Background: Women with gestational diabetes mellitus are rarely treated with a sulfonylurea drug, because of concern about teratogenicity and neonatal hypoglycemia. There is little information about the efficacy of these drugs in this group of women. Methods: We studied 404 women with singleton pregnancies and gestational diabetes that required treatment. The women were randomly assigned be- tween 11 and 33 weeks of gestation to receive gly- buride or insulin according to an intensified treatment protocol. The primary endpoint was achievement of the desired level of glycemic control. Secondary endpoints included maternal and neonatal complications. Results: The mean (±SD) pretreatment blood glucose concentration as measured at home for one week was 114±19 mg per deciliter (6.4±1.1 mmol per liter) in the glyburide group and 116±22 mg per deciliter (6.5±1.2 mmol per liter) in the insulin group (P=0.33). The mean concentrations during treatment were 105± 16 mg per deciliter (5.9±0.9 mmol per liter) in the glyburide group and 105±18 mg per deciliter (5.9±1.0 mmol per liter) in the insulin group (P=0.99). Eight women in the glyburide group (4 percent) required insulin therapy. There were no significant differences between the glyburide and insulin groups in the percentage of infants who were large for gestational age (12 percent and 13 percent, respectively); who had macrosomia, defined as a birth weight of 4000 g or more (7 percent and 4 percent); who had lung complications (8 percent and 6 percent); who had hypoglycemia (9 percent and 6 percent); who were admitted to a neonatal intensive care unit (6 percent and 7 percent); or who had fetal anomalies (2 percent and 2 percent). The cord-serum insulin concentrations were similar in the two groups, and glyburide was not detected in the cord serum of any infant in the glyburide group. Conclusion : In women with gestational diabetes, glyburide is a clinically effective alternative to insulin therapy

The obesity and diabetes epidemic is an unintended consequence of economic, social, and technological changes. In nonpregnancy, people identified as high risk to develop type 2 diabetes may delay progression by 30-70% with lifestyle interventions and pharmacological agents. In pregnancy, lifestyle interventions have been the primary focus to prevent fetal short- and long-term complications that may evolve into substantial weight gain and gestational diabetes mellitus. The dilemma for obstetricians is whether diabetes and obesity can be prevented and not simply treated after the fact. Interventions after women become pregnant may be too late to see the kinds of meaningful improvements in child and maternal health because there is a short interval from gestational diabetes mellitus diagnosis to delivery. Therefore, future efforts need to incorporate quality research, lifestyle interventions that designate time of initiation and duration during pregnancy, the preventative intervention of a prepregnant "fourth trimester," coupled with the concept of precision medicine so that there is the potential to make the impossible dream a reality.

Abstract Objective: To evaluate treatment effectiveness (diet alone, insulin or glyburide) on maternal weight gain in gestational diabetes (GDM). Methods: GDM patients were treated with diet alone, insulin or glyburide. Weight gain was stratified into: prior to GDM diagnosis, from diagnosis to delivery and total pregnancy weight gain. Good glycemic control was defined as mean blood glucose ≤105 mg/dl and obesity as Body Mass Index (BMI) ≥ 30 kg/m2, overweight BMI 25–29 kg/m2 and normal < 25 kg/m2. Results: Total weight gain was similar in all the treatment groups. Two-thirds of weight gain occurred prior to diagnosis (diet 85%, insulin 67% and glyburide 78%). Post-diagnosis, patients on diet alone gained less weight than those on insulin or glyburide (p < 0.001); insulin-treated patients showed greater weight gain than glyburide-treated patients (p < 0.001). Patients on diet with good glycemic control showed less weight gain after diagnosis than patients on insulin or glyburide (2.8 ± 13, 6.6 ± 10, 5.2 ± 7.9 lbs, respectively, p < 0.02). Poorly-controlled patients, regardless of treatment, had similar patterns of weight gain throughout pregnancy. Conclusion: Patterns of maternal weight gain in GDM pregnancies are associated with treatment modality and level of glycemic control.

OBJECTIVE:To determine if tobacco use increases the incidence of preterm premature rupture of the membranes (pPROM) or alters perinatal outcomes after pPROM.STUDY DESIGN:This is a secondary analysis of the databases of three completed Eunice Kennedy Shriver National Institute of Child Health and Human Development-supported Maternal Fetal Medicine Units Network studies. Self-reported tobacco exposure data was obtained. Its relationship with the incidence of pPROM and associated neonatal outcome measures were assessed.RESULTS:There was no difference in the incidence of pPROM when comparing nonsmokers to those using tobacco. Although a trend was seen between the incidence of pPROM and the amount smoked, this did not reach statistical significance. Among the patients with pPROM, the use of tobacco was not associated with an increase in perinatal morbidity.CONCLUSION:Our data do not support a significant relationship between tobacco use and pPROM.

To date, The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria for the diagnosis of gestational diabetes mellitus (GDM) have not been analyzed systematically for medical, social, and economic ramifications if used in substitution for the current GDM diagnostic criteria. The IADPSG dependence on expert opinion and consensus rather than on rigorously obtained outcome measures is concerning given the dramatic changes in clinical intervention and medical-resource reallocation that would follow their wide adoption. This commentary attempts to highlight needed research as well as the key knowledge gaps that should prevent adoption of the revised criteria until their effect on perinatal outcomes and health care costs is determined. In light of the overall, ethnic, and regional variation in GDM prevalence and the demands of increased GDM diagnosis on clinical resources, it may not be realistic and practical to impose universal strategies and standards for diagnosis. The newly proposed criteria may affect medical care negatively, unnecessarily stigmatize patients with a "sick label," and adversely affect health care costs without ensuring the desired improvements in maternal and neonatal outcomes. This commentary serves as a caution to not promote a new endeavor until it has been compared rigorously with current practice and its implications are understood fully.

The new criteria for diagnosis of gestational diabetes mellitus proposed by the International Association of Diabetes in Pregnancy Study Group (IADPSG) transports back the controversy and the lack of agreement to the frontlines. The recommended criteria are based on results of the observational hyperglycemia and adverse pregnancy outcome study (HAPO). These criteria will increase the frequency of gestational diabetes diagnosis by 2–8 folds, depending upon ethnicity, and prevalence of obesity. Do the costs and implied resources justify using the proposed endpoints that will define pregnancy outcome and severity especially when the appropriate outcomes and odds ratio used to define the diagnosis are questionable? Furthermore, due to the large disparity around the globe in relation to the prevalence of gestational diabetes raises the question if single diagnostic criteria can be made to fit all?!? The current review analyzes the risks, costs and benefits that may influence the rate of gestational diabetes in relation to the worldwide prevalence.

ObjectiveInsulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnant women. The purpose of this study is to describe our experience with ID compared to NPH in pregnancy.Study DesignThis is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. Patients were instructed to check glucose levels 4-7 times a day with the fasting glucose target set at 60-90mg/dL and the 2-hours post-prandial target set at <120mg/dL. Glucose control and outcome of pregnancy were compared between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Statistical analysis was performed using Chi-square and Student's t-test, as appropriate.ResultsThe study included 60 women: 30 were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean glucose concentrations, percent values within targets, rates of hyperglycemia and hypoglycemia, birthweight, rates of LGA and macrosomia are presented in the table.Tabled 1ConclusionInsulin Detemir does not appear to have any advantage over NPH with respect to glucose control, maternal hypoglycemia and birth weight in pregnant women with diabetes. ObjectiveInsulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnant women. The purpose of this study is to describe our experience with ID compared to NPH in pregnancy. Insulin Detemir (ID) is a long-acting insulin analogue widely used in the treatment of diabetes, but there are no published data on its use in pregnant women. The purpose of this study is to describe our experience with ID compared to NPH in pregnancy. Study DesignThis is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. Patients were instructed to check glucose levels 4-7 times a day with the fasting glucose target set at 60-90mg/dL and the 2-hours post-prandial target set at <120mg/dL. Glucose control and outcome of pregnancy were compared between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Statistical analysis was performed using Chi-square and Student's t-test, as appropriate. This is a retrospective cohort study of women with GDM or type 2 diabetes who were treated in our Diabetes in Pregnancy Program and required insulin therapy. Before 2010, all women requiring long-acting insulin were treated with NPH insulin. After 2010, women requiring long-acting insulin were treated with ID that was administered once or twice daily together with rapid acting insulin aspart, administered three times a day before meals. Patients were instructed to check glucose levels 4-7 times a day with the fasting glucose target set at 60-90mg/dL and the 2-hours post-prandial target set at <120mg/dL. Glucose control and outcome of pregnancy were compared between 2 groups: women treated with ID and aspart, and a control group treated with NPH and aspart. Statistical analysis was performed using Chi-square and Student's t-test, as appropriate. ResultsThe study included 60 women: 30 were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean glucose concentrations, percent values within targets, rates of hyperglycemia and hypoglycemia, birthweight, rates of LGA and macrosomia are presented in the table.Tabled 1 The study included 60 women: 30 were treated with ID (15 with type 2 DM, and 15 with GDM) and 30 were treated with NPH (10 with type 2 DM, and 20 with GDM). Mean glucose concentrations, percent values within targets, rates of hyperglycemia and hypoglycemia, birthweight, rates of LGA and macrosomia are presented in the table. ConclusionInsulin Detemir does not appear to have any advantage over NPH with respect to glucose control, maternal hypoglycemia and birth weight in pregnant women with diabetes. Insulin Detemir does not appear to have any advantage over NPH with respect to glucose control, maternal hypoglycemia and birth weight in pregnant women with diabetes.

ObjectiveEvaluate the need for pharmacologic therapy in gestational diabetes (GDM) based on the oral glucose tolerance test fasting plasma glucose (OFPG).Study DesignAn observational study of women with GDM between 2007 and 2010. On initial visit patients were counseled on diet therapy, self-monitoring blood glucose (SMBG) and instructed to test 4 to 7 times daily. Patients with an OFPG <95 mg/dl were included in this study and assigned to diet therapy. SMBG data was downloaded from glucose meters and analyzed at 2 week intervals. Targeted glycemic control was: mean fasting glucose (FBG) <95 mg/dl, mean pre-meal (PMG) <100 mg/dl, mean 2-hour post-meal (2HRG) <120 mg/dl and overall mean blood glucose (MBG) <105 mg/dl. If one or more of these targeted levels were not achieved the patient was transferred to pharmacologic therapy (glyburide or insulin). Patients were stratified into groups (G) based on OFPG: G1 55-74 mg/dl; G2 75-84 mg/dl; G3 85-94 mg/dl. Fisher's exact test and ANOVA were used for statistical analysis.Results1007 GDM patients were identified in the study period; 817 had OFPG 90%ile (LGA) in these groups. The graph below displays the comparison of the overall need for pharmacologic therapy in patients with an OFPG <95mg/dl vs. the need for therapy in the initial 2 weeks. Overall, 31% of the patients required pharmacologic therapy during pregnancy. Of these 53.9% were identified in the initial 2 week evaluation.ConclusionTabled 1View Large Image Figure ViewerDownload Hi-res image Download (PPT) ObjectiveEvaluate the need for pharmacologic therapy in gestational diabetes (GDM) based on the oral glucose tolerance test fasting plasma glucose (OFPG). Evaluate the need for pharmacologic therapy in gestational diabetes (GDM) based on the oral glucose tolerance test fasting plasma glucose (OFPG). Study DesignAn observational study of women with GDM between 2007 and 2010. On initial visit patients were counseled on diet therapy, self-monitoring blood glucose (SMBG) and instructed to test 4 to 7 times daily. Patients with an OFPG <95 mg/dl were included in this study and assigned to diet therapy. SMBG data was downloaded from glucose meters and analyzed at 2 week intervals. Targeted glycemic control was: mean fasting glucose (FBG) <95 mg/dl, mean pre-meal (PMG) <100 mg/dl, mean 2-hour post-meal (2HRG) <120 mg/dl and overall mean blood glucose (MBG) <105 mg/dl. If one or more of these targeted levels were not achieved the patient was transferred to pharmacologic therapy (glyburide or insulin). Patients were stratified into groups (G) based on OFPG: G1 55-74 mg/dl; G2 75-84 mg/dl; G3 85-94 mg/dl. Fisher's exact test and ANOVA were used for statistical analysis. An observational study of women with GDM between 2007 and 2010. On initial visit patients were counseled on diet therapy, self-monitoring blood glucose (SMBG) and instructed to test 4 to 7 times daily. Patients with an OFPG <95 mg/dl were included in this study and assigned to diet therapy. SMBG data was downloaded from glucose meters and analyzed at 2 week intervals. Targeted glycemic control was: mean fasting glucose (FBG) <95 mg/dl, mean pre-meal (PMG) <100 mg/dl, mean 2-hour post-meal (2HRG) <120 mg/dl and overall mean blood glucose (MBG) <105 mg/dl. If one or more of these targeted levels were not achieved the patient was transferred to pharmacologic therapy (glyburide or insulin). Patients were stratified into groups (G) based on OFPG: G1 55-74 mg/dl; G2 75-84 mg/dl; G3 85-94 mg/dl. Fisher's exact test and ANOVA were used for statistical analysis. Results1007 GDM patients were identified in the study period; 817 had OFPG 90%ile (LGA) in these groups. The graph below displays the comparison of the overall need for pharmacologic therapy in patients with an OFPG <95mg/dl vs. the need for therapy in the initial 2 weeks. Overall, 31% of the patients required pharmacologic therapy during pregnancy. Of these 53.9% were identified in the initial 2 week evaluation. 1007 GDM patients were identified in the study period; 817 had OFPG 90%ile (LGA) in these groups. The graph below displays the comparison of the overall need for pharmacologic therapy in patients with an OFPG <95mg/dl vs. the need for therapy in the initial 2 weeks. Overall, 31% of the patients required pharmacologic therapy during pregnancy. Of these 53.9% were identified in the initial 2 week evaluation. ConclusionTabled 1

In pregnancy complicated by diabetes periods of hyperglycemia lead to accelerated fetal growth, resulting in a large for gestational age (LGA), or macrosomic, infant. Consequently, our aim was to measure the average volatility or variability in glucose control in women with and without diabetes in pregnancy. Methods: Continuous glucose monitoring (CGM) was employed in 82 pregnant study subjects to collect and record unbiased self-monitored glucose values. We obtained results from 51 women with normal glucose tolerance in pregnancy (NGTP), 25 gestational diabetes (GDM) and 6 women with pregestational diabetes (PreGD) between 18 and 45 (32 +/- 6) years of age. Results: Significant differences (p < 0.001) were found in glucose exposure between NGT and all but PreGD; whereas the percent of time in hypoglycemia was significantly (p < 0.0001) higher in all pregnancy groups when compared to the nonpregnant sample. We conclude that CGM confirmed that diurnal glucose patterns differ throughout the day by 20% when pregnant and nonpregnant states are compared. Indeed, maintenance of a narrow range in pregnancy is characteristic in women without diabetes, and CGM throughout pregnancy is critical, if mimicking normal glucose patterns is to be achieved.

Objectives: We sought to determine the impact of maternal weight gain on fetal growth in gestational diabetes (GDM) in relation to treatment modality, body mass index (BMI) and glycemic control. Study design: Two thousand four hundred fifty-four GDMs were evaluated. Obesity was defined as BMI >29; good glycemic control ≤100 mg/dl; maternal age < and >30 years; parity ±1; large for gestational age (LGA) >90th percentile and small for gestational age (SGA) <10th percentile. Results: SGA rates were similar in all groups. Obese/overweight diet-treated women in glycemic control showed a four-fold higher rate of LGA compared to insulin-treated women. A 36-lb weight gain in insulin-treated patients had a six-fold higher risk. In poor glycemic control, LGA rates were higher in all BMI/weight gain categories. Logistic regressions for LGA/SGA revealed that level of glycemia, weight gain, parity, obesity and treatment (for LGA only) were significant. Conclusion: Different thresholds used for different maternal BMI categories in addition to the achievement of glycemic control and pharmacological therapy will enhance pregnancy outcome.

Objective: To describe gender distribution in fetuses with increased nuchal translucency (NT) measurements. Methods: All fetuses with mild (2.5–2.9 mm) and moderate (3.0–3.5 mm) NT enlargement at 12.0–12.6 weeks gestation were studied. The Z test for proportions was used to compare the gender distribution of this study group to that of all babies born at Roosevelt Hospital in 2008, and to compare the gender distributions of the subgroups. Results: 5109 patients received screening at 12.0–12.6 weeks gestation. 44 fetuses had mild and 28 had moderate enlargement, with a male-to-female ratio of 3.8:1.0, much higher than the 1.06:1.0 ratio among total births at Roosevelt Hospital in 2008 (p < 0.0001). Male-to-female ratio was 7.8:1.0 in fetuses with mild and 1.8:1.0 with moderate NT enlargement (p = 0.03). Among fetuses with mild NT enlargement, 3 males had aneuploidy; among those with moderate enlargement, 6 fetuses had aneuploidy, 3 males and 3 females. Seven pregnancies with aneuploidy were voluntarily terminated. All pregnancies carried to term were healthy. Conclusions: More males than females had mild NT enlargement on first-trimester screening, but unless aneuploidy was detected they had normal birth outcomes. A slightly larger NT may be normal in males, while indicating possible fetal abnormalities in females.

This chapter contains sections titled: The current effect of hyperglycemia in the hospitalized setting The current effect of diabetes-related hospitalizations Establishing good glycemic control for all hospitalized patients Preventing hyperglycemia in hospitalized patients: the three-component regimen Hospitalization practice guidelines for patients with diabetes Hospitalization for problems related to glycemic control Hospitalization for surgery The role of medical nutrition and activity therapy for glycemic control in the hospitalized setting Transition to care and hospital discharge Future perspectives and applications References