Maximal Tolerated Insulin Therapy in Gestational Diabetes

Abstract

Beginning in 1963 we have administered fast-acting insulin in three daily injections up to the maximal tolerated dose (M.T.D.), which can be defined as the highest quantity that can be given without bringing about hypoglycemic disturbances. This therapeutic criteria was applied both to gestational (280 pregnant women) and clinical (199 pregnant women) diabetes. M.T.D. was established on first admission to hospital and afterward controlled weekly in the outpatient clinic and during short periods of hospitalization (average of 53 days per patient). The average increase of the M.T.D. was 38 IU from 15 wk until delivery. As regards maternal blood sugar, at the M.T.D. average values at fasting and over the 24-h period were very close to the corresponding values of the control group (normal pregnancy). Total perinatal mortality (P.M.) was 2.9%; in the gestational diabetes group it was 2%. The incidence of congenital malformations (CM.) (2.4%) increased with the severity of diabetes. No congenital defects were observed in 96 infants of patients treated before the 15th wk. Labor started spontaneously in 90.4% of the cases. The incidence of cesarean section was 21% in patients in White's Classes Al and A2 (as recently redefined by Freinkel and Metzger 8 ) and 28% in other classes and that of forceps and vacuum extraction was 1% and 6%, respectively. The incidence of small-for-dates and overweight newborns from mothers with gestational and clinical diabetes without vascular complications is consistent with normal figures (macrosomia 3.4%). Small-for-dates newborns from pregnant diabetic women with vascular complications had a significant incidence. Respiratory distress syndrome (RDS) was 0.6% and hypoglycemia was 13.4%. No case of death was due to these two causes. Clinical results are discussed, DIABETES CARE3.- 489-494, MAY-JUNE 1980.

Diabetes in pregnancy 1985

“…The concept of 'maximal tolerated insulin dose' which was introduced by Roversi [25] over 20 years ago did much to encourage the more enthusiastic use of insulin, and in particular demonstrated the often very considerable increase in insulin dose needed in the pregnant diabetic mother to achieve normoglycaemia. The ability to self-monitor blood glucose has simply improved the ability to demonstrate normal glucose values.…”

Diagnosing diabetes mellitus - do we need new criteria?

“…This has resulted in much confusion and a lack of comparability between studies [53][54][55][56][57][58][59][60][61][62][63] [66,67]. Data obtained using each of these methods has been associated with maternal-fetal outcome [64,[68][69][70][71], and in some cases, to long-term outcome in the child [72][73][74][75]. The differences between cut off points used in different schemes (e. g. WHO and DPSG-EASD) reflect the inherent arbitrariness of cut off points for classifications based on continuously distributed data in the absence of evidence for a threshold predicting adverse outcomes in the mother or child.…”

Normalization of blood glucose in pregnant diabetics with the maximal tolerated dose (M.T.D.) of insulin

“…Calory intake differed from patient to patient. According to our criteria [5,6,7,8,9, 10] each < patient had been invited to choose her first menu without any restriction ön quality or quantity. Retrospective analysis showed that the calory content averaged 1900 cal/24 hours and composition, protein glucose and lipids, were respectively 15.5%, 53.2%, 31.3%, with fluctuatiqns of ± 10% in most cases [8].…”

“…They have already been reported [l, 5,6,7,8,10] and consist of: 1) a reduction in perinatal mortality (P.M.) to values (total P M. 2.9%, corrected P M. 1.9%) of the general P.M. (in 1975 total PM. of the general population in the Clinic 2.5%); 2) near disappearance of foetal macrosomia (3.3% above 4000 g) and normalization of birth weight(newbornweight does not differ from normal newbom weight) [9]; 3) a normal incidence of pathological Symptoms in newborn infants which were not however severe (respiratoiy distress syndrome 0.6%, hypoglycemia 13.4%); 4) reduction of caesarian sections to 24.6%; 5) delivery time did not have to be systematically brought forward, but only in cases where poor conditions of the foetus were apparent (labour induced in 9.6% of cases): 74.7% of the cases gave birth after the 38th week of gestation. The M.T.D.…”