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Gestational diabetes mellitus (GDM) is a strong predictor of glucose intolerance later in life. Former GDM (n = 145) and control (n = 41) subjects were studied 3-4 yr after the index pregnancy. They were subjected to a 75-g oral glucose tolerance test (OGTT) with measurements of insulin, C-peptide, and proinsulin in the basal state and every 30 min for 180 min. In the former GDM group, 5 subjects (3.4%) had developed non-insulin-dependent diabetes mellitus (NIDDM), and 32 (22%) had developed impaired glucose tolerance (IGT; by World Health Organization criteria). In the control group, 2 (4%) had IGT. In the GDM group, IGT or NIDDM was significantly associated with obesity (body mass index [BMI] greater than or equal to 25 kg/m2) and earlier diagnosis of GDM during pregnancy (P less than 0.001). Nonobese (BMI less than 25 kg/m2) GDM subjects with normal glucose tolerance at follow-up had significantly higher mean glucose (P less than 0.01), insulin (P less than 0.05), and proinsulin (P less than 0.001) values during the OGTT than control subjects, whereas there was no significant difference in C-peptide values. A comparison between control subjects with normal OGTT and BMI less than 25 kg/m2 (n = 39) and GDM subjects (n = 39) selected to have a comparable area under the glucose curve, BMI, and age demonstrated no group differences in glucose, C-peptide, or insulin levels, whereas the proinsulin levels were significantly higher (P less than 0.001) during the glucose load. The molar ratio between proinsulin and insulin was also significantly higher among the former GDM subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
Diabetes 1991 Dec
PMID:Follow-up of women with previous GDM. Insulin, C-peptide, and proinsulin responses to oral glucose load. 174 43

International agreement is lacking with regard to diagnostic criteria for gestational diabetes and its treatment. Consensus is not possible without agreement on the objectives in making the diagnosis. The most commonly used criteria in North America were validated by their predictive value for the subsequent development of overt diabetes in the years after affected pregnancies. The diagnosis is also deemed by many to be important as a risk factor for adverse perinatal outcome in the present pregnancy. Attempts have been made, in various parts of the world, to derive diagnostic criteria based on pregnancy outcome; unfortunately, these have not been so intensively studied as the standards cited above. There is also a lack of agreement on whether gestational diabetes should be considered a disease or merely a risk factor. In addition, consensus has not been reached on whether population-specific criteria should be used in each location or universally accepted diagnostic thresholds should be applied. Many philosophical questions remain unanswered, and numerous opportunities for investigation present themselves. Many of these are dealt with in this workshop-conference, whereas others remain as goals to be attained.
Diabetes 1991 Dec
PMID:Diagnosis of gestational diabetes. What are our objectives? 174 44

We prospectively evaluated fasting serum total cholesterol (chol), low- and high-density lipoprotein cholesterol (LDL-chol and HDL-chol), and triglycerides (TGs) in a large cohort of Hispanic women during the first 36 mo after pregnancies complicated by gestational diabetes mellitus (GDM). In 1340 women studied 6-12 wk postpartum (PP-GDM group), chol and LDL-chol were similar to levels in 43 postpartum control subjects without prior GDM. Compared with control subjects (2.01 +/- 1.24 mM), TG was elevated in the PP-GDM women with diabetes mellitus (DM) (2.86 +/- 2.21 mM, P less than 10(-5)) and impaired glucose tolerance (IGT) (2.64 +/- 1.68 mM, P = 0.02) but not in those with normal glucose tolerance (2.00 +/- 1.21 mM). HDL-chol was decreased in PP-GDM women with DM compared with those with normal glucose tolerance. A subgroup of 157 women with prior GDM returned for at least one annual follow-up test on nonhormonal contraception (FU-GDM: n = 60 at 3-11 mo after delivery, n = 78 at 12-23 mo, and n = 39 at 24-35 mo). The cumulative prevalence of DM by 36 mo was 40%. Chol or LDL-chol levels did not significantly change during the 1-yr intervals in the FU-GDM group and were similar to a control group of 36 women without prior GDM. TG was elevated and HDL-chol was decreased in the FU-GDM women with DM at 3-11 mo but not thereafter. Overall, the prevalence of moderate- and high-risk LDL-chol in the FU-GDM group was not different from that of control subjects. These findings suggest that lipid abnormalities are uncommon during the first 36 mo after delivery in women with recent GDM. The abnormalities found consisted of increased TG and decreased HDL-chol in subjects who had developed DM during the study period.
Diabetes 1991 Dec
PMID:Serum lipids within 36 mo of delivery in women with recent gestational diabetes. 174 45

Women with gestational diabetes mellitus (GDM) diagnosed in the period 1978-1984 were followed for on average 6 yr after the index pregnancy. Thirty percent had diabetes mellitus at the follow-up examination, and preliminary results indicate that at least another third will develop diabetes during a subsequent pregnancy. Therefore, family planning and contraceptive guidance should follow the lines for women with pregestational diabetes. When low-dose hormonal contraceptives containing ethinyl estradiol and levonorgestrel were given to women with previous GDM, glucose tolerance and lipoprotein levels remained unchanged during a 6-mo treatment. However, insulin response to oral glucose increased significantly after hormonal intake for 6 mo. A triphasic preparation resulted in a significantly lower insulin response than a low-dose monophasic preparation. However, the results indicate that low-dose oral-contraceptive compounds appear to be safe for women with previous GDM when administered for limited periods. At the follow-up examination, we found no increased risk of developing diabetes in women with previous GDM who used oral contraception. We consider the intrauterine contraceptives (IUD) a safe and effective alternative for women with previous GDM. Of 154 women with GDM, 33% chose IUD, 22% a combination-type oral contraceptive, and 16% barrier methods as their first choice of contraception 2 mo postpartum. We conclude that family planning and qualified contraceptive advice are important in women with previous GDM.
Diabetes 1991 Dec
PMID:Preconception counseling and contraception after gestational diabetes. 174 46

To monitor the severity of metabolic disturbances during gestational diabetes mellitus (GDM), some risk factors existing at the time of diagnosis must be considered, including age of the pregnant women, early gestational age at diagnosis, high fasting blood glucose level, high HbA1c or fructosamine levels, or high amniotic fluid insulin level. The degree of OGTT abnormality will also influence the therapeutic approach, although the insulin response to the glucose challenge seems to be of little discriminating value. Effectiveness of the treatment can be appreciated by self-monitoring of blood glucose, although the practical precision of these measures and their necessary repetitions will limit clear-cut evaluation of borderline cases. HbA1c and fructosamine are of little help because of lack of sensitivity and time delay between changes in blood glucose and associated glycosylated protein changes. Whether other parameters such as amino acids, growth factors, or related compounds are more specifically linked to the physiopathology of GDM complications remains to be established but would help in monitoring GDM metabolic disturbances in the future. Meanwhile, prophylactic insulin treatment may still constitute a pragmatic approach, taking into account possible and poorly appreciated drawbacks from overtreatment, e.g., maternal hyperinsulinism and chronic hypoglycemia.
Diabetes 1991 Dec
PMID:Monitoring the severity of metabolic disturbances and effectiveness of management of gestational diabetes mellitus. 174 49

Birth weights of infants of 35 gestational diabetic mothers treated with calorie restriction alone (1200-1800 kcal) were compared with those of infants of 2337 nondiabetic women, including two control groups (A and B) matched for race, body mass index, age, and parity. All women were screened for gestational diabetes with the O'Sullivan screening method, and a 3-h oral glucose tolerance test was performed on all abnormal results. Control group A mothers had a normal screen, and control group B mothers had an abnormal screen with a normal glucose tolerance test. Pregnancy weight gain was significantly less for the gestational diabetic mothers (mean +/- SD 4.6 +/- 4.9 kg) than for the general prenatal population (9.3 +/- 5.3 kg), group A control subjects (9.7 +/- 5.3 kg), and group B control subjects (9.7 +/- 5.4 kg; P less than 0.0005). No infant of a gestational diabetic mother was below the 10th percentile for weight, and birth weights were similar to those of the control groups even though weight gain after the 28th wk of gestation was only 1.7 +/- 1.6 kg. The frequency of macrosomia (birth weight greater than or equal to 4000 g) was similar among the gestational diabetic mothers (9.3%), the general prenatal population (7.4%), and group A mothers (11.6%) but significantly higher for the group B control subjects (20.9%; chi 2 = 8.57, P less than 0.005). This study demonstrated that gestational diabetic mothers who are calorie restricted have infants with normal birth weights and a frequency of macrosomia less than that of screen-positive nondiabetic women with similar macrosomic risk factors.
Diabetes 1991 Dec
PMID:Calorie restriction for treatment of gestational diabetes. 174 50

Although hypocaloric diets have been advocated for the management of the obese gravida and the obese mother with gestational diabetes, there is no general agreement on how severely calories should be restricted or on how this therapeutic approach compares with insulin therapy. The lack of consensus is in part because of the lack of studies comparing insulin management with the effects of different degrees of hypocaloric feeding and its effects on metabolism and glycemic status. We review the effects of 50 and 33% calorie restriction on glycemic status and intermediary fuel status in obese gestational diabetic subjects and compare the results with the administration of 20 U NPH and 10 U regular insulin every morning, a therapy of proven value in reducing macrosomia in gestational diabetes. When the two calorie-restriction regimens were compared after a 9-h overnight fast, glycemic status improved 10-20% on both. Ketonuria increased about twofold with 50% calorie restriction, but on average no increase in ketonuria was seen on the 33% calorie-restriction regimen. Both calorie-restriction programs led to a reduction in levels of plasma triglyceride, a correlate of infant birth weight. In contrast, the insulin regimen diminished ketonuria, but glycemic status improved little, and plasma triglyceride concentrations did not decline. Although more studies are needed to confirm these trends, the beneficial effect of 33% calorie restriction, which occurred without marked ketonuria, is consistent with previous studies in gestational diabetes. In addition, the simultaneous improvements observed in plasma glucose and triglyceride concentrations suggest that moderate calorie restriction may be valuable in preventing macrosomia in the offspring of the obese subject with gestational diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)
Diabetes 1991 Dec
PMID:Metabolic effects of hypocaloric diets in management of gestational diabetes. 174 51

We studied the relationship between 1-h glucose response and the percentage of carbohydrates in a given meal in 14 gestational diabetic women who did not require insulin therapy and were between 32 and 36 wk gestation. Each subject was greater than 130% ideal body weight and was placed on a diet of 24 kcal.kg-1.24 h-1, with 12.5% of calories at breakfast and 28% of the calories at lunch and again at dinner, with other calorie intake divided among three snacks. Glycemic response was monitored by self-monitoring of blood glucose 1 h after the start of each meal. Ten postprandial values for each meal were averaged for each of the 14 women. The correlation between percentage of carbohydrates and postprandial glucose level at 1 h was strongest for dinner (r = 0.95, P less than 0.001), with more variability seen at breakfast (r = 0.75, P = 0.002) and lunch (r = 0.86, P = 0.001). To maintain a 1-h postprandial whole-blood glucose level less than 7.78 mM required the following percentages of carbohydrates in each meal: 45% at breakfast, 55% at lunch, and 50% at dinner. If 1-h postprandial whole-blood glucose level was to remain less than 6.67 mM, then the respective values were 33, 45, and 40%. We conclude that the glycemic response to a mixed meal in subjects with gestational diabetes is highly correlated with the percentage of carbohydrates of the ingested meal and varies among individuals and among breakfast, lunch, and dinner.(ABSTRACT TRUNCATED AT 250 WORDS)
Diabetes 1991 Dec
PMID:Percentage of carbohydrate and glycemic response to breakfast, lunch, and dinner in women with gestational diabetes. 174 52

Physical training is associated with lower plasma insulin concentrations and increased sensitivity to insulin in skeletal muscle and adipose tissue of individuals with non-insulin-dependent diabetes mellitus (NIDDM). The benefits of exercise to individuals with NIDDM in terms of increased insulin sensitivity could be applied to reversing the insulin resistance associated with gestational diabetes mellitus (GDM). Exercise may also benefit women with GDM by acting as an adjunct to diet in preventing excessive weight gain and preventing or decreasing the severity of hypertension and/or hyperlipidemia during pregnancy. Regular physical exercise should be considered as a potential approach to the prevention and treatment of GDM.
Diabetes 1991 Dec
PMID:Exercise in the treatment of NIDDM. Applications for GDM? 174 53

The mainstay of management of the gestational diabetic woman is dietary manipulation to achieve and maintain normoglycemia. If normoglycemia cannot be sustained by diet alone, then insulin therapy is initiated. We instituted a series of studies to observe the value and safety of a cardiovascular fitness program to improve glucose tolerance in gestational diabetic women. We first evaluated the safety for pregnant women of five aerobic exercise machines by observing the effect of these different forms of exercise on uterine activity during the third trimester. We found that upper-extremity exercise produced no uterine contractions, but lower-extremity exercise tended to produce contractions. Upper-extremity exercise, in addition to dietary therapy, was then assigned to 10 gestational diabetic women who were matched for amount of glucose intolerance to 10 gestational diabetic women managed by diet alone. The mean fasting plasma glucose +/- SD after 6 wk was 4.87 +/- 0.34 mM in the diet group versus 3.89 +/- 0.37 mM in the diet-plus-exercise group. The mean postglucose challenge in the diet group was 10.40 +/- 0.16 mM versus 5.9 +/- 1.1 mM in the diet-plus-exercise group. Thus, upper-arm exercise may provide a useful treatment option for gestational diabetes and may obviate the need for insulin.
Diabetes 1991 Dec
PMID:Is exercise safe or useful for gestational diabetic women? 174 54


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