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Perinatal morbidity and mortality are known to be higher for the macrosomic neonate whose birth weight is 4500 g or more, compared with that of appropriate-weight term-size neonates. In a retrospective study comparing 287 macrosomic neonates with 284 appropriate-weight term-size neonates, we found that macrosomia occurred in 1.3% of our annual deliveries, with a male-to-female ratio of 2.3:1. Factors that occurred significantly more frequently in the mothers of macrosomic infants were maternal obesity, multiparity, diabetes mellitus, and previous delivery of an infant heavier than 4000 g. During the intrapartum period the incidence of labor augmentation by oxytocin, shoulder dystocia, and cesarean section was significantly greater in fetal macrosomia. Most significantly, this study revealed that macrosomia. Most significantly, this study revealed that macrosomic fetuses do not experience greater fetal distress in biophysically monitored labor than appropriate-weight term-size fetuses. Twenty-nine (10%) of the macrosomic infants required admission to the neonatal intensive care unit (NICU) compared to 9 (3%) of the control patients (P less than 0.01). This excess neonatal morbidity in the macrosomic neonates was predominantly caused by the delivery process.
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PMID:Macrosomia--maternal, fetal, and neonatal implications. 736 96

Gestational diabetes mellitus (GDM) is associated with an increased rate of fetal macrosomia. We describe the outcome of two pregnancies complicated by GDM occurring 2 years apart in a normal-weight woman. Despite adequate maternal blood glucose control during gestation, both infants were markedly oversized at birth (birth weight and length exceeded normal means by 3 and 2 S.D., respectively). The placental weights were far above normal. At birth, the siblings shared the typical appearance of a diabetes fetopathy. The first one developed transient, the second persistent neonatal hypoglycemia associated with hyperinsulinemia, that needed treatment with diazoxide for 2.5 months. Both infants normalized their growth rates during the following months; their psychomotor development assessed at 2 years and at 9 months of age, respectively, was normal. During the last trimester of the second pregnancy, the plasma concentration of placental lactogen (PL) increased to a very high level (19 micrograms/l). The maternal early insulin response to glucose increased significantly with gestation and was much above that in the non-pregnant state. This rise in insulin response could not compensate for the concomitant decrease in insulin sensitivity as assessed by the minimal model according to Bergman [2]. The pronounced fetal macrosomia described cannot be attributed to GDM only. We speculate that excess activity of lactogenic hormones like PL beside glucose contribute to exaggerated fetal beta-cell function with growth acceleration and neonatal hypoglycemia. This hypothesis is in accordance with in vitro evidence indicating that PL may have an important role in the regulation of the maternal and fetal beta-cell mass and function.
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PMID:Gestational diabetes mellitus and paradoxical fetal macrosomia--a case report. 763 72

We previously detected immunoreactive fibroblast growth factor 2 (FGF-2) in maternal and fetal circulations. Here, we determined whether the amounts of FGF-2 in term maternal serum, cord serum, and amniotic fluid were altered in pregnancies complicated by diabetes, as these are associated with a higher incidence of fetal macrosomia and increased placental size. Serum and amniotic fluid were collected at term from normal pregnancies (n = 17), women with pregestational insulin-dependent diabetes (n = 37; group A), patients with previously undiagnosed diabetes (n = 32; group B), women with gestational diabetes (n = 85; group C), and women with a milder form of glucose intolerance in pregnancy (n = 16; group D). Mean newborn weight and length, and placental weight did not significantly differ between normal and diabetic pregnancies, although the placental weight tended to be higher in the latter. However, 24% of the infants in group A and 19% in group B had a birth weight in excess of the 90th percentile. Levels of insulin in cord serum and amniotic fluid in groups A and B were significantly elevated compared to control values. FGF-2 was extracted from serum and amniotic fluid by heparin-Sepharose affinity chromatography and subjected to Western blot analysis or quantified by specific RIA. Western blot analysis of maternal serum, cord serum, and amniotic fluid from diabetic pregnant patients revealed, in each case, a single immunoreactive FGF-2 species of 18 kilodaltons; this was absent from nonpregnancy serum. In normal term pregnancies, the mean immunoreactive FGF-2 level in cord serum was 119 +/- 28 pmol/L, and that in amniotic fluid was 91 +/- 35 pmol/L. Values were significantly increased (2- to 4-fold) in both cord serum and amniotic fluid for all groups of diabetic patients. The mean FGF-2 level in normal term maternal serum was 104 +/- 24 pmol/L, and this was significantly increased in diabetic patients in groups B and C. The amount of FGF-2 in maternal serum showed a positive correlation with newborn weight and length, and placental weight (P < 0.05 or better, by Spearman rank correlation), and significant positive correlations also existed between the amounts of FGF-2 in cord serum and newborn or placental weight. The results suggest that the FGF-2 levels in maternal serum, cord serum, and amniotic fluid at term are elevated in pregnancies complicated by diabetes, and that the amounts of FGF-2 in maternal serum and cord serum are correlated with fetal and placental size.
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PMID:Fibroblast growth factor 2 is elevated in term maternal and cord serum and amniotic fluid in pregnancies complicated by diabetes: relationship to fetal and placental size. 767 5

In insulin-dependent diabetes mellitus, maternal Phosphoglucomutase genotype is a predictor of fetal macrosomia much more important than quality of metabolic control during pregnancy. In gestational diabetes and in non insulin-dependent diabetes, on the contrary, the most important predictor is the metabolic control of diabetes.
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PMID:Genetic and non genetic factors in the outcome of diabetic pregnancy. 779 Oct 12

Severe and mild deformations in newborn infants of insulin dependent diabetic mothers (IDDMs) and control mothers were evaluated with respect to the types of anomalies and previously hypothesized constraint factors. Factors evaluated were gestational length, birth weight, corrected birth weight for gestation (weight ratio), maternal height and parity, and severe deformations. Newborn infants from 81 control and 133 insulin dependent diabetic pregnancies were recruited periconceptually as part of a larger study of diabetes in early pregnancy. Examinations were done at 48 to 72 hours of life by one examiner blinded to maternal status using a checklist of major and minor deformations and malformations. Mild deformations were found to be common and were present in 84% of newborn infants. Severe deformations occurred in three (1.4%) IDMs, with two of three newborn infants having major malformations involving the CNS and/or musculoskeletal system which affected fetal movement. There was no significant difference between IDMs and control newborn infants with respect to the number with deformations; however, fetal macrosomia was not present in study participants. Using the entire cohort, a significantly greater number of deformations were present in newborn infants with a gestation > 36 weeks (P < 0.001), birth weight > 3,000 g (P < 0.001), and weight ratio > or = 1.2 (P = 0.05). There was no significant association with primiparous mothers or women with a height < 165 cm and the presence of deformations. For gestational age and birth weight, mild deformations were apparent only after 33 weeks gestation (P << 0.001) and/or birth weights of 2.0 kg or more (P << 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Deformations in infants of diabetic and control pregnancies. 785 54

Fifty gram oral glucose challenge test (50g GCT) was performed, as a screening test of diabetes mellitus (DM), in 289 pregnant women, and further, a 75g oral glucose tolerance test (OGTT) was done in those women with glucose level > 7.78 mmol/L. The results showed that 49 women had a glucose level > 7.78 mmol/L (16.96%), among whom 15 (5.19%) were identified as having gestational impaired glucose tolerance (GIGT), and 5 (1.73%) had gestational diabetes mellitus (GDM) as diagnosed by 75g OGTT. The prevalence of PIH, premature rupture of membrane, fetal macrosomia, cesarean section, perinatal morbidity were higher in GIGT and GDM mothers and there was a positive correlation between glucose level of 50g GCT and the birth weight of newborns. It suggested that 50g GCT may be a preferable screening test for GDM since it is simple and cheap with high sensitivity and specificity.
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PMID:[Carbohydrate intolerance and pregnancy outcome]. 808 28

Diabetes mellitus with its resulting derangement of various metabolic fuels, carbohydrates, amino acids, lipids, and ketones has the potential to adversely affect the developing fetus. Therefore, strict glycemic control in pregnancy has become the standard of care in modern obstetrics. A considerable amount of research has been undertaken into the metabolic changes that occur during pregnancy in both women with insulin-dependent diabetes and gestational diabetes. This paper will review current research in normal and diabetic pregnancies both in the fasting and fed states as well as during episodes of hypoglycemia. In normal pregnancy insulin secretion increases throughout gestation whereas peripheral insulin sensitivity is decreased. Fasting levels of plasma glucose are reduced by approximately 10 per cent during the first trimester. Maternal amino acid levels are also reduced in normal pregnancy, although cholesterol and triglyceride levels are increased, most dramatically in the second trimester. As gestation advances, progressively increasing amounts of insulin antagonistic hormones are secreted by the placenta. This leads to gestational diabetes in 2 to 3 per cent of women who exhibit hyperglycemia despite an increased insulin response to oral glucose as well as an increased insulin/glucagon ratio. In insulin dependent diabetes mellitus, the insulin-deficient state results in fasting and postprandial hyperaminoacidemia, hyperlipidemia, and hyperglycemia. These metabolic changes and the resulting hyperglycemic milieu can lead to fetal macrosomia that will result in maternal and fetal morbidity. Therefore, normalization of these fuels with the use of intensive insulin regimens is the goal of therapy during pregnancy.
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PMID:Metabolic changes in diabetic and nondiabetic subjects during pregnancy. 813 54

Amniotic fluid insulin levels were estimated in 30 women with insulin-dependent diabetes, 216 with gestational diabetes and 27 with normal glucose tolerance. Results were correlated with birth-weight, incidences of fetal macrosomia and neonatal hypoglycaemia, and the risk of the mothers with gestational diabetes developing diabetes mellitus on follow-up. The women with prepregnancy diabetes had significantly higher amniotic fluid insulin values and showed a significant correlation between raised liquor insulin values (> 97th percentile) and hypoglycaemia in the infant (p = 0.039). In the gestational diabetic pregnancies there were highly significant associations between elevated liquor insulin values and macrosomia (p < 0.0045) and birth-weight (p < 0.00004), and a weak correlation with neonatal blood glucose levels (p = 0.042). Women with gestational diabetes who later developed permanent diabetes mellitus had higher mean amniotic fluid insulin levels than those whose glucose tolerance remained normal on follow-up (p < or = 0.0072) and more of them had a level greater than the 97th percentile than those whose glucose tolerance remained normal (odds ratio 6.48, 95% confidence interval 1.51-27.8, p = 0.0094). However a high amniotic fluid insulin level was of less clinical value for detection of women destined to develop diabetes (7 of 25, 28%) than was the need for insulin therapy during pregnancy (18 of 39, 46%).
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PMID:Amniotic fluid insulin values in women with gestational diabetes as a predictor of emerging diabetes mellitus. 817 40

Gestational diabetes is associated with an increased risk of fetal macrosomia and perinatal death. Immigrant mothers from Vietnam who delivered in the Mercy Hospital for Women between January 1, 1979 and December 31, 1990 were investigated to assess their risk of gestational diabetes, the factors that were associated with gestational diabetes, and the prevalence of diabetes mellitus on follow-up. These mothers were compared with Australian-born mothers attending the same hospital and who delivered in the same period. Using a logistic regression model, gestational diabetes was found to be more common in Vietnam-born mothers who were older, who were primigravidas, or were underweight and the risk of gestational diabetes increased over the time period of the study. The adjusted relative risk of gestational diabetes for Vietnam-born women was 1.43 (95% confidence limits 1.10, 1.86) compared with Australian-born women. The incidence of gestational diabetes was 7.8% (144 of 1,839) in Vietnam-born mothers and 4.3% (1,173 of 27,086) in Australian-born mothers. Vietnam-born mothers also had a greater risk of diabetes mellitus on follow-up; 25% (17 of 68) of those with follow-up testing had developed diabetes mellitus within 9 years of diagnosis of gestational diabetes, in comparison with an incidence of 9% (52 of 581) of Australian-born mothers with follow-up testing. Vietnam-born mothers should have glucose tolerance testing performed during pregnancy to detect gestational diabetes and those diagnosed should have long-term follow-up to detect the development of diabetes mellitus.
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PMID:Gestational diabetes and follow-up among immigrant Vietnam-born women. 821 3

Maternal diabetes mellitus is complicated by fetal macrosomia and predisposes the offspring to diabetes, but recent evidence indicates that a low, not high, birthweight is associated with a higher incidence of Type 2 (non-insulin dependent) diabetes in adult life. To clarify the relationships between maternal glucose and insulin levels and birthweight, we measured oral glucose tolerance and neonatal weight in a large group (n = 529) of women during the 26th week of pregnancy. Women with gestational diabetes (n = 17) had more familial diabetes, higher pre-pregnancy body weight, and tended to have large-for-gestational-age babies. In contrast, women with essential hypertension (n = 10) gave birth to significantly (p < 0.01) smaller babies. In the normal group (without gestational diabetes or hypertension, n = 503), maternal body weight before pregnancy and at term, maternal height, week of delivery, gender of the newborn, and parity were all significant, independent predictors of birthweight, together explaining 23% of the variability of neonatal weight. In addition, both fasting (p < 0.006) and 2-h post-glucose (p = 0.03) maternal plasma glucose concentrations were positively associated with birthweight independent of the other physiological determinants, accounting, however, for only 10% of the explained variability. In a subgroup of 134 normal mothers with pre-pregnancy body mass index of less than 25 kg.m-2, in whom plasma insulin measurements were available, the insulin area-under-curve was inversely related to birthweight (p < 0.02) after simultaneously adjusting for physiological factors and glucose area.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Relation of birthweight to maternal plasma glucose and insulin concentrations during normal pregnancy. 830 62


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