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The significance of an elevated fasting value on the glucose tolerance test and a markedly elevated glucose challenge test in assessing pregnancy outcome
S110 SMFM Abstracts 169
December 2003 Am J Obstet Gynecol
IS SHOULDER DYSTOCIA-ASSOCIATED BRACHIAL PLEXUS PALSY MORE SEVERE AMONG INFANTS OF DIABETICS? SCOTT PETERSEN1, ROBERT ALLEN2, MICHELE DONITHAN3, PATRICIA MOORE4, LEORA ALLEN5, KATHERINE OUTLAND2, EDITH GUREWITSCH1, 1Johns Hopkins University, Gyn/Ob, Baltimore, MD 2Johns Hopkins University, Biomed Eng, Baltimore, MD 3Johns Hopkins University, Epidemiology, Baltimore, MD 4Johns Hopkins University, Gyn/Ob, Baltimore, MD 5Johns Hopkins University, Nursing, Baltimore, MD OBJECTIVE: Diabetic gravidas are at increased risk for shoulder dystocia (SD). Infants of diabetic mothers (IDM) are at risk for abnormalities of their nervous system. To test the hypothesis that among neonates with SD-associated brachial plexus palsy (BPP) permanent and severe BPP is more prevalent among IDM, we compared rates of permanent and severe BPP between IDM and nonIDM. STUDY DESIGN: Cases of SD-associated BPP culled from 2 databases (all SD deliveries [1993-2003] from a single institution and litigated cases of SDassociated permanent BPP from multiple U.S. institutions) were classified as temporary if BPP resolved by 2 yrs of age (TBPP). Permanent BPP was classified as severe if it lasted more than 2 yrs and involved the complete brachial plexus (C5-C8/T1) and/or a nerve root avulsion (SBPP). Mild permanent BPI lasted $2 yrs but did not involve the lower nerve roots or an avulsion (MBPP). NonIDM and IDM were compared for rates of permanent BPP and of SBPP, using chi-square with significance set at P < 0.05. A stepwise linear regression model was used to evaluate the effect of diabetes on permanence and severity of BPP. RESULTS: Of 218 cases of SD-associated BPP, the maternal diabetic status was known in 208 (95.4%). Of these, 56 were TBPP, 89 were MBPP, and 63 were SBPP. While macrosomia was equally prevalent among TBPP as among permanent BPP, infants with SBPP were more likely to be macrosomic than infants with TBPP or MBPP (77.2% vs 61.2%, P = 0.02). However, macrosomia was no more common among diabetics than among non-diabetics in this select population of infants with SD-associated BPP. After controlling for maternal weight and birth weight, infants of diabetics were no more likely to have either permanent or severe BPP than infants of non-diabetics. CONCLUSION: IDM with SD-associated BPP are not at increased risk for either permanent or severe BPP.
171
THE EFFECT OF DEPOT MEDROXYPROGESTERONE ACETATE ON 2HOUR GLUCOSE TOLERANCE TESTING IN POSTPARTUM GESTATIONAL DIABETES ENZIE BRISKEY1, MARY CONNELLY1, HUGH MILLER1, 1University of Arizona, Obstetrics and Gynecology, Tucson, AZ OBJECTIVE: The purpose of this study is to determine the effect of depot medroxyprogesterone acetate (DMPA) on the 2-hour postpartum (PP) oral glucose tolerance test (OGTT) in patients diagnosed with gestational diabetes (GDM). STUDY DESIGN: A retrospective multicenter cohort study encompassing 437 patients with gestational diabetes treated between 1996 and 2000. Those patients were divided into two subgroups, those who received DMPA and those who chose a non-hormonal method of contraception. The primary outcome was to compare the rate of glucose intolerance between groups. Secondary outcome measures consisted of BMI, family history of GDM, personal history of GDM in prior pregnancies, A1 and A2 GDM, gestational age at diagnosis, and birth weight to glucose intolerance. The non-hormonal and DMPA groups were compared using the 2-tailed unpaired Student’s t-test and Fisher’s exact test. RESULTS: There were 172 patients who received a postpartum OGTT who were either on DMPA or a non-hormonal method of contraception. There were 125 (73%) in the non-hormonal group and 47 (27%) in the DMPA group. Maternal age, registration BMI, delivery BMI, PP BMI, birth weight, family history of GDM, prior history of GDM, and gestational age at diagnosis of this index pregnancy were not significantly different. 4 of 73 (5%) of A1 GDM and 31/99 (31%) of the A2 GDM had abnormal PP OGTT for a RR 1.7, 95% Cl 1.45 to 2.19. 26 of 125 (20.8% of the non-hormonal group had impaired glucose tolerance, compared to 9 of 47 (19.1%) in the DMPA group (P = NS). CONCLUSION: DMPA does not influence PP glucose intolerance.
172
THE SIGNIFICANCE OF AN ELEVATED FASTING VALUE ON THE GLUCOSE TOLERANCE TEST AND A MARKEDLY ELEVATED GLUCOSE CHALLENGE TEST IN ASSESSING PREGNANCY OUTCOME WILSON QUEZADA1, DOROTHY SMOK1, GEORGE GRAHAM, III1, PATRICIA DEVINE2, 1Columbia University, Obstetrics and Gynecology, New York, NY 2 Columbia University, New York, NY OBJECTIVE: To determine if patients with gestational diabetes (GDM) and a significantly elevated glucose challenge test (GCT) or fasting value on glucose tolerance test (GTT) are at increased risk for adverse pregnancy outcome. STUDY DESIGN: A retrospective review of patients with GDM was performed. GDM was diagnosed if the GCT was >200 mg/dL, or 2 or more elevations on the GTT (fasting, 1-, 2-, and 3-hr values of 95, 180, 155, and 140, respectively). Patients were stratified into 3 groups: Group1 (fasting glucose < 95), Group 2 (fasting >95), and Group 3 (GCT >200). Chart review was performed to assess pregnancy outcome. Pregnancy outcome values included the need for insulin, birthweight, birthweight > 4000 gm, and mode of delivery. Statistical analysis was completed using the Fischer’s exact test. RESULTS: Pregnancy outcomes were reviewed for 229 patients with GDM. Comparison of the need for insulin in pregnancy, mean birthweight, birthweight > 4000 gm, and incidence of cesarean delivery revealed no statistically significant difference between the three groups. A sub-analysis comparing patients from Groups 2 and 3 (fasting > 95 or GCT > 200) with Group 1 (fasting < 95) demonstrated an increase in the incidence of birthweight > 4000 gm (18% versus 8%, P 0.071) and delivery by cesarean section (88% versus 45%, P 0.067). CONCLUSION: Pregnancies complicated by a significantly elevated GCTor an elevated fasting value on the GTT are more likely to result in a birthweight > 4000 gm and a cesarean delivery.
Table. Correlation of Diabetes with Permanence and Severity of BPP
Perm BPP SBPP
170
non-IDM (N = 167)
IDM (N = 41)
P value
94 (56.3%) 48 (28.7%)
18 (43.9%) 15 (36.6%)
0.15 0.33
A 2D-3D ULTRASOUND STUDY OF YOLK SAC IN PREGNANCIES COMPLICATED BY DIABETES MAURIZIO ANCESCHI1, ERICH COSMI2, JUAN PIAZZE1, ERMELANDO V. COSMI1, 1University of Rome La Sapienza, Inst. Gynecology, Perinatology and Child Health, Rome, Italy 2University of Sassari, Inst. Obstetrics & Gynecology, Sassari, Italy OBJECTIVE: To assess, by means of bidimensional and three-dimensional ultrasound, the diameter and the volume of the yolk sac in pregnant women affected by type 1 diabetes in the first trimester of pregnancy. STUDY DESIGN: Eighteen women affected by type 1 diabetes (IDDM) and eleven normoglycemic pregnancies as controls were considered. Pregnant women were evaluated once a week (from the 5th to 12th week of pregnancy). The ultrasound examination was initially performed in 2-D fashion with a transvaginal 6.5-MHz probe and subsequently by 3-D procedure. RESULTS: In the pregnant diabetic women, the diameter of the yolk sac overlapped that of controls in the first weeks of pregnancy; nevertheless, from the 7th-8th week, the diameter was significantly greater with a maximum diameter of 6.6 mm ,,b 0.8 (6.0 mm ,,b 0.6 in the controls) (P < .05) by 9th week, afterwards decreasing more precociously in comparison with controls. The volume of the yolk sac increased in both groups, beginning from the 5th week of pregnancy with maximum values at 10th week in the group of normal pregnancies and at 9th week in the diabetic pregnant women. CONCLUSION: The clinical and diagnostic significance of the volume of yolk sac in pregnant diabetic women is still to be defined. This determination may represent an additional tool in the monitoring of pregnant diabetic women in early pregnancy. Supported by MIUR, Italy.
Pregnancy outcome
Insulin Birthweight (gm) Birthweight > 4000 gm C/S
Fasting < 95 (n = 62)
Fasting >95 (n = 107)
GCT >200 (n = 60)
P value
54% 3367 ± 462 5% 45%
50% 3516 ± 538 19% 56%
61% 3451 ± 629 9% 32%
0.30 0.20 0.20 0.18
December 2003 Am J Obstet Gynecol
IS SHOULDER DYSTOCIA-ASSOCIATED BRACHIAL PLEXUS PALSY MORE SEVERE AMONG INFANTS OF DIABETICS? SCOTT PETERSEN1, ROBERT ALLEN2, MICHELE DONITHAN3, PATRICIA MOORE4, LEORA ALLEN5, KATHERINE OUTLAND2, EDITH GUREWITSCH1, 1Johns Hopkins University, Gyn/Ob, Baltimore, MD 2Johns Hopkins University, Biomed Eng, Baltimore, MD 3Johns Hopkins University, Epidemiology, Baltimore, MD 4Johns Hopkins University, Gyn/Ob, Baltimore, MD 5Johns Hopkins University, Nursing, Baltimore, MD OBJECTIVE: Diabetic gravidas are at increased risk for shoulder dystocia (SD). Infants of diabetic mothers (IDM) are at risk for abnormalities of their nervous system. To test the hypothesis that among neonates with SD-associated brachial plexus palsy (BPP) permanent and severe BPP is more prevalent among IDM, we compared rates of permanent and severe BPP between IDM and nonIDM. STUDY DESIGN: Cases of SD-associated BPP culled from 2 databases (all SD deliveries [1993-2003] from a single institution and litigated cases of SDassociated permanent BPP from multiple U.S. institutions) were classified as temporary if BPP resolved by 2 yrs of age (TBPP). Permanent BPP was classified as severe if it lasted more than 2 yrs and involved the complete brachial plexus (C5-C8/T1) and/or a nerve root avulsion (SBPP). Mild permanent BPI lasted $2 yrs but did not involve the lower nerve roots or an avulsion (MBPP). NonIDM and IDM were compared for rates of permanent BPP and of SBPP, using chi-square with significance set at P < 0.05. A stepwise linear regression model was used to evaluate the effect of diabetes on permanence and severity of BPP. RESULTS: Of 218 cases of SD-associated BPP, the maternal diabetic status was known in 208 (95.4%). Of these, 56 were TBPP, 89 were MBPP, and 63 were SBPP. While macrosomia was equally prevalent among TBPP as among permanent BPP, infants with SBPP were more likely to be macrosomic than infants with TBPP or MBPP (77.2% vs 61.2%, P = 0.02). However, macrosomia was no more common among diabetics than among non-diabetics in this select population of infants with SD-associated BPP. After controlling for maternal weight and birth weight, infants of diabetics were no more likely to have either permanent or severe BPP than infants of non-diabetics. CONCLUSION: IDM with SD-associated BPP are not at increased risk for either permanent or severe BPP.
171
THE EFFECT OF DEPOT MEDROXYPROGESTERONE ACETATE ON 2HOUR GLUCOSE TOLERANCE TESTING IN POSTPARTUM GESTATIONAL DIABETES ENZIE BRISKEY1, MARY CONNELLY1, HUGH MILLER1, 1University of Arizona, Obstetrics and Gynecology, Tucson, AZ OBJECTIVE: The purpose of this study is to determine the effect of depot medroxyprogesterone acetate (DMPA) on the 2-hour postpartum (PP) oral glucose tolerance test (OGTT) in patients diagnosed with gestational diabetes (GDM). STUDY DESIGN: A retrospective multicenter cohort study encompassing 437 patients with gestational diabetes treated between 1996 and 2000. Those patients were divided into two subgroups, those who received DMPA and those who chose a non-hormonal method of contraception. The primary outcome was to compare the rate of glucose intolerance between groups. Secondary outcome measures consisted of BMI, family history of GDM, personal history of GDM in prior pregnancies, A1 and A2 GDM, gestational age at diagnosis, and birth weight to glucose intolerance. The non-hormonal and DMPA groups were compared using the 2-tailed unpaired Student’s t-test and Fisher’s exact test. RESULTS: There were 172 patients who received a postpartum OGTT who were either on DMPA or a non-hormonal method of contraception. There were 125 (73%) in the non-hormonal group and 47 (27%) in the DMPA group. Maternal age, registration BMI, delivery BMI, PP BMI, birth weight, family history of GDM, prior history of GDM, and gestational age at diagnosis of this index pregnancy were not significantly different. 4 of 73 (5%) of A1 GDM and 31/99 (31%) of the A2 GDM had abnormal PP OGTT for a RR 1.7, 95% Cl 1.45 to 2.19. 26 of 125 (20.8% of the non-hormonal group had impaired glucose tolerance, compared to 9 of 47 (19.1%) in the DMPA group (P = NS). CONCLUSION: DMPA does not influence PP glucose intolerance.
172
THE SIGNIFICANCE OF AN ELEVATED FASTING VALUE ON THE GLUCOSE TOLERANCE TEST AND A MARKEDLY ELEVATED GLUCOSE CHALLENGE TEST IN ASSESSING PREGNANCY OUTCOME WILSON QUEZADA1, DOROTHY SMOK1, GEORGE GRAHAM, III1, PATRICIA DEVINE2, 1Columbia University, Obstetrics and Gynecology, New York, NY 2 Columbia University, New York, NY OBJECTIVE: To determine if patients with gestational diabetes (GDM) and a significantly elevated glucose challenge test (GCT) or fasting value on glucose tolerance test (GTT) are at increased risk for adverse pregnancy outcome. STUDY DESIGN: A retrospective review of patients with GDM was performed. GDM was diagnosed if the GCT was >200 mg/dL, or 2 or more elevations on the GTT (fasting, 1-, 2-, and 3-hr values of 95, 180, 155, and 140, respectively). Patients were stratified into 3 groups: Group1 (fasting glucose < 95), Group 2 (fasting >95), and Group 3 (GCT >200). Chart review was performed to assess pregnancy outcome. Pregnancy outcome values included the need for insulin, birthweight, birthweight > 4000 gm, and mode of delivery. Statistical analysis was completed using the Fischer’s exact test. RESULTS: Pregnancy outcomes were reviewed for 229 patients with GDM. Comparison of the need for insulin in pregnancy, mean birthweight, birthweight > 4000 gm, and incidence of cesarean delivery revealed no statistically significant difference between the three groups. A sub-analysis comparing patients from Groups 2 and 3 (fasting > 95 or GCT > 200) with Group 1 (fasting < 95) demonstrated an increase in the incidence of birthweight > 4000 gm (18% versus 8%, P 0.071) and delivery by cesarean section (88% versus 45%, P 0.067). CONCLUSION: Pregnancies complicated by a significantly elevated GCTor an elevated fasting value on the GTT are more likely to result in a birthweight > 4000 gm and a cesarean delivery.
Table. Correlation of Diabetes with Permanence and Severity of BPP
Perm BPP SBPP
170
non-IDM (N = 167)
IDM (N = 41)
P value
94 (56.3%) 48 (28.7%)
18 (43.9%) 15 (36.6%)
0.15 0.33
A 2D-3D ULTRASOUND STUDY OF YOLK SAC IN PREGNANCIES COMPLICATED BY DIABETES MAURIZIO ANCESCHI1, ERICH COSMI2, JUAN PIAZZE1, ERMELANDO V. COSMI1, 1University of Rome La Sapienza, Inst. Gynecology, Perinatology and Child Health, Rome, Italy 2University of Sassari, Inst. Obstetrics & Gynecology, Sassari, Italy OBJECTIVE: To assess, by means of bidimensional and three-dimensional ultrasound, the diameter and the volume of the yolk sac in pregnant women affected by type 1 diabetes in the first trimester of pregnancy. STUDY DESIGN: Eighteen women affected by type 1 diabetes (IDDM) and eleven normoglycemic pregnancies as controls were considered. Pregnant women were evaluated once a week (from the 5th to 12th week of pregnancy). The ultrasound examination was initially performed in 2-D fashion with a transvaginal 6.5-MHz probe and subsequently by 3-D procedure. RESULTS: In the pregnant diabetic women, the diameter of the yolk sac overlapped that of controls in the first weeks of pregnancy; nevertheless, from the 7th-8th week, the diameter was significantly greater with a maximum diameter of 6.6 mm ,,b 0.8 (6.0 mm ,,b 0.6 in the controls) (P < .05) by 9th week, afterwards decreasing more precociously in comparison with controls. The volume of the yolk sac increased in both groups, beginning from the 5th week of pregnancy with maximum values at 10th week in the group of normal pregnancies and at 9th week in the diabetic pregnant women. CONCLUSION: The clinical and diagnostic significance of the volume of yolk sac in pregnant diabetic women is still to be defined. This determination may represent an additional tool in the monitoring of pregnant diabetic women in early pregnancy. Supported by MIUR, Italy.
Pregnancy outcome
Insulin Birthweight (gm) Birthweight > 4000 gm C/S
Fasting < 95 (n = 62)
Fasting >95 (n = 107)
GCT >200 (n = 60)
P value
54% 3367 ± 462 5% 45%
50% 3516 ± 538 19% 56%
61% 3451 ± 629 9% 32%
0.30 0.20 0.20 0.18