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Aims: Our aims were, in the setting of type 2 diabetes mellitus (T2DM) in pregnancy, to investigate the association of polycystic ovary syndrome (PCOS) with perinatal outcomes and to examine whether treatment with metformin had a differential effect in those with and without PCOS. Materials and Methods: We performed a retrospective cohort study using the metformin in women with type 2 diabetes in pregnancy (MiTy) trial data. We examined differences in maternal and neonatal outcomes among MiTy participants with and without PCOS using linear and logistic regression to adjust for potential confounders. We additionally examined the relative difference in the effect of metformin treatment on pregnancy outcomes among MiTy participants with PCOS versus those without PCOS. Results: Among women with T2DM in pregnancy, PCOS was significantly associated with higher excess gestational weight gain (unadjusted 12.0 vs. 11.4 kg, adjusted mean difference 2.1 kg [0.3, 3.9], p = 0.021) and higher total insulin dose at 34–36 weeks (unadjusted 172 vs. 124 units per day, adjusted mean difference 44 units [15, 73], p = 0.004), but no difference was seen in neonatal outcomes. Unlike the non‐PCOS subgroup, metformin treatment versus placebo in the PCOS subgroup was associated with an increase in extremely large‐for‐gestational‐age infants (28.6 vs. 14.0%, p = 0.008 for interaction) and an increase in worsened pre‐existing maternal hypertension (16.7 vs. 4.5%, p = 0.046 for interaction). Conclusions: Clinicians should be alerted to the potential for high insulin requirements and excess weight gain in pregnant patients with T2DM and comorbid PCOS. Moreover, metformin may not be as beneficial in this population as previously understood. [ABSTRACT FROM AUTHOR]

Background: Women with diabetes in pregnancy have decreased exclusivity and duration of breastfeeding compared with women without diabetes, and their infants are at increased risk of hypoglycemia. Clinicians often suggest pregnant women with diabetes to express breastmilk, and studies have reported increased breastfeeding exclusivity in the early postnatal period for patients who have expressed. Little is known about longer term outcomes. We investigated whether advising low-risk women with diabetes in pregnancy to express beginning at 36 weeks of pregnancy increased exclusivity and maintenance of breastfeeding at 3 months., Methods: We conducted a multicenter, two-group, randomized controlled trial at six hospitals in Melbourne, Australia, between 2011 and 2015. Women were randomized to either standard maternity care or advised to hand express for 10 min twice daily, in addition to standard care. Women were telephoned at 12-13 weeks postpartum and asked a series of questions about feeding their baby, perceptions of their milk supply, and other health outcomes., Results: Of 631 women in the study, data for 570 (90%) were analyzed at 12-13 weeks. After adjustment, we found no evidence that women allocated to antenatal expressing were more likely to be giving only breastmilk (aRR 1.07 [95% CI 0.92-1.22]) or any breastmilk (aRR 0.99 [95% CI 0.92-1.06]) at 12-13 weeks postpartum compared with women in the standard care group., Conclusion: While the practice of antenatal expression for low-risk women with diabetes during pregnancy is promising for increasing exclusivity of breastmilk feeding in hospital, at 12-13 weeks, there was no association with breastfeeding outcomes., (© 2024 The Authors. Birth published by Wiley Periodicals LLC.)

Introduction: Some guidelines allow for the use of either insulin or noninsulin antidiabetic agents for gestational diabetes, but only insulin is recommended for pregnant women with preexisting type 2 diabetes mellitus (T2DM). We aimed to document treatment patterns in routine care for women with preexisting T2DM. Methods: We identified pregnancy cohorts within 2 US claims databases for publicly and privately insured individuals: the Medicaid Analytical eXtract (2000–2014) and OptumClinformatics (2004–2014). T2DM was classified with a validated algorithm using ICD‐9‐CM and CPT codes. We assessed medication usage over the years of the study, and changes in medication use before and after the beginning of pregnancy, using prescription fills as a proxy for the use of insulin, metformin, sulphonylureas and other noninsulin antidiabetic agents before pregnancy and during each trimester. Results: Among 12,631 women with T2DM, insulin use in pregnancy was stable over the study years (55%–60% in the 2nd trimester), but 2nd trimester use of metformin increased from <5% to 20%. Over the study period, 41% of women filled a prescription for metformin before pregnancy, 37% in the 1st trimester and 17% in the 2nd trimester. By the 2nd trimester, few women used sulphonylureas (11%) or other noninsulin antidiabetic agents (1%). Of the women on metformin only before pregnancy, 36% switched to insulin only by 2nd trimester, 11% added insulin and 16% continued on metformin only. Of the women on metformin and insulin before pregnancy, 61% switched to insulin only by 2nd trimester, 22% continued with metformin and insulin and <5% used only metformin. Conclusion: The use of insulin‐metformin combinations and other noninsulin antidiabetic drugs during pregnancy has increased. Safety studies for these medication regimens are needed. [ABSTRACT FROM AUTHOR]

Background: We aimed to report pregnancy outcomes of women with type 1 diabetes (T1D) in China, on which data were sparse. Methods: This is a nationwide retrospective study conducted in 11 general medical centers in 8 cities across China. We investigated the clinical data of all women who attended these centers with a singleton pregnancy and whose pregnancy ended between 1 January 2004 and 31 December 2014. Pregnancies of women with pregestational T1D were ascertained and compared with those of women without T1D. Results: From over 300 000 pregnancies over the 11‐year study period, we identified 265 singleton pregnancies of women with T1D. One maternal death was documented among 265 (0.37%) women with T1D and 83 among 318 486 (0.03%) women without T1D. Women with T1D suffered from higher rates of pregnancy loss (13.21% vs 2.92%, crude risk ratio [cRR] 5.08 [95% CI, 3.56‐7.26]) and preeclampsia (17.74% vs 4.20%, cRR 4.94 [95% CI, 3.60‐6.77]) compared with those without T1D. Infants of these women with T1D had elevated rates of neonatal death (5.65% vs 0.16%, cRR 37.36 [95% CI, 21.21‐65.82]) and congenital malformation(s) (8.26% vs 3.53%, cRR 2.46 [95% CI, 1.54‐3.93]) compared with those of women without T1D. No significant improvement in pregnancy outcomes in women with T1D was observed over the period 2004 to 2014. Conclusions: Pregnancy outcomes were persistently poor in women with T1D during 2004 to 2014 in China. Pregnancy care needs to be improved to reduce adverse pregnancy outcomes among Chinese women with T1D. [ABSTRACT FROM AUTHOR]

Background: Pre‐existing diabetes in pregnancy is associated with an increased risk of complications. Likewise, living in rural, regional and remote Victoria, Australia, is also associated with poorer health outcomes. There is a gap in the literature with regard to whether Victorian women with pre‐existing diabetes experience a greater risk of adverse pregnancy outcomes compared to their metropolitan counterparts. Aim: Our objective is to compare obstetric and perinatal outcomes for women with pre‐existing diabetes delivering in rural vs metropolitan hospitals in Victoria, Australia. Materials and Methods: Retrospective population‐based study using routinely collected state‐based data of singleton births to women with type 1 and type 2 diabetes who delivered in metropolitan (n = 3233) and rural hospitals (n = 693) in Victoria, Australia, between 2006–2015. Pearson's χ2 test, Fisher's exact test and MannWhitney U‐test were used to compare obstetric and perinatal outcomes between metropolitan and rural locations. Results: Delivery in a rural hospital was associated with higher rates of stillbirth (2.3% vs 1.1%, P = 0.027), macrosomia (25.9% vs 16.9%, P < 0.001), shoulder dystocia (8.4% vs 3.5%, P < 0.001) and admission to the neonatal intensive care unit/special care nursery (73.2% vs 59.3%, P < 0.001). Smoking (18.0% vs 8.9%, P < 0.001), overweight/obesity (P = 0.047) and socioeconomic disadvantage (P < 0.001) were more common in rural women. Conclusions: Women with pre‐existing diabetes who deliver in rural hospitals experience a greater risk of adverse perinatal outcomes and present with increased maternal risk factors. These results suggest a need to improve care for women with pre‐existing diabetes in rural Victoria. [ABSTRACT FROM AUTHOR]

Background: Antenatal ultrasound is used frequently in pregnancies complicated by hyperglycaemia; however, it is unclear which measurements have the greatest association with adverse neonatal outcomes. Aim: To assess the association between third trimester ultrasound parameters with adverse neonatal outcomes in pregnancies complicated by hyperglycaemia. Method: All pregnant women with gestational or type 2 diabetes who birthed in a regional hospital over 12 months were included. A composite adverse neonatal outcome was defined by one or more: admission to special care nursery, acidosis, hypoglycaemia, jaundice, shoulder dystocia, respiratory distress syndrome or 5‐minute Apgar score < 5. Logistic regression was used to determine odds ratios (OR) for an adverse neonatal outcome, according to pre‐specified cut points in both lower and upper percentiles of abdominal circumference (AC) and estimated fetal weight (EFW). Results: Of 275 births an adverse outcome occurred in 122 (44%). Unadjusted OR (95% CI) for AC ≤30th was 3.2 (1.1–8.8) and >95th percentile was 3.1 (1.5–6.0) compared with the reference group of 31–70th percentile. Unadjusted OR for EFW ≤30th was 1.5 (0.7–3.1) and >95th percentile was 3.0 (1.4–6.3). After adjusting for maternal age, body mass index, diabetes type, ethnicity, gravidity, mode of delivery and gestation at birth the OR (95% CI) were as follows: AC ≤30th percentile, 3.7 (1.1–12.4); AC >95th, 2.2 (1.1–4.8); EFW ≤30th, 2.6 (1.1–6.1); EFW >95th, 2.5 (1.1–6.1). Conclusion: An AC and EFW up to the 30th percentile may pose just as great a risk to the fetus as an AC or EFW >95th percentile in pregnancies complicated by hyperglycaemia. [ABSTRACT FROM AUTHOR]

Objective: To compare trends in pregestational (DM) and gestational diabetes (GDM) in pregnancy in rural and urban areas in the USA, because pregnant women living in rural areas face unique challenges that contribute to rural-urban disparities in adverse pregnancy outcomes., Design: Serial, cross-sectional analysis., Setting: US National Center for Health Statistics (NCHS) Natality Files from 2011 to 2019., Population: A total of 12 401 888 singleton live births to nulliparous women aged 15-44 years., Methods: We calculated the frequency (95% confidence interval [CI]) per 1000 live births, the mean annual percentage change (APC), and unadjusted and age-adjusted rate ratios (aRR) of DM and GDM in rural compared with urban maternal residence (reference) per the NCHS Urban-Rural Classification Scheme overall, and by delivery year, reported race and ethnicity, and US region (effect measure modification)., Main Outcome Measures: The outcomes (modelled separately) were diagnoses of DM and GDM., Results: From 2011 to 2019, there were increases in both the frequency (per 1000 live births; mean APC, 95% CI per year) of DM and GDM in rural areas (DM: 7.6 to 10.4 per 1000 live births; APC 2.8%, 95% CI 2.2%-3.4%; and GDM: 41.4 to 58.7 per 1000 live births; APC 3.1%, 95% CI 2.6%-3.6%) and urban areas (DM: 6.1 to 8.4 per 1000 live births; APC 3.3%, 95% CI 2.2%-4.4%; and GDM: 40.8 to 61.2 per 1000 live births; APC 3.9%, 95% CI 3.3%-4.6%). Individuals living in rural areas were at higher risk of DM (aRR 1.48, 95% CI 1.45%-1.51%) and GDM versus those in urban areas (aRR 1.17, 95% CI 1.16%-1.18%). The increased risk was similar each year for DM (interaction p = 0.8), but widened over time for GDM (interaction p < 0.01). The rural-urban disparity for DM was wider for individuals who identified as Hispanic race/ethnicity and in the South and West (interaction p < 0.01 for all); and for GDM the rural-urban disparity was generally wider for similar factors (i.e. Hispanic race/ethnicity, and in the South; interaction p < 0.05 for all)., Conclusions: The frequency of DM and GDM increased in both rural and urban areas of the USA from 2011 to 2019 among nulliparous pregnant women. Significant rural-urban disparities existed for DM and GDM, and increased over time for GDM. These rural-urban disparities were generally worse among those of Hispanic race/ethnicity and in women who lived in the South. These findings have implications for delivering equitable diabetes care in pregnancy in rural US communities., (© 2023 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Background: Some women with diabetes in pregnancy express and store colostrum in the antenatal period for the purposes of preventing and treating neonatal hypoglycaemia. Aims: Our primary aim was to compare rates of neonatal hypoglycaemia in babies born to mothers who express and store antenatal colostrum to babies born to mothers who do not. Materials and methods: Retrospective cohort study involving 357 women with diabetes in pregnancy, who had live, singleton births delivered after 36 weeks gestation, in a regional hospital in North Queensland (2014–2015). Multivariable binary logistic regression modelling identified independent characteristics associated with primary outcomes. Results: Eighty women (23%) expressed antenatal colostrum and 223 (62%) did not. One hundred and thirty‐one babies (37%) were diagnosed with hypoglycaemia. Aboriginal and Torres Strait Islander women were less likely to express than Caucasian women (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01–0.77). There were no significant differences in the rates of hypoglycaemia, or median blood glucose levels in babies born to mothers who expressed antenatal colostrum compared to babies born to mothers who did not express. Babies born to mothers who expressed were significantly less likely to receive formula in hospital compared to babies born to mothers who did not (OR 0.12, 95% CI 0.05–0.32). Conclusions: We found no independent association of expressing antenatal colostrum on rates of neonatal hypoglycaemia or median blood glucose levels. Expressing antenatal colostrum may have some benefits to the newborn such as reduced formula consumption in hospital. Further research into other methods of reducing neonatal hypoglycaemia appears warranted. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The aim of this study was to identify the main contributors to cesarean section (CS) among women with and without diabetes during pregnancy using the Robson classification and to compare CS rates within Robson groups. Methods: A population‐based cohort study was conducted of all women who gave birth in New South Wales, Australia, between 2002 and 2012. Women with pregestational diabetes (types 1 and 2) and gestational diabetes mellitus (GDM) were grouped using the Robson classification. Adjusted odd ratios (AOR) and 95% confidence intervals (CI) were calculated using multivariable logistic regression. Results: The total CS rate was 53.6% for women with pregestational diabetes, 36.8% for women with GDM and 28.5% for women without diabetes. Previous CS contributed the most to the total number of CS in all populations. For preterm birth, the contribution to the total was 20.5% for women with pregestational diabetes and 5.7% for women without diabetes. Compared to women without diabetes, for nulliparous with pregestational diabetes, the odds of CS was 1.4 (95% CI, 1.1–1.8) for spontaneous labor and 2.0 (95% CI, 1.7–2.3) for induction of labor. Conclusion: A history of CS was the main contributor to the total CS. Reducing primary CS is the first step to lowering the high rate of CS among women with diabetes. Nulliparous women were more likely to have CS if they had pregestational diabetes. This increase was also evident in all multiparous women giving birth. The high rate of preterm births and CS reflects the clinical issues for women with diabetes during pregnancy. [ABSTRACT FROM AUTHOR]

Background In the Northern Territory ( NT), 38% of 3500 births each year are to Indigenous women, 80% of whom live in regional and remote areas. Compared with the general Australian population, rates of pre-existing type 2 diabetes in pregnancy are 10-fold higher and rates of gestational diabetes are 1.5-fold higher among Indigenous women. Current practices in screening for diabetes in pregnancy in remote Australia are not known. Aims To assess current health service delivery for NT women with diabetes in pregnancy ( DIP) by surveying healthcare professionals' views and practices in DIP screening and management. Materials and Methods A cross-sectional survey of NT healthcare professionals providing clinical care for women with DIP was conducted based on pre-identified themes of communication, care-coordination, education, orientation and guidelines, logistics and access, and information technology. Results Of the 116 responders to the survey, 78% were primary healthcare professionals, 32% midwives and 25% general practitioners. High staff turnover was evident: of Central Australian professionals, only 33% (urban) and 18% (regional/remote) had been in their current position over 5 years. DIP screening was conducted at first antenatal visit by 66% and at 24-28-week gestation by 81%. Only 50% of respondents agreed that most women at their health service received appropriate care for DIP, and 41% of primary care practitioners were neutral or not confident in their skills to manage DIP. Conclusions It is promising that many healthcare professionals report following new guidelines in conducting early pregnancy screening for DIP in high risk women. Several challenges were identified in healthcare delivery to a high risk population in remote Australia. [ABSTRACT FROM AUTHOR]

Type 2 diabetes is now the most common form of pregestational diabetes. Recent data suggest that pregnancies complicated by type 2 diabetes are associated with unacceptably high fetal mortality and morbidity, at an incidence comparable to pregnancies complicated by type 1 diabetes. This review examines the literature on type 2 diabetes in pregnancy, including its incidence and potential complications. There is a need to highlight the dangers of type 2 diabetes in pregnancy to both patients and medical practitioners. Peri-conception care needs to improve to achieve better pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Reproductive medicine, COVID-19, Infectious diseases, Respiratory tract infections, Pregnancy in diabetics Alternative screening protocols may miss most cases of gestational diabetes mellitus during the COVID-19 pandemic Keywords: Pregnancy in diabetics; Reproductive medicine; COVID-19; Infectious diseases; Respiratory tract infections EN Pregnancy in diabetics Reproductive medicine COVID-19 Infectious diseases Respiratory tract infections 284 284 1 04/06/21 20210401 NES 210401 To the Editor: Siru and colleagues have raised potential concerns about the strategy recommended by the Australian Diabetes Society (ADS) and other peak bodies to diagnose gestational diabetes (GDM) during the coronavirus disease 2019 (COVID-19) pandemic.1 In their study, 46% of subjects diagnosed with GDM had a fasting blood glucose level (BGL) < 4.7 mmol/L but elevated post-load blood glucose levels, and would be missed by the ADS-recommended strategy. [Extracted from the article]

Background: Gestational diabetes mellitus (GDM) causes adverse pregnancy outcomes that can be averted by treatment from 24-28 weeks' gestation. Assessing and treating women for overt diabetes in pregnancy (ODIP) at the first antenatal clinic booking is now recommended in international guidelines. As a consequence, women with milder hyperglycaemia are being diagnosed and treated for early GDM, but randomised controlled trial (RCTs) assessing the benefits and harms of such treatment have not been undertaken. The Treatment Of Booking Gestational diabetes Mellitus (TOBOGM) study is a multi-centre RCT examining whether diagnosing and treating GDM diagnosed at booking improves pregnancy outcomes. Methods and analysis: 4000 adult pregnant women (< 20 weeks' gestation) at risk of ODIP will be recruited from 12 hospital antenatal booking clinics and referred for an oral glucose tolerance test (OGTT). 800 women with hyperglycaemia (ie, booking GDM) according to the 2014 Australasian Diabetes-in-Pregnancy Society criteria for pregnant women at 24-28 weeks' gestation will be randomised to immediate treatment for GDM (intervention) or to no treatment (control), pending the results of a second OGTT at 24-28 weeks' gestation. Antenatal and GDM care will otherwise follow local guidelines. Randomisation will be stratified by site and OGTT glycaemic risk strata. The primary pregnancy outcome is a composite of respiratory distress, phototherapy, birth trauma, birth before 37 weeks' gestation, stillbirth or death, shoulder dystocia, and birthweight ≥ 4.5 kg. The primary neonatal outcome is neonatal lean body mass. The primary maternal outcome is pre-eclampsia. Ethics approval: South Western Sydney Local Health District Research and Ethics Office (reference, 15/LPOOL/551). Dissemination of results: Peer-reviewed publications, scientific meetings, collaboration with research groups undertaking comparable studies, discussions with guideline groups and policy makers.Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12616000924459. [ABSTRACT FROM AUTHOR]

Background: Historically, pre-pregnancy diabetes (PPDM) is a recognised risk factor for poor pregnancy outcome. Co-existing pathology and adverse social determinants including rural-metropolitan inequities in health and healthcare access may confer additional risks. Multidisciplinary care before, during and after pregnancy can improve outcomes for women with PPDM and their infants. The extent to which rural Australian women and their families share in improved outcomes is unknown. We aimed to summarise maternal characteristics and pregnancy outcomes for women with PPDM, including women in rural settings and examine applications of existing clinical guidelines to rural Australian practice., Methods: We sought English language population and cohort studies about PPDM using Medline, Embase, PubMed, Australian epidemiological and international clinical practice guidelines., Results: Women with PPDM are changing: older, more obese, of lower parity, less likely to smoke, more likely to have type 2 rather than type 1 diabetes and shorter duration of PPDM. Women with PPDM continue to experience excess adverse pregnancy outcomes, including maternal morbidity, complicated birth, perinatal loss, congenital anomalies and mother-infant separation. On face value, clinical guidelines appear relevant to women living in rural settings but there are only a few, conflicting outcome studies for rural women with PPDM., Conclusions: PPDM is changing. A significant minority live in rural locations, and although perinatal mortality/morbidity seems to be improving, it is unclear if this is also true for rural women due to a lack of recent Australian studies. Further research is necessary to achieve excellence everywhere for women with PPDM and their babies., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: To compare birth weights in central Sydney to the INTERGROWTH21st international standard to describe current trends in relation to optimal growth and to define areas that may benefit from improved obstetric surveillance and intervention., Methods: Retrospective analysis of prospectively collected cohort., Design: hospital-based cohort study., Setting: Sydney Local Health District, Australia., Population or Sample: women with singleton pregnancies who had first trimester screening for aneuploidy between 16 April, 2010 and 9 March, 2012. Analysis of 2966 births., Main Outcome Measures: Large for gestational age (LGA) >4000 g, >4500 g, >5000 g, >90th, >95th, >97th centiles and small for gestational age (SGA) <1500 g, <2500 g,

Aim: We tracked the body mass index (BMI) of children born to mothers with or without gestational diabetes mellitus (GDM) or type 1 diabetes from birth to 12 years of age and examined the trends in both diseases., Methods: Antenatal and postnatal health survey data were collected from 6909 Finnish children born at six time points between 1974 and 2004. We compared the BMI trajectory between the offspring of mothers with and without GDM or type 1 diabetes, and the association between GDM and overweight offspring was analysed., Results: The prevalence of GDM and type 1 diabetes increased markedly over the study period. The BMI trajectory in the GDM or type 1 diabetes offspring differed significantly from the nondiabetic offspring. The timing of adiposity rebound occurred significantly earlier in the GDM (4.8 years) and type 1 diabetes (4.4 years) groups than the nondiabetic group (5.5 years). GDM offspring were more likely to be overweight at five, seven and 12 years of age (24.6%, 28.1%, 29.4%) than nondiabetic offspring (15.6%, 18.3%, 18.1%)., Conclusion: Children born to mothers with GDM were significantly more likely to be overweight at an early age than those born to nondiabetic mothers., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: This study evaluated mothers with diabetes to determine whether prepregnancy body mass index (BMI), BMI on delivery or gestational weight gain (GWG) had the greatest impact on maternal and neonatal outcomes., Methods: We retrospectively examined the medical charts of 634 full-term infants born to mothers with gestational diabetes mellitus not requiring insulin (n = 476), gestational diabetes mellitus requiring insulin (n = 140) and insulin-dependent diabetes mellitus (n = 18). Data regarding maternal BMI before pregnancy and on delivery were recorded, as well as maternal and neonatal complications., Results: Infants born to women who gained more than the recommended weight during pregnancy had higher birthweights, higher rates of meconium-stained amniotic fluid and neonatal hypoglycaemia. Using logistic regression, Caesarean section delivery was predicted by gestational diabetes requiring insulin, with an odds ratio (OR) of 1.76, maternal hypertension (OR 2.4), infants born large for gestational age (OR 2.78) and maternal BMI ≥ 30 on delivery (OR 1.06). Neonatal complications were predicted by maternal insulin-dependent diabetes (OR 5.21), lower gestational age (OR 0.8) and GWG above the recommended amount (OR 1.56)., Conclusion: Women with diabetes should be made aware that higher GWG can lead to Caesarean section delivery, infant macrosomia and other neonatal complications., (©2015 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Rising rates of diabetes in pregnancy have led to an escalation in research in this area. As in any area of clinical research, definitions of outcomes vary from study to study, making it difficult to compare research findings and draw conclusions. Our aim was to compile and create a repository of definitions, which could then be used universally. A systematic review of the literature was performed on published and ongoing randomized controlled trials in the area of diabetes in pregnancy between 01 Jan 2000 and 01 Jun 2012. Other sources included the World Health Organization and Academic Society Statements. The advice of experts was sought when appropriate definitions were lacking. Among the published randomized controlled trials on diabetes and pregnancy, 171 abstracts were retrieved, 64 full texts were reviewed and 53 were included. Among the ongoing randomized controlled trials published in ClinicalTrials.gov, 90 protocols were retrieved and 25 were finally included. The definitions from these were assembled and the final maternal definitions and foetal definitions were agreed upon by consensus. It is our hope that the definitions we have provided (i) will be widely used in the reporting of future studies in the area of diabetes in pregnancy, that they will (ii) facilitate future systematic reviews and formal meta analyses and (iii) ultimately improve outcomes for mothers and babies., (Copyright © 2015 John Wiley & Sons, Ltd.)

Aim: To find predictors of abnormal retinal vascularisation in moderately to late preterm newborn infants considered to have no risk of developing retinopathy of prematurity., Methods: Seventy-eight infants (34 girls) were recruited from a longitudinal study of otherwise healthy premature children born at a gestational age of 32 + 0-36 + 6 weeks. Retinal vessel morphology was evaluated at mean postnatal age 7 days. Insulin-like growth factor-I (IGF-I) levels were analysed in umbilical cord blood., Results: Of the 78 infants, 21 (27%) had abnormal retinal vessel morphology; they had significantly lower median (range) birth weight [1850 g, (1190-3260), vs. 2320, (1330-3580), p < 0.0001], shorter birth length [43.0 cm, (38-49), vs. 46.0, (40-50), p < 0.0001] and smaller head circumference [31.0 cm, (27.7-34.0), vs. 32.0, (27.5-36.5), p = 0.003]. They also had significantly lower gestational age [34 + 1 weeks, (32 + 2-35 + 3), vs. 34 + 6, (32 + 2-36 + 6), p = 0.004] and mean ± SD IGF-I levels (24.6 ± 17.0 μg/L vs. 46.7 ± 21.5, p < 0.0001). A higher percentage of these infants were small for gestational age (57.1% vs. 15.8%, p = 0.001), and maternal hypertension/preeclampsia rates were also higher (47.6% vs. 19.3%, p = 0.03). Step-wise logistic regression showed that birth weight was the strongest predictor of abnormal retinal vascularisation (p < 0.0001, odds ratio 0.040, 95% confidence interval 0.007-0.216)., Conclusion: In this population of moderately to late preterm newborns, birth weight appeared to affect the retinal vascular system., (©2014 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

With the increasing prevalence of diabetes and obesity in Australia, more women with type 2 diabetes are becoming pregnant. Our study confirms that pregnancies with type 2 diabetes have poorer outcomes and there is a strong need for further research into modification of risk factors associated with adverse pregnancy outcomes, particularly in type 2 diabetes. We believe it is time to rethink the strategies to improve their outcomes., (© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Head morphogenesis is a complex process that is controlled by multiple signaling centers. The most common defects of cranial development are craniofacial defects, such as cleft lip and cleft palate, and neural tube defects, such as anencephaly and encephalocoele in humans. More than 400 genes that contribute to proper neural tube closure have been identified in experimental animals, but only very few causative gene mutations have been identified in humans, supporting the notion that environmental influences are critical. The intrauterine environment is influenced by maternal nutrition, and hence, maternal diet can modulate the risk for cranial and neural tube defects. This article reviews recent progress toward a better understanding of nutrients during pregnancy, with particular focus on mouse models for defective neural tube closure. At least four major patterns of nutrient responses are apparent, suggesting that multiple pathways are involved in the response, and likely in the underlying pathogenesis of the defects. Folic acid has been the most widely studied nutrient, and the diverse responses of the mouse models to folic acid supplementation indicate that folic acid is not universally beneficial, but that the effect is dependent on genetic configuration. If this is the case for other nutrients as well, efforts to prevent neural tube defects with nutritional supplementation may need to become more specifically targeted than previously appreciated. Mouse models are indispensable for a better understanding of nutrient-gene interactions in normal pregnancies, as well as in those affected by metabolic diseases, such as diabetes and obesity., (© 2013 Wiley Periodicals, Inc.)

Background: Australian Aboriginal women have a high prevalence of type 2 diabetes (T2DM) in pregnancy and gestational diabetes (GDM)., Aims: To review how screening practice affects the pregnancy data of all Indigenous women and their newborns living in Cape York, Queensland., Methods: All medical charts of mothers and their neonates delivered in the regional hospital over two-one-year periods (2006 and 2008) were reviewed. Universal testing with an oral glucose tolerance test (OGTT) was introduced in 2007., Results: Gestational diabetes (GDM) increased from 4.7 to 14.2%, and T2DM was similar (2.4 and 2.3%). There were 127 deliveries in 2006 and 134 in 2008. Testing rates with OGTT improved from 31.4% in 2006 to 65.6% in 2008. Mothers with diabetes in pregnancy (DIP) were older and heavier than non-DIP mothers. Caesarean section rates were significantly higher in the DIP group compared with the non-DIP group (66 vs 25%) in both time periods. The booking weight of DIP mothers decreased 16 kg, their babies normalised their weight, length and head circumference; respiratory distress and Apgar scores improved comparing the two periods. In DIP, infants >40% had hypoglycaemia; however, rates of serious complications were low. Rates of breastfeeding were similar between groups. Follow-up rates for GDM improved from 16.6% in 2006 to 31.6% in 2008. Of those tested one-third were diagnosed with T2DM., Conclusion: The rate of GDM tripled after implementation of universal testing. Outcomes improved. There is still need for improvement in testing and follow-up practices in relation to DIP., (© 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

In this retrospective study, pregnant women with type 1 diabetes under the care of diabetes specialists pre-conception were found to have better glycaemic control and pregnancy outcomes than those not under specialist care prior to pregnancy. These differences were not seen in women with type 2 diabetes. The study showed that tight glycaemic control in women with pre-existing diabetes was associated with better pregnancy outcomes, and we believe women with type 1 diabetes should be managed by a diabetes specialist before pregnancy., (© 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: The risk of major congenital malformations (MCM) is increased in women with pregestational diabetes mellitus (PGDM). Whether this risk is increased in gestational diabetes mellitus (GDM) is still debated. The aim of this study was to perform a systematic review (and meta-analysis) of major congenital malformations in women with gestational diabetes versus a reference population., Methods: We conducted a MEDLINE search (1 January 1995 to 31 December 2009) of original studies reporting data on major congenital malformations in women with gestational diabetes and a reference group. Information on pregestational diabetes was collected when available. Two investigators considered studies for inclusion and extracted data; discrepancies were solved by consensus. Meta-analysis tools were used to summarize results. MOOSE and PRISMA guidelines were followed., Results: Two case control and 15 cohort studies were selected out of 3488 retrieved abstracts. A higher risk of major congenital malformations was observed in offspring of women with gestational diabetes with the following relative risk (RR)/odds ratios (OR) and 95% confidence intervals (CI): RR 1.16 (1.07-1.25) in cohort studies and OR 1.4 (1.22-1.62) in case control studies. Risk of major congenital malformations was much higher in offspring of women with PGDM than in those of the reference group: RR 2.66 (2.04-3.47) in cohort studies and OR 4.7 (3.01-6.95) in the single case control study providing information., Conclusion: There is a slightly higher risk of major congenital malformations in women with gestational diabetes than in the reference group. The contribution of women with overt hyperglycemia and other factors could not be ascertained. This risk, however, is much lower than in women with pregestational diabetes., (Copyright © 2011 John Wiley & Sons, Ltd.)

Patients with diabetes may undergo an approximately 24-h fast for a voluntary religious observance or in preparation for a medical procedure. Commonly, patients will manage their diabetes before and during such fasting without guidelines from their doctors, often because they did not ask for advice. The physician should therefore take the lead in advising patients how to fast safely, in order to avoid the situation wherein the patient manages medication changes on his/her own. Furthermore, it sends a message to the patient that having diabetes does not preclude living a reasonably 'normal' life, even when it comes to religious observances., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: To evaluate the value of first trimester placental biomarkers (fβ-hCG, PAPP-A, ADAM12, PP13 and PlGF) and fetal nuchal translucency (NT) in the prediction of macrosomia at birth in pregestational type-1 and type-2 diabetes (PGDM)., Design: Nested case-control study., Setting: Routine first-trimester combined test., Population: A total of 178 PGDM and 186 control pregnancies., Methods: ADAM12, PP13 and PlGF concentrations were measured in stored first-trimester serum, previously tested for fβ-hCG and PAPP-A. All concentrations were expressed as multiples of the median (MoM). Where applicable, the median MoMs of PGDM and control pregnancies were compared in relation to birthweight centiles (≤90th centile, non-macrosomic, versus >90th centile, macrosomic). Model-predicted detection rates for fixed false-positive rates were obtained for statistically significant markers, separately and in combination., Main Outcome Measures: Prediction of macrosomia in diabetic pregnancies., Results: In the PGDM group, median ADAM12 MoM (0.88; P = 0.007) was lower than in the controls. Subgroup analyses showed that median MoMs of PAPP-A (0.65), ADAM12 (0.85), PP13 (0.81) and PlGF (0.91) were only reduced in the PGDM non-macrosomic birthweight subgroup (n = 93) compared with other weight subgroups. In the PGDM macrosomic birthweight subgroup (n = 69), MoMs of all markers were comparable with the control birthweight subgroups. The screening performance for macrosomia at birth in the PGDM group provided a detection rate of 30% for a 5% false-positive rate (FPR) and 43% for a 10% FPR., Conclusions: Macrosomia at birth in PGDM pregnancies may be predicted by normal levels of PAPP-A, ADAM12, PP13 and PlGF already in the first trimester of pregnancy. Fetal birthweight in PGDM offspring is partially determined by placental development during the first trimester of pregnancy. The present increase in fetal macrosomia may be related to better early glycemic control and placentation., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

Aim: As a result of increased neonatal morbidity, the infants of diabetic mothers have routinely been admitted to a neonatal special care unit (NSCU). We therefore investigated whether the offer of rooming-in diabetic mothers and their newborn infants has an effect on neonatal morbidity., Methods: The records of an old cohort of 103 infants routinely admitted to the NSCU, and a new cohort (N = 102), offered rooming-in were assessed for neonatal morbidity., Results: Eighty-four (82%) of the new cohort infants followed their mothers to the maternity ward; whereas 19 (18%) were transferred to the NSCU chiefly because of prematurity. Ten infants were later transferred to the NSCU for minor problems. Neonatal morbidity and neonatal hypoglycaemia were significantly less common in the new cohort than in the old cohort [27 (26%) vs. 55 (54%), p < 0.001 and 42 (41%) vs. 64 (63%), p = 0.0027 respectively]. Maternal HbA1c in late pregnancy was significantly lower in the new cohort, but the only independent predictors of neonatal morbidity were belonging to the old cohort and preterm delivery., Conclusion: Neonatal care with rooming-in mothers with type 1 diabetes and their newborn infants seems safe and is associated with reduced neonatal morbidity, when compared with routine separation of infants from their mothers.

Metopic synostosis (MS) accounts for approximately 10-15% of all craniosynostosis and is etiologically heterogeneous. This study aimed to examine the causes of MS, as observed in a tertiary craniofacial unit. We reviewed the case notes of 110 children with a diagnosis of MS, attending the craniofacial unit in Oxford between 1991 and 2008. Our results showed 38 children (38/110 or 34.6%) who had at least one additional structural abnormality or had a known syndromic diagnosis were classed as having syndromic MS. Chromosomal abnormalities were noted in 8/38 (21.4%) children: mosaic marker chromosome 2, 9p deletion (2/8), 11q deletion, 12pter deletion and duplication of 15q25 with other additional chromosomal abnormalities (3/8). Other syndromic diagnoses included Silver-Russell syndrome and Greig cephalopolysyndactyly. Prenatal exposure to sodium valproate (VPA) was noted in 8/110 children (7.8%), with the dose of the VPA being >or=1,000 mg/day in all cases. Other prenatal exposures reported in this study were: maternal diabetes (6/110), enoxaparin for hypercoagulable state (1/110), and thyroxine (1/110). The majority of patients (72/110 or 65.4%) had nonsyndromic MS. Speech delay was present in 11 children with nonsyndromic MS (11/72 or 15.3%) and 10 children with syndromic MS (10/38 or 26.3%). We conclude that approximately two-thirds of all MS is nonsyndromic. Prenatal exposure to VPA is a common cause of MS. Maternal diabetes, not previously linked to MS, was noted in 5.5% of cases. Chromosomal abnormalities account for about 6% of MS. An increased risk of speech delay is seen with both the syndromic and nonsyndromic forms., ((c) 2010 Wiley-Liss, Inc.)

Congenital lumbar hernia (CLH) is rarely seen in children and the patients with CLH usually have other congenital anomalies. The most common clinical presentation of CLH, previously named lumbocostovertebral syndrome, includes hemivertebrae, absent ribs, and abdominal wall muscle hypoplasia. We report on an infant of a diabetic mother presenting with CLH with other anomalies, and we speculate that this clinical picture fits a developmental field defect associated with maternal diabetes., ((c) 2010 Wiley-Liss, Inc.)

Newborn children of diabetic mothers have an increased morbidity and mortality because of respiratory distress syndrome. We study lung histogenesis during intrauterine development of offspring of diabetic Sprague-Dawley rats at 18, 19 and 21 days of gestation (DG). Pregnant rats were grouped into diabetic (streptozotocin-induced), citrate, and control groups; five female and five male offspring were selected randomly from each group at 18, 19 and 21 DG, and a biopsy of the lung was taken and processed in paraffin for histological examination. The biopsy for the transmission electron microscopy (TEM) analysis was taken at 21 days. A delay in alveolization of the offspring at 18, 19 and 21 days of the diabetic group was observed, which was confirmed at TEM level, and also less quantity of protein D associated to surfactant in diabetic group was detected (P < 0.001). The foetuses of the diabetic group presented a delay in lung histogenesis and in differentiation of the type II pneumocytes cells, but conserved the proportion with a decrease in 50% of pneumocytes, accompanied by a diminish of protein D associated to surfactant factor.

Background: Customised birthweight centiles identify small-for-gestational-age (SGA) babies at increased risk of morbidity more accurately than population centiles, but they have not been validated in obese populations., Aims: To compare the rates of SGA by population and customised birthweight centiles in babies of women with type 2 diabetes and examine perinatal outcomes in customised SGA infants., Methods: Data were from a previous retrospective cohort study detailing pregnancy outcomes in 212 women with type 2 diabetes. Customised and population birthweight centiles were calculated; pregnancy details and neonatal outcomes were compared between groups that delivered infants who were SGA (birthweight < 10th customised centile) and appropriate weight for gestational age (AGA) (birthweight 10-90th customised centile)., Results: Fifteen (7%) babies were SGA by population centiles and 32 (15%) by customised centiles. Two babies of Indian women were reclassified from SGA to AGA by customised centiles. Nineteen babies were reclassified from AGA to SGA by customised centiles; of these, 15 (79%) were born to Polynesian women, five (26%) were born less than 32 weeks and two (11%) were stillborn. Customised SGA infants, compared with AGA infants, were more likely to be born preterm (19 (59%) vs 20 (16%), P < 0.001) and more likely to be stillborn (4 (13%) vs 0 P = 0.001). After excluding still births, admission to the neonatal unit was also more common (19 of 28 (68%) vs 43 of 127 (34%), P < 0.001)., Conclusions: In our population more babies were classified as SGA by customised compared with population centiles. These customised SGA babies have high rates of morbidity.

Aim: To determine whether the risk of stillbirth is associated with male fetal sex, fetal growth and maternal factors in an Australian population., Methods: A retrospective secondary data analysis of 16 445 singleton births was performed using a tertiary referral centre obstetric database (1995-1999). Univariate and multiple logistic regression analyses were performed., Results: Stillbirth complicated 1% of the pregnancies in the study population, and 59% of stillbirths were associated with a male fetus. Significant characteristics associated with stillbirth were intrauterine growth restriction (IUGR), birth defects, gestational age, Aboriginal ethnicity, previous stillbirth, parity greater than three and placental abruption. Male stillbirths were more likely to occur at a later gestation (median gestation 30.5 weeks, range 20-43 weeks) compared to females (median 25 weeks, range 20-40 weeks), P = 0.01. Sixty per cent of IUGR fetuses were female (P < 0.001). Male sex (odds ratio (OR) 1.5, confidence interval (CI) 1.01, 2.17, P = 0.04) and maternal type 1 diabetes (OR 4.7, CI 1.58, 14.19, P = 0.006) were independently associated with stillbirth., Conclusion: Male fetal sex and pre-existing diabetes are independent risk factors for stillbirth. Diabetes remains a significant risk for stillbirth even with contemporary monitoring and clinical management. Those diabetic pregnancies where the fetus is male require appropriate monitoring and timely interventions to achieve an optimal outcome.

Axial mesodermal dysplasia spectrum (AMDS) includes the features of other malformation complexes or sequences, such as oculo-auriculo-vertebral spectrum (OAVS) and sacral dysgenesis. We describe a new patient, an infant born to a type 1 diabetic mother, with the phenotype of AMDS as well as severe congenital cardiac anomalies including transposition of the great arteries and an atrioventricular septal defect. Congenital heart defects had been reported with OAVS, sacral dysgenesis, and in an infant born to a diabetic mother and combinations of these findings have been reported in the same patient. To our knowledge, this is the first patient with AMDS with transposition of great arteries and an atrioventricular septal defect and the second patient with AMDS who had history of parental consanguinity. The mechanism through which maternal diabetes mellitus leads to malformations is not entirely clear, but the glycemic control is essential in the care of mothers., ((c) 2007 Wiley-Liss, Inc.)

The goal of this study was to assess whether interruption of care for chronic periodontitis during pregnancy increased the risk of low-birthweight infants. A population-based case-control study was designed with 793 cases (infants < 2,500 g) and a random sample of 3,172 controls (infants >or= 2,500 g). Generalized estimating equation models were used to relate periodontal treatment history to low birthweight risk and to common risk factors. The results indicate that periodontal care utilization was associated with a 2.35-fold increased odds of self-reported smoking during pregnancy (95% confidence interval: 1.48-3.71), a 2.19-fold increased odds for diabetes (95% confidence interval: 1.21-3.98), a 3.90-fold increased odds for black race (95% confidence interval: 2.31-6.61), and higher maternal age. After adjustment for these factors, interruption of periodontal care during pregnancy did not lead to an increased risk for a low-birthweight infant when compared to women with no history of periodontal care (odds ratio, 0.96; 95% confidence interval, 0.60-1.52). In conclusion, women receiving periodontal care had genetic and environmental characteristics, such as smoking, diabetes and race, that were associated with an increased risk for low-birthweight infants. Periodontal care patterns, in and of themselves, were unrelated to low-birthweight risk.

Background: The usefulness of umbilical artery Doppler velocimetry for the monitoring of diabetic pregnancies is controversial. The aim of the present study was to assess whether umbilical artery Doppler velocity waveform analysis can predict adverse perinatal outcomes for pregnancies complicated by pre-existing diabetes mellitus., Methods: All diabetic pregnancies (type 1 and 2) delivered at Mater Mothers' Hospital, Queensland, between 1 January 1995 and 31 December 1999 were included. All pregnant diabetic women were monitored with umbilical artery Doppler velocimetry at 28, 32, 36, and 38 weeks' gestation. Adverse perinatal outcome was defined as pregnancies with one or more of the following: small-for-gestational age, Caesarean section for non-reassuring cardiotocography, fetal acidaemia at delivery, 1-min Apgar of 3 or less, 5-min Apgar of less than 7, hypoxic ischaemic encephalopathy or perinatal death. Abnormal umbilical artery Doppler velocimetry was defined as a pulsatility index of 95th centile or higher for gestation., Results: One hundred and four pregnancies in women with pre-existing diabetes had umbilical arterial Doppler studies carried out during the study period. Twenty-three pregnancies (22.1%) had an elevated pulsatility index. If the scans were carried out within 2 weeks of delivery, 71% of pregnancies with abnormal umbilical Doppler had adverse outcomes (P < 0.01; likelihood ratio, 4.2). However, the sensitivity was 35%; specificity was 94%; positive predictive value was 80%; and negative predictive value was 68%. Only 30% of women with adverse perinatal outcomes had abnormal umbilical arterial Doppler flow., Conclusion: Umbilical artery Doppler velocimetry is not a good predictor of adverse perinatal outcomes in diabetic pregnancies.

The objective of this study is to compare the accuracy of sonographic estimation of fetal weight of macrosomic babies in diabetic vs non-diabetic pregnancies. All babies weighing 4,000 g or more at birth, and who had ultrasound scans performed within one week of delivery were included in this retrospective study Pregnancies with diabetes mellitus were compared to those without diabetes mellitus. The mean simple error (actual birthweight--estimated fetal weight); mean standardised absolute error (absolute value of simple error (g)/actual birthweight (kg)); and the percentage of estimated birthweight falling within 15% of the actual birthweight between the two groups were compared. There were 9,516 deliveries during the study period. Of this total 1,211 (12.7%) babies weighed 4,000 g or more. A total of 56 non-diabetic pregnancies and 19 diabetic pregnancies were compared. The average sonographic estimation of fetal weight in diabetic pregnancies was 8% less than the actual birthweight, compared to 0.2% in the non-diabetic group (p < 0.01). The estimated fetal weight was within 15% of the birthweight in 74% of the diabetic pregnancies, compared to 93% of the non-diabetic pregnancies (p < 0.05). In the diabetic group, 26.3 % of the birthweights were underestimated by more than 15 %, compared to 5.4% in the non-diabetic group (p < 0.05). In conclusion, the prediction accuracy of fetal weight estimation using standard formulae in macrosomic fetuses is significantly worse in diabetic pregnancies compared to non-diabetic pregnancies. When sonographic fetal weight estimation is used to influence the mode of delivery for diabetic women, a more conservative cut-off needs to be considered.

Unlabelled: The effect of smoking on breastfeeding was studied in 252 mothers with insulin-dependent diabetes mellitus (IDDM) giving birth in the period 1985-1995 and of whom 31% were classified as White group B, 16% group C, 37% group D and 16% group F or R. As part of a centralized regimen a detailed smoking history was taken during pregnancy. Forty-six percent were smokers. In 1997, a questionnaire was sent out asking for information on the duration of breastfeeding. The response rate was 87%. The duration of breastfeeding was significantly longer in the non-smoking group (p = 0.004). Fifty-five percent of non-smokers versus 33% of smokers were still breastfeeding 4 mo after birth. A strong dose-response relationship was established (p = 0.009). Cox multiple regression analysis showed a significantly negative influence of smoking (p = 0.01) and of hospitalization of the infants during the first year of life (p = 0.02) and a significantly positive influence of maternal age (p = 0.02) and birthweight (p = 0.03) on the length of breastfeeding. The breastfeeding curves for non-smokers and smokers were mainly divergent in the first month after birth, suggesting that the effect of smoking on breastfeeding is mainly exerted during that period., Conclusion: Smoking exerted a strong, negative, dose-dependent influence on breastfeeding duration in mothers with IDDM. Given the hazards of smoking, the advantages of breastfeeding and the possible link between being breastfed and later development of diabetes mellitus, these results should be taken into consideration when counselling pregnant women with IDDM about smoking.

Objective: 1. To study computerised cardiotocograph parameters from women with type I diabetes; 2. to examine the significance of observed differences from the expected normal values., Design: Prospective observational study in the third trimester of pregnancy., Setting: The medical antenatal clinic of a tertiary referral centre., Population: Twenty-six women with type I diabetes mellitus with a singleton pregnancy., Methods: Computerised cardiotocograph recordings were made weekly from 28 to 39 weeks. Derived parameters were compared with the published figures for uncomplicated singleton pregnancies. Details of maternal blood sugar, labour and delivery and neonatal outcome were recorded. Data were compared between groups according to the computerised analysis of the antenatal CTGs., Results: One-hundred and thirty-one recordings were made with a median of five per patient (range 1-12). 1 1.3% showed absent episodes of high variation compared with the expected value of 0.8%, a difference of 9.5% (95% CI 4.5-15.3). Differences in short term variation, basal heart rate, frequency of fetal movements and heart rate accelerations were also found which changed with gestation. Overall these changes represented a more immature form of fetal heart rate than that which would be expected. No relationship between the changes and adverse fetal outcome could be identified., Conclusions: Significant differences exist in cardiotocographs in maternal type I diabetes compared with normal fetuses. The changes may represent a delay in fetal maturation. The analysis mode of the computer will register these as abnormal features, but there is no evidence that they are pathological. We would recommend that computerised analysis is not used to assess pregnancies complicated by maternal type I diabetes mellitus.

Objective: To identify factors independently affecting fetal weight in women with type I diabetes., Design: Prospectively recorded data in consecutive women with type I diabetes, between 1975-1992., Setting: Simpson Memorial Maternity Hospital, Edinburgh. Population Three hundred and two pregnancies with type I diabetes identified before pregnancy, with antenatal care and delivery in the Simpson Memorial Maternity Hospital, a singleton pregnancy, and the same diabetic physician., Methods: Normal ranges for birthweight were established for the total hospital population. All cases and the total population had pregnancy dating by ultrasound. The relation between standardised birthweight and explanatory variables was investigated using correlation analysis, t tests and chi2 tests as appropriate, and subsequently using multiple linear regression., Results: Standardised birthweight in cases, compared with the reference population, showed a unimodal, approximately normal distribution, markedly shifted to the right (mean + 1.26 SD). The most predictive variable was glycated haemoglobin concentration at 27-33 weeks, which explained 6.3% of the birthweight variance, while smoking explained 2.7% and maternal weight 2.0%. There was a trend towards a negative relationship with glycated haemoglobin concentration at 6-12 weeks. Smoking and glycated haemoglobin concentration were strongly intercorrelated., Conclusions: Most of the variance in standardised birthweight remains unexplained, but glycated haemoglobin concentration at 27-33 weeks is the most powerful explanatory variable. Possible reasons why there is not a stronger relationship between markers of maternal glycaemia and birthweight are discussed.

We describe the management of a diabetic primigravid woman with systemic sclerosis and thrombocytopaenia who required Caesarean section for pre-eclampsia. This was performed successfully under spinal anaesthesia.

This study was designed to explore the effects of purified insulin during early stages of chick embryo development, and to search for variations between different molecular structures of the hormone. Chicken embryos were treated in ovo with a single dose of insulin (porcine or bovine), in only one stage of development between day 0 and day 9. Two susceptible periods were found. The earliest period (day 0 to day 3), characterized by abnormalities in the caudal vertebrae and a high mortality rate, was followed by a period with a different set of malformations, a syndrome classified as achondroplasia. The rate of achondroplastic embryos was significantly higher with porcine rather than with bovine insulin. Paradoxically, insulin at physiological doses has stimulatory effects in growth and development but, in contrast, has inhibitory effects at higher doses. The precise signalling cascade of events in the target cells is still unclear. The possible interpretations of our results are discussed. The similarity between the insulin-induced abnormalities in the chicken embryos and the caudal regression syndrome, the most common malformation found in infants of diabetic women, suggests a common mechanism. This circumstance offers the chicken embryos as an excellent in vivo model for research on the mechanism of action of insulin during normal and abnormal development.

A case of Cushing syndrome in a 25-year-old female diagnosed during pregnancy is presented. The pregnancy was complicated by diabetes mellitus, pregnancy induced hypertension, prematurity and intrauterine growth retardation. The patient underwent transphenoidal pituitary adenectomy after delivery for removal of a large pituitary adenoma. The mother and infant are well 10 months after delivery.

The causes of 50 perinatal deaths which occurred over an 18-year period in the infants of women with either established (n = 205) or gestational (n = 2,442) diabetes were studied. The perinatal mortality rate in these groups was 5.4% and 1.6% respectively and the causes of deaths were similar in both groups. Intrauterine hypoxia was found to be the commonest cause of death, followed by congenital malformations and respiratory distress syndrome. The implications of these findings for measures to reduce such deaths are discussed.