . 0 2 ) and no si~gnificant difference in the GDM group between the diet- and insulin-treated mothers. Macrosomic infants (>4000 gm) had a significantly higher incidence of acidosis when compared to the <4000 gm g r o u p (28.4% vs 18.7%, p=0.01) and LGA (22.3%) when compared to the AGA (19.5%) and SGA (17.3%) newborns, p=0.0001. Significant lower arterial cord pH levels were found in the poor control mothers (p< ,001). CONCLUSION: The severity of maternal diabetes (PGDM vs GDM) as well as the accelerated fetal growth in utero are associated with a higher incidence of newborn asphyxia at term. This observation may be related to the level of hostile metabolic intrauterine environment, hyperinsulinemia, thus l e a d i n g to diabetic fetopathy.
249
SPO Abstracts
THE PREVALENCE OF GESTATIONAL DIABETES IN GRAVIDAS WITH SCREENING GLUCOSE VALUE >200 MG/DL.
January 1995 Am J Obstet Gynecol
251
van Dyk,M. Karp,O. Kalter,J. Bar,Y. Peled,A. Erman,G. Boner,J. Ovadia, O. Langer. Bellinson Medical Center, TelAviv University, Israeland UTHSCSan Antonio, TX, OBJECTIVE: To examine the effect of pre-pregnancy treatment of diabetic, nephrotic women with Captopril (angiotensin-converting enzyme inhibitor, [ACE-I]), on maternal renal function throughout pregnancy. STUDY DESIGN: Eight insulin d e p e n d e n t diabetic (IDDM), nephrotic patients planning pregnancy were treated with Captopril for a minimum of six months prior to conception, together with intensive insulin therapy. Conception was allowed when proteinuria was <500 rag/day and euglycemia was achieved. At conception Captopril was discontinued. RESULTS: Prior to Captopril treatment, proteinuria was 1633+666 mg/day. At conception, it dropped to 273+ 146 mg/day (p=0.0000) and increased gradually over the three trimesters (593+ 515, 783 + 813 and 1,000-1-1185 mg/day, respectively; p=0.2); and was 619_+411 three months postpartum. No significant change in other renal functions (CCT, creatinine, uric acid, K+ and blood pressure) was observed. Three casesof preeclampsia (PET) occurred prior to delivery. Glycemic control improved significantly at conception (p=0.0002) and patients remained euglycemic throughout pregnancy. Perinatal outcome was excellent. CONCLUSION: Captopril treatment before pregnancy has a prolonged protective effect on maternal-renal function during pregnancy and may result in a favorable fetal outcome.
J.L. Harris. P. Browl~ M. Bazarga~ B. Kendricksx Dqx,a l r a ~ of OB/GYN, Charles R. Drew University of Medicine and Science, Los Angeles, CA OBJECTIVE: To detmnine the i~waleax:e of Gestational Diabetes in 8ravidas with screening glucose values >200 mg/dl. STUDY DESIGN: Forty-eight of 180 gravidas with a one hour plasma glucose >200 mg/dl had a standard 3 hr GTI'. Perinatal outcome data including frequency of insulin therapy, mean birthweight, frequency of c/s and neonatal hypoglycemia were co~mred between all 180 gravidas in this group and 734 gravidas with 8estational diabetes based onan abnormal 3 hr GTr, by the appropriate statistical analysis. RESULTS: Forty-three of 48 gravidas (89.6%) tested d~lonst~ted an abnormal 3 hr GTT. Gravidas with screening values >200 mg/d had a higher frequency of insulin therapy, 56.9% vs. 44.3%, p<0.05. However, c/s rotes, mean birthweight, and frequency ofnennatal hypoglycemia was the same in both groups. CONCLUSIONS: A plasma glucose screen >200 mg/dl predicts gestational diabetes in 90% of eases. Perinatal outcome is not worsened in this group of patients.
2 5 0 NOT SO INTENSIVE TREATMENT OF INSULINREQUIRING DIABETES IN PREGNANCY. R. Krame~-, G. Gilson, L. lzqoierdo, L Curet. Dept. Ob/Gyn, Univ. of New Mexico, Albuquerque, NM Obieotive: To review the effectof not so intensive insulin t~,atment on the iocidmc~ of matenml and neonatal hypoglycemia and permatal ou~ in mothers with insulin-reqoiringdiabetesrnellitus. Study I)esi~: Charts wexereviewed for 182 consecutive pregnant women requiting insulin.The goal of dietary therapy was to avoid ketosis and to insure optimal weight gain based on BMI. P a ~ were instructed in home glt~ese mnit, mng. The ~ of therapy was to maintain fasting and 2-h(mrpo~prm~dialblood glumxmbetween 61 and 150 mg/dl. The insulin n:~im~ t~iliz©d was rcgula" insulin oao half honr before each meal with a mixtureof regularandNPHat bedtime. Patients ~ delivered at 38-40 weeks tmlass the clinical situation mandated earlier delivery. l/.esults: Mean bir(hweigh for all pregnancies was 316~±847 gin. 45 infants (24.7%) were greater than the 90th % for GA adjusted birthweight. 53 patients (29*/0) were delivered by primary cesarean socti(m. There were four casm of nematal hypoglycemia. There we~ two cases of severe maternal hypoglycemin,both of which were teated with ghcagon. Eleven women were Ueated for nxxlerate hypoglycemiawith IV D I 0. 5.4% of pregnancies were complicated by major c~ngenital anomalies . Eight infants (4.3%) died in the perinatai period. Three had lethal congenital anomalies for a coffected perinatal mortality of 2.'P/,. Contlmion: This degree of not so intensive treatment of insulinrequiring diabetic paamts resulted in neonatal morbidity which was comparable to that reported by other investigators utilizing tighter control (i.e. 2-hoor post prandial glucose < 120). Because our control criteria were less stringent than others have advocated, the incidence of maternal hypoglycemia was low. Not ua~octed~, the congenital ~aomely rate was increased whea companxl widi the gmoral population. This increased rate can be explained by the absence of precmr.epfional g ~ i c control.
ACE-I TREATMENT Of IDDM NEPHROTIC PATIENTS PRIOR TO PREGNANCY: MATERNAL-FETAL OUTCOME. M. Hod,D.J.
252
THE EFFECT OF DIABETES ON CORD BLOOD GAS AT TERM. M. Hod, O. Langer, M. McFarland, E. M-J.
Xenakis,B . ~ t t . Dept. of Ob/Gyn, UTHSC, San Antonio, TX, OBJECTIVE: To determine cord blood gas values (pH) in term n e w b o r n s of g e s t a t i o n a [ (GDM) and pregestational (PGDM) diabetic mothers. STUDY DESIGN: 2,044 consecutive deliveries were studied. Arterial cord pH was obtained at delivery, pH values less than 7.20 were considered as acidotic. Newborns were stratified according to the maternal diabetes category, actual birth w e i g h t and level of glycemic control. RESULTS: A significantly higher incidence of acidosis in PGDM was f o u n d w h e n c o m p a r e d t o GDM n e w b o r n s (28.6% vs 18.8%, p = 0 . 0 2 ) and no si~gnificant difference in the GDM group between the diet- and insulin-treated mothers. Macrosomic infants (>4000 gm) had a significantly higher incidence of acidosis when compared to the <4000 gm g r o u p (28.4% vs 18.7%, p=0.01) and LGA (22.3%) when compared to the AGA (19.5%) and SGA (17.3%) newborns, p=0.0001. Significant lower arterial cord pH levels were found in the poor control mothers (p< ,001). CONCLUSION: The severity of maternal diabetes (PGDM vs GDM) as well as the accelerated fetal growth in utero are associated with a higher incidence of newborn asphyxia at term. This observation may be related to the level of hostile metabolic intrauterine environment, hyperinsulinemia, thus l e a d i n g to diabetic fetopathy.