Rigid blood glucose control in pregnant diabetic women

234

Correspondence

\~ander.

entitlecl

(h. thors

matle

Ictal

monitoring

internal

I. Mewr. weighr

M.

XI\ B.: How

does maternal

matertd

weight

smoking gain?

AM.

aft&t birth ,J. ()HSTE.I.

131:x88, 1$)7x. B.: RepI) ICI Dr. Rush. A&r. ,J. ORsrEr. (;YNECOI.. 135:282, 197!). Rush. D.: Examinariorr of the relationship berween birrlrweight, cigarette smoking during pregnancy and mater11a1 weight gain, Br. J. Obstet. Gvnaecol. 81:746. 197-I. Rush. D.: Effects of’ smoking on pregnant> and newborn infants, AM. J. ORSTL’I. ~YNECOI.. 135:281, 197!). Davies, D. P.. GIGI)-. 0. I’., Ellwood, P. C:.. and Ahernethv. M.: Cigarette smoking in pregnant), association with maternal bvcight gain and f’eral growth. Lancer 1:3X. 1976. Ontario Perinatal Mortality Study Committee: Second Report of the Perinatal Mot-taliq Stud) in Ten L’niversi> Teaching Hospitala, Ontario. Canada, Toronto. IO6 I. ‘The Ontar-io Department of Health. Rttsh, D., and l&s, E. f1.: Marernal smoking: A ~a\wssment of the association with perinatal morrality, Am. .J. Epidemiol. 96: 183. 11172. Mever. M. B.. ‘Tonascia, J. A.. and Buck. <:.: .The interrrIationship ot maternal smoking and inct-cased perinatal mortality with other t-isk thctors. Further analysis of the OntaCo Perinatal Mortalitv Study. 196Ob 196 I, Am. J. Epiderniol. 100:443, lYi-,. Mewr-. M. B., Jonas. B. S.. and Tonascia. J. .A.: Perinatal (‘\ents associated with maternal smoking during pregnanny, Am. J, Epidemiol. 103:464, 1976. Rush. I)., Stein, %., and Susser. $1.: A randomized controlled trial of. prenatal nutritional supplemenration in New York City, Pediatrics 65:683. 1980. Ru41. D.. Stein. Z., and Susser. M.: Diet in Pregnancy: A Randomized Controlled Trial of Nutritional Supplements, Ne\G York. 19X0, Alan R. Lisa. (;\I’NECOL..

Meyer.

1. .i.

6.

7.

x.

Cl.

10.

11.

hl.

External versus 7‘0 thr Editon : 1 find Discukon

it

that

o~vii

to wction

Ix

internal

ing,

he

of

disturbing the

arricle

to

b!

Iar-n

Hacsslcin

for

in and

the Nis-

IIac-sslcin

but

monitoring I ii-tile

of

its

1121 electronic ;is

being

of

alid

the 1 find

cncc’s clifl’erenw

in fetal

inakr

;I lLx

some

tliscriniinating

that

f’ull

hcnefit

~nan\

of

1wi.e

of the

obtained

thP

As blood

both false

ester-

;~iidyxd reassurance applicarion

lx~soii;~l

and

interiial

clecI ~vould

reported

thcrr thy

patients

during f’alse

be

clrcii-onic from

many

aid

experi-

writrad

Thcrefort*.

csternal

modalitits positive

an

that

of.

that

that lxen

versus

isc~latrtl.

the

b\ minimal

shai-p

studies

realization

fetal

upon In\

tlrscril)tioli3

segregating with

times

I’ol-

cxtrrrial

are

Ironic

;d has

that

f’utuic

;IIIS-

electrode.

potential iii

in

elec

have

sc-alp

believe

monitoring

niotiitoring the

to the

diagnosis

tronic

t> lx,

to

, by

is equally

ati)renierltioneti

I-~versetl fetal

it clitfidt c otic-crriing

direct. the

11.acing

onI\

internal

obscrmonitor-

in labor.

a1.c thy

nionitk

disquietingly.

direct

aiid

5vlisitivit?,

reassuring,

rapidly,

or to

Man\

fttal

the

in tlcwrib

oi- hrirnanl~

precision.

or l’oi-

esterIi;kl

patieiits

internal.

by xrtitact.

influeiic-c

(indirect)

csternal

that

superioi-

;111-

electronic

esperience

electi-onic;dlv

far

the

the

tracing.

clinicxl

pregnant

ic5”

that

specified

\v;3\

hex3

to concl~itlc

that

is

pi-egrianc

l t)8()), esternal

ti-aciiiq

me

trrni

cone neyyitivv

tktal iiittwial ma\

li;lvc

l~~bor.

Ho\\

Ii x ing

externalI\?

Rigid blood women only

c-itha

Dr.

it perf’wnietl

hcnrficial.

7‘0

very

was

when

~~iicrmtrolletl

c ultatioti.

fetal monitoring

(F.FM)

fetal let1

tuni

2-l.i.

as IO whether-

a monitor

ha\e

in

l :ci:

distinction

;i niistliagrioscd

\kitioru

and

no

tirnr

ing

clibtrc55

(;YNEC:OI..

(direct),

first

REFERENCES

“Fetal

,J. ~)BSlT’l’.

glucose

control

in pregnant

diabetic

I:‘d;tO,:\:

w sugar

haw

wine control

to iii

i-ecogni~t: insulin-del,endent

the

baluc

of diabetic-

tight pa-

Correspondence

ticllts during pregnarlcy, we are reminded by and colleag~~es’ that perhaps such rigid control ncc-ess;i~~) loi- a successful perinatal outcome.

Leveno is unIn my opitlioll, thih ma)’ be appealing, but upon more detailed 0bwr\ ation and analysis. it may not be as cost effective as c,lIe would think. Liberal and prolonged hospitalizatiotls in most cases may not be cost effective if one looks at the cc>mplications, some of cvhich may be monitored and a\c~ted on an outpatient basis. This is especially trtle 1, l~cn one considers that intensive monitoring, such a, estriol and the nonstress test, was not essential ;untl WI, not part of their protocol. Indeed, one ma) attempt. in IveIl-selected and highly motivated patients. tigllt colitrol and close monitoring at minimal costs. In t\\ o sttrtlic\. one !‘rom Texas’ and one from Italy,’ the aut hol.c ;I( hieved good results. These studies are simiIal- in ttlat tlley did not require highly sophisticated monitor-ing techniques. They are also similar in that little Ilosl’italization initially (2 to ~3 days) \vas needed antI a nwre prolonged period (4 to 6 weeks) was reqmred prior to deli\erv. I wonder if Iiospitalization. which was liberal in both of thrsc series, wo~~ld be enough to achieve good results. 111 the series from Italy it was emphasized that the insulin requirements were well established and spontaneow labor was anticipated. The study from Texas crnl)ha
235

rigid control will prevent many complications and this in turn may hopefully lead to an improved quality of babies. Perhaps one ought not to-judge success by such a crude measurement as the mortality rate bul rathel by the quality of the survivors. I invite comments from authors as well as from other concerned investigators regarding the trencl in IMJIagement of pregnant diabetic patients as it concerns the degree of blood sugar control and the intcnsit); of fetal surveillance so that we may explore the limits and direction in which we are moving. 0b.ttrtric.t

und

Gywrolog~

Matrmal-Fetal Medirine Lutheran General Hovf,itcll I775 Dunper Street Pork Ridge, Illinois (70068

REFERENCES

Leveno. K. J., Hauth, J. C., Gilstrap, L. C., 111, and WhalIcy. P. J,: Appraisal of “rigid” blood glucose control during pregnancy in the overtly diabetic woman, AM. J. OBSTET. GYNEC~L. 135:853. 1979. Roversi, G. D., Gargiulo, M., Nicolini. U.. et al.: A new approarh to the treatment of diabetic pregnant women, AM. J, OBSTET. GYNECOL. 135:567, 1979.

Reply to Dr. Semchyshyn To the Editors:

Dr. Semchyshyn correctly points out that extensive hospitalization was an important factor in ac-hieving successful pregnancy for our patients. We must emphasize that our liberal use of hospitalization was in part for the purpose of improving glucose control according to the prevailing national trend in this direcin well-selected and high11 tion. Unquestionably. “. motivated patients .” ambulatory management can be successful. The patient population at Parkland Memorial Hospital is primarily indigent and we find that in-hospital management most dependably provides our patients with the care they need. Dr. Semchyshyn suggests use of antepartum electronic and hormonal tests of fetal-placental condition as a replacement for prolonged hospitalization. He also suggests that these tests may be useful in preventing preterm delivery and the associated neonatal complications of prematurity. We agree that certain neonatal complications are the result of preterm delivery. It is impossible for 11s to address directly the role of’ stress tests and estriol measurements in preventing preterm delivery since we did not use these methods of fetal surveillance. In a report by Gabbe and associates,’ antepartum testing permitted SSs of women to be delivered beyond 38 lveeks of gestation. However, as