Several groups have reported a risk of fetal macrosomia in pregnancies with maternal glucose intolerance which is intermediate between gestational diabetes (GDM) and normal glucose tolerance. The present study was designed to determine whether these pregnancies are also at risk for fetal obesity, hyperinsulinism and placental villous immaturity. 325 women with risk factors for GDM underwent a 75 g OGTT interpreted according to the O'Sullivan criteria. All women who met the criteria for GDM were managed with diet therapy. Insulin therapy was added for women with a mean serum glucose value > 100 mg/dl on a 24 hour glucose profile. Patients not meeting the GDM criteria were managed without special intervention. Primary outcome variables were measures of neonatal weight and skinfold thickness, fetal and neonatal insulin and glucose concentration, and placental villous maturation. Outcome parameters were compared among three groups: pregnancies with normal OGTT (control, n = 95), 1 abnormal value in the OGTT (1 abnl, n = 76) and GDM (n = 154). The outcome of pregnancies with 1 abnormal value in the OGTT was different from those with normal OGTT. Regarding fetal growth, rates of LGA were approximately twice as high in groups with one abnormal value and GDM (21% and 24%) compared to women with normal OGTTs (11%: p < 0.05 vs GDM and p = 0.07 vs 1 abnormal value). The percent of infants with skinfold thickness > 90th percentile was also greater in the 1 abnormal value and GDM groups (31.1 and 31.6% respectively) compared to controls (19.2%; p < 0.05 for GDM vs control only). Regarding fetal hyperinsulinism, AFI concentrations were similar in control and GDM groups (3.1 +/- 0.4 and 3.4 +/- 0.8 microU/ml, respectively), but were higher in the group with one abnormal OGTT value (4.3 +/- 1.2 microU/ml, p < 0.05 vs controls). Cord blood insulin: glucose ratios were elevated in both the 1 abnormal value and GDM groups (0.22 +/- 0.05 and 0.20 +/- 0.02 microU/ml per mg/dl), compared to controls (0.12 +/- 0.01 microU/ml per mg/dl, p < 0.05 vs 1 abnormal value). Neonatal glycemia < 30 mg/dl was significantly more common in the one abnormal value than in the control group (49% vs 34% of infants) and intermediate in the GDM group (40%). Severe placental villous immaturity was more than twice as frequent in the 1 abnormal value group compared to controls (24% vs 9%, p < 0.05) and the most frequent in the GDM group (33%; p < 0.001 vs controls). Pregnancies with glucose intolerance below the thresholds for diagnosis of GDM have an increased risk for fetal obesity, hyperinsulinism, postpartum hypoglycemia and placental immaturity. These findings indicate the continuum of risk for fetal morbidity associated with increasing maternal glucose intolerance in pregnancy.

This article evaluates the clinical relevance of ultrasonography during pregnancy complicated by diabetes for fetal surveillance, assessment of diabetes impact, guidance of diabetes treatment, and obstetric management. Although ultrasound has improved, its effect on reduction of perinatal morbidity and mortality remains to be proven, and its use to detect large-for-gestational-age fetuses is unreliable. Clinical decisions based on birth weight prediction by sonography are often in error. Measurement of the insulin-sensitive fetal fat layer and fetal abdominal circumference may better reflect the impact of diabetes on the fetus.In Brief

Zusammenfassung: Glukosestoffwechselstörungen in der Schwang er schaft sind mit eine m geh äuften Auftr eten vo n Zottenr eifung sst örungen der Plazenta asso ztert. Die fr age ist. wie der orale Gluk osetol eranzt est (oCn) und das Insulin im Fruc htw asser (FW-Ins) und im Nabels chn urbl ut (NS-Ins) mit der Inziden z de r Zottenunreife korrelieren. Insbesondere wurde n die Auswirkung en eine r gren zwerti gen mütterlichen Glukosetoleranz (IGT) untersucht. für d ie bisher keine t he rapeutischen Maßnahmen gefordert w urden. Bei 248 Plazent en wurde morphologisch der Zottenreifestand untersucht und entsprechend des Schweregrades in schwere. mitt elschwere und ge ringgradige Zottenreifungsst örung einge teilt. Ein 75 g oGIT lag in allen Fällen vor (1 path. Wert-IGT, 2 path. Wert e = GDM). FW-Ins-Prob en wurde sub parta l bei 141 Geburte n gewonn en. NS-Ins-Prob en wu rden bei 224 Neug eb or en en abg enommen. Es zeigte sich ein signifikanter Zusammenh ang (p = 0.02) zwische n oGIT und Zottenunreife. Eine schwere Reifung sstörung fand sich bei norm alem oGIT in 9 %. bei IGT in 24 % und bei GDM in 32 %. Dazu kam en 14% bzw. 13% und 20 % mittelschwere Reifun gsst örungen. Das FW-Ins zeigte e be nfalls eine sig nifikante Korrelation zur Zottenreife (p = 0.02). für da s NS-Ins ließ ein Tren d festst ellen (p = 0.09). Es best eht ein enge r Zusammenh ang zwischen de m Schweregrad eine r mütterlichen Glukoseintoleranz und der Auspr ägung vo n Zottenu nreife. Bemerkenswert ist. da ß sich beim IGT ein fast dr eifach höh erer Anteil von schwerer Zottenu nreife er gab als bei nor malem oGIT. Angesicht s von insgesamt 37 % Zottenreifung sstörung mit Funktionseinschränkung bei gr enzwertiger Glukoseintoleranz (ICT) ist zu erwägen. Schwang ere mit IGT sowo hl bezüg lich Stoffwechselkontrollen als auch fetale r Überwachung Gestationsdiabeti kerinnen gleichzusetzen. Maturatlon DIsorders of Placenta VlIIi in Gestational Diabetes-wlth Respect to Maternal and Fetal Parameters of Carbohydrate MetaboUsm: Disord ers of carbo hydrate met abolism in pregnancy are associate d wlth a high incidenc e of maturat ion disord ers of placenta villi. The qu est ion was. wh ethe r th ere Is a corr elat ion between th e oGlT and insulin in amnioti e fluid (AFI) and eordbl ood (CBI) and th e ineidenee of villous immat urity. Special inte rest was given to th e effect of impaired gluc ose toler ance (IGT) for wh ich no th erapeutical measures are dem and ed up to now. In 248 placentas th e level of villous maturity was mo rphologically investig ated and was c1assified according to th e degree of severity into severe, mod

Maternal glucose tolerance in pregnancy is determined by an oral glucose tolerance test (oGTT). The presented study deals with the question whether the risk of the fetus developing hyperinsulinism can be correctly estimated by the result of the oGTT. Investigations were made if there is a correlation between the oGTT and the mean blood glucose levels (MBG) and the fetal glucose metabolism measured by amniotic fluid insulin (AFI) at birth. 158 amniotic fluid samples were collected during labour. In 136 samples insulin levels below the threshold of 7 microU/ml were found, in 22 samples above 7 microU/ml. An oGTT was performed in all pregnancies (threshold: 95/165/145/125 mg%). 52 women showed normal oGTT, 28 had impaired glucose tolerance (IGT) with one pathologic value and 78 women had gestational diabetes (GDM) with two elevated values. Elevated insulin levels > 7 microU/ml were found in 6% of the cases with normal oGTT, in 29% of the cases with IGT and in 14% when GDM was diagnosed (p = 0.02). The MBG was significantly higher in cases with elevated AFI than with normal AFI, 92 mg% versus 83 mg% (p = 0.02). Therefore hyperinsulinism of the fetus was found twice as often in cases with IGT than in GDM diagnosed by oGTT. Borderline glucose tolerance with only one pathologic value in the oGTT has more affect on the fetal glucose metabolism than has been assumed up to now. This may be caused by insufficient therapeutic intervention and deterioration of glucose tolerance during pregnancy. The diagnosis of IGT should be followed by therapeutic efforts and intensive care of the fetus as in cases of GDM.