Another chance for me to be informed about birthy stuff whilst pregnant - Gestational Diabetes

I realise I launched into my thoughts on my experience with gestational diabetes quite late on in the journey without actually talking about the whole GD thing from the beginning.

The main reason for that, is that once again I found myself in the midst of having to deal with yet another pregnancy and birth related 'problem' whilst being pregnant.  I don't deal brilliantly with stress at the best of times but whilst pregnant well thats a whole nother level.  I felt optimistic that having an independent midwife this time round would make things less stressy than having to deal with a multitude of NHS staff.  I was visualising my homebirth more and more frequently now we had settled into our new home and not once did it have NHS intervention or any issues attached to it.


"Gestational diabetes mellitus (GDM) is a (usually) temporary form of diabetes that occurs during pregnancy. It happens when the hormones made by the placenta during pregnancy make it harder for insulin to work. Insulin is a hormone that helps process your food and keeps your blood glucose level stable. If you can’t make enough insulin your blood glucose levels will rise. High blood glucose levels can cause the baby to put on too much weight. This can impact on the baby’s well being and your delivery and can affect the baby’s health later in its life"Understanding Diabetes - Natasha Leader

During my 18week midwife appointment, my sugar levels from peeing on a stick were very high.  We put it down to the fact that it had been Halloween the night before and we had all eaten a tremendous amount of sweeties!!  I had been given a blood test a few weeks before, which luckily (since we hadn't asked for it), showed my sugar levels as being within the normal limits.  I was advised to cut out refined sugar.  It had been on my mind to at least cut down.

Then at my 27week midwife appointment, my sugar levels were once again raised.  This time and for some unknown reason, except that I am possibly an idiot, I had a bowl of coco pops and raw milk just before she arrived.  I had a major craving for this childhood cereal because I was loving enjoying milk again after stopping whilst breastfeeding.  I have not had sugary cereal like this for at least 4 years.  We cut down gradually by calling it weekend cereal and only having at weekend for a while, until I stopped it altogether.  There was clearly some subconscious voodoo wake up call type thing going on.  I also think it was a last blow out as me and the girls were stopping ALL refined sugar that week after a particularly crazy December of sweets and chocolate.

Then at 30weeks more sugar showed in my urine so this time it was decided I should get a glucose Tolerance Test.  I also fell into a lot of risk categories for possibly having gestational diabetes: older mama, overweight, previous big baby and two family members with late onset type 2 diabetes.

The main concern with gestational diabetes is the size of the baby, a large baby at full term can in some cases cause shoulder dystocia, something my IM has had no experience with either.  Other issues are hypoglycaemia in the newborn who is used to having large amounts in utero.  This can also be due to stress after birth, so skin to skin straight away and establishing breastfeeding are of the utmost importance.  To this end, I am sorting out expressing colostrum and organising donor milk just in case there are problems and my baby needs milk before my own milk comes in.  (video for expressing)

So a week later after researching as much as I could about 'consuming a phenomenal amount of sugar after eating nothing and testing my sugar levels' that's where I found myself.  I was not keen on doing the test since a lot of articles I read seem to question the validity of it.  Michel Odent talks about the discrepancies in diagnosis and whether this is a disease or a diagnosis.

We made the decision based on my other risk factors and the fact that our IM midwife had never had a client with GD before, so she was unclear yet of protocols and risks.  It is also good to have a more clear answer than the peeing on a stick test.

I had also begun my diet change.  After discussing it with my CC mothers group, most of whom are incredibly knowledgeable with regards to healthy dietary habits, I formulated a nominal can and can't have list based on low and high GI.  Basically, the foods with a lot of carbohydrates.  The can have is much larger so I have not included it, but it contains many many vegetables, black eyed beans, quinoa and brown rice instead of white forms of pasta.  I will right more about my diet at a later stage as in midst of it at moment!

CAN'T

white potato – sweet potato instead

white pasta – wholemeal instead

white bread

white cous cous

white rice -wholemeal instead

fruit juice

honey (have small amounts occasionally)

milk

yoghurt

bananas (can have half) -  

all sugar (had already stopped this a month or so before)

the fruit one is a hard one since I ate tons before, now half an apple or two tangerines or half a banana are my allowance probably not all at once!

I also bought a blood glucose monitor and started checking my levels first thing in the morning.  I would recommend starting to monitor 2hrs after eating and keeping a food diary as soon as possible, but for me, it was a lot to take in, a lot of changes being made and a lot of information being researched that I was just not ready to incorporate that regime if I didn't HAVE to. I managed the food diary.

[A very important issue to note regarding blood glucose monitors are that they have a discrepancy rate of 10% which means that if I get a reading of 6.5mmol it could mean 7.15 or 5.85 which, when one is trying to keep levels below a certain criteria, can make a massive difference.  The other issue with the monitor is that the way the blood is taken can also affect the reading.  Fingers should be clean since there is glucose on so many things from paper to the counter or food that may have been touched hours before.  Also, the way the blood comes out makes a difference.  The finger pricker is meant to cause enough blood to appear to be sucked onto the strip but often it doesn't and squeezing can cause plasma to come out which affects the reading.  All of these together often leaves me feeling very frustrated and upset and quite often makes me think that the whole thing is a waste of time, completely impossible to monitor and means nothing]

I can tell you I was crying whilst I ingested the 75g of lucozade plus into my body, because not only did it have caffeine (which I don't normally have) but it had various other colourings and additives that I don't want my children going near, especially my unborn ones.  I let the midwife know in no uncertain terms how appalling it was that this was their drink of choice.  Being there also felt to me as the start of a whole NHS invasion into my life which we had chosen to avoid this time around and this was even more upsetting.

Blood Sugar Levels for pregnant - non pregnant

Unfortunately, the result were not up to standards.  6mmol at fasting and 9.3mmol at 2hours.  This is where I have my issues.   Different levels from different sources, different doctors using different numbers.  The interpretations all depend on which protocol whichever particular hospital is using.  For ours, it was the SIGN guidelines, Scotland specific. <5.1mmol at fasting and <8.5mmol at 2hours.

Whatever way we looked at, I had gestational diabetes and a complete overhaul of my diet was required.  I was given an appointment at the clinic for 3days time and sent on my not so merry way, flying as high as a kite and wired to the moon on sugar.  The effect lasted most of the day and was not pleasant.

The day before my first clinic appointment, my midwife came for another check up and we found ketones in my urine.  I still do not understand fully what this meant, neither did she but made it clear I was to let them know at my appointment the next day.  There are studies regarding the long term effects of GD and of ketones on my child but I decided it is not the best place (35weeks, emotional, stressed and generally peeved) to be reading about that kind of thing.  I will at some point, when I am feeling stronger.  Informed is the key but overwhelmed is inadvisable, i know my limits!

The diabetic clinic appointment was actually not as invasive or threatening as I had worried it might be.  We were seen by a very informed and friendly diabetic nurse who answered all my questions and allowed me to follow her into the testing room and stand talking with her whilst she checked my urine and ketones.  I was given the all clear on both counts, no infection, no ketones.  My blood glucose level that day was 6.4mmol and I was informed that they were very happy with the results and I was to keep my levels between 5mmol and 8mmol.  We spoke with a dietician who looked at the diet I had been keeping since 23rd January and told me the reason I may have ketones, is that there was just not enough carbohydrates in my diet and so I had begun using fat as an energy source instead of carbohydrate or sugar.  Ordinarily this would have pleased me greatly..burning fat YAY! (akin to atkins diet)  Unfortunately, she was unable to tell me, as were most of the doctors I spoke to, the risk for my baby of having ketones in my body.  I was simply told it was not a great state to be in for the baby.  This dietician basically told me to eat more carbohydrates in my diet.  I decided not to discuss with her my views on wheat and dairy, as it seemed her basis for discussion was for people with a completely different diet than mine.  I was thoroughly confused with her advice to eat more carbohydrates (bread, potato, pasta) as I knew that would increase my blood glucose levels.  I already did not eat the white forms of these anyway and rarely if ever ate bread any more.

As it turns out,  my downfall and major error was really my portion sizes.  I followed her advice for a few days and soon realised that even though brown rice or basmati rice or even quinoa are low in carbohydrates compared to their white counterparts, eating a huge portion is still going to push my glucose level through the roof!!

During this appointment I also made sure I had a very important test called the HBA1C.  During my initial phone call with the Dr regarding my appointment, he seemed very non-committal over the importance of this test, so I was relieved I would not have to fight to have it done.  Basically, this test shows the average blood glucose levels over the past 8-12weeks since our amazing bodies store this information for us!!  It lets you know, how long the sugar issue has been going on.  Mine was within normal limits which shows that this was a relatively new problem and had not simply been missed.

I left that appointment feeling pleased with all my results and optimistic about my abilities to control my blood glucose levels with my diet.

13days later I met with the big guns at the obstetric diabetic clinic.  It was quite a full waiting room.  I had been pre-warned that there could be at least 6 people in the room and not to freak out at this, it was not a reflection on my progress but merely a way of seeing all relevant people at the one time and place.  Still, it was overwhelming to walk into a roomful of unrecognisable faces.  Faces of NHS staff who could potentially scupper my homebirth plans.

Did you know that within the NHS, there is ONE woman who has gestational diabetes and this is how they deal with it?  Same measures for everyone, all treated as that one clinical patient.  These are my husbands words on one problem with NHS being involved in pregnancy

"The real problem with the nhs being involved in a pregnancy is everything is reduced to risk and risk management.  Of course the NHS provides an important and valuable service when needed.  But the NHS views risk factors as the start of the road to maximum intervention.  Everything becomes an exercise in monitoring and assessing risk based on current studies and statistics.  
Mothers are removed from deciding what they want, from knowing what they need, or choosing how they want the birth to be… unless they are prepared to battle.  The mother’s focus shifts from preparing for the birth to dealing with the NHS.  The power of a woman to take control of her birth experience is undermined at the very moment that she needs to be connecting with her capabilities and strength"


They basically wanted to start me on insulin straight away and outlined their protocols for this outcome, which is full time monitoring and attached to machines.  Not the community midwife unit, not at home but in their medicalised labour ward.  It was handed to me as the only option but unusually he did say it was still my decision at the moment. For some reason, they also changed their own bracket for my blood levels to 5mmol-7mmol, a total difference to two weeks previous which  upset me greatly as it makes controlling with diet even harder.

I also declined the scan and my midwife was quite surprised to note that there was no palpation of the baby or any hands on checking whatsoever.  They made another appointment for two weeks later.  I doubt it even occurred to them that I was not accepting outright and would make a decision later regarding the scan.


I came away from the meeting with the following thoughts:

"Processing the info and crapness of info, But as of right now I am screaming NOOOoooo
No placetal function cord doppler sizing
No hospital labour hooked up to iv machines
No monitoring
No progressing police
No
No
No
No
NOOOOOOOOOOOOOOOOOOOOOOoooooooooooooooooooo"


They asked me to keep them informed of my blood levels by calling in with my numbers, which brings me to my other post which were my first thoughts on the whole GD experience.

This has been my journey so far....I have decided to have the scan on Wednesday, my midwife would feel more comfortable knowing a rough size estimate although by her calculations I have been consistently 2cm more than my week with no major increases.  Also, it helps to appease the NHS, not that it should be a major factor, I just do not want to have another battle and fight with them.  I fully expect the placental and cord function to be normal and the baby's growth to be slightly high (growth scans are still notoriously inaccurate)but I think it will be manageable.  After all I have done this twice before!!



Meltdowns - minimal
Losing the Plot - intermittent
Breastfeeding - got the colostrum bottles, now waiting to pump at 36weeks!

CLICK HERE FOR RESOURCES AND ARTICLES USED FOR OUR RESEARCH

Resources for Gestatonal diabetes

This is some of the many resources we used for GD

Understanding Gestational Diabetes - Natasha Leader 

How can I tell whether I'm at high risk for gestational diabetes?

Shoulder Dystocia The real story  - Midwife Thinking

The Importance of colostrum - La Leche League 

Donor Milk - Human milk for human babies

Hand expression of Breastmilk - Stanford School of Medicine

Gestational diabetes - Revisited - Bellies and Bumps

Gestational diabetes: A diagnosis still looking for a disease? - Michel Odent

SIGN - Scottish Intercollegiate Guidelines Network - Management of Diabetes

Ketones in Urine During Pregnancy

What is HBA1C?

Diet Preparation for 3hr glucose tolerance Test - Ronnie Falcao

Normal Blood sugars in Pregnancy - Diabetes Update Blood Sugar 101

Glucose Tolerance in Adults After Prenatal Exposure To Famine - the Lancet

Gestational Diabetes - Homebirth Reference site

Gestational Diabetes in Pregnancy - BellyBelly

Gestational Diabetes - the Emporer Has No Clothes - Henci Goer

Gestational Diabetes - KMom

Gestational Diabetes Troubleshooting High Readings - KMom

Gestational Diabetes The Numbers Game - KMom

Systematic Review of Herbs and Dietary Supplements for Glycemic Control in Diabetes

Michel Odent on GD "Gestational Diabetes: A Diagnosis Still Looking For a Disease?"

"Gestational Diabetes: A Diagnosis Still Looking For a Disease?"

Primal Health Research: A New Era in Health Research
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road
London NW3 2JR
Summer 2004 Vol. 12 No.1 

An article of the same title appeared in The Journal of Prenatal & Perinatal Psychology and Health (JOPPPAH) Volume 19, Number 2, Winter 2004

Nowhere in obstetrics is there such a discrepancy between evidence and practice as in the matter of gestational diabetes. This diagnosis has been mentioned briefly in several issues of our newsletter, in order to illustrate the frequent “nocebo effect” of prenatal care. (1,2,3,4) I have recently received so many phone calls of sorely distressed women that I find it necessary to provide updated answers to frequently asked questions. 

How to explain? How to explain with simple words the real meaning of this scary diagnosis? How to explain that it is not a disease like with symptoms leading to complementary inquiries, but the mere interpretation of a laboratory test? 

It is essential to emphasize that such a diagnosis is made after the “glucose tolerance test” is included in the battery of tests routinely offered to pregnant women. It is easy to illustrate this fact by referring to the results of a huge Canadian study.(5) In some parts of Ontario routine screening was interrupted in 1989, while it remained usual elsewhere in that state. It became clear that the only effect of routine glucose tolerance test screening was to tell 2.7% of pregnant women that they have gestational diabetes. It did not change the statistics of prenatal mortality and morbidity. 

Simple physiological explanations can also help reassure a certain number of women. One role of the placenta is to manipulate maternal physiology for fetal benefit. The placenta may be presented as the advocate of the baby, so that the transfer of nutrients to the fetus is optimized. It is via hormonal messages that the placenta can influence maternal physiology. The fetal demand for glucose increase gradually throughout pregnancy. The mother is supposed to react to this demand by reducing her sensitivity to insulin.(6) This leads to a tendency towards hyperglycaemia that is easily detectable after a meal or after ingesting glucose. Some women can compensate their peaks of hyperglycaemia more effectively than others by increasing insulin secretion. When hyperglycaemia peaks above a pre-determined conventional threshold, the term “gestational diabetes” is used. In general glucose tolerance will recover its usual levels after the birth of the baby. 


Practical recommendations

The practical advice one can give to women carrying the label of “gestational diabetes” should be given to all pregnant women & another reason to question the practical benefits of such a diagnosis. This advice concerns lifestyle, particularly nutrition and physical activity. 

Nutritional counseling should focus on the quality of carbohydrates. The most useful way to rank foods is according to their “glycaemic index” (GI). Pregnant women must be encouraged to prefer, as far as possible, low GI foods. A food has a high index when its absorption is followed by a fast and significant increase of glycaemia. In practice this means, for example, that pregnant women must avoid the countless soft drinks that are widely available today, and that they must also avoid adding too much sugar or honey in their tea or coffee. Incidentally, one can wonder if the tolerance test, which implies glucose consumption (the highest substance on the GI), is perfectly neutral and harmless. GI tables of hundreds of foods have been published in authoritative medical journals.(7) These tables must be looked at carefully, because the data they provide are often surprising for those who are still influenced by old classifications contrasting simple sugars and complex carbohydrates. Such classifications were based on the mere chemical formula. 

From such tables we can learn in particular that breakfast cereals based on oats and barley have a low index. Wholemeal bread and pasta also are low-index foods. Potatoes and pizzas,(8) on the other hand, have a high index and should therefore be consumed with moderation. Comparing glucose and fructose (the sugar of fruit) is a way to realize the lack of correlation between chemical formula and GI. Both are hexoses (small molecules with six atoms of carbon) and have pretty similar chemical formulas. Yet the index of glucose is 100&versus 23 for fructose. This means that pregnant women must be encourage to eat fruit and vegetables, an important point since pre-eclampsia is associated with an oxidative stress. 

The quantity of carbohydrates should also be taken into consideration. French nutritionists showed that, among pregnant women with reduced glucose tolerance, there is no risk of having high birth weight babies if the daily consumption of carbohydrates is above 210g a day.(9) This implies a moderate lipid intake. About lipids, the focus should also be on their quality, the ratio between different fatty acids. For example we must take into account the fact that monounsaturated fatty acids (such as the oleic acid of olive oil) tend to increase the sensitivity to insulin. We must also stress that the developing brain has enormous need of very long chain polyunsaturates, particularly those abundant and preformed in the sea food chain.(10) 

Advice regarding physical activity is based on theoretical considerations and on the results of observational studies. Skeletal muscle cells initially use glycogen stores for energy but are soon forced to use blood glucose, thus lowering glycaemia in the short term.(11) In addition, exercise has been shown to increase the insulin sensitivity of muscles and glucose uptake into muscular cells, regardless of insulin levels,(12) resulting in lower glycaemia. The effect of exercise on glucose tolerance has been demonstrated among extremely overweight women (body mass index above 33). 10.3% of obese women who took no exercise had a significant reduction of glucose tolerance, compared with 5.7% of those who did any exercise one or more times a week.(13) “A walk in the shopping mall for half an hour to an hour a couple of times a week is all that is needed”, says author Raul Artal. According to what we currently know, the benefits of a regular physical activity in pregnancy should be a routine discussion during prenatal visits, whatever the results of sophisticated tests. 

Looking for a disease 

Almost everywhere in the world, “gestational diabetes” is a frequent diagnosis. We should therefore not be surprised by the tendency to assign it the status of a disease. This might appear as a feat, since this diagnosis is not based on any specific symptom, but just on the effects of an intervention (giving glucose) on blood biochemistry. 

One of the ways to transform a diagnosis into a disease is to list its complications. The well-documented fact that women carrying this label are more at risk than others to develop later on in life a non-insulin dependent diabetes has often been presented as a complication.(14) But this “type 2 diabetes” is not a consequence of reduced glucose tolerance in pregnancy. It is simply the expression, in another context, of a particular metabolic type. One might even claim that the only interest of glucose tolerance test in pregnancy is to identify a population at risk of developing a type 2 diabetes. But when a woman is looking forward to having a baby, is it the right time to bother her with glucose intake and blood samples, and to tell her that she is more at risk than others to have a future chronic disease? It is probably more important to talk routinely about nutrition and exercise. 

Gestational hypertension has also been presented as a complication of gestational diabetes. In fact an isolated increased blood pressure in pregnancy is a transitory physiological reaction associated with good perinatal outcomes.(15, 16, 17, 18) Once more the concomitant expression of a particular metabolic type should not be confused with the evolution of a disease towards complications. 

Professor Jarrett, a London epidemiologist, made a synthesis of the questions inspired by such associations. He stressed that women who carry this label are, on average, older and heavier than the overall population of pregnant women, and their average blood pressure is higher. This is enough to explain differences in perinatal outcomes. The results of glucose tolerance tests are superfluous. According to Professor Jarrett, gestational diabetes is a “non-entity”.(19) 

The concept of fetal complications is also widespread. Fetal death has long been thought to be associated with gestational diabetes. However all well-designed studies looking at comparable groups of women dismissed this belief, in populations as divers as Western European (20) or Chinese (21), and also in Singapore (22) and Mauritius.(23) High birth weight has also been presented as a complication. In fact it should be considered an association whose expression is influenced by maternal age, parity and the degree of nutritional unbalance. If there is a cause and effect relation, it might be the other way round: a big baby requires more glucose than a small one. It is significant that in the case of twins “when the demand is double” the glucose tolerance test is more often positive than for singleton pregnancies. Only hypoglycemia of the newborn baby might be considered a complication, although there are multiple risk factors. 

Another way to transform a diagnosis into a disease is to establish therapeutic guidelines. Until now, no study has ever demonstrated any positive effect of a pharmacological treatment on the maternal and neonatal morbidity rates, in a population with impaired glucose tolerance. On the contrary no pharmacological particular treatment is able to reduce the risks of neonatal hypoglycaemia.(24,25) However gestational diabetes is often treated with drugs. The frequency of pharmacological treatment has even been evaluated among the fellows of the American College of Obstetricians and Gynecologists (ACOG).(26) It appears that 96% of these practitioners routinely screen for gestational diabetes. When glycaemic control is not considered acceptable, 82% prescribe insulin right away, while 13% try first glyburide, an hypoglycaemic oral drug of the sulfonylureas family. 

While practitioners are keen on drugs, there are more and more studies comparing the advantages of human insulin and synthetic insulins lispro and aspart,(27, 28) or comparing the effects of twice-daily regimen with four-times-daily regimen of short-acting and intermediate-actinginsulins.(29) Meanwhile the comparative advantages of several oral hypoglycaemic drugs are also evaluated. The criteria are always short- term and “glycaemic control” is the main objective.(30) The fact, for example, that sulfonylureas cross the placenta should lead to caution and to raise questions about the long-term future of children exposed to such drugs during crucial phases of their development. 

The nocebo effect of prenatal care 

After reaching the conclusion that the term “gestational diabetes” is useless, one can wonder if it is really harmless. Today we understand that our health is to a great extent shaped in the womb.(31) Furthermore we can interpret more easily the effects of maternal emotional states on the growth and development of the fetus. In the current scientific context we can therefore claim that the main preoccupation of health professionals who meet pregnant women should be to protect their emotional state. In other words the first duty of midwives, doctors and other practitioners involved in prenatal care should be to avoid any sort of “nocebo effect”. 

There is a nocebo effect whenever a health professional does more harm than good by interfering with the belief system, the imagination or the emotional state of a patient or of a pregnant woman. The nocebo effect is inherent in conventional prenatal care, which is constantly focusing on potential problems. Every visit is an opportunity to be reminded of all the risks associated with pregnancy and delivery. The vocabulary can dramatically influence the emotional state of pregnant women. The term “gestational diabetes” is a perfect example. 

When analyzing the most common reasons for phone calls by anxious pregnant women, I have found that, more often than not, health professionals are ignorant of or misinterpret the medical literature, and that they lack of understanding and respect for one of the main roles of the placenta, which is to manipulate maternal physiology for fetal benefit.

Prenatal care will also be much cheaper on the day when the medical and scientific literature will be better interpreted! 

Michel Odent 

Références : 

1 - Odent M. The Nocebo effect in prenatal care. Primal Heath Research Newsletter 1994; 2: 2-6.

2 - Odent M. Back to the Nocebo effect. Primal Heath Research Newsletter 1995; 5 (4).

3 - Odent M. Antenatal scare. Primal Heath Research Newsletter 2000; 7 (4).

4 - Odent M. The rise of preconceptional counselling vs the decline of medicalized care in pregnancy. Primal Health Research Newsletter 2002;10(3)

5 - Wen SW, Liu S, Kramer MS, et al. Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes. Am J Epidemiol 2000; 152(11): 1009-14.

6 - Vambergue A, Valat AS, Dufour P, et al. Pathophysiologie du diabète gestationnel. J Gynecol Obstet Biol Reprod (Paris) 2002 ; 31(6 Suppl) : 4S3-4S10.

7 - Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values. Am J Clin Nutr 2002; 76(1): 5-56.

8 - Ahern JA. Exaggerated hyperglycemia after a pizza meal in well-controlled diabetics. Diabetes Care 1993; 16: 578-80.

9 - Romon M, Nuttens MC, Vambergue A, et al. Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes. J Am Diet Assoc 2001; 101(8): 897-902.

10 - Odent MR, McMillan L, Kimmel T. Prenatal care and sea fish. Eur J Obstet Gynecol Biol Reprod 1996; 68: 49-51.

11 - Chipkin S, Klugh S, Chasan-Taber L. Exercise and diabetes. Cardiol Clin 2001; 19: 489-505.

12 - Wojtaszewski JP, Nielsen JN, Richter EA. Invited review: effect of acute exercise on insulin signaling and action in humans. J Appl Physiol 2002; 93(1): 384-92.

13 - Dye TD, Knox KL, Artal R, et al. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997; 146(11): 961-5.

14 - Kim C, Newton R, Knopp R. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25: 1862-8 

15 - Symonds EM. Aetiology of pre-eclampsia: a review. J R Soc Med 1980; 73: 871-75.

16 - Naeye EM. Maternal blood pressure and fetal growth. Am J Obstet Gynecol 1981; 141: 780-87.

17 - Kilpatrick S. Unlike pre-eclampsia, gestational hypertension is not associated with increased neonatal and maternal morbidity except abruptio. SPO abstracts. Am J Obstet Gynecol 1995; 419: 376.

18 - Curtis S, et al. Pregnancy effects of non-proteinuric gestational hypertension. SPO Abstracts. Am J Obst Gynecol 1995; 418: 376.

19 - Jarrett RJ. Gestational diabetes : a non-entity ? BMJ1993 ; 306 : 37-38.

20 - Roberts RN, Moohan JM, Foo RL, et al. Fetal outcomes in mothers with impaired glucose tolerance in pregnancy. Diabet Med 1993; 10(5): 438- 43.

21 - Lao TT, Ho LF. Impaired glucose tolerance and pregnancy outcome in Chinese women with high body mass index. Hum Reprod 2000; 15(8): 1826- 9.

22 - Tan Y, Yeo GS. Impaired glucose tolerance in pregnancy_is it of consequence ? Aust NZ J Obstet Gynaecol 1996; 36(3): 248-55.

23 - Ramtoola S, Home P, Damry H, et al. Gestational impaired glucose tolerance does not increase perinatal mortality in a developing country: cohort study. BMJ 2001;322: 1025-6.

24 - Jensen DM, Sorensen B, Feilberg-Jorgensen N, et al. Maternal and perinatal outcomes in 143 Danish women with gestational diabetes mellitus and 143 controls with a similar risk profile. Diabet Med 2000; 17(4): 281-6.

25 - Hellmuth E, Damm P, Moldted-Pederson L. Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabetes Med 2000; 17(7): 507-11.

26- Gabbe SG, Gregory RP, Power ML, et al. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004; 103(6): 1229-34.

27 - Jovanovic L, Ilic S, Pettitt D, et al. Metabolic and immunologic effects of insulin lispro in gestational diabetes. Diabetes Care 1999; 22: 1422-7.

28 - Pettitt D, Ospina P, Kolaczynski J, et al. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Diabetes Care 2003; 26(1): 183-6.

29 - Nachum Z, Ben-Shlomo I, Weiner E, et al. Twice daily versus four times daily insulin regimens for diabetes in pregnancy: randomized controlled trial. BMJ 1999; 319: 1223-7.

30 - Langer O, Conway D, Berkus M, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med 2000; 343: 1134-8.

31 -La banque de données du Primal Health Research Centre est spécialisée dans les études explorant les conséquences à long terme de ce qui se passe au début de la vie.