Low values on 50 gram glucose challenge test or oral 100 gram glucose tolerance test are associated with good perinatal outcome. Pregnancy Insulin, Glucose, and BMI Contribute to Birth Outcomes in Nondiabetic Mothers Pregnancy glycaemia and cord-blood levels of insulin and leptin in Pakistani and white British mother–offspring pairs: findings from a prospective pregnancy cohort Diagnosis of gestational diabetes mellitus: falling through the net Association of Maternal Diabetes Mellitus in Pregnancy With Offspring Adiposity Into Early Adulthood: Sibling Study in a Prospective Cohort of 280 866 Men From 248 293 Families Metformin should be considered in the treatment of gestational diabetes: a prospective randomised study [Glibenclamide in the treatment for gestational diabetes mellitus in a compared study to insulin]. 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We set out to reevaluate the hypothesis that high normal ( negative ) results of 50 g oral glucose challenge test or high normal glucose level on 100 g oral glucose tolerance test are associated with complications of pregnancy and delivery .  This was a prospect i ve study involving 735 nondiabetic women . The first group ( n=352 ) was made up of pregnant women with normal 50 g oral glucose challenge test without previous history of diabetes mellitus or gestational diabetes . The second group ( n=383 ) was made up of pregnant women without previous history of diabetes mellitus or gestational diabetes with an abnormal 50 g oral glucose challenge test and with normal 100 g oral glucose tolerance test and not more than one previous delivery . In nondiabetic women , we demonstrated a positive correlation between high normal 50 g glucose challenge test values and the incidence of preeclampsia , caesarean section rate , macrosomia , neonatal hyperlipidaemia and minor congenital abnormalities . We failed to confirm any relationship to any pregnancy complication in pregnant women with 2-hour glucose levels in the range 6.7 - 9.1 mmol/l on the 100 g oral glucose tolerance test . We have demonstrated a positive relationship between the incidence of premature rupture of membranes and 1-hour glucose level , caesarean section rate and maternal 1-hour glucose level or 1-hour glucose level minus fasting glucose level of 4.2 mmol/l , instrumental delivery rate and maternal 3-hour glucose level , incidence of neonatal macrosomia and 1-hour glucose level , and incidence of neonatal hyperlipidaemia and at least one high but normal glucose level on the 100 g oral glucose tolerance test . With regard to pregnancy and delivery complications there were no significant difference if the high normal value is on the 50 g glucose challenge test or on the 100 g oral glucose tolerance test . It is concluded that one high normal 100 g oral glucose tolerance test or high normal 50 g glucose challenge test are associated with adverse pregnancy and delivery outcome . Nondiabetic women with 50 g glucose challenge test value of 6.1 mmol/l and /or 100 g oral glucose tolerance test values of 5 mmol/l have a favourable pregnancy and delivery outcome OBJECTIVE —We investigated the effects of normal variations in maternal glycemia on birth size and other birth outcomes . RESEARCH DESIGN AND METHODS —Women in two unselected birth cohorts , one retrospective ( n = 3,158 ) and one prospect i ve ( n = 668 ) , underwent an oral glucose challenge at 28 weeks of gestation . In the retrospective study , glycemia was linked to routine birth records . In the prospect i ve study , offspring adiposity was assessed by skinfold thickness from birth to age 24 months . RESULTS —In the retrospective study , within the nondiabetic range ( 2.1–7.8 mmol/l ) , each 1 mmol/l rise in the mother 's 60-min glucose level was associated with a ( mean ± SEM ) 2.1 ± 0.8 % ( P = 0.006 ) rise in absolute risk of assisted vaginal delivery , a 3.4 ± 0.8 % ( P < 0.0001 ) rise in emergency cesarean delivery , a 3.1 ± 0.7 % ( P < 0.0001 ) rise in elective cesarean delivery , and a 46 ± 8 g ( P < 0.0001 ) increase in offspring birth weight . In the prospect i ve study , fetal macrosomia ( birth weight > 90th centile ) was independently related to the mother 's fasting glucose ( odds ratio 2.61 per + 1 mmol/l [ 95 % CI 1.15–5.93 ] ) and prepregnancy BMI ( 1.10 per + 1 kg/m2 [ 1.04–1.18 ] ) . The mother 's higher fasting glycemia ( P = 0.004 ) , lower insulin sensitivity ( P = 0.01 ) , and lower insulin secretion ( P = 0.02 ) were independently related to greater offspring adiposity at birth . During postnatal follow-up , the correlation between the mother 's glycemia and offspring adiposity disappeared by 3 months , whereas prepregnancy BMI was associated with offspring adiposity that was only apparent at 12 and 24 months ( both P < 0.05 ) . CONCLUSIONS —Prepregnancy BMI , pregnancy glycemia , insulin sensitivity , and insulin secretion all contribute to offspring adiposity and macrosomia and may be separate targets for intervention to optimize birth outcomes and later offspring health Aims /hypothesisTo determine the extent to which gestational fasting and postload levels of glucose explain differences in infant fat mass between UK-born Pakistani and white British infants . Methods Analyses were undertaken in a prospect i ve pregnancy cohort study of 1,415 women and their singleton live-born infants ( 629 white British and 786 Pakistani ) . Infant fat mass was assessed by cord-blood leptin levels and fetal insulin secretion by cord-blood insulin levels . Maternal OGTTs were completed at 26–28 weeks of gestation . Results Pakistani women had higher fasting and postload glucose levels and greater incidence of gestational diabetes than white British women .  Higher fasting and postload glucose levels were associated with higher cord-blood levels of insulin and leptin in all participants , irrespective of ethnicity . Cord-blood leptin levels were 16 % ( 95 % CI 6 , 26 ) higher in Pakistani than in white British infants . After adjustment for fasting glucose levels , this difference attenuated to 7 % ( −3 , 16 ) , and with additional adjustment for cord-blood insulin levels it attenuated further to 5 % ( −4 , 14 ) . Path analyses supported the hypothesis that fasting glucose levels mediate the relationship of Pakistani ethnicity to greater fat mass at birth , as measured by cord-blood leptin levels ; on average , 19 % of this mediation involved fetal insulin secretion . Postload glucose levels did not act as an important mediator of ethnic differences in cord-blood leptin levels . Results were very similar when 130 women with gestational diabetes were removed . Conclusions /interpretationThese novel findings suggest a role of maternal pregnancy glycaemia in mediating differences in fat mass between Pakistani and white British infants Aims /hypothesisGestational diabetes mellitus ( GDM ) is associated with increased risks to mother and child , but globally agreed diagnostic criteria remain elusive . Identification of women with GDM is important , as treatment reduces adverse outcomes such as perinatal death , shoulder dystocia and neonatal hypoglycaemia . Recently , the UK ’s National Institute for Health and Care Excellence ( NICE ) recommended new diagnostic thresholds for GDM which are different from the International Association of the Diabetes and Pregnancy Study Groups ( IADPSG ) criteria endorsed by the WHO . The study aim was to assess neonatal and obstetric outcomes among women who would test positive for the IADPSG criteria but negative for the NICE 2015 criteria . Methods Data from 25,543 consecutive singleton live births ( 2004–2008 ) were obtained retrospectively from hospital records . Women were screened with a r and om plasma glucose ( RPG ; 12–16 weeks ) and a 50 g glucose challenge test ( GCT ; 26–28 weeks ) . If RPG > 7.0 mmol/l , GCT > 7.7 mmol/l or symptoms were present , a 75 g OGTT was offered ( n = 3,848 ) . Results In this study , GDM prevalence was 4.13 % ( NICE 2015 ) and 4.62 % ( IADPSG ) . Women who ‘ fell through the net ’ , testing NICE-negative but IADPSG-positive ( n = 387 ) , had a higher risk of having a large-for-gestational-age ( LGA ) infant ( birthweight > 90th percentile for gestational age ; adjusted OR [ 95 % CI ] 3.12 [ 2.44 , 3.98 ] ) , Caesarean delivery ( 1.44 [ 1.15 , 1.81 ] ) and polyhydramnios ( 6.90 [ 3.94 , 12.08 ] ) compared with women with negative screening results and no OGTT ( n = 21,695 ) . LGA risk was highest among women with fasting plasma glucose 5.1–5.5 mmol/l ( n = 167 ) : the mean birthweight was 350 g above that of the reference population and 37.7 % of infants were LGA . Conclusions /interpretationThe IADPSG criteria identify women at substantial risk of complications who would not be identified by the NICE 2015 criteria Background — Maternal diabetes mellitus in pregnancy results in greater  offspring adiposity  at birth . It is unclear whether it is associated with greater adiposity into adulthood , and if so , whether this is via intrauterine mechanisms or shared familial characteristics . Methods and Results — A record-linkage prospect i ve cohort study of 280 866 singleton-born Swedish men from 248 293 families was used to explore the intrauterine effect of maternal diabetes mellitus on offspring body mass index ( BMI ) in early adulthood . Maternal diabetes mellitus during pregnancy was associated with greater mean BMI at age 18 in their sons . The difference in BMI was similar within brothers and between nonsiblings . BMI of men whose mothers had diabetes mellitus during their pregnancy was on average 0.94 kg/m2 greater ( 95 % confidence interval [ CI ] , 0.35 to 1.52 ) than in their brothers born before their mother was diagnosed with diabetes , after adjustment for birth year , maternal age , parity and education , birth weight , gestational age , and age at assessment of BMI . Early-pregnancy BMI was positively associated with son 's BMI between nonsiblings , but there was no association within brothers . Adjustment of the maternal diabetes-offspring BMI association for maternal BMI did not alter the association either within brothers or between nonsiblings . Results were also robust to sensitivity analyses restricting the within-sibling analyses to siblings born within 3 years of each other . Conclusion — Maternal diabetes mellitus has long-term consequences for greater BMI in offspring ; this association is likely to be via intrauterine mechanisms , and is independent of maternal BMI in early pregnancy Please cite this paper as : Ijäs H , Vääräsmäki M , Morin‐Papunen L , Keravuo R , Ebeling T , Saarela T , Raudaskoski T. Metformin should be considered in the treatment of gestational diabetes : a prospect i ve r and omised study . BJOG 2011;118:880–885 OBJECTIVES To study glibenclamide as a treatment for gestational diabetes mellitus ( GDM ) and its impact on newborn birth weight and neonatal glycemia as compared to insulin . METHODS A r and omized and open-label clinical trial , conducted from October 1st , 2003 to March 8 , 2005 . Seventy-two pregnant women with gestational diabetes mellitus requiring drug therapy were r and omized and allocated into two groups -- insulin and glibenclamide . RESULTS The general characteristics in both groups were similar , except for the results of the 75 g OGTT , which were higher in the glibenclamide group ( p= 0.02 ) . Maternal fasting and postpr and ial glucose levels presented no difference . Six ( 18.75 % ) pregnant women received the maximum dose of glibenclamide with no glycemic control . The birth weight was higher in the group treated with glibenclamide ( p= 0.01 ) , and the incidence of macrosomic newborns statistically different ( p= 0.01 ) . Neonatal hypoglycemia was more frequent ( p= 0.01 ) in newborns of glibenclamide group , with one single case of persistent hypoglycemia . CONCLUSION Glibenclamide can be the first line drug for glycemic control in most GDM patients . The birth weight and incidence of hypoglycemia were higher in the glibenclamide group , but with one single case of persistent hypoglycemia that required intravenous infusion of glucose Aims /hypothesisNew diagnostic criteria for gestational diabetes mellitus ( GDM ) have recently been published . We wished to evaluate what impact these new criteria would have on GDM prevalence and outcomes in a predominantly European population . Methods The Atlantic Diabetes In Pregnancy ( DIP ) programme performed screening for GDM in 5,500 women with an oral glucose tolerance test at 24–28 weeks . GDM was defined according to the new International Association of Diabetes and Pregnancy Study Groups ( IADPSG ) criteria and compared with previous WHO criteria ; maternal and neonatal adverse outcomes were prospect ively recorded . Results Of the participants , 12.4 % and 9.4 % were diagnosed with GDM using IADPSG and WHO criteria , respectively . IADPSG GDM pregnancies were associated with a statistically significant increased incidence of adverse maternal outcomes ( gestational hypertension , polyhydramnios and Caesarean section ) and neonatal outcomes ( prematurity , large for gestational age , neonatal unit admission , neonatal hypoglycaemia and respiratory distress ) . The odds ratio for the development of these adverse outcomes remained significant after adjustment for maternal age , body mass index and non-European ethnicity . Those women who were classified as having normal glucose tolerance by WHO criteria but as having GDM by IADPSG criteria also had significant adverse pregnancy outcomes . Conclusions /interpretationGDM prevalence is higher when using newer IADPSG , compared with WHO , criteria , and these women and their offspring experience significant adverse pregnancy outcomes . Higher rates of GDM pose a challenge to healthcare systems , but improved screening provides an opportunity to attempt to reduce the associated morbidity for mother and child Abstract Objective : To evaluate the perinatal impact of metformin and glyburide in the treatment of gestational diabetes mellitus ( GDM ) . Methods : A r and omized clinical trial conducted from July 2008 until September 2010 studied 200 pregnant women with GDM who required adjunctive therapy to diet and physical activity . Patients were r and omized to use metformin ( n=104 ) or glyburide ( n=96 ) . The drugs were replaced by insulin when they reached the maximum dose without glycemic control . Assessed outcomes : weight and neonatal blood glucose . Results : : No difference was found ( P>0.05 ) between the groups regarding maternal age , gestational age at inclusion , body mass index , glucose levels in oral glucose tolerance test ( OGTT ) 75 g and glycemic control . Difference was found in the number of previous pregnancies ( 2.84 vs. 2.47 , P=0.04 ) and weight gain during pregnancy ( 7.78 vs. 9.84 , P=0.04 ) in the metformin group and glyburide respectively . The perinatal results showed no difference ( P>0.05 ) in the percentage of cesarean deliveries , gestational age at delivery , number of newborns large for gestational age ( LGA ) , neonatal hypoglycemia , admission to intensive care unit and perinatal death . We found differences in weight ( 3193 g vs. 3387 g , P=0.01 ) and ponderal index ( 2.87 vs. 2.96 , P=0.05 ) of newborns , and in neonatal blood glucose levels at the 1st ( 59.78 vs. 54.08 , P=0.01 ) and 3rd h ( 61.53 vs. 55.89 , P=0.01 ) after birth between the metformin and glyburide groups respectively . Conclusions : Weight and ponderal index were lower in the newborns of the metformin group ; glucose levels ( 1st and 3rd h after birth ) were lower in the glyburide group OBJECTIVE Our purpose was to assess maternal-fetal outcomes in patients with increasing carbohydrate intolerance not meeting the current criteria for the diagnosis of gestational diabetes . STUDY DESIGN We conducted a prospect i ve analytic cohort study in which nondiabetic women aged > or = 24 years , receiving prenatal care in three Toronto teaching hospitals , were eligible for enrollment . A glucose challenge test and an oral glucose tolerance test were administered at 26 and 28 weeks ' gestation , respectively ; risk factors for unfavorable maternal-fetal outcomes were recorded . Caregivers and patients were blinded to glucose values except when test results met the current criteria for gestational diabetes . RESULTS Of 4274 patients screened , 3836 ( 90 % ) continued to the diagnostic oral glucose tolerance test . The study cohort was formed by the 3637 ( 95 % ) patients without gestational diabetes , carrying singleton fetuses . Increasing carbohydrate intolerance in women without overt gestational diabetes was associated with a significantly increased incidence of cesarean sections , preeclampsia , macrosomia , and need for phototherapy , as well as an increased length of maternal and neonatal hospital stay . Multivariate analysis showed that increasing carbohydrate intolerance is an independent predictor for various unfavorable outcomes . CONCLUSION Increasing maternal carbohydrate intolerance in pregnant women without gestational diabetes is associated with a grade d increase in adverse maternal-fetal outcomes OBJECTIVES To assess the prevalence and association of frequently used screening risk factors for gestational diabetes mellitus ( GDM ) and to compare the validity and cost of universal screening with risk factor screening . METHOD A cross-sectional survey of 768 pregnant women at > or = 24 weeks ' gestation who were attending the antenatal clinic at the Hospital Universiti Kebangsaan Malaysia ( HUKM ) was made . Risk factors were determined using a question naire . An abnormal oral glucose tolerance test was defined as a 2-h post-pr and ial blood sugar level of > or = 7.8 mmol/l . RESULTS A total of 191 pregnant mothers ( 24.9 % ) had GDM . The most commonly identified screening factors were positive family history of diabetes mellitus ( 31.4 % ) , history of spontaneous abortion ( 17.8 % ) , vaginal discharge and pruritus vulvae in current pregnancy ( 16.0 % ) , and maternal age greater than 35 years ( 14.7 % ) . Five hundred and thirteen mothers ( 66.8 % ) had at least one risk factor . All screening risk factors , except past history of diabetes mellitus in previous pregnancy and maternal age , were not significantly associated with abnormal glucose tolerance ( GT ) .  Risk factor screening gave a sensitivity of 72.2 % and a specificity of 35.0 % . Universal screening would cost RM 12.06 while traditional risk factor screening would cost RM 11.15 per identified case and will have missed 53 of the 191 cases . CONCLUSIONS Risk factor screening scored poorly in predicting GDM . Cost analysis of universal compared with traditional risk factor screening showed a negligible difference . Thus universal screening appears to be the most reliable method of diagnosing GDM CONTEXT A past history of gestational diabetes mellitus ( GDM ) confers a very high risk of postpartum development of diabetes , particularly type 2 diabetes . OBJECTIVE The Diabetes Prevention Program ( DPP ) sought to identify individuals with impaired glucose tolerance ( IGT ) and intervene in an effort to prevent or delay their progression to diabetes . This analysis examined the differences between women enrolled in DPP with and without a reported history of GDM . DESIGN The DPP was a r and omized , controlled clinical trial . SETTING The study was a multicenter , National Institutes of Health-sponsored trial carried out at 27 centers including academic and Indian Health Services sites . PATIENTS A total of 2190 women were r and omized into the DPP and provided information for past history of GDM . This analysis addressed the differences between those 350 women providing a past history of GDM and those 1416 women with a previous live birth but no history of GDM . INTERVENTIONS Subjects were r and omized to either st and ard lifestyle and placebo or metformin therapy or to an intensive lifestyle intervention . MAIN OUTCOMES The primary outcome was the time to development of diabetes ascertained by semiannual fasting plasma glucose and annual oral glucose tolerance testing . Assessment s of insulin secretion and insulin sensitivity were also performed . RESULTS Whereas entering the study with similar glucose levels , women with a history of GDM r and omized to placebo had a crude incidence rate of diabetes 71 % higher than that of women without such a history . Among women reporting a history of GDM , both intensive lifestyle and metformin therapy reduced the incidence of diabetes by approximately 50 % compared with the placebo group , whereas this reduction was 49 and 14 % , respectively in parous women without GDM . These data suggest that metformin may be more effective in women with a GDM history as compared with those without . CONCLUSIONS Progression to diabetes is more common in women with a history of GDM compared with those without GDM history despite equivalent degrees of IGT at baseline . Both intensive lifestyle and metformin are highly effective in delaying or preventing diabetes in women with IGT and a history of GDM Aims /hypothesisThe cost-effectiveness of eight strategies for screening for gestational diabetes ( including no screening ) was estimated with respect to the level of individual patient risk . Methods Cost – utility analysis using a decision analytic model populated with efficacy evidence pooled from recent r and omised controlled trials , from the funding perspective of the National Health Service in Engl and and Wales . Seven screening strategies using various combinations of screening and diagnostic tests were tested in addition to no screening . The primary outcome measure was the incremental cost per quality -adjusted life-year ( QALY ) over a lifetime . Results The strategy that has the greatest likelihood of being cost-effective is dependent on the risk of gestational diabetes mellitus for each individual woman . When gestational diabetes mellitus risk is < 1 % then the no screening/treatment strategy is cost-effective ; where risk is between 1.0 % and 4.2 % fasting plasma glucose followed by OGTT is most likely to be cost-effective ; and where risk is > 4.2 % , universal OGTT is most likely to be cost-effective . However , acceptability of the test alters the most cost-effective strategy . Conclusions /interpretationScreening for gestational diabetes can be cost-effective . The best strategy is dependent on the underlying risk of each individual and the acceptability of the tests used . The current study suggests that if a woman ’s individual risk of gestational diabetes could be accurately predicted , then healthcare re source allocation could be improved by providing an individualised screening strategy Background / Objectives : The current study was performed to investigate the effects of the Dietary Approaches to Stop Hypertension ( DASH ) eating plan on pregnancy outcomes in pregnant women with gestational diabetes mellitus (GDM).Subjects/ Methods : This r and omized controlled clinical trial was performed among 52 women diagnosed with GDM . Participants were r and omly assigned to consume either the control ( n=26 ) or the DASH diet ( n=26 ) for 4 weeks . The control diet was design ed to contain 45–55 % carbohydrates , 15–20 % protein and 25–30 % total fat . The DASH diet was rich in fruits , vegetables , whole grains and low-fat dairy products , and contained lower amounts of saturated fats , cholesterol and refined grains with a total of 2400 mg/day sodium . The numbers of women who commenced insulin therapy after dietary intervention , the mode of delivery and prevalence of polyhydramnios were assessed . The length , weight and head circumference of infants were measured during the first 24 h after birth . Results : Whereas 46.2 % of women in the DASH diet needed to have a cesarean section , this percentage for the control group was 80.8 % ( P=0.01 ) . The percentage of those who needed to commence insulin therapy after intervention was also significantly different between the two groups ( 23 % for DASH vs 73 % for control group , P<0.0001 ) . Infants born to mothers on the DASH diet had significantly lower weight ( 3222.7 vs 3818.8 g , P<0.0001 ) , head circumference ( 34.2 vs 35.1 cm , P=0.01 ) and ponderal index ( 2.50 vs 2.87 kg/m3 , P<0.0001 ) compared with those born to mothers on the control diet . Conclusions : In conclusion , consumption of DASH diet for 4 weeks among pregnant women with GDM result ed in improved pregnancy outcomes OBJECTIVE To determine if pregnancies with an abnormal glucose challenge test ( GCT ) but a normal ( GTT ) are at increased risk for fetal macrosomia or an adverse pregnancy outcome . STUDY DESIGN This prospect i ve observational study matched women with an abnormal glucose challenge test and a normal GTT with the next patient with a normal GCT . RESULTS Over 12 months , 107 women with abnormal GCT were matched with 107 women with normal GCT . Women with an abnormal GCT were older ( 27.3 vs. 24.7 , p = 0.001 ) and less likely to be African-American ( OR = 2.2 , 95 % CI 1.06 - 4.49 ) but no more likely to have an adverse pregnancy outcome . ROC curves could not differentiate between macrosomic vs non-macrosomic newborns using GCT values . CONCLUSION Women with an abnormal GCT but a normal GTT are more likely to be older , less likely to be African-American , but no more likely to have an adverse pregnancy outcome or a macrosomic fetus CONTEXT Gestational hyperglycemia increases the risk of obesity and diabetes in offspring later in life . OBJECTIVE We examined the relationship between gestational glycemia and neonatal adiposity in a multiethnic cohort of Singaporean neonates . DESIGN A prospect i ve mother-offspring cohort study recruited 1247 pregnant mothers ( 57.2 % Chinese , 25.5 % Malay , 17.3 % Indian ) and performed 75-g , 2-hour oral glucose tolerance tests at 26 - 28 weeks ' gestation ; glucose levels were available for 1081 participants .  Neonatal anthropometry ( birth weight , length , triceps , and subscapular skinfolds ) was measured , and percentage body fat ( % BF ) was derived using our published equation . Associations of maternal glucose with excessive neonatal adiposity [ large for gestational age ; % BF ; and sum of skinfolds (∑SFT)>90th centile ] were assessed using multiple logistic regression analyses . RESULTS Adjusting for potential confounders we observed strong positive continuous associations across the range of maternal fasting and 2-hour glucose in relation to excessive neonatal adiposity ; each 1 SD increase in fasting glucose was associated with 1.31 [ 95 % confidence interval ( CI ) 1.10 - 1.55 ] , 1.72 ( 95 % CI 1.31 - 2.27 ) and 1.64 ( 95 % CI 1.32 - 2.03 ) increases in odds ratios for large for gestational age and % BF and ∑SFT greater than the 90th centile , respectively . Corresponding odds ratios for 2-hour glucose were 1.11 ( 95 % CI 0.92 - 1.33 ) , 1.55 ( 95 % CI 1.10 - 2.20 ) , and 1.40 ( 95 % CI 1.10 - 1.79 ) , respectively . The influence of high maternal fasting glucose on neonatal ∑SFT was less pronounced in Indians compared with Chinese ( interaction P=.005 ) . CONCLUSIONS A continuous relationship between maternal glycemia and excessive neonatal adiposity extends across the range of maternal glycemia . Compared with Chinese infants , Indian infants may be less susceptible to excessive adiposity from high maternal glucose levels The data for medical decision analyses are often unreliable . Traditional sensitivity analysis --varying one or more probability or utility estimates from baseline values to see if the optimal strategy changes -- is cumbersome if more than two values are allowed to vary concurrently . This paper describes a practical method for probabilistic sensitivity analysis , in which uncertainties in all values are considered simultaneously . The uncertainty in each probability and utility is assumed to possess a probability distribution . For ease of application we have used a parametric model that permits each distribution to be specified by two values : the baseline estimate and a bound ( upper or lower ) of the 95 percent confidence interval . Following multiple simulations of the decision tree in which each probability and utility is r and omly assigned a value within its distribution , the following results are recorded : ( a ) the mean and st and ard deviation of the expected utility of each strategy ; ( b ) the frequency with which each strategy is optimal ; ( c ) the frequency with which each strategy " buys " or " costs " a specified amount of utility relative to the remaining strategies . As illustrated by an application to a previously published decision analysis , this technique is easy to use and can be a valuable addition to the armamentarium of the decision analyst Mixed treatment comparison ( MTC ) meta- analysis is a generalization of st and ard pairwise meta- analysis for A vs B trials , to data structures that include , for example , A vs B , B vs C , and A vs C trials . There are two roles for MTC : one is to strengthen inference concerning the relative efficacy of two treatments , by including both ' direct ' and ' indirect ' comparisons . The other is to facilitate simultaneous inference regarding all treatments , in order for example to select the best treatment . In this paper , we present a range of Bayesian hierarchical models using the Markov chain Monte Carlo software WinBUGS . These are multivariate r and om effects models that allow for variation in true treatment effects across trials . We consider models where the between-trials variance is homogeneous across treatment comparisons as well as heterogeneous variance models . We also compare models with fixed ( unconstrained ) baseline study effects with models with r and om baselines drawn from a common distribution . These models are applied to an illustrative data set and posterior parameter distributions are compared . We discuss model critique and model selection , illustrating the role of Bayesian deviance analysis , and node-based model criticism . The assumptions underlying the MTC models and their parameterization are also discussed Summary Background Diagnosis of gestational diabetes predicts risk of infants who are large for gestational age ( LGA ) and with high adiposity , which in turn aims to predict a future risk of obesity in the offspring . South Asian women have higher risk of gestational diabetes , lower risk of LGA , and on average give birth to infants with greater adiposity than do white European women . Whether the same diagnostic criteria for gestational diabetes should apply to both groups of women is unclear . We aim ed to assess the association between maternal glucose and adverse perinatal outcomes to ascertain whether thresholds used to diagnose gestational diabetes should differ between south Asian and white British women . We also aim ed to assess whether ethnic origin affected prevalence of gestational diabetes irrespective of criteria used . Methods We used data ( including results of a 26–28 week gestation oral glucose tolerance test ) of women from the Born in Bradford study , a prospect i ve study that recruited women attending the antenatal clinic at the Bradford Royal Infirmary , UK , between 2007 and 2011 and who intended to give birth to their infant in that hospital . We studied the association between fasting and 2 h post-load glucose and three primary outcomes ( LGA [ defined as birthweight > 90th percentile for gestational age ] , high infant adiposity [ sum of skinfolds > 90th percentile for gestational age ] , and caesarean section ) . We calculated adjusted odds ratios ( ORs ) and their 95 % confidence intervals ( CIs ) for a 1 SD increase in fasting and post-load glucose . We established fasting and post-load glucose thresholds that equated to an OR of 1·75 for LGA and high infant adiposity in each group of women to identify ethnic-specific criteria for diagnosis of gestational diabetes . Findings Of 13 773 pregnancies , 3420 were excluded from analyses . Of 10 353 eligible pregnancies , 4088 women were white British , 5408 were south Asian , and 857 were of other ethnic origin . The adjusted ORs of LGA per 1 SD fasting glucose were 1·22 ( 95 % CI 1·08–1·38 ) in white British women and 1·43 ( 1·23–1·67 ) in south Asian women ( pinteraction with ethnicity = 0·39 ) . Results for high infant adiposity were 1·35 ( 1·23–1·49 ) and 1·35 ( 1·18–1·54 ; pinteraction with ethnicity=0·98 ) , and for caesarean section they were 1·06 ( 0·97–1·16 ) and 1·11 ( 1·02–1·20 ; pinteraction with ethnicity=0·47 ) . Associations between post-load glucose and the three primary outcomes were weaker than for fasting glucose . A fasting glucose concentration of 5·4 mmol/L or a 2 h post-load level of 7·5 mmol/L identified white British women with 75 % or higher relative risk of LGA or high infant adiposity ; in south Asian women , the cutoffs were 5·2 mmol/L or 7·2 mml/L ; in the whole cohort , the cutoffs were 5·3 mmol/L or 7·5 mml/L. The prevalence of gestational diabetes in our cohort ranged from 1·2 % to 8·7 % in white British women and 4 % to 24 % in south Asian women using six different criteria . Compared with the application of our whole-cohort criteria , use of our ethnic-specific criteria increased the prevalence of gestational diabetes in south Asian women from 17·4 % ( 95 % CI 16·4–18·4 ) to 24·2 % ( 23·1–25·3 ) . Interpretation Our data support the use of lower fasting and post-load glucose thresholds to diagnose gestational diabetes in south Asian than white British women . They also suggest that diagnostic criteria for gestational diabetes recommended by UK NICE might underestimate the prevalence of gestational diabetes compared with our criteria or those recommended by the International Association of Diabetes and Pregnancy Study Groups and WHO , especially in south Asian women . Funding The National Institute for Health Research OBJECTIVES The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia , birth trauma , neonatal hypoglycemia , and operative delivery . The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study , by determining realistic accrual rates , and by detecting any major adverse outcomes in the control group that received routine obstetric care . STUDY DESIGN The study was a prospect i ve r and omized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes . Women r and omized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care , and women in the control arm received routine obstetric care . RESULTS Three hundred women with gestational diabetes mellitus were studied . There was no difference in maternal age , weight , or length of gestation between groups . The treatment mean birth weight was 3437 + /- 575 gm compared with 3544 + /- 601 gm in the control group , a difference of 107 gm ( not significant ) . Macrosomia rates were similar . There was no birth trauma in either group . The frequency of neonatal hypoglycemia and other metabolic complications was the same . The mode of delivery also showed similar patterns . The treatment group had significantly lower prepr and ial and postpr and ial glucose levels by 32 weeks ' gestation , which continued to term . CONCLUSION This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight , birth trauma , operative delivery , or neonatal metabolic disorders . It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings Aims /hypothesisIt is currently not clear how to construct a time- and cost-effective screening strategy for gestational diabetes mellitus ( GDM ) . Thus , we elaborated a simple screening algorithm combining ( 1 ) fasting plasma glucose ( FPG ) measurement ; and ( 2 ) a multivariable risk estimation model focused on individuals with normal FPG levels to decide if a further OGTT is indicated . Methods A total of 1,336 women were prospect ively screened for several risk factors for GDM within a multicentre study conducted in Austria . Of 714 women ( 53.4 % ) who developed GDM using recent diagnostic guidelines , 461 were sufficiently screened with FPG .  A risk prediction score was finally developed using data from the remaining 253 women with GDM and 622 healthy women . The screening algorithm was vali date d with a further 258 pregnant women . Results A risk estimation model including history of GDM , glycosuria , family history of diabetes , age , preconception dyslipidaemia and ethnic origin , in addition to FPG , was accurate for detecting GDM  in participants with normal FPG . Including an FPG pretest , the receiver operating characteristic AUC of the screening algorithm was 0.90 ( 95 % CI 0.88 , 0.91 ) . A cut-off value of 0.20 was able to differentiate between low and intermediate risk for GDM with a high sensitivity . Comparable results were seen with the validation cohort . Moreover , we demonstrated an independent association between values derived from the risk estimation and macrosomia in offspring ( OR 3.03 , 95 % CI 1.79 , 5.19 , p < 0.001 ) . Conclusions /interpretationThis study demonstrates a new concept for accurate but cheap GDM screening . This approach should be further evaluated in different population s to ensure an optimised diagnostic algorithm BACKGROUND We conducted a r and omized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications . METHODS We r and omly assigned women between 24 and 34 weeks ' gestation who had gestational diabetes to receive dietary advice , blood glucose monitoring , and insulin therapy as needed ( the intervention group ) or routine care . Primary outcomes included serious perinatal complications ( defined as death , shoulder dystocia , bone fracture , and nerve palsy ) , admission to the neonatal nursery , jaundice requiring phototherapy , induction of labor , cesarean birth , and maternal anxiety , depression , and health status . RESULTS The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group ( 1 percent vs. 4 percent ; relative risk adjusted for maternal age , race or ethnic group , and parity , 0.33 ; 95 percent confidence interval , 0.14 to 0.75 ; P=0.01 ) . However , more infants of women in the intervention group were admitted to the neonatal nursery ( 71 percent vs. 61 percent ; adjusted relative risk , 1.13 ; 95 percent confidence interval , 1.03 to 1.23 ; P=0.01 ) . Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group ( 39 percent vs. 29 percent ; adjusted relative risk , 1.36 ; 95 percent confidence interval , 1.15 to 1.62 ; P<0.001 ) , although the rates of cesarean delivery were similar ( 31 percent and 32 percent , respectively ; adjusted relative risk , 0.97 ; 95 percent confidence interval , 0.81 to 1.16 ; P=0.73 ) . At three months post partum , data on the women 's mood and quality of life , available for 573 women , revealed lower rates of depression and higher scores , consistent with improved health status , in the intervention group . CONCLUSIONS Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman 's health-related quality of life Aims /hypothesisThe aim of the study was to examine the association of existing diabetes ( i.e. already diagnosed prior to pregnancy ) , gestational diabetes and glycosuria ( both diagnosed and ascertained during pregnancy ) with birthweight and future offspring BMI , waist circumference and fat mass ( assessed by dual x-ray emission absorptiometry ) . Methods A prospect i ve pregnancy/birth cohort study was performed using data from the Avon Longitudinal Study of Parents and Children . Results Among 10,591 mother – offspring pairs included in analyses with birth size , women with existing diabetes ( n = 40 ) , those diagnosed with gestational diabetes ( n = 53 ) and those with at least two episodes of + + glycosuria ( n = 372 ) had greater  mean birthweight and odds for macrosomia  ( birthweight > 4,000 g ) than women with none of these . Adjusted odds ratios for macrosomia were 3.56 ( 95 % CI 1.53–8.28 ) , 5.50 ( 95 % CI 1.18–10.30 ) and 1.58 ( 95 % CI 1.18–2.12 ) for existing diabetes , gestational diabetes and glycosuria , respectively . Among 6,842 mother – offspring pairs with anthropometric measurements at age 9–11 years , maternal gestational diabetes and glycosuria ( but not existing diabetes ) were associated with increased offspring odds of general or central overweight/obesity . For gestational diabetes , these associations attenuated towards the null with adjustment for maternal prepregnancy BMI , but independent associations remained for glycosuria . The adjusted odds ratio for general overweight/obesity when comparing women with at least two episodes of + + glycosuria with those with no evidence of diabetes or glycosuria was 1.35 ( 95 % CI 1.00–1.82 ) and that for central obesity ( top 10 % waist circumference vs all others ) was 1.31 ( 95 % CI 1.00–1.72 ) . Conclusions /interpretationThese results provide some evidence for a long-term effect of maternal glycaemia in pregnancy on offspring obesity risk AIMS We compared metformin with insulin as treatment of gestational diabetes mellitus ( GDM ) . Furthermore , we aim ed to characterize  metformin-treated patients needing additional insulin to achieve prespecified glucose targets . METHODS We conducted a single centre r and omized controlled study with non-inferiority design comparing metformin and insulin in the treatment of 217 GDM patients having birth weight as primary outcome variable . RESULTS There were no significant differences in mean birth weight expressed in grams [ + 15 ( 90 % confidence interval ( CI ) : -121 to 89 ) ] or SD units [ + 0.04 ( 90 % CI : -0.27 to 0.18 ) ] between the metformin and insulin groups . There were no significant differences in neonatal or maternal data between the groups . Only 23 ( 20.9 % ) of the 110 patients in the metformin group needed additional insulin .  Compared with the patients on metformin only , those needing additional insulin  were older ( p = 0.04 ) , their oral glucose tolerance test had been performed earlier and diabetes therapy started earlier in gestation ( p = 0.01 and p = 0.004 , respectively ) . The risk for additional insulin was 4.6-fold in women with baseline serum fructosamine concentration above median compared with those below median . CONCLUSIONS Metformin is an effective alternative to insulin in the treatment of GDM patients . Serum fructosamine may help in predicting the adequacy of metformin treatment alone OBJECTIVE To compare glycemic control and neonatal outcomes in women with gestational diabetes mellitus ( GDM ) treated with metformin vs. insulin . STUDY DESIGN Women with GDM not controlled with diet and exercise were r and omized to metformin ( n = 32 ) or insulin ( n = 31 ) . The levels of glycemic control as well as maternal/neonatal complications were evaluated . RESULTS The mean ( + /- SD ) fasting and 2-hour postpr and ial blood glucose did not differ statistically between the 2 treatment groups . No patient failed metformin and required insulin . The majority ( 27/32 ) were easily controlled on the initial dosage ( 500 mg twice a day ) . Gestational age at entry and delivery ( p = 0.077 , 0.412 ) were similar . The difference in the rate of cesarean delivery was not statistically significant between the 2 groups ( p = 0.102 ) . Neonatal statistics were also not different between the metformin and insulin groups : birth weight , Apgar score at 5 minutes , respiratory distress syndrome , hyperbilirubinemia , neonatal hypoglycemia and neonatal intensive care unit admission ( p = 0.144 - 0.373 ) . CONCLUSION Based on these preliminary data , metformin appears to be an effective alternative to insulin in the treatment of GDM AIM A prediction rule for gestational diabetes mellitus ( GDM ) could be helpful in early detection and increased efficiency of screening . A prediction rule by means of a clinical scoring system is available , but has never been vali date d externally . The aim of this study was to vali date the scoring system . METHODS We used data from a prospect i ve cohort study . Women were assigned a score based on age , BMI and ethnicity . Performance of the scoring system was evaluated in terms of discrimination and calibration ( agreement between clinical score and observed probability of GDM ) . We compared the efficiency of a screening strategy derived from the scoring system with conventional screening . RESULTS We studied 1266 women . Forty-seven women had GDM ( 3.7 % ) . The scoring system discriminated moderately ( area under the curve=0.64 ( 95 % CI 0.56 - 0.72 ) ) . Calibration was limited ( chi(2)=8.89 , p=0.06 ) . The screening strategy derived from the scoring system reduced the number of women needed to be screened with 25 % for a comparable detection rate to universal screening . CONCLUSION Despite moderate discriminative capacity and calibration of the scoring system , the screening strategy based on the scoring system appears clinical ly useful . There is need for better prediction models for GDM Background : Few studies have been done on the use of metformin in pregnancy and their results were not similar , therefore this research is performed to compare neonatal outcomes of metformin and insulin in the treatment of gestational diabetes . Methods : In this prospect i ve r and omized trial , 200 pregnant women within their 24th to 34th weeks of gestation with gestational diabetes , single fetus pregnancy , and in need of hyperglycemia treatment were entered and grouped as either metformin or insulin . Data related to maternal and neonatal outcomes were recorded and analyzed . Results : Considering data recorded of HbA1c at the beginning of pregnancy , pregnancy induced hypertension , preeclampsia , birth weight , dystocia , first and 5th min APGAR , neonatal sepsis , rout of delivery , liver function tests of neonate , hypoglycemia , anomaly , and still birth , there were no significant statistical differences between groups . The end pregnancy HbA1c , maternal weight gain during pregnancy , preterm labor , neonatal jaundice , respiratory distress and hospitalization of infants were higher in insulin group . Conclusions : Considering data from this study , metformin is efficient to control hyperglycemia in pregnancy . It is suggested performing more studies to evaluate long term side effects of metformin in pregnancy with higher sample size and longer follow-up of newborns Objective : To describe how maternal obesity prevalence varies by established international and South Asian specific body mass index ( BMI ) cut-offs in women of Pakistani origin and investigate whether different BMI thresholds can help to identify women at risk of adverse pregnancy and birth outcomes . Design : Prospect i ve bi-ethnic birth cohort study ( the Born in Bradford ( BiB ) cohort ) . Setting : Bradford , a deprived city in the North of the UK . Participants : A total of 8478 South Asian and White British pregnant women participated in the BiB cohort study .Main outcome measures : Maternal obesity prevalence ; prevalence of known obesity-related adverse pregnancy outcomes : mode of birth , hypertensive disorders of pregnancy ( HDP ) , gestational diabetes , macrosomia and pre-term births . Results : Application of South Asian BMI cut-offs increased prevalence of obesity in Pakistani women from 18.8 ( 95 % confidence interval ( CI ) 17.6–19.9 ) to 30.9 % ( 95 % CI 29.5–32.2 ) . With the exception of pre-term births , there was a positive linear relationship between BMI and prevalence of adverse pregnancy and birth outcomes , across almost the whole BMI distribution . Risk of gestational diabetes and HDP increased more sharply in Pakistani women after a BMI threshold of at least 30 kg m−2 , but there was no evidence of a sharp increase in any risk factors at the new , lower thresholds suggested for use in South Asian women . BMI was a good single predictor of outcomes ( area under the receiver operating curve : 0.596–0.685 for different outcomes ) ; prediction was more discriminatory and accurate with BMI as a continuous variable than as a binary variable for any possible cut-off point . Conclusion : Applying the new South Asian threshold to pregnant women would markedly increase those who were referred for monitoring and lifestyle advice . However , our results suggest that lowering the BMI threshold in South Asian women would not improve the predictive ability for identifying those who were at risk of adverse pregnancy outcomes OBJECTIVE To develop a model for the prediction of gestational diabetes mellitus ( GDM ) from maternal characteristics and biochemical markers at 11 to 13 weeks ' gestation . METHODS A prospect i ve screening study on early prediction of pregnancy complications ( n = 11 , 464 ) , including 297 ( 2.6 % ) cases of GDM was used to create the predictive model of GDM based on maternal characteristics .  Maternal serum concentrations of adiponectin , follistatin-like-3 ( FSTL3 ) and sex hormone-binding globulin ( SHBG ) were measured in a case-control study of 80 women who developed GDM and 300 controls . RESULTS In the screening study , maternal age , body mass index , racial origin , previous history of GDM and macrosomic neonate were significant independent predictors of future GDM . In the GDM group , compared to controls , the median multiple of the normal median adiponectin ( 0.66 ; IQR : 0.5 - 0.9 vs 1.02 ; IQR : 0.7 - 1.29 ) and SHBG ( 0.81 ; IQR : 0.6 - 1.04 vs 1.02 ; IQR : 0.8 - 1.2 ) was lower ( p < 0.05 ) , but FSTL3 was not significantly different . In screening for GDM by maternal characteristics , the detection rate was 61.6 % at a false-positive rate of 20 % and the detection increased to 74.1 % by the addition of adiponectin and SHBG . CONCLUSION First-trimester screening for GDM can be provided by a combination of maternal characteristics and biomarkers OBJECTIVE To compare management based on maternal glycemic criteria with management based on relaxed glycemic criteria and fetal abdominal circumference ( AC ) measurements in order to select patients for insulin treatment of gestational diabetes mellitus ( GDM ) with fasting hyperglycemia . RESEARCH DESIGN AND METHODS In a pilot study , 98 women with fasting plasma glucose ( FPG ) concentrations of 105 - 120 mg/dl were r and omized . The st and ard group received insulin treatment . The experimental group received insulin if the AC , measured monthly , was > or = 70th percentile and /or if any venous FPG measurement was > 120 mg/dl . Power was projected to detect a 250-g difference in birth weights . RESULTS Gestational ages , maternal glycemia , and AC percentiles were similar at r and omization . After initiation of protocol , venous FPG ( P = 0.003 ) and capillary blood glucose levels ( P = 0.049 ) were significantly lower in the st and ard group . Birth weights ( 3,271 + /- 458 vs. 3,369 + /- 461 g ) , frequencies of birth weights > 90th percentile ( 6.3 vs 8.3 % ) , and neonatal morbidity ( 25 vs. 25 % ) did not differ significantly between the st and ard and experimental groups , respectively . The cesarean delivery rate was significantly lower ( 14.6 vs. 33.3 % , P = 0.03 ) in the st and ard group ; this difference was not explained by birth weights . In the experimental group , infants of women who did not receive insulin had lower birth weights than infants of mothers treated with insulin ( 3,180 + /- 425 vs. 3,482 + /- 451 g , P = 0.03 ) . CONCLUSIONS In women with GDM and fasting hyperglycemia , glucose plus fetal AC measurements identified pregnancies at low risk for macrosomia and result ed in the avoidance of insulin therapy in 38 % of patients without increasing rates of neonatal morbidity This paper is concerned with whether mothers who are more adipose or have higher glucose levels during pregnancy may overfeed their developing infants in utero and in doing so may set them on a pathway to greater adiposity throughout their lives . If this is the case , then the more adipose daughters of these mothers may also subsequently overfeed their infants in utero , thereby perpetuating the risk of greater adiposity across generations . I begin with the historical context of how gestational diabetes was first recognized and early evidence that diabetes in pregnancy results in increased birth size and adiposity . I then consider four questions , which are the main focus of the paper . Each of the four questions involves an exposure during pregnancy and evidence concerned with whether the exposure is causally related to offspring adiposity via intra-uterine mechanisms . The four related exposures are : ( i ) pregnancy diabetes ; ( ii ) extreme maternal pregnancy obesity ( 440 kg/m or meeting criteria for bariatric surgery ) ; ( iii ) incrementally greater pre-/early pregnancy adiposity across the whole distribution seen in pregnant women ; and ( iv ) gestational weight gain . Since r and omized controlled trial evidence is not available I focus on methods that can provide the best causal evidence from observational data such as negative control studies , family comparisons and using genetic variants as instrumental variables ( i.e. Mendelian r and omization studies ) . Having addressed these four questions I go on to briefly discuss the possible role of epigenetic modification mediating any effects of maternal exposures on offspring outcomes . I conclude with a discussion about the future research and policy implication s of evidence to date in this field OBJECTIVE Gestational diabetes mellitus ( GDM ) may cause obesity in the offspring . The objective was to assess the effect of treatment for mild GDM on the BMI of 4- to 5-year-old children . RESEARCH DESIGN AND METHODS Participants were 199 mothers who participated in a r and omized controlled trial of the treatment of mild GDM during pregnancy and their children . Trained nurses measured the height and weight of the children at preschool visits in a state-wide surveillance program in the state of South Australia . The main outcome measure was age- and sex-specific BMI Z score based on st and ards of the International Obesity Task Force . RESULTS At birth , prevalence of macrosomia ( birth weight ≥4,000 g ) was 5.3 % among the 94 children whose mothers were in the intervention group , and 21.9 % among the 105 children in the routine care control group . At 4- to 5-years-old , mean ( SD ) BMI Z score was 0.49 ( 1.20 ) in intervention children and 0.41 ( 1.40 ) among controls . The difference between treatment groups was 0.08 ( 95 % CI −0.29 to 0.44 ) , an estimate minimally changed by adjustment for maternal race , parity , age , and socio-economic index ( 0.08 [ −0.29 to 0.45 ] ) . Evaluating BMI ≥85th percentile rather than continuous BMI Z score gave similarly null results . CONCLUSIONS Although treatment of GDM substantially reduced macrosomia at birth , it did not result in a change in BMI at age 4- to 5-years-old One hundred eight gestational diabetics were r and omized to receive either diet alone or diet plus insulin ( 20 units NPH and 10 units regular ) for glycemic control . Blood glucose levels were evaluated weekly in a high-risk clinic where medical and nutritional support and counseling were provided . Among 68 women successfully treated for a minimum of 6 weeks , the mean birth weight , macrosomia rate , and ponderal index were reduced significantly in the insulin- treated group . Insulin  reduced birth weights significantly in women with a delivery weight of 200 lb or more ( 4060 ± 342 versus 3397 ± 640 g ) and in those with a delivery weight less than 200 lb ( 3324 ± 448 versus 3047 ± 394 g ) . No patient with good glucose control and a maternal delivery weight under 200 lb had a newborn over 4000 g. Patients failing glycemic control were at greatest risk ( 30 % ) for fetal overgrowth whether initially receiving insulin or not . Maternal obesity or failure to achieve glycemic control should alert the clinician to a substantially increased risk of macrosomia OBJECTIVE To assess blood glucose control and neonatal outcomes when women with gestational diabetes mellitus ( GDM ) were treated with metformin or glyburide . METHODS When an appropriate diet was insufficient to control their blood glucose levels , women with GDM were r and omized to a glyburide or a metformin treatment group . If the maximum dose was reached , the assessed drug was replaced by insulin . The primary outcome measures analyzed were maternal glucose levels during pregnancy , birth weight , and neonatal glucose levels . RESULTS The only significant difference in outcome between the 2 treatment drugs was that maternal weight gain during pregnancy was less in the metformin ( n=40 ) than in the glyburide group ( n=32 ) ( 10.3 kg vs 7.6 kg ; P=0.02 ) . No differences were found in treatment failure , mean level of fasting or postpr and ial plasma glucose , rate of participants with glycated hemoglobin , birth weight , rate of large-for-gestational-age newborns , or newborns with hypoglycemia . CONCLUSION The treatment of GDM with metformin or glyburide was found to be equivalent for both women and newborns OBJECTIVE To estimate the prevalence of and associated factors in  gestational diabetes mellitus ( GDM )  and its seasonal variation . STUDY DESIGN A clinic-based , prospect i ve , case register study was conducted from January 1996 to December 1997 . A total of 4,942 consecutive Caucasian , pregnant women aged 15 - 46 years , free of a history of diabetes mellitus , underwent r and om plasma glucose screening and a 75-g , 2-hour oral glucose tolerance test  in Plymouth , U.K. The mean ( SD ) age of the women was 28.2 ( 5.5 ) years . Women with and without GDM were compared . RESULTS The prevalence of GDM among the subjects was 1.8 % ( 95 % CI 1.4,2.2 ) . The prevalence of GDM increased with the mother 's age and r and om plasma glucose level and decreased with the duration of pregnancy . Using a stepwise binary logistic regression model , older age ( relative prevalence [ RP ] 1.08 [ 95 % CI 1.04 , 1.12 ] ) and higher r and om plasma glucose ( RP 2.99 [ 95 % CI 2.51 , 3.551 ) were significant predictors of GDM . The monthly prevalence of GDM ranged from 2.9 % ( 95 % CI 1.5 , 5.0 ) in June to 1.1 % ( 95 % CI 0.3,2.8 ) in November . The seasonal GDM rate ranged from 2.3 % ( 95 % CI 1.5 , 3.2 ) in spring to 1.4 % ( 95 % CI 0.8 , 2.3 ) in winter . The differences were not statistically significant for either the month ( p = 0.82 ) or season ( p = 0.41 ) . CONCLUSION The prevalence ( 1.8 % ) of GDM in this representative sample of Caucasian pregnant women was lower than the 3 - 5 % typically reported in other European and North American studies , and there was no seasonal pattern Objective . To evaluate the accuracy of diagnosing gestational diabetes mellitus ( GDM ) by a 2‐h blood glucose value ≥9.0 mmol/l in the 75 g oral glucose tolerance test ( OGTT ) . The maternal and neonatal outcome in women with a 2‐h blood glucose value just below this limit , 8.0–8.9 mmol/l , is analyzed . The outcome is compared to a r and omly selected control group Objective : To evaluate the association between obesity , glucose challenge test ( GCT ) and pregnancy outcome . Methods : A prospect i ve cohort study of 6854 consecutive gravid patients screened for gestational diabetes ( GDM ) using 50-gram GCT , at 24–28 weeks ' gestation was performed . A screening value ⩾ 130 mg/dl was followed by 100 gr oral GTT . Patients who were diagnosed with GDM were excluded . For purpose of analysis patients were categorized by prepregnancy BMI and by different GCT thresholds . Maternal outcome was defined by rate of preeclampsia , gestational age at delivery , cesarean section ( CS ) rate and the need for labor induction . Neonatal outcome was defined by fetal size ( macrosomia/LGA ) , arterial cord pH , respiratory complications and neonatal intensive care unit ( NICU ) admission . Results : Overall , a positive GCT result ( GCT ⩾ 130 mg/dl ) was identified in 2541/6854 ( 37 % ) women . GDM was further diagnosed in 464/6854 ( 6.8 % ) of subjects . In both groups of screening results ( > 130 mg/dl and < 130 mg/dl ) , the obese women were significantly older , gained more weight during pregnancy and had a lower rate of nulliparity in comparison to the non obese women . The obese women had higher rates of macrosomia , LGA and induction of labor . No difference was found in mean birth weight , the total rate of cesarean section , preterm delivery , 5 minute Apgar score ⩽ 7 , mean arterial cord pH , NICU admission and a need for respiratory support in comparison to non obese women in both groups of screening results . A gradual increase in the rate of macrosomia , LGA and cesarean section was identified in both obese and non-obese women in relation to increasing GCT severity categories . Conclusion : Fetal size and cesarean section rate are associated with the degree of carbohydrate intolerance ( screening results ) . Furthermore , obesity remains the main contributor impacting fetal size OBJECTIVE We hypothesized that body composition would be similar among neonates of women with gestational diabetes ( GDM ) treated with glyburide or insulin . STUDY DESIGN Women with GDM requiring medical therapy were r and omized to insulin or glyburide . The primary outcome was percent neonatal fat mass measured by total body electrical conductivity . Secondary outcomes included anthropometrics , glycemic control , and biomarkers . Statistical analysis included Student t test , chi(2 ) , and regression modeling . RESULTS Eighty-two neonates underwent postnatal measurements . Baseline factors were not different by group . Neonatal percent fat mass did not differ between treatment groups ( 11.2 + /- 4.2 vs 12.8 + /- 5.7 ) . Fat mass , body mass index , ponderal index , skinfold sum , and arm fat area were not different when analyzed by intent to treat or actual treatment group . Cord concentrations of biomarkers were also similar . CONCLUSION There was no difference in neonatal adiposity in infants of women treated for GDM with glyburide or insulin OBJECTIVE We evaluated whether improvements in pregnancy outcomes after treatment of mild gestational diabetes mellitus differed in magnitude on the basis of fetal gender . STUDY DESIGN This is a secondary analysis of a masked r and omized controlled trial of treatment for mild gestational diabetes mellitus . The results included preeclampsia or gestational hypertension , birthweight , neonatal fat mass , and composite adverse outcomes for both neonate ( preterm birth , small for gestational age , or neonatal intensive care unit admission ) and mother ( labor induction , cesarean delivery , preeclampsia , or gestational hypertension ) . After stratification according to fetal gender , the interaction of gender with treatment status was estimated for these outcomes . RESULTS Of the 469 pregnancies with male fetuses , 244 pregnancies were assigned r and omly to treatment , and 225 pregnancies were assigned r and omly to routine care . Of the 463 pregnancies with female fetuses , 233 pregnancies were assigned r and omly to treatment , and 230 pregnancies were assigned r and omly to routine care . The interaction of gender with treatment status was significant for fat mass ( P = .04 ) and birthweight percentile ( P = .02 ) . Among women who were assigned to the treatment group , male offspring were significantly more likely to have both a lower birthweight percentile ( 50.7 ± 29.2 vs 62.5 ± 30.2 percentile ; P < .0001 ) and less neonatal fat mass ( 487 ± 229.6 g vs 416.6 ± 172.8 g ; P = .0005 , ) whereas these differences were not significant among female offspring . There was no interaction between fetal gender and treatment group with regard to other outcomes . CONCLUSION The magnitude of the reduction of a newborn 's birthweight percentile and neonatal fat mass that were related to the treatment of mild gestational diabetes mellitus appears greater for male neonates OBJECTIVE The objective of the study was to compare premixed insulin aspart 30 ( BIAsp 30 ) vs premixed human insulin 30 ( BHI 30 ) on efficacy , safety , fetal and perinatal outcomes in pregnancies associated with gestational diabetes mellitus [ GDM ] . This was the first r and omized study to use pre mixed insulin analogue [ BIAsp ] in GDM . METHODS The study population consisted of 76 GDM women assigned to BIAsp 30 ( group A ) and an equal number to BHI 30 ( group B ) . RESULTS There was no statistically significant difference between the age , BMI , gestational weeks and glycemic level at entry between the group A and group B women ( p > 0.05 ) . There was no statistical difference between the two groups in glycemic control or insulin dose ( p > 0.05 ) before confinement . The frequency of birth weight of new born above 90 percentile was 6.8 % in Group 1 and 9.2 % in Group 2 . The proportion of macrosomia was higher in Group 2 when compared to Group 1 , however the difference was not statistically significant ( P = 0.819 ) . CONCLUSION BIAsp was safe during pregnancy and pregnant women found it convenient due to meal time dosing . Fetal outcome using BIAsp was also comparable with BHI 30 OBJECTIVE To examine the association between levels of hyperglycemia , determined by each prenatal oral glucose tolerance test ( OGTT ) value ( fasting , 1 and 2 h ) , and maternal and perinatal outcomes and to determine whether the risk for these outcomes differs for women whose value(s ) equaled or exceeded the thresholds for gestational diabetes mellitus ( GDM ) established by the International Association of Diabetes in Pregnancy Study Groups ( IADPSG ) . RESEARCH DESIGN AND METHODS This article discusses a retrospective study of 8,711 women , delivering at ≥20 weeks ' gestation , who had a prenatal 2-h 75-g OGTT without a prior 50-g challenge and were not treated with insulin , glyburide , diet , and /or exercise during pregnancy . Associations between adverse outcomes and elevated OGTT values are reported . RESULTS After excluding treated women , 19.4 % of the remaining women had IADPSG-defined GDM . Continuous fasting , 1- and 2-h OGTT measures , and GDM ( yes/no ) were significantly associated with most adverse outcomes . However , the magnitude and significance of risk for these outcomes differed by various combinations of abnormal glucose values . Women with normal fasting and elevated postload values were at higher risk for preterm delivery , gestational hypertension , and having an infant with hyperbilirubinema , whereas women with elevated fasting and normal postload values were at higher risk of having a large-for-gestational-age infant , compared with women without GDM . CONCLUSIONS Risks for different adverse outcomes vary depending on which single or combined IADPSG-defined OGTT thresholds are equaled or exceeded . Prospect i ve studies are needed to determine whether changing pre- and postpr and ial glucose targets during pregnancy will more uniformly reduce adverse outcomes OBJECTIVE This study was performed to prospect ively evaluate a screening model for gestational diabetes mellitus on the basis of clinical risk indicators . STUDY DESIGN In a prospect i ve multicenter study with 5235 consecutive pregnant women , diagnostic testing with a 2-hour 75-g oral glucose tolerance test was routinely performed in women with risk indicators and offered to women without risk indicators as part of the study . RESULTS Forty-four percent of the women underwent testing , 43 % declined participation , 6 % did not speak Danish , and 7 % could not be contacted . By extrapolation of the results from tested women to the whole group in question , a 2.4 % prevalence of gestational diabetes mellitus was calculated . Sensitivity and specificity of the model was 80.6 ( 73.7 - 87.6 ) and 64.8 ( 63.5 - 66.1 ) , respectively ( 95 % CIs ) . CONCLUSION Under ideal conditions , sensitivity of the model was comparable with universal screening by fasting glucose or a 1-hour 50-g glucose challenge test . Both screening and diagnostic testing could be avoided in two thirds of all pregnant women RATIONALE , AIMS AND OBJECTIVE To investigate whether the introduction of a programme of optimising drug treatment , intensive education and self-monitoring of patients diagnosed with gestational diabetes mellitus ( GDM ) at an early stage ( < 20 gestational weeks ) , will improve management outcomes as determined by objective measures of patient knowledge about diabetes , glycaemia control , maternal/neonatal complications , and health-related quality of life . METHODS The study was a r and omized , controlled , longitudinal , prospect i ve clinical trial performed at Al-Ain Hospital , Al-Ain , United Arab Emirates . Over an 18-month period , patients diagnosed with GDM were recruited and were r and omly assigned to either an intervention or a control group , in a ratio of 3:2 . Intervention patients received a structured pharmaceutical care service ( including education and introduction of intensive self-monitoring ) while control patients received traditional services . Patients were followed up from time of recruitment until 6 months postnatally at scheduled outpatient clinics . A range of clinical and humanistic outcome measures , including maternal and neonatal complications , were used to assess the impact of the intervention . RESULTS A total of 165 patients ( 99 intervention , 66 control ) completed the study . The intervention patients exhibited a range of benefits from the provision of the programme when compared with control group patients . Statistically significant ( P < 0.05 ) improvements were shown in the intervention group for knowledge of diabetes , health-related quality of life ( as determined by the SF36 ) , control of plasma glucose and HbA(1c ) , maternal complications [ e.g. decreased incidence of pre-eclampsia ( 5.1 % vs. 16.7 % ) , eclampsia ( 1.0 % vs. 7.6 % ) , episodes of severe hyperglycaemia ( 3.0 % vs. 19.7 % ) and need for Caesarean section ( 7.1 % vs. 18.2 % ) ] , and neonatal complications [ e.g. decreased incidence of neonatal hypoglycaemia ( 2.0 % vs. 10.6 % ) , respiratory distress at birth ( 4.0 % vs. 15.2 % ) , hyperbilirubinaemia ( 1.0 % vs. 12.1 % ) and large for gestational age ( 9.0 % vs. 22.7 % ) ] . CONCLUSION The research provides clear evidence that provision of pharmaceutical care adds value to the management of GDM as exemplified by improved maternal and neonatal outcomes Summary : A r and omised controlled trial was design ed to determine the effect of moderate 30 % maternal dietary energy restriction on the requirement for maternal insulin therapy  and the incidence of macrosomia in gestational diabetes .  Although the control group restricted their intake to a level similar to that of the intervention group ( 6845 kiloJoules ( kJ ) versus 6579 kJ ) , the result ing cohort could not identify any adverse effect of energy restriction in pregnancy . Energy restriction did not alter the frequency of insulin therapy ( 17.5 % in the intervention group and 16.9 % in the control group ) . Mean birth weight  ( 3461 g in the intervention group and 3267 g in the control group ) was not affected . There was a trend in the intervention group towards later gestational age at commencement of insulin therapy ( 33 weeks versus 31 weeks ) and lower maximum daily insulin dose ( 23 units versus 60 units ) which did not reach statistical significance . Energy restriction did not cause an increase in ketonemia A cost analysis of glucose screening was studied prospect ively in 434 patients . All patients underwent a 50-gm oral glucose load followed by a 1-hour plasma glucose screen test at 28 weeks ( + /- 2 weeks ) . Patients with a screen test greater than or equal to 130 mg/dl plasma glucose were further tested with an oral glucose tolerance test . Also , previously described clinical risk factors for diabetes were documented on all patients . A 3.3 % prevalence of gestational diabetes was found in 178 patients with risk factors , compared with 2.4 % of 256 patients without risk factors , not a significant difference . Ten of the 12 gestational diabetics were at least 24 years old , so that screening only this subgroup would still retain a good sensitivity ( 83 % ) but at half the cost of universal screening . Screening on the basis of risk factors other than age is inefficient . Though testing only patients who are 24 years of age or older is more cost effective than universal screening , an individual decision must be made regarding its reduced sensitivity Aims /hypothesisThe aim of this study was to investigate whether the higher prevalence of insulin resistance and glucose intolerance in urban compared with rural Indian men is related to their higher adiposity ( percentage body fat ) and the associated inflammatory state . Methods We studied 149 rural , 142 urban slum and 150 urban middle-class male residents ( age 30–50 years ) , who were selected by stratified r and om sampling . We measured body fat ( bioimpedance ) , waist circumference , glucose tolerance ( 75 g OGTT ) , insulin resistance [ homeostasis model assessment ( HOMA-IR ) ] , beta cell function ( insulinogenic index ) and inflammatory markers ( total leucocyte count , IL-6 , TNF-α and C-reactive protein ) . Results Adiposity , waist circumference , HOMA-IR , insulinogenic index and both fasting and 120 min plasma glucose concentrations increased progressively from rural through to urban slum and urban middle-class men . Inflammatory markers were higher in urban than in rural men . Adiposity was strongly related to HOMA-IR ( r = 0.57 , p < 0.001 ) and to insulinogenic index and glycaemic parameters ( r = 0.25 , p < 0.001 for both ) . Adiposity explained approximately two thirds of the difference in HOMA-IR between the urban middle-class men and the rural and slum residents , but its contribution to the difference in insulinogenic index and 120 min plasma glucose concentration was not significant . Inclusion of C-reactive protein , IL-6 and total leucocyte count in the models did not further explain these results , nor did the inclusion of waist circumference . There was a significant residual difference after these adjustments . Conclusions /interpretationAdiposity is a major contributor to the difference in insulin resistance between rural and urban Indian men ; there was no additional contribution from inflammation or central obesity . Other unmeasured factors also seem to contribute to the metabolic differences between rural and urban men AIMS To evaluate the effect of metformin and insulin in glycemic control and compare pregnancy outcome in women with gestational diabetes mellitus ( GDM ) . METHODS This r and omized controlled trial was conducted in GDM women with singleton pregnancy and gestational age between 20 and 34 weeks who did not achieve glycemic control on diet were assigned r and omly to receive either metformin ( n=80 ) or insulin ( n=80 ) . The primary outcomes were maternal glycemic control and birth weight . The secondary outcomes were neonatal and obstetric complications . RESULTS Two groups were comparable regarding the maternal characteristics . Two groups were similar in mean FBS ( P=0.68 ) and postpr and ial measurements ( P=0.87 ) throughout GDM treatment . The neonates of metformin group had less rate of birth weight centile > 90 than insulin group ( RR : 0.5 , 95 % CI : 0.3 - 0.9 , P=0.012 ) . Maternal weight gain was reduced in the metformin group ( P<0.001 ) . Two groups were comparable according to neonatal and obstetric complications ( P>0.05 ) . In metformin group 14 % of women needed to supplemental insulin to achieve euglycemia . CONCLUSION Metformin is an effective and safe alternative treatment to insulin for women with GDM . This study does not show significant risk of maternal or neonatal adverse outcome with the use of metformin Summary : We determined in nondiabetic women , the relationship of plasma glucose values obtained 2 hours after a 75 g oral glucose challenge test ( GCT ) at 16–20 weeks ' gestation , with the incidence of macrosomia in term deliveries ( 37–41 weeks ' gestation ) . From 1988–1990 , in a systematic screening programme data collected prospect ively from 1,331 women were analysed retrospectively . Women with gestational diabetes or impaired glucose tolerance ( n = 53 ) were excluded . The rest ( n = 1,278 ) had no evidence of glucose intolerance including 1,215 women with normal plasma glucose by GCT ( < 7.8 mmol/L 2 hours after 75 g oral glucose load ) and 63 women with abnormal GCT but no abnormal value at a glucose tolerance test . The GCT values were divided into 5 groups : Group A ( < 4.5 mmol/L ) , B ( 4.5‐5.5 mmol/L ) , C ( 5.6‐6.6 mmol/L ) , D ( 6.7‐7.7 mmol/L ) and E ( > 7.8 mmol/L ) . The variables studied were age , parity , gestational age at delivery and incidence of macrosomia The purpose of this study was to examine pregnancy outcome in women with abnormal oral glucose tolerance tests , in relation to treatment with diet and insulin . Glucose tolerance tests , done because of well-known historical risk factors , were considered abnormal if two or more readings exceeded the following : fasting , 110 ; 1 hour , 170 ; 2 hours , 120 ; and 3 hours , 110 ( all in mg/100 mL , measured as total reducing substances in whole venous blood ) . Those with positive tests were divided r and omly into a “ positive-control ” group ( n 308 ) that received  st and ard prenatal care or a “ positive-treated ” group ( n 307 ) that received dietary instructions ( 30 kcal/kg ideal body weight , 40 % as carbohydrate , and 1.5–2 g protein/kg body weight ) and insulin ( initial dose 10 U per day of intermediate-acting insulin , adjusted subsequently as directed by blood and urine studies ) , beginning at usually about 32 weeks . A third group ( n 328 ) , termed “ negative controls , ” had exhibited normal glucose tolerance testing . The three groups were similar , except that those with abnormal glucose tolerance tended to be older and heavier , as expected . With respect to outcome , infants with birth weights exceeding 9 lb were three times as frequent in positive-control subjects as in either positive-treated subjects or negative controls ( 13.1 % , 4.3 % , and 3.7 % , respectively ) . Perinatal deaths ( 28 weeks ’ gestation through 14 days after birth ) were similar in the two positive groups ( 4.9 % in control and 4.3 % in treated ) and significantly higher than in negative controls ( 1.9 % ) , with the increase involving both fetal and neonatal components . The conclusions were 1 ) abnormal glucose tolerance during pregnancy leads to larger infants and higher perinatal mortality and 2 ) treatment with diet and insulin ameliorates the former but not the latter . This study concerned what O’Sullivan called potential diabetes and others at the time termed latent or chemical diabetes or prediabetes , but what today we refer to as gestational diabetes . Acceptance of it as a pathologic entity was far from unanimous in 1966 . O’Sullivan resolved the controversy with this large , well- design ed , and well-analyzed clinical trial . The immediate influence was two-fold . In the first place , it settled the existing disagreement as to whether or not impaired glucose tolerance adversely influences pregnancy outcome ; large infants occurred three times as frequently and perinatal deaths were more than doubled in women with abnormal carbohydrate metabolism . Second , the findings of the intervention trial indicated clearly that treatment of gestational diabetes with diet and insulin in late gestation normalizes birth weight ( although it did not seem to influence perinatal mortality ) , a finding confirmed a number of times by subsequent investigators . Incidentally , the frequencies of both fetal and neonatal deaths may seem high , but it needs to be remembered that this experience ante date d the advent of modern fetal surveillance and neonatal intensive care . John B. O’Sullivan , a pioneer in clinical research in gestational diabetes , was an internist . He defined st and ards for the oral glucose tolerance test in pregnancy that , though modified slightly by subsequent investigators , are basically those in use today . Born in 1926 , he received his medical education in his native Irel and before immigrating to the United States in 1955 . After further training in internal medicine at the Lahey Clinic , he took a faculty position at the Boston University School of Medicine , where he did his original work on early diabetes as medical director of the Prenatal Metabolism Clinic at Boston City Hospital and chief of medicine at St. Margaret ’s Hospital . In addition to his position as Associate Professor at Boston University , he also served on the faculties of the Harvard and Yale medical schools . Later he was director of employee health for the Liberty Mutual Insurance Company . He died of cancer in August 2001 Aims Gestational diabetes mellitus ( GDM ) is associated with adverse maternal and fetal outcome . Screening for GDM is therefore recommended but the best screening method remains controversial . This prospect i ve , r and omized study compared a risk factor‐based screening programme with a universally based one Forty-one patients with gestational diabetes requiring insulin were enrolled in a r and omized study to investigate the efficacy of an exercise program in normalizing glucose tolerance . Seventeen of 21 patients completed the exercise program while maintaining normoglycemia and obviating  insulin therapy . Maternal and neonatal complications did not differ between the study and control groups . The type of program described appears to be safe and can serve as a model for exercise prescription for pregnant diabetic women to attain improved glucose tolerance OBJECTIVES Muscle-thin but adipose ( ' thin-fat ' ) body composition of south Asian adults contributes to their high risk of type 2 diabetes . Studies in Pune , India showed that this phenotype is present at birth . We aim ed to determine if south Indian babies have a ' thin-fat ' phenotype and if this persists in childhood . DESIGN Prospect i ve cohort study . SETTING Holdsworth Memorial Hospital , Mysore , India . SUBJECTS Children ( n = 663 ) whose mothers were recruited from the antenatal clinics . METHODS Weight , length , head , mid-upper-arm , abdominal circumferences ; triceps and subscapular skinfolds  were measured at birth , one and four years , and compared with white Caucasian babies born in Southampton , UK ( birth ) , and UK and Dutch growth st and ards ( one and four years ) . RESULTS Mysore babies were lighter ( 2983 g vs 3472 g ; -1.10 SD , CI -1.16 , -1.02 ) and smaller in all body measurements than UK neonates ( P < 0.001 ) . The deficit was greatest for mid-upper-arm ( -1.07 SD ) , head ( -0.89 SD ) and abdominal circumferences ( -0.73 SD ) , and least for length ( -0.25 SD ) and subscapular skinfold thickness ( -0.19 SD ) . Predictors of skinfold thickness were maternal body mass index ( P < 0.001 ) and socio-economic status ( P = 0.05 ) . At four years , subscapular skinfold thickness was larger than UK ( + 0.18 SD , CI + 0.11 , + 0.25 ; P < 0.001 ) and Dutch st and ards ( + 0.61 SD , CI + 0.51 , + 0.71 ; P < 0.001 ) , despite all other body measurements remaining smaller . Predictors of 4-year skinfold thickness were neonatal skinfold thickness ( P = 0.001 ) and maternal insulin concentrations ( P = 0.05 ) . CONCLUSIONS Mysore newborns have a ' thin-fat ' phenotype . This may reflect the action of genes and /or the ' maternal environment ' . The phenotype persists in childhood , and may be the forerunner of a diabetogenic adult phenotype Infant macrosomia is a serious medical concern . Pregnant women who do not meet the specific diagnosis for gestational diabetes may still have glucose-mediated macrosomia . In Santa Barbara County all pregnant women are screened for gestational diabetes at 24 - 28 weeks with a 50-g , 1-hr glucose challenge test ( GCT ) . All patients who fail this test are placed on a st and ard euglycemic diet ( 40 % carbohydrate , 20 % protein , 40 % fat ) and perform home glucose monitoring of fasting and postpr and ial glucose levels . The objective of this study was to examine the effectiveness of this treatment program in decreasing infant macrosomia , maternal and infant morbidity , maternal complications , and operative delivery . We studied 103 women who had a positive GCT , but a negative 100-g , 3-hr oral glucose tolerance test ( OGTT ) . The women were r and omly assigned to either experimental or control groups with experimental women receiving dietary counseling and home glucose monitoring instruction ( HBGM ) . HBGM diaries were review ed weekly by clinic nurses . All women had hemoglobin A1c ( HbA1c ) tests at 28 and 32 weeks . Maternal and fetal charts were review ed to determine delivery type and complications , indications for cesarean section ( C-section ) , and infant gestational age , gender , Apgar scores , birth weight , morbidities , and congenital anomalies . Of the 103 women , 5 women required insulin treatment , 1 woman had an abortion , and 14 women were indeterminate regarding compliance or were control women who received diet counseling and HBGM . The results are based on 83 women--48 control and 35 experimental . There were no significant differences between the groups for age , parity , or weight at 28 - 30 weeks or 37 weeks to delivery , or HbA1c at 28 weeks . HbA1c was significantly higher in control women at 32 weeks . Birth weight expressed in grams or as a percentile specific for gender , ethnicity , and gestational age was significantly higher in control infants . Birth weight was significantly correlated with maternal intake weight , weight at 28 - 30 weeks , and weight at delivery and with HbA1c at 32 weeks ' gestation . There were no significant differences between groups for maternal complications . Groups were significantly different for mode of delivery with experimental women having more induced vaginal deliveries but fewer repeat C-sections than control women . Groups were not different for primary C-sections . Women who fail the GCT , but not the OGTT and thus do not receive the diagnosis of GDM are still at risk for delivering a macrosomic infant and operative delivery . Our program of treatment for all women who fail the GCT improves outcome by reducing infant birth weight and the number of cesarean sections This prospect i ve investigation evaluated the reproducibility of the 100 gm oral glucose tolerance test .  Sixty-four obstetric patients with greater than or equal to 135 mg/dl on the 50 gm oral glucose screening test were scheduled for the 100 gm test . All patients repeated the oral glucose tolerance test in 1 to 2 weeks . Both tests included a preparatory diet , and testing conditions were identical . There were no significant differences in the mean test values at each testing interval when the entire study population was considered . Patients were then divided into four groups according to the outcome of the two tests . Forty-eight of 64 ( 75 % ) had normal results at each testing period ( group 1 ) ; 11 of 64 ( 17 % ) had initially normal results and abnormal results on retest ( group 2 ) ; 3 of 64 ( 5 % ) had initially abnormal results and normal results on retest ( group 3 ) ; 2 of 64 ( 3 % ) had abnormal results at both testing phases ( group 4 ) . There were no significant differences between oral glucose tolerance test results within groups 1 and 4 . However , significant differences occurred within groups 2 and 3 between the two tests . Group 2 patients had a greater frequency of an abnormal 1-hour value on the test than group 1 patients ( p = 0.001 ) . Overall , the reproducibility of the oral glucose tolerance test was 78 % ( 50 of 64 ) . We recommend the oral glucose tolerance test be repeated when the 1-hour value is abnormal or when the fasting blood sugar , 1-hour , and 2-hour values are near the upper end of the normal range 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 r and omly assigned between 11 and 33 weeks of gestation to receive glyburide or insulin according to an intensified treatment protocol . The primary end point was achievement of the desired level of glycemic control . Secondary end points 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 . CONCLUSIONS In women with gestational diabetes , glyburide is a clinical ly effective alternative to insulin therapy INTRODUCTION Nutrition therapy is an integral part of the management of gestational diabetes mellitus ( GDM ) . Most women with GDM are treated by nutritional management alone . The goal of our study was to compare low and high carbohydrate diets in their effectiveness , safety and tolerability in women with GDM . MATERIAL AND METHODS The study group consisted of 30 Caucasian women newly diagnosed with GDM , with a mean age of 28.7 + /- 3.7 years and pregnancy duration of 29.2 + /- 5.4 weeks . The patients were r and omised into two groups : those on a low and those on a high carbohydrate diet ( 45 % vs. 65 % respectively of energy supply coming from carbohydrates ) . The presence of urine ketones was controlled every day . After two weeks daily glucose profiles and compliance with the recommended diets were analysed . RESULTS Glucose concentration before implementation of the diet regimen did not differ between groups . No changes in fasting blood glucose were noticed in the group that had followed a low carbohydrate diet , although a significant decrease in glucose concentration was observed after breakfast ( 102 + /- 16 vs. 94 + /- 11 mg/dl ) , lunch ( 105 + /- 12 vs. 99 + /- 9 mg/dl ) and dinner ( 112 + /- 16 vs. 103 + /- 13 mg/dl ) ( p < 0.05 ) . In the high carbohydrate diet group fasting and after-breakfast glucose concentration did not change . A significant decrease in glycaemia was noticed after lunch ( 106 + /- 15 vs. 96 + /- 7 mg/dl ) and dinner ( 107 + /- 12 vs. 97 + /- 7 mg/dl ) ( p < 0.05 ) . Ketonuria was not observed in either group . Obstetrical outcomes did not differ between groups . CONCLUSIONS Both high and low carbohydrate diets are effective and safe . A diet with carbohydrate limitation should be recommended to women who experience the highest glycaemia levels after breakfast OBJECTIVE To evaluate glycemic control in women receiving metformin or insulin for gestational diabetes , and to identify factors predicting the need for supplemental insulin in women initially treated with metformin . STUDY DESIGN Women with gestational diabetes who failed to achieve glycemic control with diet and exercise were r and omized to receive metformin ( n = 47 ) or insulin ( n = 47 ) . Criteria for inclusion were singleton pregnancy , diet , and exercise for a minimum period of 1 week without satisfactory glycemic control , absence of risk factors for lactic acidosis , and absence of anatomic and /or chromosome anomalies of the conceptus . Patients who were lost to prenatal follow-up were excluded . RESULTS Comparison of mean pretreatment glucose levels showed no significant difference between groups ( P = .790 ) . After introduction of the drug , lower mean glucose levels were observed in the metformin group ( P = .020 ) , mainly because of lower levels after dinner ( P = .042 ) . Women using metformin presented less weight gain ( P = .002 ) and a lower frequency of neonatal hypoglycemia ( P = .032 ) . Twelve women in the metformin group ( 26.08 % ) required supplemental insulin for glycemic control . Early gestational age at diagnosis ( odds ratio , 0.71 ; 95 % confidence interval , 0.52 - 0.97 ; P = .032 ) and mean pretreatment glucose level ( odds ratio , 1.061 ; 95 % confidence interval , 1.001 - 1.124 ; P = .046 ) were identified as predictors of the need for insulin . CONCLUSION Metformin was found to provide adequate glycemic control with lower mean glucose levels throughout the day , less weight gain and a lower frequency of neonatal hypoglycemia . Logistic regression analysis showed that gestational age at diagnosis and mean pretreatment glucose level were predictors of the need for supplemental insulin therapy in women initially treated with metformin OBJECTIVE To assess the relationship between a low 50-g 1-hour glucose loading test ( GLT ) and maternal and neonatal outcomes in women without diabetes . STUDY DESIGN This was a secondary analysis of a multicenter observational cohort from a r and omized trial of treatment for mild gestational diabetes . Maternal and neonatal outcomes were compared between women with GLT values < 90 mg/dL and those with results 90 to 119 mg/dL. RESULTS Of 436 enrolled women , 297 ( 68.1 % ) had a GLT result of 90 to 119 mg/dL and 139 ( 31.9 % ) had a result of < 90 mg/dL. There was a lower incidence of neonatal hypoglycemia in those with a GLT < 90 mg/dL ( 5.7 % versus 16.5 % , p = 0.006 ) . Other outcomes were not associated with test results . CONCLUSION A GLT result < 90 mg/dL compared with 90 to 119 mg/dL is associated with a lower risk of neonatal hypoglycemia , but no other significant findings CONTEXT Gestational diabetes ( GDM ) confers a high risk of  type 2 diabetes .  In the Diabetes Prevention Program ( DPP ) , intensive lifestyle ( ILS ) and metformin prevented or delayed diabetes in women with a history of GDM . OBJECTIVE The objective of the study was to evaluate the impact of ILS and metformin intervention over 10 years in women with and without a history of GDM in the DPP/Diabetes Prevention Program Outcomes Study . DESIGN This was a r and omized controlled clinical trial with an observational follow-up . SETTING The study was conducted at 27 clinical centers . PARTICIPANTS Three hundred fifty women with a history of GDM and 1416 women with previous live births but no history of GDM participated in the study . The participants had an elevated body mass index and fasting glucose and impaired glucose tolerance at study entry . INTERVENTIONS Interventions included placebo , ILS , or metformin . OUTCOMES MEASURE Outcomes measure was diabetes mellitus . RESULTS Over 10 years , women with a history of GDM assigned to placebo had a 48 % higher risk of developing diabetes compared with women without a history of GDM . In women with a history of GDM , ILS and metformin reduced progression to diabetes compared with placebo by 35 % and 40 % , respectively . Among women without a history of GDM , ILS reduced the progression to diabetes by 30 % , and metformin did not reduce the progression to diabetes . CONCLUSIONS Women with a history of GDM are at an increased risk of developing diabetes . In women with a history of GDM in the DPP/Diabetes Prevention Program Outcomes Study , both lifestyle and metformin were highly effective in reducing progression to diabetes during a 10-year follow-up period . Among women without a history of GDM , lifestyle but not metformin reduced progression to diabetes OBJECTIVE To estimate the percentage of pregnant women who would not be screened and the percentage of women with gestational diabetes mellitus ( GDM ) who would possibly remain undiagnosed if the American Diabetes Association 's ( ADA 's ) new selective screening recommendations are used rather than universal screening for GDM . RESEARCH DESIGN AND METHODS Since 1987 , the University of Michigan Health System has performed universal screening for GDM . In 1997 , the ADA recommended that women having all four of the following characteristics need not be screened : age < 25 years , not members of an ethnic/racial group with a high prevalence of diabetes , normal body weight , and no family history of diabetes . We studied a r and om sample of the 25,118 deliveries at the University of Michigan between 1987 and 1997 to determine the prevalence of these four characteristics in our obstetric population . We also studied the prevalence of these four characteristics in 200 women who were diagnosed with GDM in the Endocrine Testing Unit and delivered at the University of Michigan between 1987 and 1997 . RESULTS Approximately 10 - 11 % of women who delivered possessed all four low-risk characteristics and would not have been screened for GDM according to the new ADA recommendations . Only 4 % of women ( 5 of 141 ) with GDM who delivered and for whom data on all four characteristics were reported possessed all four low-risk characteristics and would not have been screened . CONCLUSIONS If the new ADA selective screening recommendations are used , few women with GDM will be missed ( 4 % ) but approximately 90 % of pregnant women will still need to be screened for GDM The benefits of exercise and behavioural recommendations in gestational diabetes mellitus ( GDM ) are controversial . In a r and omized trial with a 2 × 2 factorial design , we examined the effect of exercise and behavioural recommendations on metabolic variables , and maternal/neonatal outcomes in 200 GDM patients . All women were given the same diet : group D received dietary recommendations only ; group E was advised to briskly walk 20‐min/day ; group B received behavioural dietary recommendations ; group BE was prescribed the same as B + E.  Dietary habits improved in all groups . In a multivariable regression model , fasting glucose did not change . Exercise , but not behavioural recommendations , was associated with the reduction of postpr and ial glucose ( p < 0001 ) , glycated haemoglobin ( HbA1c ; p < 0.001 ) , triglycerides ( p = 0.02 ) and C‐reactive protein ( CRP ; p < 0.001 ) and reduced any maternal/neonatal complications ( OR = 0.50 ; 95%CI=0.28–0.89;p = 0.02 ) . In GDM patients  a simple exercise programme reduced maternal postpr and ial glucose , HbA1c , CRP , triglycerides and any maternal/neonatal complications , but not fasting glucose values Objective The objective of this study was to investigate early influences of postnatal growth on blood pressure ( BP ) in healthy , British-born South Asian and European origin infants . We tested the hypotheses that South Asian infants would be smaller in all body dimensions ( length and weight ) with higher relative truncal skinfold thickness at birth , and that increased ( central ) adiposity and accelerated growth up to 1 year would be associated with higher BP in both ethnic groups . Patients and methods Five hundred and sixty infants were followed prospect ively from birth to 3 and /or 12 months with measures of anthropometry and resting BP , compared against a UK 1990 growth reference , and analysed using regression methods . Results Marked differences in birth size persisted , as expected , between European and South Asian babies , but with a sexual dichotomy : South Asian boys were smaller in all anthropometric parameters ( P < 0.001 ) , including skinfolds ( P < 0.05 ) , than European boys , but South Asian girls , although smaller in length and weight , had similar skinfolds to European girls and thus a slightly larger subscapular skinfold thickness relative to birth weight [ 1.3 versus 1.2 , mean difference 0.07 , 95 % confidence interval ( CI ) 0.0009–0.14 , P = 0.047 ] . The dichotomy persisted postnatally ; South Asian boys showed a striking early increase in weight and length compared with European boys , associated with significant accrual of subscapular fat ( 6.1 versus 5.3 mm , mean difference 0.8 , 95 % CI 0.3–1.3 , P = 0.003 ) . In gender and ethnicity adjusted regression models , infants with the largest weight st and ard deviation score ( SDS ) increases in the first 3 months had the highest 12-month systolic BP ( β = 2.4 , 95 % CI 0.5–4.2 , P = 0.01 ) , while those with the greatest birth length ( β = 0.7 , 95 % CI 0.05–1.4 , P = 0.04 ) but the smallest changes in length over 3–12 months ( β = −0.57 , 95 % CI −0.95 to −0.19 , P = 0.004 ) had the highest diastolic BP . Conclusions Ethnic and gender differences in growth and adiposity present in early infancy include truncal fat preservation in South Asian girls from birth , which in boys is related to rapid early weight gain . Weight gain during the first 3 months appears to drive the rise in systolic BP to 1 year , itself a likely driver of later BP AIM The aim of this study was to assess the efficacy of glyburide in the treatment of gestational diabetes mellitus and to compare the maternal and fetal outcome between two groups treated either with insulin or glyburide . MATERIAL AND METHODS Women with gestational diabetes not responding to diet control were r and omized into two groups : ( i ) the control group receiving insulin ( n = 32 ) ; and ( ii ) the study group receiving glyburide ( n = 32 ) . Primary outcome was assessed in terms of achievement of glycemic control and secondary outcome was assessed by the incidence of maternal and fetal complications in the insulin and glyburide treated groups . RESULTS The achievement of glycemic control between the insulin and the glyburide treated groups showed no significant difference ( 97.1 % , 93.8 % ) . The occurrence of maternal complications ( P = 0.87 ) and fetal complications ( P = 0.32 ) were comparable between the insulin and glyburide treated groups . CONCLUSION Glyburide was found to be as efficacious as insulin in achieving euglycemia in the treatment of gestational diabetic women who require treatment beyond diet control OBJECTIVE This study identified the impact of intensive therapy on neonatal outcomes in women with gestational diabetes mellitus ( GDM ) and determined the effects on the postpartum metabolic status of the mothers . RESEARCH DESIGN AND METHODS In total , 127 pregnant women with GDM were r and omly selected to receive an intensive treatment regimen , which included one-to-one education , lifestyle intervention , scheduled clinic visits , strict glucose control , and frequent glucose self-monitoring . Meanwhile , 148 age-matched pregnant women with GDM were selected as controls and given the st and ard treatment regimen .  Pregnancy outcomes including parameters related to the GDM mothers and to their neonates were comparatively analyzed between the two treatment groups . GDM patient follow-up ( range , 1 - 3 years after delivery ) included an oral glucose tolerance test and measurements of lipid concentration and insulin secretion . The insulinogenic index ( ΔInsulin(30 min)/ΔBlood glucose(30 min ) ) and homeostasis model assessment index of β-cell function and insulin resistance were calculated . The patients ' demographic and anthropometric data were also recorded for comparative analysis . RESULTS Compared with GDM patients receiving st and ard treatment , GDM patients receiving intensive treatment had lower instances of premature delivery ( 2.4 % vs. 8.3 % , P<0.05 ) and neonatal care unit admission ( 21.3 % vs. 33.3 % , P<0.05 ) and lower neonatal birth weight ( 3.26±0.53 vs. 3.45±0.55 kg , P<0.0001 ) . At follow-up , GDM patients from the intensive treatment group had a smaller waist circumference ( 75.83±3.11 vs. 78.34±4.20 cm , P<0.01 ) , lower 30-min glucose levels after a 75-g glucose load ( 8.26±1.85 vs. 9.46±2.74 mmol/L , P<0.05 ) , and higher high-density lipoprotein levels ( 1.30±0.24 vs. 1.18±0.23 mmol/L , P<0.05 ) . CONCLUSIONS The intensive GDM treatment regimen led to healthier outcomes for the women , the neonates , and the birth event and was associated with better maternal metabolic situations in the months and years after delivery A r and omized , open-label , parallel study was conducted to assess the efficacy and safety of premixed insulin aspart 30 ( biphasic insulin aspart [ BIAsp ] 30 ) in managing gestational diabetes mellitus ( GDM ) . A total of 323 women with GDM registered at a single center in India were r and omly assigned to receive 6 U of either BIAsp 30 ( Group A ) or premixed human insulin ( biphasic human insulin [ BHI ] 30 ; Group B ) in a 1:1 ratio . Subjects performed home glucose monitoring and visited their care provider twice a month . The primary outcome was the degree of neonatal macrosomia ( neonatal birth weight > 90th percentile ) . Groups A and B were demographically comparable at study entry . Before labor onset , Groups A and B achieved similar degrees of fasting plasma glucose and postpr and ial plasma glucose control ( 92.97 ± 14.44 vs. 95.43 ± 18.96 and 127.59 ± 28.99 vs. 126.98 ± 29.89 , respectively ; both p = NS ) . Neonatal macrosomia frequency was 6.3 % in Group A and 6.9 % in Group B ; however , this difference was not statistically significant . By last visit , the required insulin dose was significantly lower for Group A than Group B ( 19.83 ± 15.75 IU vs. 26.34 ± 23.15 IU , respectively ; p = 0.006 ) . BIAsp 30 was noninferior to BHI 30 , producing comparable fetal outcomes when administered during pregnancy . Based on final doses , BIAsp 30 may offer greater treat-to-target potential for pregnant women
BACKGROUND Gestational diabetes mellitus ( GDM ) is associated with a higher risk of important adverse outcomes .
Practice varies and the best strategy for identifying and treating GDM is unclear .
AIM To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with GDM .