Obstetrics

Mild gestational diabetes significantly raises the risk of cryptorchidism in male offspring, reported Dr. Helena E. Virtanen of the University of Turku, Finland, and her associates.

Even mothers who had an abnormal result on a single oral glucose tolerance test (OGTT) but no diabetes diagnosis were at increased risk of delivering a boy with cryptorchidism, the researchers reported (J. Clin. Endocrin. Metab. 2006 Oct. 10 [Epub doi:10.1210/jc.2006–1420]).

They reviewed the pregnancy records of 1,288 singleton boys born at one hospital who had participated in previous research. The 125 boys with congenital cryptorchidism served as cases in this study, and the 1,163 boys who had normal testicular descent at birth served as controls.

Among the cases, 13 mothers (10%) had diet-treated gestational diabetes, and an additional 7 (6%) had at least one abnormal result on OGTT but no diabetes diagnosis, for an overall 16%. In contrast, among the controls, only 47 mothers (4%) had a diabetes diagnosis and an additional 54 (5%) had an abnormal OGTT result, for an overall 9%.

The significantly elevated risk for cryptorchidism remained constant after the data were adjusted for known confounders such as advanced maternal age and maternal smoking, as well as for proposed risk factors that might confound the association, such as prematurity and low birth weight.

Maternal diabetes status had no apparent effect on the rate of spontaneous testicular descent by the age of 3 months or on the rate of bilateral vs. unilateral cryptorchidism. “Considering our results, the increasing prevalence of gestational diabetes may have considerable effect on [future] male reproductive health,” Dr. Virtanen and her associates noted.

Mild gestational diabetes significantly raises the risk of cryptorchidism in male offspring, reported Dr. Helena E. Virtanen of the University of Turku, Finland, and her associates.

Even mothers who had an abnormal result on a single oral glucose tolerance test (OGTT) but no diabetes diagnosis were at increased risk of delivering a boy with cryptorchidism, the researchers reported (J. Clin. Endocrin. Metab. 2006 Oct. 10 [Epub doi:10.1210/jc.2006–1420]).

They reviewed the pregnancy records of 1,288 singleton boys born at one hospital who had participated in previous research. The 125 boys with congenital cryptorchidism served as cases in this study, and the 1,163 boys who had normal testicular descent at birth served as controls.

Among the cases, 13 mothers (10%) had diet-treated gestational diabetes, and an additional 7 (6%) had at least one abnormal result on OGTT but no diabetes diagnosis, for an overall 16%. In contrast, among the controls, only 47 mothers (4%) had a diabetes diagnosis and an additional 54 (5%) had an abnormal OGTT result, for an overall 9%.

The significantly elevated risk for cryptorchidism remained constant after the data were adjusted for known confounders such as advanced maternal age and maternal smoking, as well as for proposed risk factors that might confound the association, such as prematurity and low birth weight.

Maternal diabetes status had no apparent effect on the rate of spontaneous testicular descent by the age of 3 months or on the rate of bilateral vs. unilateral cryptorchidism. “Considering our results, the increasing prevalence of gestational diabetes may have considerable effect on [future] male reproductive health,” Dr. Virtanen and her associates noted.

Mild gestational diabetes significantly raises the risk of cryptorchidism in male offspring, reported Dr. Helena E. Virtanen of the University of Turku, Finland, and her associates.

Even mothers who had an abnormal result on a single oral glucose tolerance test (OGTT) but no diabetes diagnosis were at increased risk of delivering a boy with cryptorchidism, the researchers reported (J. Clin. Endocrin. Metab. 2006 Oct. 10 [Epub doi:10.1210/jc.2006–1420]).

They reviewed the pregnancy records of 1,288 singleton boys born at one hospital who had participated in previous research. The 125 boys with congenital cryptorchidism served as cases in this study, and the 1,163 boys who had normal testicular descent at birth served as controls.

Among the cases, 13 mothers (10%) had diet-treated gestational diabetes, and an additional 7 (6%) had at least one abnormal result on OGTT but no diabetes diagnosis, for an overall 16%. In contrast, among the controls, only 47 mothers (4%) had a diabetes diagnosis and an additional 54 (5%) had an abnormal OGTT result, for an overall 9%.

The significantly elevated risk for cryptorchidism remained constant after the data were adjusted for known confounders such as advanced maternal age and maternal smoking, as well as for proposed risk factors that might confound the association, such as prematurity and low birth weight.

Maternal diabetes status had no apparent effect on the rate of spontaneous testicular descent by the age of 3 months or on the rate of bilateral vs. unilateral cryptorchidism. “Considering our results, the increasing prevalence of gestational diabetes may have considerable effect on [future] male reproductive health,” Dr. Virtanen and her associates noted.

SAN FRANCISCO — The “fast and furious” increase in obesity in the United States and a correlative rise in the incidence of gestational diabetes justify aggressive screening of pregnant women for the disorder, Dr. E. Albert Reece said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“The numbers are quite staggering,” said Dr. Reece, dean of the school of medicine and vice president of medical affairs at the University of Maryland, Baltimore.

Fifteen years ago, the incidence of gestational diabetes was 1%–3%. Today, it's 4%–8%, he said.

Screening is aimed at reducing the risk of perinatal loss, but it also confers what Dr. Reece termed “fringe benefits,” namely, reducing the risk of fetal macrosomia, operative delivery, birth trauma, and metabolic derangements in the neonate.

Screening raises awareness of the long-term possibility of type II diabetes arising in the mother and, years later, the offspring.

“Diabetes begets diabetes,” said Dr. Reece, who advocates screening every pregnant woman for gestational diabetes at least once during pregnancy.

The tradition of screening at 24–28 weeks' gestation is “entirely arbitrary”—chosen by convention to pick up 85% of cases while there is still time in the pregnancy to intervene.

However, clinicians should be aware that 15% of cases will be missed by screening at that time point.

“If you are very suspicious, due to habitus or history, repeat it at 33–34 weeks,” he advised.

Choosing which test to use can be important, according to Dr. Reece.

Intravenous glucose tolerance testing is nonphysiologic, failing to simulate the normal process of glucose disposal, and therefore useless, he said.

Random blood glucose value testing isn't much better, since it is an insensitive test. “It should be used only when nothing else is available,” he said. “It is better than nothing at all.”

Capillary whole blood glucose testing uses a pinprick to obtain blood that is analyzed by a portable meter. It is convenient and cost-effective, but the meter should be calibrated regularly with results obtained in a hospital laboratory to ensure its accuracy.

Most common, of course, are fasting oral glucose tolerance tests.

These tests are most accurate when the pancreas is adequately primed prior to a 3-hour glucose tolerance test. This cannot always be ensured when people skip meals or follow unusual diets, said Dr. Reece.

That's why he advises patients to eat two to three slices of bread with each meal for 3 days before the test, which involves drinking a glucose solution and having blood drawn 1 hour later.

Nicotine, caffeine, many drugs, bed rest, and exertion may also interfere with test results.

If a patient vomits Glucola, the standard glucose solution used in fasting oral glucose tolerance testing, a culinary glucose polymer, Polycose, can be used instead, said Dr. Reece.

Even more palatable for some women is the jelly bean test, standardized by Boyd and associates and found to be “incredibly consistent” with Glucola in terms of sensitivity and specificity, and positive predictive value.

However, that accuracy is ensured only if one uses the exact protocol described by Boyd or one later tested by Lamar and colleagues: 18 or 26 Brach's jelly beans, with blood drawn 1, 2, and 3 hours later (Am. J. Obstet. Gynecol. 1995;173:1889–92 and Am. J. Obstet. Gynecol. 1999;181[5 pt. 1]:1154–7).

Two relatively new methods—glycohemoglobin A₁ and a fructosamine-based test—are too insensitive to be used in screening for gestational diabetes, Dr. Reece said.

A breakfast tolerance test involving a specific 600-kcal meal before the blood draw achieves a sensitivity of 75% and specificity of 95% if a 120-mg/dL value is used, and a sensitivity of 96% and specificity of 74% if a threshold is set at 100 mg/dL. It's acceptable, but “cumbersome” to adjust the thresholds, he said.

“I've never used it.”

A diagnosis of gestational diabetes is generally reserved for patients who have at least two abnormal oral glucose tolerance tests. Research suggests, however, that potential adverse pregnancy outcomes can occur with just one abnormal result, reflecting impaired glucose metabolism.

Dr. Reece believes one abnormal test warrants at least dietary therapy and retesting, while two abnormal tests during pregnancy may require more aggressive interventions, including oral glucose therapy and possibly insulin.

SAN FRANCISCO — The “fast and furious” increase in obesity in the United States and a correlative rise in the incidence of gestational diabetes justify aggressive screening of pregnant women for the disorder, Dr. E. Albert Reece said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“The numbers are quite staggering,” said Dr. Reece, dean of the school of medicine and vice president of medical affairs at the University of Maryland, Baltimore.

Fifteen years ago, the incidence of gestational diabetes was 1%–3%. Today, it's 4%–8%, he said.

Screening is aimed at reducing the risk of perinatal loss, but it also confers what Dr. Reece termed “fringe benefits,” namely, reducing the risk of fetal macrosomia, operative delivery, birth trauma, and metabolic derangements in the neonate.

Screening raises awareness of the long-term possibility of type II diabetes arising in the mother and, years later, the offspring.

“Diabetes begets diabetes,” said Dr. Reece, who advocates screening every pregnant woman for gestational diabetes at least once during pregnancy.

The tradition of screening at 24–28 weeks' gestation is “entirely arbitrary”—chosen by convention to pick up 85% of cases while there is still time in the pregnancy to intervene.

However, clinicians should be aware that 15% of cases will be missed by screening at that time point.

“If you are very suspicious, due to habitus or history, repeat it at 33–34 weeks,” he advised.

Choosing which test to use can be important, according to Dr. Reece.

Intravenous glucose tolerance testing is nonphysiologic, failing to simulate the normal process of glucose disposal, and therefore useless, he said.

Random blood glucose value testing isn't much better, since it is an insensitive test. “It should be used only when nothing else is available,” he said. “It is better than nothing at all.”

Capillary whole blood glucose testing uses a pinprick to obtain blood that is analyzed by a portable meter. It is convenient and cost-effective, but the meter should be calibrated regularly with results obtained in a hospital laboratory to ensure its accuracy.

Most common, of course, are fasting oral glucose tolerance tests.

These tests are most accurate when the pancreas is adequately primed prior to a 3-hour glucose tolerance test. This cannot always be ensured when people skip meals or follow unusual diets, said Dr. Reece.

That's why he advises patients to eat two to three slices of bread with each meal for 3 days before the test, which involves drinking a glucose solution and having blood drawn 1 hour later.

Nicotine, caffeine, many drugs, bed rest, and exertion may also interfere with test results.

If a patient vomits Glucola, the standard glucose solution used in fasting oral glucose tolerance testing, a culinary glucose polymer, Polycose, can be used instead, said Dr. Reece.

Even more palatable for some women is the jelly bean test, standardized by Boyd and associates and found to be “incredibly consistent” with Glucola in terms of sensitivity and specificity, and positive predictive value.

However, that accuracy is ensured only if one uses the exact protocol described by Boyd or one later tested by Lamar and colleagues: 18 or 26 Brach's jelly beans, with blood drawn 1, 2, and 3 hours later (Am. J. Obstet. Gynecol. 1995;173:1889–92 and Am. J. Obstet. Gynecol. 1999;181[5 pt. 1]:1154–7).

Two relatively new methods—glycohemoglobin A₁ and a fructosamine-based test—are too insensitive to be used in screening for gestational diabetes, Dr. Reece said.

A breakfast tolerance test involving a specific 600-kcal meal before the blood draw achieves a sensitivity of 75% and specificity of 95% if a 120-mg/dL value is used, and a sensitivity of 96% and specificity of 74% if a threshold is set at 100 mg/dL. It's acceptable, but “cumbersome” to adjust the thresholds, he said.

“I've never used it.”

A diagnosis of gestational diabetes is generally reserved for patients who have at least two abnormal oral glucose tolerance tests. Research suggests, however, that potential adverse pregnancy outcomes can occur with just one abnormal result, reflecting impaired glucose metabolism.

Dr. Reece believes one abnormal test warrants at least dietary therapy and retesting, while two abnormal tests during pregnancy may require more aggressive interventions, including oral glucose therapy and possibly insulin.

SAN FRANCISCO — The “fast and furious” increase in obesity in the United States and a correlative rise in the incidence of gestational diabetes justify aggressive screening of pregnant women for the disorder, Dr. E. Albert Reece said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“The numbers are quite staggering,” said Dr. Reece, dean of the school of medicine and vice president of medical affairs at the University of Maryland, Baltimore.

Fifteen years ago, the incidence of gestational diabetes was 1%–3%. Today, it's 4%–8%, he said.

Screening is aimed at reducing the risk of perinatal loss, but it also confers what Dr. Reece termed “fringe benefits,” namely, reducing the risk of fetal macrosomia, operative delivery, birth trauma, and metabolic derangements in the neonate.

Screening raises awareness of the long-term possibility of type II diabetes arising in the mother and, years later, the offspring.

“Diabetes begets diabetes,” said Dr. Reece, who advocates screening every pregnant woman for gestational diabetes at least once during pregnancy.

The tradition of screening at 24–28 weeks' gestation is “entirely arbitrary”—chosen by convention to pick up 85% of cases while there is still time in the pregnancy to intervene.

However, clinicians should be aware that 15% of cases will be missed by screening at that time point.

“If you are very suspicious, due to habitus or history, repeat it at 33–34 weeks,” he advised.

Choosing which test to use can be important, according to Dr. Reece.

Intravenous glucose tolerance testing is nonphysiologic, failing to simulate the normal process of glucose disposal, and therefore useless, he said.

Random blood glucose value testing isn't much better, since it is an insensitive test. “It should be used only when nothing else is available,” he said. “It is better than nothing at all.”

Capillary whole blood glucose testing uses a pinprick to obtain blood that is analyzed by a portable meter. It is convenient and cost-effective, but the meter should be calibrated regularly with results obtained in a hospital laboratory to ensure its accuracy.

Most common, of course, are fasting oral glucose tolerance tests.

These tests are most accurate when the pancreas is adequately primed prior to a 3-hour glucose tolerance test. This cannot always be ensured when people skip meals or follow unusual diets, said Dr. Reece.

That's why he advises patients to eat two to three slices of bread with each meal for 3 days before the test, which involves drinking a glucose solution and having blood drawn 1 hour later.

Nicotine, caffeine, many drugs, bed rest, and exertion may also interfere with test results.

If a patient vomits Glucola, the standard glucose solution used in fasting oral glucose tolerance testing, a culinary glucose polymer, Polycose, can be used instead, said Dr. Reece.

Even more palatable for some women is the jelly bean test, standardized by Boyd and associates and found to be “incredibly consistent” with Glucola in terms of sensitivity and specificity, and positive predictive value.

However, that accuracy is ensured only if one uses the exact protocol described by Boyd or one later tested by Lamar and colleagues: 18 or 26 Brach's jelly beans, with blood drawn 1, 2, and 3 hours later (Am. J. Obstet. Gynecol. 1995;173:1889–92 and Am. J. Obstet. Gynecol. 1999;181[5 pt. 1]:1154–7).

Two relatively new methods—glycohemoglobin A₁ and a fructosamine-based test—are too insensitive to be used in screening for gestational diabetes, Dr. Reece said.

A breakfast tolerance test involving a specific 600-kcal meal before the blood draw achieves a sensitivity of 75% and specificity of 95% if a 120-mg/dL value is used, and a sensitivity of 96% and specificity of 74% if a threshold is set at 100 mg/dL. It's acceptable, but “cumbersome” to adjust the thresholds, he said.

“I've never used it.”

A diagnosis of gestational diabetes is generally reserved for patients who have at least two abnormal oral glucose tolerance tests. Research suggests, however, that potential adverse pregnancy outcomes can occur with just one abnormal result, reflecting impaired glucose metabolism.

Dr. Reece believes one abnormal test warrants at least dietary therapy and retesting, while two abnormal tests during pregnancy may require more aggressive interventions, including oral glucose therapy and possibly insulin.

NEW ORLEANS — Women who become mothers in their 50s with egg donation are no less able to handle the physical and mental demands of parenting compared with their younger counterparts, according to a study presented at the annual meeting of the American Society for Reproductive Medicine.

“We jumped to some conclusions in the past that weren't necessarily correct about older women's reduced parenting capabilities,” said the study's lead investigator, Dr. Anne Z. Steiner of the University of North Carolina in Chapel Hill.

Her study surveyed women in their 50s who had conceived and delivered after egg donation and matched them to an equal number of women in their 40s and 30s who also had conceived and delivered following in vitro fertilization. The 64 respondents (18 in their 50s, 24 in their 40s, and 22 in their 30s) had children aged 3 or 4 years old at the time of the study.

The surveys covered issues of parenting stress, using the Parenting Stress Index/Short Form questionnaire. Physical and mental function also were assessed, along with information on demographics, family structure, and child care, to determine a measure of “total parenting stress.”

Overall, the study found no significant difference in physical or mental function or parental stress between the older women and their younger counterparts. Women in their 50s had a nonsignificantly lower physical function score compared with women in their 30s (55 vs. 57), but all scores were higher than the average national female score (49), said Dr. Steiner. Mental function scores were slightly higher for women in their 50s compared with women in their 30s (54 vs. 50), but again, this difference was not significant. Adjustments for race, employment status, use of child care services, age and health of the child, gestational order, and family income did not alter the findings.

“To our knowledge this is the first study to evaluate parenting in women who conceive after age 50,” wrote the study's authors. “Our data do not support the hypothesis that mothers of advanced maternal age have reduced parenting capacity.”

NEW ORLEANS — Women who become mothers in their 50s with egg donation are no less able to handle the physical and mental demands of parenting compared with their younger counterparts, according to a study presented at the annual meeting of the American Society for Reproductive Medicine.

“We jumped to some conclusions in the past that weren't necessarily correct about older women's reduced parenting capabilities,” said the study's lead investigator, Dr. Anne Z. Steiner of the University of North Carolina in Chapel Hill.

Her study surveyed women in their 50s who had conceived and delivered after egg donation and matched them to an equal number of women in their 40s and 30s who also had conceived and delivered following in vitro fertilization. The 64 respondents (18 in their 50s, 24 in their 40s, and 22 in their 30s) had children aged 3 or 4 years old at the time of the study.

The surveys covered issues of parenting stress, using the Parenting Stress Index/Short Form questionnaire. Physical and mental function also were assessed, along with information on demographics, family structure, and child care, to determine a measure of “total parenting stress.”

Overall, the study found no significant difference in physical or mental function or parental stress between the older women and their younger counterparts. Women in their 50s had a nonsignificantly lower physical function score compared with women in their 30s (55 vs. 57), but all scores were higher than the average national female score (49), said Dr. Steiner. Mental function scores were slightly higher for women in their 50s compared with women in their 30s (54 vs. 50), but again, this difference was not significant. Adjustments for race, employment status, use of child care services, age and health of the child, gestational order, and family income did not alter the findings.

“To our knowledge this is the first study to evaluate parenting in women who conceive after age 50,” wrote the study's authors. “Our data do not support the hypothesis that mothers of advanced maternal age have reduced parenting capacity.”

NEW ORLEANS — Women who become mothers in their 50s with egg donation are no less able to handle the physical and mental demands of parenting compared with their younger counterparts, according to a study presented at the annual meeting of the American Society for Reproductive Medicine.

“We jumped to some conclusions in the past that weren't necessarily correct about older women's reduced parenting capabilities,” said the study's lead investigator, Dr. Anne Z. Steiner of the University of North Carolina in Chapel Hill.

Her study surveyed women in their 50s who had conceived and delivered after egg donation and matched them to an equal number of women in their 40s and 30s who also had conceived and delivered following in vitro fertilization. The 64 respondents (18 in their 50s, 24 in their 40s, and 22 in their 30s) had children aged 3 or 4 years old at the time of the study.

The surveys covered issues of parenting stress, using the Parenting Stress Index/Short Form questionnaire. Physical and mental function also were assessed, along with information on demographics, family structure, and child care, to determine a measure of “total parenting stress.”

Overall, the study found no significant difference in physical or mental function or parental stress between the older women and their younger counterparts. Women in their 50s had a nonsignificantly lower physical function score compared with women in their 30s (55 vs. 57), but all scores were higher than the average national female score (49), said Dr. Steiner. Mental function scores were slightly higher for women in their 50s compared with women in their 30s (54 vs. 50), but again, this difference was not significant. Adjustments for race, employment status, use of child care services, age and health of the child, gestational order, and family income did not alter the findings.

“To our knowledge this is the first study to evaluate parenting in women who conceive after age 50,” wrote the study's authors. “Our data do not support the hypothesis that mothers of advanced maternal age have reduced parenting capacity.”

NEW ORLEANS — Women seeking infertility treatment should be warned about the increased risks associated with pregnancy at older ages, according to Barbara Luke, Sc.D., professor at the School of Nursing & Health Studies, University of Miami at Coral Gables in Florida.

In an analysis of more than 8 million singleton live births to women aged 30–54 years, her study found significantly increased risks of pregnancy complications and adverse outcomes as women aged.

The study used the U.S. Birth Cohort Linked Birth/Infant Death data set of singleton live births of 20 weeks' gestation or more between 1995 and 2000. Births to women aged 30–34 years were the reference, and the study controlled for maternal race, smoking, macrosomia, and breech or malpresentation. The highest risks were seen in women aged 45 years and older, but “many risks are significantly elevated by age 35–39 years,” Dr. Luke said in an interview.

Looking at the overall population, the study found that two of the greatest health risks for older pregnant women—chronic hypertension and diabetes—may be present even before pregnancy. Chronic hypertension (hypertension developing before pregnancy or up to 20 weeks' gestation) was highest in women aged 45 or older (adjusted odds ratio of 3.7 for primiparas and 4.89 for multiparas), as was diabetes (AOR of 2.19 for primiparas and 2.58 for multiparas). Pregnancy-associated hypertension, defined as developing after 20 weeks' gestation, was another important risk in this age group (AOR 1.55 for primiparas and 2.13 for multiparas), Dr. Luke said.

Similarly, premature rupture of membranes (PROM), premature birth (less than 32 weeks' gestation), and infant death were markedly increased by age 35–39 years, with the greatest risk in women 45 years and older (AOR 1.02, 2.11, and 2.68, respectively, for primiparas and AOR 1.38, 1.77, and 1.92, respectively, for multiparas).

The risk of precipitous labor and stimulation of labor decreased with age, but the risk of excessive bleeding, dysfunctional labor, induction of labor, and prolonged labor all increased as women got older.

Primary cesarean section increased with age in both primiparas and multiparas (AOR 3.15 and 2.65 in the oldest age group), while forceps, vacuum, and vaginal deliveries actually decreased with age in the primiparous group (AOR 0.90, 0.73, and 0.32, respectively), said Dr. Luke. In the oldest multiparous group the risk of repeat section increased (AOR 1.56), forceps and vacuum deliveries increased (AOR 1.29 and 1.08), and vaginal births after cesarean section decreased (AOR 0.64).

“This is particularly worrisome since with C-section there is a doubling of the neonatal mortality rate and an increased risk of stillborn and placental complications in subsequent pregnancies,” she noted.

There is also evidence of long-term health implications for women who develop pregnancy complications such as preeclampsia and preterm birth, Dr. Luke concluded.

NEW ORLEANS — Women seeking infertility treatment should be warned about the increased risks associated with pregnancy at older ages, according to Barbara Luke, Sc.D., professor at the School of Nursing & Health Studies, University of Miami at Coral Gables in Florida.

In an analysis of more than 8 million singleton live births to women aged 30–54 years, her study found significantly increased risks of pregnancy complications and adverse outcomes as women aged.

The study used the U.S. Birth Cohort Linked Birth/Infant Death data set of singleton live births of 20 weeks' gestation or more between 1995 and 2000. Births to women aged 30–34 years were the reference, and the study controlled for maternal race, smoking, macrosomia, and breech or malpresentation. The highest risks were seen in women aged 45 years and older, but “many risks are significantly elevated by age 35–39 years,” Dr. Luke said in an interview.

Looking at the overall population, the study found that two of the greatest health risks for older pregnant women—chronic hypertension and diabetes—may be present even before pregnancy. Chronic hypertension (hypertension developing before pregnancy or up to 20 weeks' gestation) was highest in women aged 45 or older (adjusted odds ratio of 3.7 for primiparas and 4.89 for multiparas), as was diabetes (AOR of 2.19 for primiparas and 2.58 for multiparas). Pregnancy-associated hypertension, defined as developing after 20 weeks' gestation, was another important risk in this age group (AOR 1.55 for primiparas and 2.13 for multiparas), Dr. Luke said.

Similarly, premature rupture of membranes (PROM), premature birth (less than 32 weeks' gestation), and infant death were markedly increased by age 35–39 years, with the greatest risk in women 45 years and older (AOR 1.02, 2.11, and 2.68, respectively, for primiparas and AOR 1.38, 1.77, and 1.92, respectively, for multiparas).

The risk of precipitous labor and stimulation of labor decreased with age, but the risk of excessive bleeding, dysfunctional labor, induction of labor, and prolonged labor all increased as women got older.

Primary cesarean section increased with age in both primiparas and multiparas (AOR 3.15 and 2.65 in the oldest age group), while forceps, vacuum, and vaginal deliveries actually decreased with age in the primiparous group (AOR 0.90, 0.73, and 0.32, respectively), said Dr. Luke. In the oldest multiparous group the risk of repeat section increased (AOR 1.56), forceps and vacuum deliveries increased (AOR 1.29 and 1.08), and vaginal births after cesarean section decreased (AOR 0.64).

“This is particularly worrisome since with C-section there is a doubling of the neonatal mortality rate and an increased risk of stillborn and placental complications in subsequent pregnancies,” she noted.

There is also evidence of long-term health implications for women who develop pregnancy complications such as preeclampsia and preterm birth, Dr. Luke concluded.

NEW ORLEANS — Women seeking infertility treatment should be warned about the increased risks associated with pregnancy at older ages, according to Barbara Luke, Sc.D., professor at the School of Nursing & Health Studies, University of Miami at Coral Gables in Florida.

In an analysis of more than 8 million singleton live births to women aged 30–54 years, her study found significantly increased risks of pregnancy complications and adverse outcomes as women aged.

The study used the U.S. Birth Cohort Linked Birth/Infant Death data set of singleton live births of 20 weeks' gestation or more between 1995 and 2000. Births to women aged 30–34 years were the reference, and the study controlled for maternal race, smoking, macrosomia, and breech or malpresentation. The highest risks were seen in women aged 45 years and older, but “many risks are significantly elevated by age 35–39 years,” Dr. Luke said in an interview.

Looking at the overall population, the study found that two of the greatest health risks for older pregnant women—chronic hypertension and diabetes—may be present even before pregnancy. Chronic hypertension (hypertension developing before pregnancy or up to 20 weeks' gestation) was highest in women aged 45 or older (adjusted odds ratio of 3.7 for primiparas and 4.89 for multiparas), as was diabetes (AOR of 2.19 for primiparas and 2.58 for multiparas). Pregnancy-associated hypertension, defined as developing after 20 weeks' gestation, was another important risk in this age group (AOR 1.55 for primiparas and 2.13 for multiparas), Dr. Luke said.

Similarly, premature rupture of membranes (PROM), premature birth (less than 32 weeks' gestation), and infant death were markedly increased by age 35–39 years, with the greatest risk in women 45 years and older (AOR 1.02, 2.11, and 2.68, respectively, for primiparas and AOR 1.38, 1.77, and 1.92, respectively, for multiparas).

The risk of precipitous labor and stimulation of labor decreased with age, but the risk of excessive bleeding, dysfunctional labor, induction of labor, and prolonged labor all increased as women got older.

Primary cesarean section increased with age in both primiparas and multiparas (AOR 3.15 and 2.65 in the oldest age group), while forceps, vacuum, and vaginal deliveries actually decreased with age in the primiparous group (AOR 0.90, 0.73, and 0.32, respectively), said Dr. Luke. In the oldest multiparous group the risk of repeat section increased (AOR 1.56), forceps and vacuum deliveries increased (AOR 1.29 and 1.08), and vaginal births after cesarean section decreased (AOR 0.64).

“This is particularly worrisome since with C-section there is a doubling of the neonatal mortality rate and an increased risk of stillborn and placental complications in subsequent pregnancies,” she noted.

There is also evidence of long-term health implications for women who develop pregnancy complications such as preeclampsia and preterm birth, Dr. Luke concluded.

BOSTON — Live births occurred in 70% of heart transplant recipients who became pregnant after surgery, according to a review of 36 patients with 60 singleton pregnancies reported to the National Transplantation Pregnancy Registry.

Of 42 live-born children, 36 were healthy and developing well at the time of follow-up. Three children were receiving medical management for cardiomyopathy, the same diagnosis for which their mothers received transplants. Among the other three children, one underwent a hypospadias repair, one was treated for attention-deficit hyperactivity disorder, and one died from a traumatic injury, Lisa A. Coscia reported during a poster session at the 2006 World Transplant Congress.

These 42 children were born at a mean gestational age of 37 weeks (5 were premature) and with a mean birth weight of 2.67 kg. A cesarean section was performed in 14 deliveries. Neonatal complications developed in 11 cases.

In the 18 unsuccessful pregnancies, 11 fetuses were aborted spontaneously and 5 for therapeutic reasons. One woman had an ectopic pregnancy and another had a stillborn delivery, according to Ms. Coscia, a registered nurse in the department of surgery at Temple University, Philadelphia.

The 36 patients conceived their pregnancies a mean of 5 years after their transplants, although this ranged from as little as 0.2 years to as much as 15 years. They had an average age of 28 years at conception, ranging from 18 to 39 years.

During pregnancy, hypertension was the most common comorbidity (43%) among the women, followed by infections (14%), preeclampsia (11%), and gestational diabetes (3%).

Nine of the mothers (25%) died after pregnancy, although all of the deaths occurred more than 2 years post partum. These deaths were attributed to cardiac arrest (two), acute rejection (two), and in one patient each, vasculopathy, atherosclerosis, sepsis, lymphoma, and noncompliance. The other 27 mothers (75%) had adequate graft function at follow-up.

According to data collected by the U.S. Organ Procurement and Transplantation Network, the 5-year Kaplan-Meier patient survival rate for heart transplants performed in women between 1997 and 2004 (pregnancies not considered) is just over 69%.

The possibility of maternal death unrelated to pregnancy should be included during prepregnancy counseling, Ms. Coscia advised in her poster at the congress, which was sponsored by the American Society of Transplant Surgeons, the American Society of Transplantation, and the Transplantation Society.

BOSTON — Live births occurred in 70% of heart transplant recipients who became pregnant after surgery, according to a review of 36 patients with 60 singleton pregnancies reported to the National Transplantation Pregnancy Registry.

Of 42 live-born children, 36 were healthy and developing well at the time of follow-up. Three children were receiving medical management for cardiomyopathy, the same diagnosis for which their mothers received transplants. Among the other three children, one underwent a hypospadias repair, one was treated for attention-deficit hyperactivity disorder, and one died from a traumatic injury, Lisa A. Coscia reported during a poster session at the 2006 World Transplant Congress.

These 42 children were born at a mean gestational age of 37 weeks (5 were premature) and with a mean birth weight of 2.67 kg. A cesarean section was performed in 14 deliveries. Neonatal complications developed in 11 cases.

In the 18 unsuccessful pregnancies, 11 fetuses were aborted spontaneously and 5 for therapeutic reasons. One woman had an ectopic pregnancy and another had a stillborn delivery, according to Ms. Coscia, a registered nurse in the department of surgery at Temple University, Philadelphia.

The 36 patients conceived their pregnancies a mean of 5 years after their transplants, although this ranged from as little as 0.2 years to as much as 15 years. They had an average age of 28 years at conception, ranging from 18 to 39 years.

During pregnancy, hypertension was the most common comorbidity (43%) among the women, followed by infections (14%), preeclampsia (11%), and gestational diabetes (3%).

Nine of the mothers (25%) died after pregnancy, although all of the deaths occurred more than 2 years post partum. These deaths were attributed to cardiac arrest (two), acute rejection (two), and in one patient each, vasculopathy, atherosclerosis, sepsis, lymphoma, and noncompliance. The other 27 mothers (75%) had adequate graft function at follow-up.

According to data collected by the U.S. Organ Procurement and Transplantation Network, the 5-year Kaplan-Meier patient survival rate for heart transplants performed in women between 1997 and 2004 (pregnancies not considered) is just over 69%.

The possibility of maternal death unrelated to pregnancy should be included during prepregnancy counseling, Ms. Coscia advised in her poster at the congress, which was sponsored by the American Society of Transplant Surgeons, the American Society of Transplantation, and the Transplantation Society.

BOSTON — Live births occurred in 70% of heart transplant recipients who became pregnant after surgery, according to a review of 36 patients with 60 singleton pregnancies reported to the National Transplantation Pregnancy Registry.

Of 42 live-born children, 36 were healthy and developing well at the time of follow-up. Three children were receiving medical management for cardiomyopathy, the same diagnosis for which their mothers received transplants. Among the other three children, one underwent a hypospadias repair, one was treated for attention-deficit hyperactivity disorder, and one died from a traumatic injury, Lisa A. Coscia reported during a poster session at the 2006 World Transplant Congress.

These 42 children were born at a mean gestational age of 37 weeks (5 were premature) and with a mean birth weight of 2.67 kg. A cesarean section was performed in 14 deliveries. Neonatal complications developed in 11 cases.

In the 18 unsuccessful pregnancies, 11 fetuses were aborted spontaneously and 5 for therapeutic reasons. One woman had an ectopic pregnancy and another had a stillborn delivery, according to Ms. Coscia, a registered nurse in the department of surgery at Temple University, Philadelphia.

The 36 patients conceived their pregnancies a mean of 5 years after their transplants, although this ranged from as little as 0.2 years to as much as 15 years. They had an average age of 28 years at conception, ranging from 18 to 39 years.

During pregnancy, hypertension was the most common comorbidity (43%) among the women, followed by infections (14%), preeclampsia (11%), and gestational diabetes (3%).

Nine of the mothers (25%) died after pregnancy, although all of the deaths occurred more than 2 years post partum. These deaths were attributed to cardiac arrest (two), acute rejection (two), and in one patient each, vasculopathy, atherosclerosis, sepsis, lymphoma, and noncompliance. The other 27 mothers (75%) had adequate graft function at follow-up.

According to data collected by the U.S. Organ Procurement and Transplantation Network, the 5-year Kaplan-Meier patient survival rate for heart transplants performed in women between 1997 and 2004 (pregnancies not considered) is just over 69%.

The possibility of maternal death unrelated to pregnancy should be included during prepregnancy counseling, Ms. Coscia advised in her poster at the congress, which was sponsored by the American Society of Transplant Surgeons, the American Society of Transplantation, and the Transplantation Society.

PHOENIX — Infants are rarely born with suppressed thyroid function if their mothers have Graves' disease but continue to take lower doses of thyroid medication during pregnancy, based on data from 249 pregnant Graves' disease patients.

Maternal free thyroxine (FT4) levels just above normal (at least 1.9 ng/dL) were associated with normal FT4 levels in the newborn, Dr. Naoko Momotani said at the annual meeting of the American Thyroid Association.

Although previous research has suggested that a mother's thyroid hormone level is linked to her newborn's health, this study is the first to show such a relationship, said Dr. Momotani of the Tokyo Health Service Association in Tokyo.

Graves' disease involves overactivity of the entire thyroid gland, which can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus, which prevents fetal hypothyroidism.

“But the drug doses that are ideal for the mother might be too much for the fetus,” Dr. Momotani said.

Keeping pregnant Graves' disease patients in a mild hyperthyroid state may be a noninvasive way to care for these women and prevent thyroid problems in the fetus, she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT4 level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth.

There were no cases of below-normal fetal FT4 levels and only one case of elevated TSH in a fetus among women whose FT4 levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL).

By contrast, a total of 102 mothers had normal free T4 levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT4 and/or high TSH levels at birth. But only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism. One infant had both suppressed TSH and normal free T4 levels at birth, which suggested central hypothyroidism, and the mother's FT4 in this case was 2.1 ng/dL.

It is important to remember that the range of FT4 values in women with Graves' disease varies, and some infants may have initial suppressed thyroid function, but most of these infants do well with close follow-up, Dr. Momotani said.

PHOENIX — Infants are rarely born with suppressed thyroid function if their mothers have Graves' disease but continue to take lower doses of thyroid medication during pregnancy, based on data from 249 pregnant Graves' disease patients.

Maternal free thyroxine (FT4) levels just above normal (at least 1.9 ng/dL) were associated with normal FT4 levels in the newborn, Dr. Naoko Momotani said at the annual meeting of the American Thyroid Association.

Although previous research has suggested that a mother's thyroid hormone level is linked to her newborn's health, this study is the first to show such a relationship, said Dr. Momotani of the Tokyo Health Service Association in Tokyo.

Graves' disease involves overactivity of the entire thyroid gland, which can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus, which prevents fetal hypothyroidism.

“But the drug doses that are ideal for the mother might be too much for the fetus,” Dr. Momotani said.

Keeping pregnant Graves' disease patients in a mild hyperthyroid state may be a noninvasive way to care for these women and prevent thyroid problems in the fetus, she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT4 level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth.

There were no cases of below-normal fetal FT4 levels and only one case of elevated TSH in a fetus among women whose FT4 levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL).

By contrast, a total of 102 mothers had normal free T4 levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT4 and/or high TSH levels at birth. But only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism. One infant had both suppressed TSH and normal free T4 levels at birth, which suggested central hypothyroidism, and the mother's FT4 in this case was 2.1 ng/dL.

It is important to remember that the range of FT4 values in women with Graves' disease varies, and some infants may have initial suppressed thyroid function, but most of these infants do well with close follow-up, Dr. Momotani said.

PHOENIX — Infants are rarely born with suppressed thyroid function if their mothers have Graves' disease but continue to take lower doses of thyroid medication during pregnancy, based on data from 249 pregnant Graves' disease patients.

Maternal free thyroxine (FT4) levels just above normal (at least 1.9 ng/dL) were associated with normal FT4 levels in the newborn, Dr. Naoko Momotani said at the annual meeting of the American Thyroid Association.

Although previous research has suggested that a mother's thyroid hormone level is linked to her newborn's health, this study is the first to show such a relationship, said Dr. Momotani of the Tokyo Health Service Association in Tokyo.

Graves' disease involves overactivity of the entire thyroid gland, which can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus, which prevents fetal hypothyroidism.

“But the drug doses that are ideal for the mother might be too much for the fetus,” Dr. Momotani said.

Keeping pregnant Graves' disease patients in a mild hyperthyroid state may be a noninvasive way to care for these women and prevent thyroid problems in the fetus, she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT4 level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth.

There were no cases of below-normal fetal FT4 levels and only one case of elevated TSH in a fetus among women whose FT4 levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL).

By contrast, a total of 102 mothers had normal free T4 levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT4 and/or high TSH levels at birth. But only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism. One infant had both suppressed TSH and normal free T4 levels at birth, which suggested central hypothyroidism, and the mother's FT4 in this case was 2.1 ng/dL.

It is important to remember that the range of FT4 values in women with Graves' disease varies, and some infants may have initial suppressed thyroid function, but most of these infants do well with close follow-up, Dr. Momotani said.

VERONA, ITALY — Newly developed consensus guidelines recommend thyroid-function screening in high-risk pregnant women, but stop short of calling for universal screening.

An international task force, under the auspices of the Endocrine Society, examined 10 key topics related to pregnancy and thyroid. The end result was an 86-page, single-spaced document encompassing 35 recommendations, many of which were reached after a diplomatic search for compromise, Dr. Daniel Glinoer said at a joint meeting of the Italian Association of Clinical Endocrinologists and the American Association of Clinical Endocrinologists.

The difficulty stemmed from the paucity of prospective randomized trials in the field, the contrasting approaches of endocrinologists and ob.gyns. on some controversial issues, and the appearance of additional data even as the task force was writing the guidelines. “Altogether, this effort represented a tremendous challenge that was much more difficult than anticipated,” said Dr. Glinoer, who represented the European Thyroid Association on the task force and is chief of the thyroid investigation clinic at the Centre Hôpitalier Universitaire Saint-Pierre, Brussels.

Despite compromises on many recommendations, the American College of Obstetricians and Gynecologists (ACOG) opted not to endorse the final guidelines. Dr. Sarah Kilpatrick, who represented ACOG on the task force, acknowledged that a great deal of time and work went into the guidelines.

“Unfortunately, the data available are not consistently good, and there are still many differences of opinion between endocrinologists and perinatologists about how to interpret the data and best manage pregnant women,” Dr. Kilpatrick, professor and head of the department of ob.gyn. and vice dean of the college of medicine at the University of Illinois at Chicago, said in an interview. “ACOG did not endorse these guidelines because many of the recommendations made by the guidelines were based on poor evidence with a recommendation level of inconclusive.”

For screening purposes, the task force identified high-risk women as those with a personal history of thyroid or autoimmune disorders; a family history of thyroid disorders; or a personal history of infertility or preterm delivery.

For maternal hypothyroidism, which affects 2.5%–3% of pregnant women, the task force recommends a targeted case-finding approach at the first prenatal visit or at diagnosis of pregnancy. The preconception thyroxine dosage should be adjusted to reach a serum thyroid-stimulating hormone (TSH) level no higher than 2.5 microIU/L. The thyroxine dosage usually needs to be incremented by 4–8 weeks of gestation, and these patients may require a 30%–50% increase in dosage, said Dr. Glinoer.

If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests should be normalized as rapidly as possible, in view of the potential obstetric complications and risks for the offspring associated with undisclosed prolonged hypothyroidism. Thyroxine dosage should be titrated to rapidly reach and thereafter maintain serum TSH concentrations of less than 2.5 microIU/L in the first trimester or less than 3 microIU/L in the second and third trimesters, or to trimester-specific normal TSH ranges, which Dr. Glinoer admitted haven't been universally established.

There was a consensus against advising termination of pregnancy, even if overt hypothyroidism is diagnosed late, he said.

If a subnormal serum TSH concentration is detected, hyperthyroidism must be distinguished from both normal physiology and hyperemesis gravidarum because of the adverse effects of overt hyperthyroidism on mother and fetus. Antithyroid drug (ATD) therapy should be either initiated for those with a new diagnosis of hyperthyroidism resulting from Graves' disease or adjusted for those with a prior history to maintain maternal free thyroxine levels in the trimester-specific normal pregnancy range, if available, or near the upper limit of the nonpregnant reference range, he said.

Because evidence suggests that methimazole may be associated with congenital anomalies, the task force recommends propylthiouracil (PTU) as first-line medication, especially during the first trimester. Methimazole may be prescribed if PTU is not available, or if a patient can't tolerate or has an adverse reaction to PTU.

The task force concluded that subtotal thyroidectomy may be indicated for maternal Graves' disease if there are severe adverse reactions to ATD therapy, if persistently high ATD doses are required, or if a patient is nonadherent to ATD therapy and has uncontrolled hyperthyroidism. The best time to perform surgery is the second trimester.

There is no evidence that treating subclinical hyperthyroidism improves pregnancy outcome, and it could potentially adversely affect the fetus, he said.

VERONA, ITALY — Newly developed consensus guidelines recommend thyroid-function screening in high-risk pregnant women, but stop short of calling for universal screening.

An international task force, under the auspices of the Endocrine Society, examined 10 key topics related to pregnancy and thyroid. The end result was an 86-page, single-spaced document encompassing 35 recommendations, many of which were reached after a diplomatic search for compromise, Dr. Daniel Glinoer said at a joint meeting of the Italian Association of Clinical Endocrinologists and the American Association of Clinical Endocrinologists.

The difficulty stemmed from the paucity of prospective randomized trials in the field, the contrasting approaches of endocrinologists and ob.gyns. on some controversial issues, and the appearance of additional data even as the task force was writing the guidelines. “Altogether, this effort represented a tremendous challenge that was much more difficult than anticipated,” said Dr. Glinoer, who represented the European Thyroid Association on the task force and is chief of the thyroid investigation clinic at the Centre Hôpitalier Universitaire Saint-Pierre, Brussels.

Despite compromises on many recommendations, the American College of Obstetricians and Gynecologists (ACOG) opted not to endorse the final guidelines. Dr. Sarah Kilpatrick, who represented ACOG on the task force, acknowledged that a great deal of time and work went into the guidelines.

“Unfortunately, the data available are not consistently good, and there are still many differences of opinion between endocrinologists and perinatologists about how to interpret the data and best manage pregnant women,” Dr. Kilpatrick, professor and head of the department of ob.gyn. and vice dean of the college of medicine at the University of Illinois at Chicago, said in an interview. “ACOG did not endorse these guidelines because many of the recommendations made by the guidelines were based on poor evidence with a recommendation level of inconclusive.”

For screening purposes, the task force identified high-risk women as those with a personal history of thyroid or autoimmune disorders; a family history of thyroid disorders; or a personal history of infertility or preterm delivery.

For maternal hypothyroidism, which affects 2.5%–3% of pregnant women, the task force recommends a targeted case-finding approach at the first prenatal visit or at diagnosis of pregnancy. The preconception thyroxine dosage should be adjusted to reach a serum thyroid-stimulating hormone (TSH) level no higher than 2.5 microIU/L. The thyroxine dosage usually needs to be incremented by 4–8 weeks of gestation, and these patients may require a 30%–50% increase in dosage, said Dr. Glinoer.

If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests should be normalized as rapidly as possible, in view of the potential obstetric complications and risks for the offspring associated with undisclosed prolonged hypothyroidism. Thyroxine dosage should be titrated to rapidly reach and thereafter maintain serum TSH concentrations of less than 2.5 microIU/L in the first trimester or less than 3 microIU/L in the second and third trimesters, or to trimester-specific normal TSH ranges, which Dr. Glinoer admitted haven't been universally established.

There was a consensus against advising termination of pregnancy, even if overt hypothyroidism is diagnosed late, he said.

If a subnormal serum TSH concentration is detected, hyperthyroidism must be distinguished from both normal physiology and hyperemesis gravidarum because of the adverse effects of overt hyperthyroidism on mother and fetus. Antithyroid drug (ATD) therapy should be either initiated for those with a new diagnosis of hyperthyroidism resulting from Graves' disease or adjusted for those with a prior history to maintain maternal free thyroxine levels in the trimester-specific normal pregnancy range, if available, or near the upper limit of the nonpregnant reference range, he said.

Because evidence suggests that methimazole may be associated with congenital anomalies, the task force recommends propylthiouracil (PTU) as first-line medication, especially during the first trimester. Methimazole may be prescribed if PTU is not available, or if a patient can't tolerate or has an adverse reaction to PTU.

The task force concluded that subtotal thyroidectomy may be indicated for maternal Graves' disease if there are severe adverse reactions to ATD therapy, if persistently high ATD doses are required, or if a patient is nonadherent to ATD therapy and has uncontrolled hyperthyroidism. The best time to perform surgery is the second trimester.

There is no evidence that treating subclinical hyperthyroidism improves pregnancy outcome, and it could potentially adversely affect the fetus, he said.

VERONA, ITALY — Newly developed consensus guidelines recommend thyroid-function screening in high-risk pregnant women, but stop short of calling for universal screening.

An international task force, under the auspices of the Endocrine Society, examined 10 key topics related to pregnancy and thyroid. The end result was an 86-page, single-spaced document encompassing 35 recommendations, many of which were reached after a diplomatic search for compromise, Dr. Daniel Glinoer said at a joint meeting of the Italian Association of Clinical Endocrinologists and the American Association of Clinical Endocrinologists.

The difficulty stemmed from the paucity of prospective randomized trials in the field, the contrasting approaches of endocrinologists and ob.gyns. on some controversial issues, and the appearance of additional data even as the task force was writing the guidelines. “Altogether, this effort represented a tremendous challenge that was much more difficult than anticipated,” said Dr. Glinoer, who represented the European Thyroid Association on the task force and is chief of the thyroid investigation clinic at the Centre Hôpitalier Universitaire Saint-Pierre, Brussels.

Despite compromises on many recommendations, the American College of Obstetricians and Gynecologists (ACOG) opted not to endorse the final guidelines. Dr. Sarah Kilpatrick, who represented ACOG on the task force, acknowledged that a great deal of time and work went into the guidelines.

“Unfortunately, the data available are not consistently good, and there are still many differences of opinion between endocrinologists and perinatologists about how to interpret the data and best manage pregnant women,” Dr. Kilpatrick, professor and head of the department of ob.gyn. and vice dean of the college of medicine at the University of Illinois at Chicago, said in an interview. “ACOG did not endorse these guidelines because many of the recommendations made by the guidelines were based on poor evidence with a recommendation level of inconclusive.”

For screening purposes, the task force identified high-risk women as those with a personal history of thyroid or autoimmune disorders; a family history of thyroid disorders; or a personal history of infertility or preterm delivery.

For maternal hypothyroidism, which affects 2.5%–3% of pregnant women, the task force recommends a targeted case-finding approach at the first prenatal visit or at diagnosis of pregnancy. The preconception thyroxine dosage should be adjusted to reach a serum thyroid-stimulating hormone (TSH) level no higher than 2.5 microIU/L. The thyroxine dosage usually needs to be incremented by 4–8 weeks of gestation, and these patients may require a 30%–50% increase in dosage, said Dr. Glinoer.

If overt hypothyroidism is diagnosed during pregnancy, thyroid function tests should be normalized as rapidly as possible, in view of the potential obstetric complications and risks for the offspring associated with undisclosed prolonged hypothyroidism. Thyroxine dosage should be titrated to rapidly reach and thereafter maintain serum TSH concentrations of less than 2.5 microIU/L in the first trimester or less than 3 microIU/L in the second and third trimesters, or to trimester-specific normal TSH ranges, which Dr. Glinoer admitted haven't been universally established.

There was a consensus against advising termination of pregnancy, even if overt hypothyroidism is diagnosed late, he said.

If a subnormal serum TSH concentration is detected, hyperthyroidism must be distinguished from both normal physiology and hyperemesis gravidarum because of the adverse effects of overt hyperthyroidism on mother and fetus. Antithyroid drug (ATD) therapy should be either initiated for those with a new diagnosis of hyperthyroidism resulting from Graves' disease or adjusted for those with a prior history to maintain maternal free thyroxine levels in the trimester-specific normal pregnancy range, if available, or near the upper limit of the nonpregnant reference range, he said.

Because evidence suggests that methimazole may be associated with congenital anomalies, the task force recommends propylthiouracil (PTU) as first-line medication, especially during the first trimester. Methimazole may be prescribed if PTU is not available, or if a patient can't tolerate or has an adverse reaction to PTU.

The task force concluded that subtotal thyroidectomy may be indicated for maternal Graves' disease if there are severe adverse reactions to ATD therapy, if persistently high ATD doses are required, or if a patient is nonadherent to ATD therapy and has uncontrolled hyperthyroidism. The best time to perform surgery is the second trimester.

There is no evidence that treating subclinical hyperthyroidism improves pregnancy outcome, and it could potentially adversely affect the fetus, he said.

BOSTON — Severely obese women who underwent bariatric surgery and had major weight loss prior to pregnancy reduced the likelihood of macrosomia and subsequent obesity in their offspring, Dr. John G. Kral said at the annual meeting of NAASO, the Obesity Society.

What's more, the children of these mothers have been followed for 2–18 years and have no higher rate of obesity than does the larger age-matched background population in Quebec, where the study was done, he said.

The surgical procedure the women underwent was a pyloris-sparing biliopancreatic diversion (BPD), which is not only maldigestive but also malabsorptive. This of course raises concerns for pregnancy, with potential vitamin deficiencies, undernutrition, and low birth weight among the offspring, but the results have been reassuring, he said.

Dr. Kral and his coinvestigators from the department of surgery, Laval University, Quebec, followed a cohort of 45 children born before their mothers had surgery and 172 born after the surgery. The children are now aged 7 years or older, and in those born before surgery the prevalence of obesity is 60%, while among those born after the surgery the prevalence is 37%, said Dr. Kral of the State University of New York Health Science Center at Brooklyn.

According to the National Longitudinal Survey of Children and Youth in Canada, the overall prevalence of obesity among Canadian children in that age group is 38%.

Moreover, not only did the prevalence of obesity fall by 52% but also the prevalence of severe obesity fell by 45.1%, and there was no increase in low birth weight, he said.

Malabsorptive BPD surgery does not cause maternal stress or create “a famine situation in utero,” Dr. Kral said. Rather, it provides in utero benefits of energy homeostasis, euglycemia, and normalization of insulin and lipid levels, he said.

The odds ratio for obesity in children of very obese mothers is 60-fold, at least in part because of genetic factors, but by normalizing the fetal environment this surgery actually abrogates the genotype, he explained.

Dr. Kral and his coinvestigators had previously reported on a group of 783 women who underwent BPD and replied to a questionnaire that asked about pre- and postoperative pregnancies. Among the findings of that survey were that 82.6% of the women had a normal weight gain during postoperative pregnancy, the incidence of fetal macrosomia decreased from 34.8% to 7.7%, and the incidence of normal birth weight increased from 62.1% to 82.7%.

The investigators wrote, “We believe that the overall normalization of birth weights in these severely obese women is a consequence of the improved maternal physiological environment following BPD, including better glucose metabolism, lower blood pressure, and better hormonal function” (Obes. Surg. 2004;14:318–24).

BOSTON — Severely obese women who underwent bariatric surgery and had major weight loss prior to pregnancy reduced the likelihood of macrosomia and subsequent obesity in their offspring, Dr. John G. Kral said at the annual meeting of NAASO, the Obesity Society.

What's more, the children of these mothers have been followed for 2–18 years and have no higher rate of obesity than does the larger age-matched background population in Quebec, where the study was done, he said.

The surgical procedure the women underwent was a pyloris-sparing biliopancreatic diversion (BPD), which is not only maldigestive but also malabsorptive. This of course raises concerns for pregnancy, with potential vitamin deficiencies, undernutrition, and low birth weight among the offspring, but the results have been reassuring, he said.

Dr. Kral and his coinvestigators from the department of surgery, Laval University, Quebec, followed a cohort of 45 children born before their mothers had surgery and 172 born after the surgery. The children are now aged 7 years or older, and in those born before surgery the prevalence of obesity is 60%, while among those born after the surgery the prevalence is 37%, said Dr. Kral of the State University of New York Health Science Center at Brooklyn.

According to the National Longitudinal Survey of Children and Youth in Canada, the overall prevalence of obesity among Canadian children in that age group is 38%.

Moreover, not only did the prevalence of obesity fall by 52% but also the prevalence of severe obesity fell by 45.1%, and there was no increase in low birth weight, he said.

Malabsorptive BPD surgery does not cause maternal stress or create “a famine situation in utero,” Dr. Kral said. Rather, it provides in utero benefits of energy homeostasis, euglycemia, and normalization of insulin and lipid levels, he said.

The odds ratio for obesity in children of very obese mothers is 60-fold, at least in part because of genetic factors, but by normalizing the fetal environment this surgery actually abrogates the genotype, he explained.

Dr. Kral and his coinvestigators had previously reported on a group of 783 women who underwent BPD and replied to a questionnaire that asked about pre- and postoperative pregnancies. Among the findings of that survey were that 82.6% of the women had a normal weight gain during postoperative pregnancy, the incidence of fetal macrosomia decreased from 34.8% to 7.7%, and the incidence of normal birth weight increased from 62.1% to 82.7%.

The investigators wrote, “We believe that the overall normalization of birth weights in these severely obese women is a consequence of the improved maternal physiological environment following BPD, including better glucose metabolism, lower blood pressure, and better hormonal function” (Obes. Surg. 2004;14:318–24).

BOSTON — Severely obese women who underwent bariatric surgery and had major weight loss prior to pregnancy reduced the likelihood of macrosomia and subsequent obesity in their offspring, Dr. John G. Kral said at the annual meeting of NAASO, the Obesity Society.

What's more, the children of these mothers have been followed for 2–18 years and have no higher rate of obesity than does the larger age-matched background population in Quebec, where the study was done, he said.

The surgical procedure the women underwent was a pyloris-sparing biliopancreatic diversion (BPD), which is not only maldigestive but also malabsorptive. This of course raises concerns for pregnancy, with potential vitamin deficiencies, undernutrition, and low birth weight among the offspring, but the results have been reassuring, he said.

Dr. Kral and his coinvestigators from the department of surgery, Laval University, Quebec, followed a cohort of 45 children born before their mothers had surgery and 172 born after the surgery. The children are now aged 7 years or older, and in those born before surgery the prevalence of obesity is 60%, while among those born after the surgery the prevalence is 37%, said Dr. Kral of the State University of New York Health Science Center at Brooklyn.

According to the National Longitudinal Survey of Children and Youth in Canada, the overall prevalence of obesity among Canadian children in that age group is 38%.

Moreover, not only did the prevalence of obesity fall by 52% but also the prevalence of severe obesity fell by 45.1%, and there was no increase in low birth weight, he said.

Malabsorptive BPD surgery does not cause maternal stress or create “a famine situation in utero,” Dr. Kral said. Rather, it provides in utero benefits of energy homeostasis, euglycemia, and normalization of insulin and lipid levels, he said.

The odds ratio for obesity in children of very obese mothers is 60-fold, at least in part because of genetic factors, but by normalizing the fetal environment this surgery actually abrogates the genotype, he explained.

Dr. Kral and his coinvestigators had previously reported on a group of 783 women who underwent BPD and replied to a questionnaire that asked about pre- and postoperative pregnancies. Among the findings of that survey were that 82.6% of the women had a normal weight gain during postoperative pregnancy, the incidence of fetal macrosomia decreased from 34.8% to 7.7%, and the incidence of normal birth weight increased from 62.1% to 82.7%.

The investigators wrote, “We believe that the overall normalization of birth weights in these severely obese women is a consequence of the improved maternal physiological environment following BPD, including better glucose metabolism, lower blood pressure, and better hormonal function” (Obes. Surg. 2004;14:318–24).

INDIANAPOLIS — Myths about the effects of breast-feeding, the promotion and availability of formula, and the absence of maternal role models are combining to thwart breast-feeding among urban African American women, Dr. Hari B. Srinivasan said during a poster presentation at the annual meeting of the Midwest Society for Pediatric Research.

In a study that mined data similar to those from a 2004 national survey by the Centers for Disease Control and Prevention, Dr. Srinivasan found that fewer than half of African American mothers initiate breast-feeding immediately following an in-hospital educational support program.

The study from Chicago's Sinai Children's Hospital revealed that among Hispanic and white mothers, the rate of breast-feeding initiation was 78% and 72%, respectively. The national goal is to have 75% of mothers initiate breast-feeding by 2010.

“This is a cultural issue. Breast-feeding education has to be started early in schools and in communities,” said Dr. Srinivasan, who is an assistant professor of pediatrics and an attending neonatologist at Sinai. He noted that if one generation chooses breast-feeding over formula, the next generation is more likely to follow suit.

“Also, the Women, Infants and Children program makes formula available to anyone who qualifies and who wants it free of cost. Although WIC is a good program, it serves as a disincentive to breast-feeding, especially among poorer populations. And every woman leaving the hospital after delivery gets a small bag from Ross Pharmaceuticals, and in that bag is a can of formula; so hospitals reinforce formula use,” Dr. Srinivasan said.

He pointed out that obstetricians serve as the first line of defense against formula use. “Obstetricians should get involved in educating patients about the benefits of breast-feeding early, during prenatal visits, and in the first 48 hours after delivery,” he said, adding that it's then up to pediatricians to pick up the ball.

In talking with his patients, Dr. Srinivasan discovered that many harbor negative myths, such as the myth that breast-feeding can cause a loss of breast contour and can slow weight loss after delivery.

“In actuality, women who breast-feed tend to return to their prepregnancy weights faster than those who don't,” he noted.

In this study, data on breast-feeding initiation rates for 3,324 infants were prospectively collected for a 1-year period. The overall breast-feeding initiation rate for the population was 68%.

Earlier this year, the Centers for Disease Control and Prevention reported that in 2004, 71.5% of non-Hispanic white children were ever breast-fed, compared with 50% of non-Hispanic black children. Among those who were ever breast-fed, 54% of white and 43% of black children continued breast-feeding until age 6 months (MMWR 2006;55:335–9).

“Strenuous public health efforts are needed to improve breast-feeding behaviors, particularly among black women and socially disadvantaged groups,” Dr. Srinivasan concluded.

'Strenuous public health efforts are needed to improve breast-feeding behaviors.' DR. SRINIVASAN

INDIANAPOLIS — Myths about the effects of breast-feeding, the promotion and availability of formula, and the absence of maternal role models are combining to thwart breast-feeding among urban African American women, Dr. Hari B. Srinivasan said during a poster presentation at the annual meeting of the Midwest Society for Pediatric Research.

In a study that mined data similar to those from a 2004 national survey by the Centers for Disease Control and Prevention, Dr. Srinivasan found that fewer than half of African American mothers initiate breast-feeding immediately following an in-hospital educational support program.

The study from Chicago's Sinai Children's Hospital revealed that among Hispanic and white mothers, the rate of breast-feeding initiation was 78% and 72%, respectively. The national goal is to have 75% of mothers initiate breast-feeding by 2010.

“This is a cultural issue. Breast-feeding education has to be started early in schools and in communities,” said Dr. Srinivasan, who is an assistant professor of pediatrics and an attending neonatologist at Sinai. He noted that if one generation chooses breast-feeding over formula, the next generation is more likely to follow suit.

“Also, the Women, Infants and Children program makes formula available to anyone who qualifies and who wants it free of cost. Although WIC is a good program, it serves as a disincentive to breast-feeding, especially among poorer populations. And every woman leaving the hospital after delivery gets a small bag from Ross Pharmaceuticals, and in that bag is a can of formula; so hospitals reinforce formula use,” Dr. Srinivasan said.

He pointed out that obstetricians serve as the first line of defense against formula use. “Obstetricians should get involved in educating patients about the benefits of breast-feeding early, during prenatal visits, and in the first 48 hours after delivery,” he said, adding that it's then up to pediatricians to pick up the ball.

In talking with his patients, Dr. Srinivasan discovered that many harbor negative myths, such as the myth that breast-feeding can cause a loss of breast contour and can slow weight loss after delivery.

“In actuality, women who breast-feed tend to return to their prepregnancy weights faster than those who don't,” he noted.

In this study, data on breast-feeding initiation rates for 3,324 infants were prospectively collected for a 1-year period. The overall breast-feeding initiation rate for the population was 68%.

Earlier this year, the Centers for Disease Control and Prevention reported that in 2004, 71.5% of non-Hispanic white children were ever breast-fed, compared with 50% of non-Hispanic black children. Among those who were ever breast-fed, 54% of white and 43% of black children continued breast-feeding until age 6 months (MMWR 2006;55:335–9).

“Strenuous public health efforts are needed to improve breast-feeding behaviors, particularly among black women and socially disadvantaged groups,” Dr. Srinivasan concluded.

'Strenuous public health efforts are needed to improve breast-feeding behaviors.' DR. SRINIVASAN

INDIANAPOLIS — Myths about the effects of breast-feeding, the promotion and availability of formula, and the absence of maternal role models are combining to thwart breast-feeding among urban African American women, Dr. Hari B. Srinivasan said during a poster presentation at the annual meeting of the Midwest Society for Pediatric Research.

In a study that mined data similar to those from a 2004 national survey by the Centers for Disease Control and Prevention, Dr. Srinivasan found that fewer than half of African American mothers initiate breast-feeding immediately following an in-hospital educational support program.

The study from Chicago's Sinai Children's Hospital revealed that among Hispanic and white mothers, the rate of breast-feeding initiation was 78% and 72%, respectively. The national goal is to have 75% of mothers initiate breast-feeding by 2010.

“This is a cultural issue. Breast-feeding education has to be started early in schools and in communities,” said Dr. Srinivasan, who is an assistant professor of pediatrics and an attending neonatologist at Sinai. He noted that if one generation chooses breast-feeding over formula, the next generation is more likely to follow suit.

“Also, the Women, Infants and Children program makes formula available to anyone who qualifies and who wants it free of cost. Although WIC is a good program, it serves as a disincentive to breast-feeding, especially among poorer populations. And every woman leaving the hospital after delivery gets a small bag from Ross Pharmaceuticals, and in that bag is a can of formula; so hospitals reinforce formula use,” Dr. Srinivasan said.

He pointed out that obstetricians serve as the first line of defense against formula use. “Obstetricians should get involved in educating patients about the benefits of breast-feeding early, during prenatal visits, and in the first 48 hours after delivery,” he said, adding that it's then up to pediatricians to pick up the ball.

In talking with his patients, Dr. Srinivasan discovered that many harbor negative myths, such as the myth that breast-feeding can cause a loss of breast contour and can slow weight loss after delivery.

“In actuality, women who breast-feed tend to return to their prepregnancy weights faster than those who don't,” he noted.

In this study, data on breast-feeding initiation rates for 3,324 infants were prospectively collected for a 1-year period. The overall breast-feeding initiation rate for the population was 68%.

Earlier this year, the Centers for Disease Control and Prevention reported that in 2004, 71.5% of non-Hispanic white children were ever breast-fed, compared with 50% of non-Hispanic black children. Among those who were ever breast-fed, 54% of white and 43% of black children continued breast-feeding until age 6 months (MMWR 2006;55:335–9).

“Strenuous public health efforts are needed to improve breast-feeding behaviors, particularly among black women and socially disadvantaged groups,” Dr. Srinivasan concluded.

'Strenuous public health efforts are needed to improve breast-feeding behaviors.' DR. SRINIVASAN

Women who are diagnosed with gestational diabetes during pregnancy may be at greater risk for cardiovascular events later in life, reported Dr. Darcy B. Carr and her associates, of the University of Washington, Seattle.

Previous studies have demonstrated that women with a history of gestational diabetes mellitus (GDM) are at increased risk for a wide array of cardiovascular risk factors, including central adiposity, insulin resistance, dyslipidemia, and hypertension. Now, data from the Genetics of Non-Insulin-Dependent Diabetes (GENNID) study suggest that among women with a family history of type 2 diabetes, these risk factors actually translate into a significantly higher prevalence of cardiovascular disease events in those with prior GDM.

“Interventions have been shown to reduce the progression to type 2 diabetes in subjects at risk for the disease, including women with a history of GDM, and offer primary prevention of cardiovascular disease (CVD) events in established type 2 diabetes. We believe our findings provide a strong rationale to further consider efforts to target women who have a history of GDM with interventions in order to improve both their metabolic and cardiovascular health,” Dr. Carr and her associates wrote (Diabetes Care 2006;29:2078–83).

In GENNID, genetic and phenotypic information was collected at multiple U.S. sites between 1993 and 2001 from families with type 2 diabetes. Among parous women in the study who had a first-degree relative with type 2 diabetes but who did not have pregestational diabetes themselves, a total of 332 reported having had GDM during at least one previous pregnancy, while 662 did not report a history of GDM.

At a mean follow-up of 30 years after the index pregnancy, the women with prior GDM were younger (49 vs. 52 years), more likely to be African American (40% vs. 29%), and less likely to be postmenopausal (48% vs. 58%) than were those without GDM.

Although both groups were obese, women in the prior GDM group had a more atherogenic lipid profile and higher fasting plasma glucose and insulin levels, suggesting increased insulin resistance. Among the risk factors that were reported by significantly more women in the GDM group were history of hypertension (47% vs. 37%), dyslipidemia (34% vs. 26%), and type 2 diabetes (93% vs. 63%). Among women who had these risk factors, those with GDM were diagnosed with them at younger ages: 40 vs. 48 years for hypertension, 48 vs. 52 for dyslipidemia, and 37 vs. 47 for type 2 diabetes.

Women with GDM were more than three times as likely as those without GDMto meet all the criteria for metabolic syndrome, even after adjusting for age, menopausal status, and race/ethnicity, Dr. Carr and her associates reported.

Self-reported history of cardiovascular disease (coronary artery disease [CAD] and/or stroke) was significantly more common in women with prior GDM (odds ratio 1.85) and remained significant after adjustment for race/ethnicity, age, and menopausal status (OR 1.66). Overall, cardiovascular disease was reported by 15.5% with GDM compared with 12% without, CAD by 12% vs. 11%, and stroke by 6% vs. 5%.

The CVD and CAD differences were statistically significant, but stroke was not, due to small numbers of patients, the investigators said.

Among the 890 women for whom complete data for metabolic syndrome criteria were available, a history of GDM was associated with an independent risk for CVD after adjustment for metabolic syndrome (OR 1.74) and for type 2 diabetes (OR 1.56).

Women who are diagnosed with gestational diabetes during pregnancy may be at greater risk for cardiovascular events later in life, reported Dr. Darcy B. Carr and her associates, of the University of Washington, Seattle.

Previous studies have demonstrated that women with a history of gestational diabetes mellitus (GDM) are at increased risk for a wide array of cardiovascular risk factors, including central adiposity, insulin resistance, dyslipidemia, and hypertension. Now, data from the Genetics of Non-Insulin-Dependent Diabetes (GENNID) study suggest that among women with a family history of type 2 diabetes, these risk factors actually translate into a significantly higher prevalence of cardiovascular disease events in those with prior GDM.

“Interventions have been shown to reduce the progression to type 2 diabetes in subjects at risk for the disease, including women with a history of GDM, and offer primary prevention of cardiovascular disease (CVD) events in established type 2 diabetes. We believe our findings provide a strong rationale to further consider efforts to target women who have a history of GDM with interventions in order to improve both their metabolic and cardiovascular health,” Dr. Carr and her associates wrote (Diabetes Care 2006;29:2078–83).

In GENNID, genetic and phenotypic information was collected at multiple U.S. sites between 1993 and 2001 from families with type 2 diabetes. Among parous women in the study who had a first-degree relative with type 2 diabetes but who did not have pregestational diabetes themselves, a total of 332 reported having had GDM during at least one previous pregnancy, while 662 did not report a history of GDM.

At a mean follow-up of 30 years after the index pregnancy, the women with prior GDM were younger (49 vs. 52 years), more likely to be African American (40% vs. 29%), and less likely to be postmenopausal (48% vs. 58%) than were those without GDM.

Although both groups were obese, women in the prior GDM group had a more atherogenic lipid profile and higher fasting plasma glucose and insulin levels, suggesting increased insulin resistance. Among the risk factors that were reported by significantly more women in the GDM group were history of hypertension (47% vs. 37%), dyslipidemia (34% vs. 26%), and type 2 diabetes (93% vs. 63%). Among women who had these risk factors, those with GDM were diagnosed with them at younger ages: 40 vs. 48 years for hypertension, 48 vs. 52 for dyslipidemia, and 37 vs. 47 for type 2 diabetes.

Women with GDM were more than three times as likely as those without GDMto meet all the criteria for metabolic syndrome, even after adjusting for age, menopausal status, and race/ethnicity, Dr. Carr and her associates reported.

Self-reported history of cardiovascular disease (coronary artery disease [CAD] and/or stroke) was significantly more common in women with prior GDM (odds ratio 1.85) and remained significant after adjustment for race/ethnicity, age, and menopausal status (OR 1.66). Overall, cardiovascular disease was reported by 15.5% with GDM compared with 12% without, CAD by 12% vs. 11%, and stroke by 6% vs. 5%.

The CVD and CAD differences were statistically significant, but stroke was not, due to small numbers of patients, the investigators said.

Among the 890 women for whom complete data for metabolic syndrome criteria were available, a history of GDM was associated with an independent risk for CVD after adjustment for metabolic syndrome (OR 1.74) and for type 2 diabetes (OR 1.56).

Women who are diagnosed with gestational diabetes during pregnancy may be at greater risk for cardiovascular events later in life, reported Dr. Darcy B. Carr and her associates, of the University of Washington, Seattle.

Previous studies have demonstrated that women with a history of gestational diabetes mellitus (GDM) are at increased risk for a wide array of cardiovascular risk factors, including central adiposity, insulin resistance, dyslipidemia, and hypertension. Now, data from the Genetics of Non-Insulin-Dependent Diabetes (GENNID) study suggest that among women with a family history of type 2 diabetes, these risk factors actually translate into a significantly higher prevalence of cardiovascular disease events in those with prior GDM.

“Interventions have been shown to reduce the progression to type 2 diabetes in subjects at risk for the disease, including women with a history of GDM, and offer primary prevention of cardiovascular disease (CVD) events in established type 2 diabetes. We believe our findings provide a strong rationale to further consider efforts to target women who have a history of GDM with interventions in order to improve both their metabolic and cardiovascular health,” Dr. Carr and her associates wrote (Diabetes Care 2006;29:2078–83).

In GENNID, genetic and phenotypic information was collected at multiple U.S. sites between 1993 and 2001 from families with type 2 diabetes. Among parous women in the study who had a first-degree relative with type 2 diabetes but who did not have pregestational diabetes themselves, a total of 332 reported having had GDM during at least one previous pregnancy, while 662 did not report a history of GDM.

At a mean follow-up of 30 years after the index pregnancy, the women with prior GDM were younger (49 vs. 52 years), more likely to be African American (40% vs. 29%), and less likely to be postmenopausal (48% vs. 58%) than were those without GDM.

Although both groups were obese, women in the prior GDM group had a more atherogenic lipid profile and higher fasting plasma glucose and insulin levels, suggesting increased insulin resistance. Among the risk factors that were reported by significantly more women in the GDM group were history of hypertension (47% vs. 37%), dyslipidemia (34% vs. 26%), and type 2 diabetes (93% vs. 63%). Among women who had these risk factors, those with GDM were diagnosed with them at younger ages: 40 vs. 48 years for hypertension, 48 vs. 52 for dyslipidemia, and 37 vs. 47 for type 2 diabetes.

Women with GDM were more than three times as likely as those without GDMto meet all the criteria for metabolic syndrome, even after adjusting for age, menopausal status, and race/ethnicity, Dr. Carr and her associates reported.

Self-reported history of cardiovascular disease (coronary artery disease [CAD] and/or stroke) was significantly more common in women with prior GDM (odds ratio 1.85) and remained significant after adjustment for race/ethnicity, age, and menopausal status (OR 1.66). Overall, cardiovascular disease was reported by 15.5% with GDM compared with 12% without, CAD by 12% vs. 11%, and stroke by 6% vs. 5%.

The CVD and CAD differences were statistically significant, but stroke was not, due to small numbers of patients, the investigators said.

Among the 890 women for whom complete data for metabolic syndrome criteria were available, a history of GDM was associated with an independent risk for CVD after adjustment for metabolic syndrome (OR 1.74) and for type 2 diabetes (OR 1.56).