My watch list
my.chemeurope.com  
Login  

Gestational diabetes



Gestational diabetes
Classification & external resources
ICD-10 O24.
ICD-9 648.8
MedlinePlus 000896

Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied.[1] No specific cause has been identified, but it is believed that the hormones produced during pregnancy reduce a woman's sensitivity to insulin, resulting in high blood sugar levels.

Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect high levels of glucose in blood samples.

Babies born to mothers with gestational diabetes are at increased risk of complications, primarily growth abnormalities and chemical imbalances such as low blood sugar. Gestational diabetes is a reversible condition and women who have adequate control of glucose levels can effectively decrease the associated risks and give birth to healthy babies.

Women with gestational diabetes are at high risk of developing type 2 diabetes mellitus after pregnancy, while their offspring are prone to developing childhood obesity, with type 2 diabetes later in life. Most patients are treated only with diet modification and moderate exercise but some take anti-diabetic drugs, including insulin therapy.

Diabetes mellitus
Types of Diabetes
Diabetes mellitus type 1
Diabetes mellitus type 2
Gestational diabetes

Pre-diabetes:
Impaired fasting glycaemia
Impaired glucose tolerance

Disease Management
Diabetes management:
Diabetic diet
Anti-diabetic drugs
Conventional insulinotherapy
Intensive insulinotherapy
Other Concerns
Cardiovascular disease

Diabetic comas:
Diabetic hypoglycemia
Diabetic ketoacidosis
Nonketotic hyperosmolar

Diabetic myonecrosis
Diabetic nephropathy
Diabetic neuropathy
Diabetic retinopathy

Diabetes and pregnancy

Blood tests
Blood sugar
Fructosamine
Glucose tolerance test
Glycosylated hemoglobin

Contents

Definition

Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy".[2] This definition acknowledges the possibility that patients may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether or not symptoms subside after pregnancy is also irrelevant to the diagnosis .[3]

Epidemiology

The frequency of gestational diabetes varies widely by study depending on the population studied and the study design. It occurs in between 5 and 10% of all pregnancies (between 1-14% in various studies).[3]

Pathophysiology

  The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is increased insulin resistance. Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to the insulin receptor. The interference probably occurs at the level of the cell signaling pathway behind the insulin receptor.[4]. Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin is needed to overcome this resistance; about 1.5-2.5 times more insulin is produced in a normal pregnancy.[4]

Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which progresses thereafter to levels seen in non-pregnant patients with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance they cannot compensate with increased production in the β-cells of the pancreas. Placental hormones, and to a lesser extent increased fat deposits during pregnancy, seem to mediate insulin resistance during pregnancy. Cortisol and progesterone are the main culprits, but human chorionic somatomammotropin, prolactin and estradiol contribute too.[4]

How this imbalance between insulin needs and production develops in GDM, remains unclear. Suggested mechanisms are similar to those in type 2 diabetes: autoimmunity, single gene mutations, and other mechanisms.[5]

Because glucose travels across the placenta (through diffusion facilitated by GLUT3 carriers), the fetus is exposed to higher glucose levels. This leads to increased fetal levels of insulin (insulin itself cannot cross the placenta). The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia). After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia).[6]

Risk factors and symptoms

Classical risk factors for developing gestational diabetes are the following:[7]

  • a previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia
  • a family history revealing a first degree relative with type 2 diabetes
  • maternal age - a woman's risk factor increases the older she is (especially if older than 35 years of age)
  • ethnic background (those with higher risk factors include African-Americans, North American native peoples and Hispanics)
  • being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively.[8]
  • a previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000 g)
  • previous poor obstetric history

In addition to this, statistics show a double risk of GDM in smokers[9] Polycystic ovarian syndrome is also a risk factor.[7] Some studies have looked at more controversial potential risk factors, such as short stature.[10]

Frequently women with gestational diabetes exhibit no symptoms (which is an argument in favour of screening during pregnancy). However, possible symptoms include increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision.

Diagnosis and screening

Because GDM is asymptomatic in most cases, the diagnosis of gestational diabetes is a process that takes into account a clinical assessment of risk factors, screening tests and diagnostic tests. These tests look for high levels of glucose in plasma or serum. This can be done in a stepwise approach where a suspicious result on a screening test is followed by diagnosic test. Alternatively, a more complicated diagnostic test can be used directly at the first antenatal visit in high-risk patients (for example in those with polycystic ovarian syndrome or acanthosis nigricans).[6]

Tests for gestational diabetes
Non-challenge blood glucose tests
  • Fasting glucose test
  • 2-hour postprandial (after a meal) glucose test
  • Random glucose test
Screening glucose challenge test
Oral glucose tolerance test (OGTT)

Non-challenge blood glucose tests involve measuring glucose levels in blood samples without challenging the subject with glucose solutions. A blood glucose levels can be determined when fasting, 2 hours after a meal, or simply at any random time. Both screening glucose challenge tests and oral glucose tolerance tests involve drinking a glucose solution, to check how the body handles this glucose challenge.

The screening glucose challenge test and oral glucose tolerance test involve drinking a standard solution with a high concentration of glucose, which has a very sweet taste some women find unpleasant. Sometimes, artificial flavours are added for this reason. Some women may experience nausea during the test, and more so with higher glucose levels.[11][12]

Screening pathways

Screening and diagnostic measures are controversial and differ between countries, in part due to differences in population risks, cost-effectiveness considerations, and lack of an evidence base to support large national screening programs.[13] The most elaborate regime entails a random blood glucose test during a booking visit, a screening glucose challenge test around 24-28 weeks' gestation, followed by an OGTT if the tests are outside normal limits. If there is a high suspicion, women may be tested earlier.[3]

In the United States, most obstetricians prefer universal screening of all women with a screening glucose tolerance test.[14] In the United Kingdom, obstetric units often rely on risk factors and a random blood glucose test.[15][6] The American Diabetes Association and the Society of Obstetricians and Gynecologists of Canada recommend routine screening unless the patient is low risk (this means the woman must be younger than 25 years and have a body mass index less than 27, with no personal, ethnic or family risk factors)[3][13] The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening.[16][17]

Urinary glucose testing

Women with GDM may have high glucose levels in their urine (glucosuria). Although dipstick testing is widely practiced, it performs poorly, and discontinuing routine testing has not been shown to cause underdiagnosis where universal screening is performed.[18] Increased glomerular filtration rates during pregnancy contribute to some 50% of women having glucose in their urine on dipstick tests at some point during their pregnancy. The sensitivity of glucosuria for GDM in the first 2 trimesters is only around 10% and the positive predictive value is around 20%.[19][20]

Non-challenge blood glucose tests

When a plasma glucose level is found to be higher than 126 mg/dl (7.0 mmol/l) after fasting, or over 200 mg/dl (11.1 mmol/l) on any occasion, and if this is confirmed on a subsequent day, the diagnosis of GDM is made, and no further testing is required.[3] These tests are typically performed at the first antenatal visit. They are patient-friendly and inexpensive, but have a lower test performance compared to the other tests, with moderate sensitivity, low specificity and high false positive rates.[21][22][23]

Screening glucose challenge test

The screening glucose challenge test is performed between 24-28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). It involves drinking a solution containing 50 grams of glucose, and measuring blood levels 1 hour later.[24]

If the cut-off point is set at 140 mg/dl (7.8 mmol/l), 80% of women with GDM will be detected.[3] If this threshold for further testing is lowered to 130 mg/dl, 90% of GDM cases will be detected, but there will also be more woman who will be subjected to a consequent OGTT unnecessarily.

Oral glucose tolerance test

The oral glucose tolerance test (OGTT)[25] should be done in the morning after an overnight fast of between 8 and 14 hours. During the three previous days the subject must have an unrestricted diet (containing at least 150 g carbohydrate per day) and unlimited physical activity. The subject should remain seated during the test and should not smoke throughout the test.

The test involves drinking a solution containing a certain amount of glucose, and drawing blood to measure glucose levels at the start and on set time intervals thereafter.

The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes.[26]

The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:

  • Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
  • 1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
  • 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
  • 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)

An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify less women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test.[27]

The glucose values used to detect gestational diabetes were first determined by O'Sullivan and Mahan (1964) in a retrospective study (using a 100 grams of glucose OGTT) designed to detect risk of developing type 2 diabetes in the future. The values were set using whole blood and required two values reaching or exceeding the value to be positive. [28] Subsequent information has led to alteration in O'Sullivan's criteria. When methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed.

Complications

GDM poses a risk to mother and child. This risk is largely related to high blood glucose levels and its consequences. Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably.[29]

The main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal special care unit.

Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic) and small for gestational age. Macrosomia in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section) or problems during vaginal delivery (such as shoulder dystocia). Macrosomia may affect 12% of normal women compared to 20% of patients with GDM.[6] Labelling a woman as having GDM may in itself increase the risk of having a caesarean section.[30][31]

Neonates are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia).

GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation.

Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown to be an independent risk factor for birth defects. Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy, whereas GDM gradually develops and is least pronounced during the first trimester. Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations; this is thought to be due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy.[32][33][34]

Because of conflicting studies, it is unclear at the moment whether or not women with GDM have a higher risk of preeclampsia.[35]

Prognosis

Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence.[36]

If a woman develops gestational diabetes, it implies her body processes glucose differently. Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women who needed insulin treatment, had antibodies associated with diabetes (such as antibodies against glutamate decarboxylase, islet cell antibodies and/or insulinoma antigen-2), women with more than two previous pregnancies, and women who were obese (in order of importance).[37][38] Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years.[28] Studies in which women with GDM were followed for more than 10 years indicate that the long-term risk is approximately 70%.[5] In populations with a low risk for type 2 diabetes, in lean subjects and in patients with auto-antibodies, there is a higher rate of women developing type 1 diabetes.[38]

The child has an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life.[39] This risk relates to increased maternal glucose values.[40] It is currently unclear how much genetic susceptibility and environmental factors each contribute to this risk, and if treatment of GDM can influence this outcome.[41]

There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37962 patients were reported to have GDM, and there was a tendency towards more breast and pancreatic cancer, but more research is needed.[42][43]

Classification

The White classification, named after Priscilla White[44] who pioneered in research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and diabetes that existed prior to pregnancy (pregestational diabetes). These two groups are further subdivided according to their associated risks and management.[45]

There are 2 subtypes of gestational diabetes (diabetes which began during pregnancy):

  • Type A1: abnormal oral glucose tolerance test (OGTT) but normal blood glucose levels during fasting and 2 hours after meals; diet modification is sufficient to control glucose levels
  • Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required

The second group of diabetes which existed prior to pregnancy is also split up into several subtypes.

Treatment

The goal of treatment is to reduce the risks of GDM for mother and child. Scientific evidence is beginning to show that controlling glucose levels can result in less serious fetal complications (such as macrosomia) and increased maternal quality of life. Unfortunately, treatment of GDM is also accompanied by more infants admitted to neonatal wards and more inductions of labour, with no proven decrease in cesarean section rates or perinatal mortality.[46][47] These findings are still recent and controversial.[48]

Counselling before pregnancy (for example, about preventive folic acid supplements) and multidisciplinary management are important for good pregnancy outcomes.[49] Most women can be managed with dietary changes and exercise. Self monitoring of blood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy.

Any diet needs to provide sufficient calories for pregnancy. The main goal of dietary modifications is to avoid peaks in blood sugar levels. This can be done by spreading carbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more.[7]

Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM.[7][50]

  Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low.[29][51]

There is some evidence that certain oral glycemic agents such as glyburide[52] (a second generation sulfonylurea) might be safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes. However, few studies have been performed as of this time and this is not a generally accepted treatment. These agents may be used in research settings, or if the patient needs intervention but refuses insulin therapy, and is aware of the risks.[7] Metformin has shown promising results but is less well studied. Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels.[53]

Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child.[54]

A repeat OGTT should be carried out 2-4 months after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised.[7]

Controversy

Gestational diabetes is a controversial subject. Some critics question wether or not GDM is a disease in its own right. Labelling women as 'suffering from GDM' seems to predispose them to more interventions for perceived increased risks, while treatment of GDM has not been proven to affect major outcome parameters such as perinatal mortality and cesarian section rates. Lack of reproducebility of glucose tolerance testing is another problem area.[55]

See also

References

  1. ^ Thomas R Moore, MD et. al. Diabetes Mellitus and Pregnancy. med/2349 at eMedicine. Version: Jan 27, 2005 update.
  2. ^ Metzger BE, Coustan DR (Eds.). Proceedings of the Fourth International Work-shop-Conference on Gestational Diabetes Mellitus. Diabetes Care 1998; 21 (Suppl. 2): B1–B167.
  3. ^ a b c d e f American Diabetes Association. Gestational Diabetes Mellitus. Diabetes Care 2004; 27: S88-90. PMID 14693936
  4. ^ a b c Carr DB, Gabbe S. Gestational Diabetes: Detection, Management, and Implications. Clin Diabetes 1998; 16(1): 4.
  5. ^ a b Buchanan TA, Xiang AH. Gestational diabetes mellitus. J Clin Invest 2005; 115(3): 485–491.
  6. ^ a b c d Kelly L, Evans L, Messenger D. Controversies around gestational diabetes. Practical information for family doctors. Can Fam Physician 2005; 51: 688-95. PMID 15934273 Full text at PMC: 15934273
  7. ^ a b c d e f Ross G. Gestational diabetes. Aust Fam Physician 2006; 35(6): 392-6. PMID 16751853
  8. ^ Chu SY, Callaghan WM, Kim SY, Schmid CH, Lau J, England LJ, Dietz PM. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care 2007; 30(8): 2070-6. PMID 17416786
  9. ^ England LJ, Levine RJ, Qian C, et. al. Glucose tolerance and risk of gestational diabetes mellitus in nulliparous women who smoke during pregnancy. Am J Epidemiol 2004; 160(12): 1205-13. PMID 15583373
  10. ^ Ma RM, Lao TT, Ma CL, et. al. Relationship between leg length and gestational diabetes mellitus in Chinese pregnant women. Diabetes Care 2007; 30(11): 2960-1. PMID 17666468
  11. ^ Sievenpiper JL, Jenkins DJ, Josse RG, Vuksan V. Dilution of the 75-g oral glucose tolerance test improves overall tolerability but not reproducibility in subjects with different body compositions. Diabetes Res Clin Pract 2001; 51(2): 87-95. PMID 11165688
  12. ^ Reece EA, Holford T, Tuck S, Bargar M, O'Connor T, Hobbins JC. Screening for gestational diabetes: one-hour carbohydrate tolerance test performed by a virtually tasteless polymer of glucose. Am J Obstet Gynecol 1987; 156(1): 132-4. PMID 3799747
  13. ^ a b Berger H, Crane J, Farine D, et. al. Screening for gestational diabetes mellitus. J Obstet Gynaecol Can 2002; 24: 894–912. PMID 12417905
  14. ^ Gabbe SG, Gregory RP, Power ML, Williams SB, Schulkin J. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004; 103(6): 1229-34. PMID 15172857
  15. ^ Mires GJ, Williams FL, Harper V. Screening practices for gestational diabetes mellitus in UK obstetric units. Diabet Med 1999; 16(2): 138-41. PMID 10229307
  16. ^ Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2003; 27(Suppl 2): 1–140.
  17. ^ Gabbe SG, Graves CR. Management of diabetes mellitus complicating pregnancy. Obstet Gynecol 2003; 102(4): 857-68. PMID 14551019
  18. ^ Rhode MA, Shapiro H, Jones OW 3rd. Indicated vs. routine prenatal urine chemical reagent strip testing. J Reprod Med 2007; 52(3): 214-9. PMID 17465289
  19. ^ Alto WA. No need for glycosuria/proteinuria screen in pregnant women. J Fam Pract 2005; 54(11): 978-83. PMID 16266604
  20. ^ Ritterath C, Siegmund T, Rad NT, Stein U, Buhling KJ. Accuracy and influence of ascorbic acid on glucose-test with urine dip sticks in prenatal care. J Perinat Med 2006; 34(4): 285-8. PMID 16856816
  21. ^ Agarwal MM, Dhatt GS. Fasting plasma glucose as a screening test for gestational diabetes mellitus. Arch Gynecol Obstet 2007; 275(2): 81-7. PMID 16967273
  22. ^ Sacks DA, Chen W, Wolde-Tsadik G, Buchanan TA. Fasting plasma glucose test at the first prenatal visit as a screen for gestational diabetes. Obstet Gynecol 2003; 101(6): 1197-203. PMID 12798525
  23. ^ Agarwal MM, Dhatt GS, Punnose J, Zayed R. Gestational diabetes: fasting and postprandial glucose as first prenatal screening tests in a high-risk population. J Reprod Med 2007; 52(4): 299-305. PMID 17506370
  24. ^ What I need to know about Gestational Diabetes. National Diabetes Information Clearinghouse. National Diabetes Information Clearinghouse (2006). Retrieved on 2006-11-27.
  25. ^ Glucose tolerance test. MedlinePlus, November 8, 2006.
  26. ^ Carpenter MW, Coustan DR. Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol 1982; 144(7): 768-73. PMID 83071919
  27. ^ Mello G, Elena P, Ognibene A, Cioni R, Tondi F, Pezzati P, Pratesi M, Scarselli G, Messeri G. Lack of concordance between the 75-g and 100-g glucose load tests for the diagnosis of gestational diabetes mellitus. Clin Chem 2006; 52(9): 1679-84. PMID 16873295
  28. ^ a b Gestational Diabetes. Diabetes Mellitus & Pregnancy - Gestational Diabetes. Armenian Medical Network (2006). Retrieved on 2006-11-27.
  29. ^ a b Langer O, Rodriguez DA, Xenakis EM, McFarland MB, Berkus MD, Arrendondo F. Intensified versus conventional management of gestational diabetes. Am J Obstet Gynecol 1994; 170(4): 1036-46. PMID 8166187
  30. ^ Naylor CD, Sermer M, Chen E, Farine D. Selective screening for gestational diabetes mellitus. Toronto Trihospital Gestational Diabetes Project Investigators. N Engl J Med 1997; 337(22): 1591–1596. PMID 9371855
  31. ^ Jovanovic-Peterson L, Bevier W, Peterson CM. The Santa Barbara County Health Care Services program: birth weight change concomitant with screening for and treatment of glucose-intolerance of pregnancy: a potential cost-effective intervention? Am J Perinatol 1997; 14(4): 221-8. PMID 9259932
  32. ^ Allen VM, Armson BA, Wilson RD, et. al. Teratogenicity associated with pre-existing and gestational diabetes. J Obstet Gynaecol Can 2007; 29(11): 927-34. PMID 17977497
  33. ^ Martínez-Frías ML, Frías JP, Bermejo E, Rodríguez-Pinilla E, Prieto L, Frías JL. Pre-gestational maternal body mass index predicts an increased risk of congenital malformations in infants of mothers with gestational diabetes. Diabet Med 2005; 22(6): 775-81. PMID 15910631
  34. ^ Savona-Ventura C, Gatt M. Embryonal risks in gestational diabetes mellitus. Early Hum Dev 2004; 79(1): 59-63. PMID 15449398
  35. ^ Leguizamón GF, Zeff NP, Fernández A. Hypertension and the pregnancy complicated by diabetes. Curr Diab Rep 2006; 6(4): 297-304. PMID 16879782
  36. ^ Kim C, Berger DK, Chamany S. Recurrence of gestational diabetes mellitus: a systematic review. Diabetes Care 2007; 30(5): 1314-9. PMID 17290037
  37. ^ Löbner K, Knopff A, Baumgarten A, et. al. Predictors of postpartum diabetes in women with gestational diabetes mellitus. Diabetes 2006; 55(3): 792-7. PMID 16505245
  38. ^ a b Järvelä IY, Juutinen J, Koskela P et. al. Gestational diabetes identifies women at risk for permanent type 1 and type 2 diabetes in fertile age: predictive role of autoantibodies. Diabetes Care 2006; 29(3): 607-12. PMID 16505514
  39. ^ Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics 2005; 115(3): e290-6. PMID 15741354
  40. ^ Hillier TA, Pedula KL, Schmidt MM, Mullen JA, Charles MA, Pettitt DJ. Childhood obesity and metabolic imprinting: the ongoing effects of maternal hyperglycemia. Diabetes Care 2007; 30(9): 2287-92. PMID 17519427
  41. ^ Metzger BE. Long-term Outcomes in Mothers Diagnosed With Gestational Diabetes Mellitus and Their Offspring. Clin Obstet Gynecol 2007; 50(4): 972-9. PMID 17982340
  42. ^ Perrin MC, Terry MB, Kleinhaus K, et. al. Gestational diabetes and the risk of breast cancer among women in the Jerusalem Perinatal Study. Breast Cancer Res Treat 2007 [Epub]. PMID 17476589
  43. ^ Perrin MC, Terry MB, Kleinhaus K, et. al. Gestational diabetes as a risk factor for pancreatic cancer: a prospective cohort study. BMC Med 2007; 5: 25. Full text at PMC: 17705823
  44. ^ White P. Pregnancy complicating diabetes. Am J Med 1949; 7: 609. PMID 15396063
  45. ^ Gabbe S.G., Niebyl J.R., Simpson J.L. OBSTETRICS: Normal and Problem Pregnancies. Fourth edition. Churchill Livingstone, New York, 2002. ISBN 0-443-06572-1
  46. ^ Crowther CA, Hiller JE, Moss JR et. al, Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352(24): 2477-86. PMID 15951574
  47. ^ Sermer M, Naylor CD, Gare DJ et. al. Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. The Toronto Tri-Hospital Gestational Diabetes Project. Am J Obstet Gynecol 1995; 173(1): 146-56. PMID 7631672
  48. ^ Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational diabetes and impaired glucose tolerance in pregnancy. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003395. PMID 12917965
  49. ^ Kapoor N, Sankaran S, Hyer S, Shehata H. Diabetes in pregnancy: a review of current evidence. Curr Opin Obstet Gynecol 2007; 19(6): 586-590. PMID 18007138
  50. ^ Mottola MF. The role of exercise in the prevention and treatment of gestational diabetes mellitus. Curr Sports Med Rep 2007; 6(6): 381-6. PMID 18001611
  51. ^ Walkinshaw SA. Very tight versus tight control for diabetes in pregnancy (WITHDRAWN). Cochrane Database Syst Rev 2007; (2): CD000226. PMID 17636623
  52. ^ Kremer CJ, Duff P. Glyburide for the treatment of gestational diabetes. Am J Obstet Gynecol 2004; 190(5): 1438-9. PMID 15167862
  53. ^ Simmons D, Walters BN, Rowan JA, McIntyre HD. Metformin therapy and diabetes in pregnancy. Med J Aust 2004; 180(9): 462-4. PMID 15115425
  54. ^ Taylor JS, Kacmar JE, Nothnagle M, Lawrence RA. A systematic review of the literature associating breastfeeding with type 2 diabetes and gestational diabetes. J Am Coll Nutr 2005; 24(5): 320-6. PMID 16192255
  55. ^ Murray Enkin, Marc J.N.C. Keirse, James Neilson, et. al. A Guide to Effective Care in Pregnancy and Childbirth: Chapter 11: Gestational Diabetes (requires login). Oxford University Press, 2000.
 
This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Gestational_diabetes". A list of authors is available in Wikipedia.
Your browser is not current. Microsoft Internet Explorer 6.0 does not support some functions on Chemie.DE