Timothy F. Kirn

SEATTLE — Postprandial glucose levels seem to play an important and often overlooked role in cardiovascular disease in type 2 diabetes patients, Dr. Richard Hellman said at the annual meeting of the American Association of Clinical Endocrinologists.

“If you don't look at the postprandial events, you probably are not going to be successful in bringing the [HbA_1c] levels into the target ranges that any of us would consider appropriate,” said Dr. Hellman, who is an endocrinologist at the University of Missouri-Kansas City and the president of the AACE.

Both the contribution of postprandial hyperglycemia and the cardiovascular risk decrease along a continuum, so the lower the HbA_1c level that a patient can achieve, the lower that patient's cardiovascular risk will be, Dr. Hellman added.

The fact that postprandial hyperglycemia can be as crucial as fasting hyperglycemia was elucidated a few years ago in a study that computed the contributions of postprandial and fasting glucose to HbA_1c levels in treated patients with diabetes, Dr. Hellman explained.

According to the study, when patients are not well controlled, the largest contribution to the HbA_1c level is from fasting glucose.

However, as patients come under better glucose control, postprandial glucose accounts for a greater contribution.

For example, the study findings showed that when the HbA_1c level is 8.5%–9.2%, postprandial hyperglycemia accounts for a little less than 50% of the HbA_1c level, but when the HbA_1c is lower than 7.3%, postprandial hyperglycemia accounts for about 70% (Diabetes Care 2003;26:881–5).

“I think this was a profound observation,” Dr. Hellman said.

Current data from a number of different surveys suggest that, overall, the lipid and glucose levels of patients with type 2 diabetes are not well managed, and that in recent years management has been getting worse, according to Dr. Hellman.

One of those studies recently reported that glycemic control (defined as an HbA_1c level below 7%) was being achieved in only 36% of type 2 diabetes patients, compared with 45% of patients in the early 1990s (Diabetes Care 2004;27:17–20).

The optimal way for type 2 diabetes patients to achieve glycemic control—and thereby reduce their cardiovascular risk—is to adopt a multifactorial approach to management.

This approach should include diet modification, exercise, and aggressive treatment of hyperlipidemia, hypertension, and elevated glucose levels, Dr. Hellman said.

SEATTLE — Postprandial glucose levels seem to play an important and often overlooked role in cardiovascular disease in type 2 diabetes patients, Dr. Richard Hellman said at the annual meeting of the American Association of Clinical Endocrinologists.

“If you don't look at the postprandial events, you probably are not going to be successful in bringing the [HbA_1c] levels into the target ranges that any of us would consider appropriate,” said Dr. Hellman, who is an endocrinologist at the University of Missouri-Kansas City and the president of the AACE.

Both the contribution of postprandial hyperglycemia and the cardiovascular risk decrease along a continuum, so the lower the HbA_1c level that a patient can achieve, the lower that patient's cardiovascular risk will be, Dr. Hellman added.

The fact that postprandial hyperglycemia can be as crucial as fasting hyperglycemia was elucidated a few years ago in a study that computed the contributions of postprandial and fasting glucose to HbA_1c levels in treated patients with diabetes, Dr. Hellman explained.

According to the study, when patients are not well controlled, the largest contribution to the HbA_1c level is from fasting glucose.

However, as patients come under better glucose control, postprandial glucose accounts for a greater contribution.

For example, the study findings showed that when the HbA_1c level is 8.5%–9.2%, postprandial hyperglycemia accounts for a little less than 50% of the HbA_1c level, but when the HbA_1c is lower than 7.3%, postprandial hyperglycemia accounts for about 70% (Diabetes Care 2003;26:881–5).

“I think this was a profound observation,” Dr. Hellman said.

Current data from a number of different surveys suggest that, overall, the lipid and glucose levels of patients with type 2 diabetes are not well managed, and that in recent years management has been getting worse, according to Dr. Hellman.

One of those studies recently reported that glycemic control (defined as an HbA_1c level below 7%) was being achieved in only 36% of type 2 diabetes patients, compared with 45% of patients in the early 1990s (Diabetes Care 2004;27:17–20).

The optimal way for type 2 diabetes patients to achieve glycemic control—and thereby reduce their cardiovascular risk—is to adopt a multifactorial approach to management.

This approach should include diet modification, exercise, and aggressive treatment of hyperlipidemia, hypertension, and elevated glucose levels, Dr. Hellman said.

SEATTLE — Postprandial glucose levels seem to play an important and often overlooked role in cardiovascular disease in type 2 diabetes patients, Dr. Richard Hellman said at the annual meeting of the American Association of Clinical Endocrinologists.

“If you don't look at the postprandial events, you probably are not going to be successful in bringing the [HbA_1c] levels into the target ranges that any of us would consider appropriate,” said Dr. Hellman, who is an endocrinologist at the University of Missouri-Kansas City and the president of the AACE.

Both the contribution of postprandial hyperglycemia and the cardiovascular risk decrease along a continuum, so the lower the HbA_1c level that a patient can achieve, the lower that patient's cardiovascular risk will be, Dr. Hellman added.

The fact that postprandial hyperglycemia can be as crucial as fasting hyperglycemia was elucidated a few years ago in a study that computed the contributions of postprandial and fasting glucose to HbA_1c levels in treated patients with diabetes, Dr. Hellman explained.

According to the study, when patients are not well controlled, the largest contribution to the HbA_1c level is from fasting glucose.

However, as patients come under better glucose control, postprandial glucose accounts for a greater contribution.

For example, the study findings showed that when the HbA_1c level is 8.5%–9.2%, postprandial hyperglycemia accounts for a little less than 50% of the HbA_1c level, but when the HbA_1c is lower than 7.3%, postprandial hyperglycemia accounts for about 70% (Diabetes Care 2003;26:881–5).

“I think this was a profound observation,” Dr. Hellman said.

Current data from a number of different surveys suggest that, overall, the lipid and glucose levels of patients with type 2 diabetes are not well managed, and that in recent years management has been getting worse, according to Dr. Hellman.

One of those studies recently reported that glycemic control (defined as an HbA_1c level below 7%) was being achieved in only 36% of type 2 diabetes patients, compared with 45% of patients in the early 1990s (Diabetes Care 2004;27:17–20).

The optimal way for type 2 diabetes patients to achieve glycemic control—and thereby reduce their cardiovascular risk—is to adopt a multifactorial approach to management.

This approach should include diet modification, exercise, and aggressive treatment of hyperlipidemia, hypertension, and elevated glucose levels, Dr. Hellman said.

LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.

But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Hirsutism is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.

“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”

Hirsutism affects 7% of women, Dr. Azziz said. He reviewed records for 873 untreated women with known androgen excess and 659 untreated women who presented with hirsutism. Among the women with androgen excess, 76% had hirsutism, and 85% of those presenting with hirsutism had a defined androgen disorder. The most common androgen disorder, found in 78% of the 659 women who presented with hirsutism, was PCOS.

PCOS is a diagnosis of exclusion, Dr. Azziz said. Fortunately, tumors of the adrenal glands and the ovaries only occur in hirsute women at about the same rate as in the general population, according to his large series of patients.

Ninety-five percent of tumors are detected clinically, not by androgen testing, he said.

For ruling out other conditions, the history—Are the signs and symptoms new or established?—and physical examination—Is the patient cushingoid?—are key, he said.

Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.

If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.

“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.

He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which does not include the lower arms and legs, where many nonhirsute women are hairy.

Once a physician gets acquainted with using the scale, it can be quite helpful, particularly since laboratory measurements of androgen levels are quite unreliable because the normal range is so great, he said.

“If you do it in all the patients, over time, your data will be reliable within your practice,” he said.

Medical therapy generally needs two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.

The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism. But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said.

Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.

In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.

Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.

Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months.

Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.

About 80% of patients will have a good response with combination therapy.

In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.

Plucking is probably not a good idea, said Dr. Azziz, because it can cause folliculitis. Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.

But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Hirsutism is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.

“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”

Hirsutism affects 7% of women, Dr. Azziz said. He reviewed records for 873 untreated women with known androgen excess and 659 untreated women who presented with hirsutism. Among the women with androgen excess, 76% had hirsutism, and 85% of those presenting with hirsutism had a defined androgen disorder. The most common androgen disorder, found in 78% of the 659 women who presented with hirsutism, was PCOS.

PCOS is a diagnosis of exclusion, Dr. Azziz said. Fortunately, tumors of the adrenal glands and the ovaries only occur in hirsute women at about the same rate as in the general population, according to his large series of patients.

Ninety-five percent of tumors are detected clinically, not by androgen testing, he said.

For ruling out other conditions, the history—Are the signs and symptoms new or established?—and physical examination—Is the patient cushingoid?—are key, he said.

Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.

If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.

“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.

He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which does not include the lower arms and legs, where many nonhirsute women are hairy.

Once a physician gets acquainted with using the scale, it can be quite helpful, particularly since laboratory measurements of androgen levels are quite unreliable because the normal range is so great, he said.

“If you do it in all the patients, over time, your data will be reliable within your practice,” he said.

Medical therapy generally needs two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.

The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism. But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said.

Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.

In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.

Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.

Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months.

Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.

About 80% of patients will have a good response with combination therapy.

In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.

Plucking is probably not a good idea, said Dr. Azziz, because it can cause folliculitis. Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.

But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Hirsutism is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.

“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”

Hirsutism affects 7% of women, Dr. Azziz said. He reviewed records for 873 untreated women with known androgen excess and 659 untreated women who presented with hirsutism. Among the women with androgen excess, 76% had hirsutism, and 85% of those presenting with hirsutism had a defined androgen disorder. The most common androgen disorder, found in 78% of the 659 women who presented with hirsutism, was PCOS.

PCOS is a diagnosis of exclusion, Dr. Azziz said. Fortunately, tumors of the adrenal glands and the ovaries only occur in hirsute women at about the same rate as in the general population, according to his large series of patients.

Ninety-five percent of tumors are detected clinically, not by androgen testing, he said.

For ruling out other conditions, the history—Are the signs and symptoms new or established?—and physical examination—Is the patient cushingoid?—are key, he said.

Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.

If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.

“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.

He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which does not include the lower arms and legs, where many nonhirsute women are hairy.

Once a physician gets acquainted with using the scale, it can be quite helpful, particularly since laboratory measurements of androgen levels are quite unreliable because the normal range is so great, he said.

“If you do it in all the patients, over time, your data will be reliable within your practice,” he said.

Medical therapy generally needs two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.

The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism. But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said.

Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.

In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.

Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.

Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months.

Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.

About 80% of patients will have a good response with combination therapy.

In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.

Plucking is probably not a good idea, said Dr. Azziz, because it can cause folliculitis. Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Obesity does not appear to be associated with venous disease and varicose veins generally, Dr. Jean-Patrick Benigni said at the annual meeting of the American Venous Forum.

“In an obese population, evidence of an association between obesity and venous reflux is not so high,” said Dr. Benigni of the unit of cardiovascular pathology at Begin Hospital, Saint-Mandé, France.

Dr. Benigni did a clinical examination and duplex ultrasound in 757 obese patients, of whom 90% were female.

The evaluation found that 22% had varicose veins, slightly less than the estimated prevalence in the general female population of 25%. The percentage with varicose veins was the same whether body mass index was above 40 mg/kg

About 5% of the subjects had lower-extremity edema. But in subjects who were CEAP (clinical, etiologic, anatomic, and pathophysiologic) classes 3 or 4, defined as the presence of edema or skin changes without ulceration, only 33% were found to have venous reflux on duplex ultrasound.

Another report also found no evidence of increased venous disease in the morbidly obese (J. Vasc. Surg. 2003;37:79–85), Dr. Benigni said.

He conjectured that venous disease is related to circulatory system problems, not directly to obesity itself.

However, Dr. Frank Padberg Jr., a professor of surgery at the New Jersey Medical School, Newark, and author of the report cited by Dr. Benigni, cautioned that “varicose veins can be hidden under the layers of adipose.”

SAN DIEGO — Obesity does not appear to be associated with venous disease and varicose veins generally, Dr. Jean-Patrick Benigni said at the annual meeting of the American Venous Forum.

“In an obese population, evidence of an association between obesity and venous reflux is not so high,” said Dr. Benigni of the unit of cardiovascular pathology at Begin Hospital, Saint-Mandé, France.

Dr. Benigni did a clinical examination and duplex ultrasound in 757 obese patients, of whom 90% were female.

The evaluation found that 22% had varicose veins, slightly less than the estimated prevalence in the general female population of 25%. The percentage with varicose veins was the same whether body mass index was above 40 mg/kg

About 5% of the subjects had lower-extremity edema. But in subjects who were CEAP (clinical, etiologic, anatomic, and pathophysiologic) classes 3 or 4, defined as the presence of edema or skin changes without ulceration, only 33% were found to have venous reflux on duplex ultrasound.

Another report also found no evidence of increased venous disease in the morbidly obese (J. Vasc. Surg. 2003;37:79–85), Dr. Benigni said.

He conjectured that venous disease is related to circulatory system problems, not directly to obesity itself.

However, Dr. Frank Padberg Jr., a professor of surgery at the New Jersey Medical School, Newark, and author of the report cited by Dr. Benigni, cautioned that “varicose veins can be hidden under the layers of adipose.”

SAN DIEGO — Obesity does not appear to be associated with venous disease and varicose veins generally, Dr. Jean-Patrick Benigni said at the annual meeting of the American Venous Forum.

“In an obese population, evidence of an association between obesity and venous reflux is not so high,” said Dr. Benigni of the unit of cardiovascular pathology at Begin Hospital, Saint-Mandé, France.

Dr. Benigni did a clinical examination and duplex ultrasound in 757 obese patients, of whom 90% were female.

The evaluation found that 22% had varicose veins, slightly less than the estimated prevalence in the general female population of 25%. The percentage with varicose veins was the same whether body mass index was above 40 mg/kg

About 5% of the subjects had lower-extremity edema. But in subjects who were CEAP (clinical, etiologic, anatomic, and pathophysiologic) classes 3 or 4, defined as the presence of edema or skin changes without ulceration, only 33% were found to have venous reflux on duplex ultrasound.

Another report also found no evidence of increased venous disease in the morbidly obese (J. Vasc. Surg. 2003;37:79–85), Dr. Benigni said.

He conjectured that venous disease is related to circulatory system problems, not directly to obesity itself.

However, Dr. Frank Padberg Jr., a professor of surgery at the New Jersey Medical School, Newark, and author of the report cited by Dr. Benigni, cautioned that “varicose veins can be hidden under the layers of adipose.”

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that it was easy for patients to do well. But that is not really the case, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819–23).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women with gestational diabetes, who were between 24 weeks' and 33 weeks' gestation, to routine diabetes care and education or to routine care plus insulin therapy. The researchers reported that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477–86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467–70).

Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134–8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin.

It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that it was easy for patients to do well. But that is not really the case, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819–23).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women with gestational diabetes, who were between 24 weeks' and 33 weeks' gestation, to routine diabetes care and education or to routine care plus insulin therapy. The researchers reported that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477–86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467–70).

Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134–8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin.

It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that it was easy for patients to do well. But that is not really the case, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819–23).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women with gestational diabetes, who were between 24 weeks' and 33 weeks' gestation, to routine diabetes care and education or to routine care plus insulin therapy. The researchers reported that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477–86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467–70).

Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134–8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin.

It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

SEATTLE — Since islet allograft transplantation for diabetes is still not very successful over the long term, it may be time to reconsider using the liver as the location for infusing the transplant cells, Dr. R. Paul Robertson said at the annual meeting of the American Association of Clinical Endocrinologists.

“They should be getting out of the liver,” he said. “There is just no reason to attack the liver like that.”

When the group from the University of Alberta, Edmonton, first published its islet transplantation results in 2000, researchers reported good success with the liver as the transplantation site; 100% of the patients were insulin free out to 1 year post procedure, said Dr. Robertson, a professor of medicine and pharmacology at the University of Washington, Seattle, who has done metabolic studies on transplant recipients.

But now with reports of patients out to 5 years, it seems that majority of the Edmonton group's transplantations did not last. The median duration of function of an islet transplant appears to be about 15 months. Of 65 patients reported on in 2005 by the group, 15% had failed, 77% had returned to insulin therapy, and only 8% remained completely insulin free, Dr. Robertson noted (Diabetes 2005;54:2060–9).

Moreover, while centers such as the University of Miami, the University of Minnesota, and the University of Pennsylvania have done successful islet transplants, at least three other places have had no success, including the University of Washington, Dr. Robertson said.

The problem may be the liver, he said. The liver is the repository for the transplant drugs used to prevent rejection—which may be toxic to the islets—as well as for all the other environmental toxins.

In addition, use of the liver was thought to have the advantage of being physiologically appropriate, because the pancreas dumps insulin through the liver. It also was considered a safe procedure, because the cells are simply infused into the hepatic portal vein, where they are then washed into the organ.

But canine experiments suggest that the islets may not function optimally in the liver. And there have been serious adverse events reported with the procedure. According to one report, 41% of patients transplanted in Edmonton had complications that required hospitalization, Dr. Robertson said.

Other experiments have investigated infusing the islets into the intraperitoneal space, subcutaneously, and next to the kidney. “We need to be patient and support this kind of research,” Dr. Robertson said.

SEATTLE — Since islet allograft transplantation for diabetes is still not very successful over the long term, it may be time to reconsider using the liver as the location for infusing the transplant cells, Dr. R. Paul Robertson said at the annual meeting of the American Association of Clinical Endocrinologists.

“They should be getting out of the liver,” he said. “There is just no reason to attack the liver like that.”

When the group from the University of Alberta, Edmonton, first published its islet transplantation results in 2000, researchers reported good success with the liver as the transplantation site; 100% of the patients were insulin free out to 1 year post procedure, said Dr. Robertson, a professor of medicine and pharmacology at the University of Washington, Seattle, who has done metabolic studies on transplant recipients.

But now with reports of patients out to 5 years, it seems that majority of the Edmonton group's transplantations did not last. The median duration of function of an islet transplant appears to be about 15 months. Of 65 patients reported on in 2005 by the group, 15% had failed, 77% had returned to insulin therapy, and only 8% remained completely insulin free, Dr. Robertson noted (Diabetes 2005;54:2060–9).

Moreover, while centers such as the University of Miami, the University of Minnesota, and the University of Pennsylvania have done successful islet transplants, at least three other places have had no success, including the University of Washington, Dr. Robertson said.

The problem may be the liver, he said. The liver is the repository for the transplant drugs used to prevent rejection—which may be toxic to the islets—as well as for all the other environmental toxins.

In addition, use of the liver was thought to have the advantage of being physiologically appropriate, because the pancreas dumps insulin through the liver. It also was considered a safe procedure, because the cells are simply infused into the hepatic portal vein, where they are then washed into the organ.

But canine experiments suggest that the islets may not function optimally in the liver. And there have been serious adverse events reported with the procedure. According to one report, 41% of patients transplanted in Edmonton had complications that required hospitalization, Dr. Robertson said.

Other experiments have investigated infusing the islets into the intraperitoneal space, subcutaneously, and next to the kidney. “We need to be patient and support this kind of research,” Dr. Robertson said.

SEATTLE — Since islet allograft transplantation for diabetes is still not very successful over the long term, it may be time to reconsider using the liver as the location for infusing the transplant cells, Dr. R. Paul Robertson said at the annual meeting of the American Association of Clinical Endocrinologists.

“They should be getting out of the liver,” he said. “There is just no reason to attack the liver like that.”

When the group from the University of Alberta, Edmonton, first published its islet transplantation results in 2000, researchers reported good success with the liver as the transplantation site; 100% of the patients were insulin free out to 1 year post procedure, said Dr. Robertson, a professor of medicine and pharmacology at the University of Washington, Seattle, who has done metabolic studies on transplant recipients.

But now with reports of patients out to 5 years, it seems that majority of the Edmonton group's transplantations did not last. The median duration of function of an islet transplant appears to be about 15 months. Of 65 patients reported on in 2005 by the group, 15% had failed, 77% had returned to insulin therapy, and only 8% remained completely insulin free, Dr. Robertson noted (Diabetes 2005;54:2060–9).

Moreover, while centers such as the University of Miami, the University of Minnesota, and the University of Pennsylvania have done successful islet transplants, at least three other places have had no success, including the University of Washington, Dr. Robertson said.

The problem may be the liver, he said. The liver is the repository for the transplant drugs used to prevent rejection—which may be toxic to the islets—as well as for all the other environmental toxins.

In addition, use of the liver was thought to have the advantage of being physiologically appropriate, because the pancreas dumps insulin through the liver. It also was considered a safe procedure, because the cells are simply infused into the hepatic portal vein, where they are then washed into the organ.

But canine experiments suggest that the islets may not function optimally in the liver. And there have been serious adverse events reported with the procedure. According to one report, 41% of patients transplanted in Edmonton had complications that required hospitalization, Dr. Robertson said.

Other experiments have investigated infusing the islets into the intraperitoneal space, subcutaneously, and next to the kidney. “We need to be patient and support this kind of research,” Dr. Robertson said.

LOS ANGELES — Treating genital herpes simplex virus with acyclovir diminishes vaginal HIV shedding and plasma HIV levels in women coinfected with HSV and HIV, which suggests that treating herpes could have a role in reducing HIV transmission, according to two studies presented at the 14th Conference on Retroviruses and Opportunistic Infections.

A study conducted in Thailand by the U.S. Centers for Disease Control and Prevention found that 55% of treated women had a significant reduction in vaginal viral shedding during their treatment, said Dr. Eileen Dunne, of the Division of Sexually Transmitted Diseases Prevention of the CDC.

In a study from South Africa, treated women had a reduction in herpes simplex virus type 2; 63% less vaginal shedding, compared with placebo-control women; and a 43% reduction in plasma HIV levels, said Dr. Sinead Delany-Moretlwe, director of research for the reproductive health and HIV research unit at the University of the Witwatersrand, Johannesberg, South Africa.

Neither study was without some equivocal results that tempered the investigators' overall assessment of the findings, but both investigators nevertheless concluded that their trial showed benefit. Both also noted that although their studies were short, they were optimistic that longer trials, currently underway, of HSV suppressive therapy and actual HIV transmission would find that such therapy reduced transmission.

Each trial lasted only 3 months.

The Thailand study analyzed data from 67 women coinfected with HSV and HIV. The women were assigned into one of two groups. One group was treated for 1 month with acyclovir 800 mg twice daily, and the other served as a control. After a 1-month washout with no drugs, the groups were switched.

Overall, 34% of the women had no vaginal HIV shedding at baseline and so had no change through the trial. However, 55% of the subjects did have a significant reduction in HIV shedding while on acyclovir. And there was a 2.8-fold drop in HIV load in vaginal lavage samples, which was statistically significant, though the mean 0.4-log drop in viral load is not far above the 0.3 sensitivity limit of HIV viral load testing.

Dr. Dunne noted, however, that most of the women had never had herpes symptoms, and their HIV was in such an early stage that it was not being treated. And, she said, the treatment might have a more profound effect on people with more advanced disease.

“You might expect the impact would be greater in a group with immunosuppression or a group with symptomatic herpes,” she said.

“We are hopeful that this study foreshadows positive results from the ongoing trials that are evaluating the effect of suppressive therapy [of HSV] on transmission of HIV,” she added.

The South African study had 169 women treated with acyclovir (400 mg twice daily) or placebo for 3 months. Like the patients in the other study, they were HIV positive and not on antiretroviral therapy.

The study found no statistically significant drop in the vaginal HIV viral load. But it did find a 2.4-fold decline in mean plasma viral load relative to placebo, and a larger percentage of the treated patients were found not to be shedding HIV at all visits. Of the treated women, 23% were found to be shedding at fewer than half of their weekly visits, versus 17% of the placebo-control women.

By the third month, HSV shedding had been reduced by 63% in the treated patients, compared with the placebo group.

“We believe this warrants further investigation over a longer follow-up,” Dr. Delany-Moretlwe said.

LOS ANGELES — Treating genital herpes simplex virus with acyclovir diminishes vaginal HIV shedding and plasma HIV levels in women coinfected with HSV and HIV, which suggests that treating herpes could have a role in reducing HIV transmission, according to two studies presented at the 14th Conference on Retroviruses and Opportunistic Infections.

A study conducted in Thailand by the U.S. Centers for Disease Control and Prevention found that 55% of treated women had a significant reduction in vaginal viral shedding during their treatment, said Dr. Eileen Dunne, of the Division of Sexually Transmitted Diseases Prevention of the CDC.

In a study from South Africa, treated women had a reduction in herpes simplex virus type 2; 63% less vaginal shedding, compared with placebo-control women; and a 43% reduction in plasma HIV levels, said Dr. Sinead Delany-Moretlwe, director of research for the reproductive health and HIV research unit at the University of the Witwatersrand, Johannesberg, South Africa.

Neither study was without some equivocal results that tempered the investigators' overall assessment of the findings, but both investigators nevertheless concluded that their trial showed benefit. Both also noted that although their studies were short, they were optimistic that longer trials, currently underway, of HSV suppressive therapy and actual HIV transmission would find that such therapy reduced transmission.

Each trial lasted only 3 months.

The Thailand study analyzed data from 67 women coinfected with HSV and HIV. The women were assigned into one of two groups. One group was treated for 1 month with acyclovir 800 mg twice daily, and the other served as a control. After a 1-month washout with no drugs, the groups were switched.

Overall, 34% of the women had no vaginal HIV shedding at baseline and so had no change through the trial. However, 55% of the subjects did have a significant reduction in HIV shedding while on acyclovir. And there was a 2.8-fold drop in HIV load in vaginal lavage samples, which was statistically significant, though the mean 0.4-log drop in viral load is not far above the 0.3 sensitivity limit of HIV viral load testing.

Dr. Dunne noted, however, that most of the women had never had herpes symptoms, and their HIV was in such an early stage that it was not being treated. And, she said, the treatment might have a more profound effect on people with more advanced disease.

“You might expect the impact would be greater in a group with immunosuppression or a group with symptomatic herpes,” she said.

“We are hopeful that this study foreshadows positive results from the ongoing trials that are evaluating the effect of suppressive therapy [of HSV] on transmission of HIV,” she added.

The South African study had 169 women treated with acyclovir (400 mg twice daily) or placebo for 3 months. Like the patients in the other study, they were HIV positive and not on antiretroviral therapy.

The study found no statistically significant drop in the vaginal HIV viral load. But it did find a 2.4-fold decline in mean plasma viral load relative to placebo, and a larger percentage of the treated patients were found not to be shedding HIV at all visits. Of the treated women, 23% were found to be shedding at fewer than half of their weekly visits, versus 17% of the placebo-control women.

By the third month, HSV shedding had been reduced by 63% in the treated patients, compared with the placebo group.

“We believe this warrants further investigation over a longer follow-up,” Dr. Delany-Moretlwe said.

LOS ANGELES — Treating genital herpes simplex virus with acyclovir diminishes vaginal HIV shedding and plasma HIV levels in women coinfected with HSV and HIV, which suggests that treating herpes could have a role in reducing HIV transmission, according to two studies presented at the 14th Conference on Retroviruses and Opportunistic Infections.

A study conducted in Thailand by the U.S. Centers for Disease Control and Prevention found that 55% of treated women had a significant reduction in vaginal viral shedding during their treatment, said Dr. Eileen Dunne, of the Division of Sexually Transmitted Diseases Prevention of the CDC.

In a study from South Africa, treated women had a reduction in herpes simplex virus type 2; 63% less vaginal shedding, compared with placebo-control women; and a 43% reduction in plasma HIV levels, said Dr. Sinead Delany-Moretlwe, director of research for the reproductive health and HIV research unit at the University of the Witwatersrand, Johannesberg, South Africa.

Neither study was without some equivocal results that tempered the investigators' overall assessment of the findings, but both investigators nevertheless concluded that their trial showed benefit. Both also noted that although their studies were short, they were optimistic that longer trials, currently underway, of HSV suppressive therapy and actual HIV transmission would find that such therapy reduced transmission.

Each trial lasted only 3 months.

The Thailand study analyzed data from 67 women coinfected with HSV and HIV. The women were assigned into one of two groups. One group was treated for 1 month with acyclovir 800 mg twice daily, and the other served as a control. After a 1-month washout with no drugs, the groups were switched.

Overall, 34% of the women had no vaginal HIV shedding at baseline and so had no change through the trial. However, 55% of the subjects did have a significant reduction in HIV shedding while on acyclovir. And there was a 2.8-fold drop in HIV load in vaginal lavage samples, which was statistically significant, though the mean 0.4-log drop in viral load is not far above the 0.3 sensitivity limit of HIV viral load testing.

Dr. Dunne noted, however, that most of the women had never had herpes symptoms, and their HIV was in such an early stage that it was not being treated. And, she said, the treatment might have a more profound effect on people with more advanced disease.

“You might expect the impact would be greater in a group with immunosuppression or a group with symptomatic herpes,” she said.

“We are hopeful that this study foreshadows positive results from the ongoing trials that are evaluating the effect of suppressive therapy [of HSV] on transmission of HIV,” she added.

The South African study had 169 women treated with acyclovir (400 mg twice daily) or placebo for 3 months. Like the patients in the other study, they were HIV positive and not on antiretroviral therapy.

The study found no statistically significant drop in the vaginal HIV viral load. But it did find a 2.4-fold decline in mean plasma viral load relative to placebo, and a larger percentage of the treated patients were found not to be shedding HIV at all visits. Of the treated women, 23% were found to be shedding at fewer than half of their weekly visits, versus 17% of the placebo-control women.

By the third month, HSV shedding had been reduced by 63% in the treated patients, compared with the placebo group.

“We believe this warrants further investigation over a longer follow-up,” Dr. Delany-Moretlwe said.

LOS ANGELES — The recent evidence suggests that many pregnant women who are hypothyroid are not picked up as such by their medical providers, to the detriment of the mother and child, Dr. Jorge H. Mestman said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

The experts cannot seem to reach a consensus on whether pregnant women should be screened routinely for thyroid disease, but even hypothyroidism that is subclinical prior to pregnancy appears to have quite a severe, negative impact on the pregnancy and the child, said Dr. Mestman, director of the Center for Diabetes and Metabolic Diseases at the University of Southern California, Los Angeles.

“There is no agreement,” Dr. Mestman said. “This is going to be up to you. You have to decide in your office if you are going to check everybody for thyroid disease in the same way as for diabetes.”

One important new study might not have been seen by many in the obstetrics community because it was published in an endocrinology journal, he noted.

The investigators in the study attempted to see if the strategy of identifying women at high risk of thyroid disease (those with a personal or family history) and performing thyroid testing only in those women would pick up most cases.

They enrolled 1,560 pregnant women on their first prenatal visit, and tested their thyroid function to determine whether they had thyroid antibodies. A total of 40 of the women were found to have elevated thyroid-stimulating hormone (TSH) levels, and 28 (70%)of those were in the high-risk group. That is, they had a personal history of thyroid disease or an autoimmune disease, or a family history of thyroid disease. But the other 12 women had no history and would not therefore have received testing according to the protocol being examined by the study. Thus, these 12 hypothyroid women (30%) would have been missed, the investigators said (J. Clin. Endocrinol. Metab. 2007;92:203-7).

Chronic thyroiditis has an incidence in women of child-bearing age of between 5% and 20%, Dr. Mestman said. Subclinical hypothyroidism—a normal thyroxine (T4) level but an elevated TSH—may have an incidence of 2%.

Many studies have shown that hypothyroidism, even subclinical hypothyroidism, is associated with greater risk of miscarriage and premature delivery, anywhere from a two- to fivefold higher risk.

One study that looked at the children of mothers who were hypothyroid during pregnancy found that at age 7-9 years those children had a mean IQ that was 4 points lower than that of a group of control children. The mean IQ of children of women who were hypothyroid during pregnancy and not treated was 7 points lower (N. Engl. J. Med. 1999;341:549-55).

The detrimental effects of hypothyroidism presumably occur because the mother produces all the thyroid hormone for her fetus during the first trimester at least, and fetal brains have been shown to have thyroid hormone receptors.

During the first trimester, T4 levels need to increase by 50%, which is why women who may be subclinical before conception can run into trouble. They cannot compensate for the increased demand.

By the second and third trimester, T4 levels return to normal; however, some women who become hypothyroid during the first trimester will become hypothyroid again after delivery. Those women will become hyperthyroid for the first 3 months after delivery, and then hypothyroid for approximately another 6 months. Of those, about 30% will become clinically hypothyroid within 5 years. All of these women should be followed for thyroid function after their pregnancy, Dr. Mestman said. The pattern can occur even after spontaneous abortion.

The good news is that treatment prevents pregnancy complications, Dr. Mestman said. In a series of 88 hypothyroid women seen at his institution, the pregnancy complication rate of those who never became euthyroid during their pregnancy was 32% (6 of 19 patients), compared with a rate of 17% in those women who became euthyroid but only after 20 weeks' gestation (7 of 42), and 5% in those who became euthyroid before 20 weeks (1 of 21).

One of the tragedies they observed in that series of women concerned the 30% who were already on levothyroxine prior to their pregnancy, Dr. Mestman said. Some of them were told to stop all medications when they became pregnant and they stopped their thyroid medication.

Another, more recent study also looked at the pregnancy complication rate in women who were euthyroid but who had thyroid peroxidase antibodies. They treated half of a group of 115 antibody-positive women with levothyroxine, and compared those women with 869 pregnant women who were antibody negative.

The treated antibody-positive women had a miscarriage rate of 3%, similar to the rate in the control group, 2%. But the untreated antibody-positive women had a rate of 14%. The treated women had a premature delivery rate of 7%, similar to the 8% for the control group. That compared with a rate of 22% for the untreated women.

Given those findings, Dr. Mestman recommended that antibody-positive euthyroid women who are pregnant should be treated. The treatment should include a prenatal vitamin with 150 mcg of iodine, because there is some suggestion that many Americans may no longer get adequate iodine in their diet. And they should have their TSH and T4 levels monitored every 4-6 weeks during the first 20 weeks of pregnancy.

After 20 weeks, they should have their TSH and T4 measured once at 28 weeks. In addition, they should be treated with 50-75 mcg a day of levothyroxine. If the patient is already on levothyroxine at the time, the dose should be increased by 25 mcg.

“Early treatment prevents all the known complications,” Dr. Mestman said.

LOS ANGELES — The recent evidence suggests that many pregnant women who are hypothyroid are not picked up as such by their medical providers, to the detriment of the mother and child, Dr. Jorge H. Mestman said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

The experts cannot seem to reach a consensus on whether pregnant women should be screened routinely for thyroid disease, but even hypothyroidism that is subclinical prior to pregnancy appears to have quite a severe, negative impact on the pregnancy and the child, said Dr. Mestman, director of the Center for Diabetes and Metabolic Diseases at the University of Southern California, Los Angeles.

“There is no agreement,” Dr. Mestman said. “This is going to be up to you. You have to decide in your office if you are going to check everybody for thyroid disease in the same way as for diabetes.”

One important new study might not have been seen by many in the obstetrics community because it was published in an endocrinology journal, he noted.

The investigators in the study attempted to see if the strategy of identifying women at high risk of thyroid disease (those with a personal or family history) and performing thyroid testing only in those women would pick up most cases.

They enrolled 1,560 pregnant women on their first prenatal visit, and tested their thyroid function to determine whether they had thyroid antibodies. A total of 40 of the women were found to have elevated thyroid-stimulating hormone (TSH) levels, and 28 (70%)of those were in the high-risk group. That is, they had a personal history of thyroid disease or an autoimmune disease, or a family history of thyroid disease. But the other 12 women had no history and would not therefore have received testing according to the protocol being examined by the study. Thus, these 12 hypothyroid women (30%) would have been missed, the investigators said (J. Clin. Endocrinol. Metab. 2007;92:203-7).

Chronic thyroiditis has an incidence in women of child-bearing age of between 5% and 20%, Dr. Mestman said. Subclinical hypothyroidism—a normal thyroxine (T4) level but an elevated TSH—may have an incidence of 2%.

Many studies have shown that hypothyroidism, even subclinical hypothyroidism, is associated with greater risk of miscarriage and premature delivery, anywhere from a two- to fivefold higher risk.

One study that looked at the children of mothers who were hypothyroid during pregnancy found that at age 7-9 years those children had a mean IQ that was 4 points lower than that of a group of control children. The mean IQ of children of women who were hypothyroid during pregnancy and not treated was 7 points lower (N. Engl. J. Med. 1999;341:549-55).

The detrimental effects of hypothyroidism presumably occur because the mother produces all the thyroid hormone for her fetus during the first trimester at least, and fetal brains have been shown to have thyroid hormone receptors.

During the first trimester, T4 levels need to increase by 50%, which is why women who may be subclinical before conception can run into trouble. They cannot compensate for the increased demand.

By the second and third trimester, T4 levels return to normal; however, some women who become hypothyroid during the first trimester will become hypothyroid again after delivery. Those women will become hyperthyroid for the first 3 months after delivery, and then hypothyroid for approximately another 6 months. Of those, about 30% will become clinically hypothyroid within 5 years. All of these women should be followed for thyroid function after their pregnancy, Dr. Mestman said. The pattern can occur even after spontaneous abortion.

The good news is that treatment prevents pregnancy complications, Dr. Mestman said. In a series of 88 hypothyroid women seen at his institution, the pregnancy complication rate of those who never became euthyroid during their pregnancy was 32% (6 of 19 patients), compared with a rate of 17% in those women who became euthyroid but only after 20 weeks' gestation (7 of 42), and 5% in those who became euthyroid before 20 weeks (1 of 21).

One of the tragedies they observed in that series of women concerned the 30% who were already on levothyroxine prior to their pregnancy, Dr. Mestman said. Some of them were told to stop all medications when they became pregnant and they stopped their thyroid medication.

Another, more recent study also looked at the pregnancy complication rate in women who were euthyroid but who had thyroid peroxidase antibodies. They treated half of a group of 115 antibody-positive women with levothyroxine, and compared those women with 869 pregnant women who were antibody negative.

The treated antibody-positive women had a miscarriage rate of 3%, similar to the rate in the control group, 2%. But the untreated antibody-positive women had a rate of 14%. The treated women had a premature delivery rate of 7%, similar to the 8% for the control group. That compared with a rate of 22% for the untreated women.

Given those findings, Dr. Mestman recommended that antibody-positive euthyroid women who are pregnant should be treated. The treatment should include a prenatal vitamin with 150 mcg of iodine, because there is some suggestion that many Americans may no longer get adequate iodine in their diet. And they should have their TSH and T4 levels monitored every 4-6 weeks during the first 20 weeks of pregnancy.

After 20 weeks, they should have their TSH and T4 measured once at 28 weeks. In addition, they should be treated with 50-75 mcg a day of levothyroxine. If the patient is already on levothyroxine at the time, the dose should be increased by 25 mcg.

“Early treatment prevents all the known complications,” Dr. Mestman said.

LOS ANGELES — The recent evidence suggests that many pregnant women who are hypothyroid are not picked up as such by their medical providers, to the detriment of the mother and child, Dr. Jorge H. Mestman said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

The experts cannot seem to reach a consensus on whether pregnant women should be screened routinely for thyroid disease, but even hypothyroidism that is subclinical prior to pregnancy appears to have quite a severe, negative impact on the pregnancy and the child, said Dr. Mestman, director of the Center for Diabetes and Metabolic Diseases at the University of Southern California, Los Angeles.

“There is no agreement,” Dr. Mestman said. “This is going to be up to you. You have to decide in your office if you are going to check everybody for thyroid disease in the same way as for diabetes.”

One important new study might not have been seen by many in the obstetrics community because it was published in an endocrinology journal, he noted.

The investigators in the study attempted to see if the strategy of identifying women at high risk of thyroid disease (those with a personal or family history) and performing thyroid testing only in those women would pick up most cases.

They enrolled 1,560 pregnant women on their first prenatal visit, and tested their thyroid function to determine whether they had thyroid antibodies. A total of 40 of the women were found to have elevated thyroid-stimulating hormone (TSH) levels, and 28 (70%)of those were in the high-risk group. That is, they had a personal history of thyroid disease or an autoimmune disease, or a family history of thyroid disease. But the other 12 women had no history and would not therefore have received testing according to the protocol being examined by the study. Thus, these 12 hypothyroid women (30%) would have been missed, the investigators said (J. Clin. Endocrinol. Metab. 2007;92:203-7).

Chronic thyroiditis has an incidence in women of child-bearing age of between 5% and 20%, Dr. Mestman said. Subclinical hypothyroidism—a normal thyroxine (T4) level but an elevated TSH—may have an incidence of 2%.

Many studies have shown that hypothyroidism, even subclinical hypothyroidism, is associated with greater risk of miscarriage and premature delivery, anywhere from a two- to fivefold higher risk.

One study that looked at the children of mothers who were hypothyroid during pregnancy found that at age 7-9 years those children had a mean IQ that was 4 points lower than that of a group of control children. The mean IQ of children of women who were hypothyroid during pregnancy and not treated was 7 points lower (N. Engl. J. Med. 1999;341:549-55).

The detrimental effects of hypothyroidism presumably occur because the mother produces all the thyroid hormone for her fetus during the first trimester at least, and fetal brains have been shown to have thyroid hormone receptors.

During the first trimester, T4 levels need to increase by 50%, which is why women who may be subclinical before conception can run into trouble. They cannot compensate for the increased demand.

By the second and third trimester, T4 levels return to normal; however, some women who become hypothyroid during the first trimester will become hypothyroid again after delivery. Those women will become hyperthyroid for the first 3 months after delivery, and then hypothyroid for approximately another 6 months. Of those, about 30% will become clinically hypothyroid within 5 years. All of these women should be followed for thyroid function after their pregnancy, Dr. Mestman said. The pattern can occur even after spontaneous abortion.

The good news is that treatment prevents pregnancy complications, Dr. Mestman said. In a series of 88 hypothyroid women seen at his institution, the pregnancy complication rate of those who never became euthyroid during their pregnancy was 32% (6 of 19 patients), compared with a rate of 17% in those women who became euthyroid but only after 20 weeks' gestation (7 of 42), and 5% in those who became euthyroid before 20 weeks (1 of 21).

One of the tragedies they observed in that series of women concerned the 30% who were already on levothyroxine prior to their pregnancy, Dr. Mestman said. Some of them were told to stop all medications when they became pregnant and they stopped their thyroid medication.

Another, more recent study also looked at the pregnancy complication rate in women who were euthyroid but who had thyroid peroxidase antibodies. They treated half of a group of 115 antibody-positive women with levothyroxine, and compared those women with 869 pregnant women who were antibody negative.

The treated antibody-positive women had a miscarriage rate of 3%, similar to the rate in the control group, 2%. But the untreated antibody-positive women had a rate of 14%. The treated women had a premature delivery rate of 7%, similar to the 8% for the control group. That compared with a rate of 22% for the untreated women.

Given those findings, Dr. Mestman recommended that antibody-positive euthyroid women who are pregnant should be treated. The treatment should include a prenatal vitamin with 150 mcg of iodine, because there is some suggestion that many Americans may no longer get adequate iodine in their diet. And they should have their TSH and T4 levels monitored every 4-6 weeks during the first 20 weeks of pregnancy.

After 20 weeks, they should have their TSH and T4 measured once at 28 weeks. In addition, they should be treated with 50-75 mcg a day of levothyroxine. If the patient is already on levothyroxine at the time, the dose should be increased by 25 mcg.

“Early treatment prevents all the known complications,” Dr. Mestman said.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis.

In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before the mother's diagnosis (Diabetes 2000;49:2208-11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m2 heavier than were their nonexposed siblings.

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth.

They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546-47).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, when he manages maternal diabetes in pregnancy, he is mindful that it can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” he said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth or nutrient restricted, it shunts nutrients to the most essential organs.

One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis.

In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before the mother's diagnosis (Diabetes 2000;49:2208-11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m2 heavier than were their nonexposed siblings.

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth.

They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546-47).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, when he manages maternal diabetes in pregnancy, he is mindful that it can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” he said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth or nutrient restricted, it shunts nutrients to the most essential organs.

One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis.

In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before the mother's diagnosis (Diabetes 2000;49:2208-11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m2 heavier than were their nonexposed siblings.

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth.

They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546-47).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, when he manages maternal diabetes in pregnancy, he is mindful that it can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” he said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth or nutrient restricted, it shunts nutrients to the most essential organs.

One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that patients could easily do well. But that is not really so, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases in Los Angeles.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819-23). Another recent study, of pregnant women with diabetes in Canada, found much the same thing; moreover, these researchers compared pregnancy outcomes from 1988 to 2002 and saw almost no improvement over that time (Obstet. Gynecol. 2006;108:644-50).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women who had gestational diabetes at between 24 weeks' and 33 weeks' gestation to routine diabetes care and education or to routine care and insulin therapy. The researchers found that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477-86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467-70). Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

“These authors showed that the higher the fasting glucose, the more complications,” Dr. Mestman noted.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134-8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman said he uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin. It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

“I will tell you that there are very few endocrinologists who are using oral agents during pregnancy; but I am one of them,” he said.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that patients could easily do well. But that is not really so, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases in Los Angeles.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819-23). Another recent study, of pregnant women with diabetes in Canada, found much the same thing; moreover, these researchers compared pregnancy outcomes from 1988 to 2002 and saw almost no improvement over that time (Obstet. Gynecol. 2006;108:644-50).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women who had gestational diabetes at between 24 weeks' and 33 weeks' gestation to routine diabetes care and education or to routine care and insulin therapy. The researchers found that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477-86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467-70). Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

“These authors showed that the higher the fasting glucose, the more complications,” Dr. Mestman noted.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134-8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman said he uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin. It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

“I will tell you that there are very few endocrinologists who are using oral agents during pregnancy; but I am one of them,” he said.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that patients could easily do well. But that is not really so, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases in Los Angeles.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819-23). Another recent study, of pregnant women with diabetes in Canada, found much the same thing; moreover, these researchers compared pregnancy outcomes from 1988 to 2002 and saw almost no improvement over that time (Obstet. Gynecol. 2006;108:644-50).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women who had gestational diabetes at between 24 weeks' and 33 weeks' gestation to routine diabetes care and education or to routine care and insulin therapy. The researchers found that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477-86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467-70). Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

“These authors showed that the higher the fasting glucose, the more complications,” Dr. Mestman noted.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134-8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman said he uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin. It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

“I will tell you that there are very few endocrinologists who are using oral agents during pregnancy; but I am one of them,” he said.

VAIL, COLO. — Many pediatric dermatologists have begun to treat molluscum contagiosum with cantharidin, a blistering agent produced by a beetle, instead of with liquid nitrogen.

The reason they have switched is that cantharidin is much less painful and very well tolerated, Dr. Lawrence F. Eichenfield said at a meeting sponsored by the American Academy of Pediatrics.

“It has been shown in a variety of studies [to be] a highly effective agent,” said Dr. Eichenfield, a pediatric dermatologist at the University of California, San Diego, and Rady Children's Hospital, also in San Diego. The majority of the time, he said, one to three 4-hour applications are sufficient to treat the lesions. Cantharidin “is much less painful and traumatizing than either curettage or liquid nitrogen.”

Molluscum lesions resolve within 8 months 70% of the time, but if one decides to treat, then cantharidin is the treatment of choice, Dr. Eichenfield said.

He uses the method made popular by a report in 2000 from investigators at Northwestern University, Chicago—a method he has begun to teach to pediatricians.

In their report, the Northwestern investigators said they had treated 300 patients with cantharidin and later interviewed their parents. The researchers said that, with an average of two treatments, 90% of the patients were cleared of their lesions. Another 8% had improvement but were not cleared by the treatment, although their lesions resolved afterward (J. Am. Acad. Dermatol. 2000;43:503–7).

About 92% of the patients experienced blistering, and 37% reported erythema at the site after treatment, which lasted for up to 3 weeks. A total of 14% reported mild to moderate pain after treatment and 10% reported a transient burning sensation. Other adverse events—including pruritus (6%) and bleeding (1%)—occurred less frequently. There were no serious events.

When the parents were interviewed, 95% said they would have their child treated the same way again. Of the 14 who said they would not, three gave their child's blistering as the reason and one mentioned pain. The others said they did not find the multiple visits convenient or did not give a reason.

In the Northwestern method used by Dr. Eichenfield, the cantharidin (0.7% concentration) is daubed on the lesions with the wooden end of a cotton-swab, sparing the surrounding skin. He treats no more than 20 lesions at a time; he does not treat facial lesions with this method.

The sites are not occluded afterward, and the agent is washed off with soap and water 4–6 hours later, Dr. Eichenfield said.

The treatment is relatively safe, but he recommends physicians be trained before using cantharidin. “If not done appropriately, you can get very severe blisters.”

Cantharidin 'is much less painful and traumatizing than either curettage or liquid nitrogen. DR. EICHENFIELD

VAIL, COLO. — Many pediatric dermatologists have begun to treat molluscum contagiosum with cantharidin, a blistering agent produced by a beetle, instead of with liquid nitrogen.

The reason they have switched is that cantharidin is much less painful and very well tolerated, Dr. Lawrence F. Eichenfield said at a meeting sponsored by the American Academy of Pediatrics.

“It has been shown in a variety of studies [to be] a highly effective agent,” said Dr. Eichenfield, a pediatric dermatologist at the University of California, San Diego, and Rady Children's Hospital, also in San Diego. The majority of the time, he said, one to three 4-hour applications are sufficient to treat the lesions. Cantharidin “is much less painful and traumatizing than either curettage or liquid nitrogen.”

Molluscum lesions resolve within 8 months 70% of the time, but if one decides to treat, then cantharidin is the treatment of choice, Dr. Eichenfield said.

He uses the method made popular by a report in 2000 from investigators at Northwestern University, Chicago—a method he has begun to teach to pediatricians.

In their report, the Northwestern investigators said they had treated 300 patients with cantharidin and later interviewed their parents. The researchers said that, with an average of two treatments, 90% of the patients were cleared of their lesions. Another 8% had improvement but were not cleared by the treatment, although their lesions resolved afterward (J. Am. Acad. Dermatol. 2000;43:503–7).

About 92% of the patients experienced blistering, and 37% reported erythema at the site after treatment, which lasted for up to 3 weeks. A total of 14% reported mild to moderate pain after treatment and 10% reported a transient burning sensation. Other adverse events—including pruritus (6%) and bleeding (1%)—occurred less frequently. There were no serious events.

When the parents were interviewed, 95% said they would have their child treated the same way again. Of the 14 who said they would not, three gave their child's blistering as the reason and one mentioned pain. The others said they did not find the multiple visits convenient or did not give a reason.

In the Northwestern method used by Dr. Eichenfield, the cantharidin (0.7% concentration) is daubed on the lesions with the wooden end of a cotton-swab, sparing the surrounding skin. He treats no more than 20 lesions at a time; he does not treat facial lesions with this method.

The sites are not occluded afterward, and the agent is washed off with soap and water 4–6 hours later, Dr. Eichenfield said.

The treatment is relatively safe, but he recommends physicians be trained before using cantharidin. “If not done appropriately, you can get very severe blisters.”

Cantharidin 'is much less painful and traumatizing than either curettage or liquid nitrogen. DR. EICHENFIELD

VAIL, COLO. — Many pediatric dermatologists have begun to treat molluscum contagiosum with cantharidin, a blistering agent produced by a beetle, instead of with liquid nitrogen.

The reason they have switched is that cantharidin is much less painful and very well tolerated, Dr. Lawrence F. Eichenfield said at a meeting sponsored by the American Academy of Pediatrics.

“It has been shown in a variety of studies [to be] a highly effective agent,” said Dr. Eichenfield, a pediatric dermatologist at the University of California, San Diego, and Rady Children's Hospital, also in San Diego. The majority of the time, he said, one to three 4-hour applications are sufficient to treat the lesions. Cantharidin “is much less painful and traumatizing than either curettage or liquid nitrogen.”

Molluscum lesions resolve within 8 months 70% of the time, but if one decides to treat, then cantharidin is the treatment of choice, Dr. Eichenfield said.

He uses the method made popular by a report in 2000 from investigators at Northwestern University, Chicago—a method he has begun to teach to pediatricians.

In their report, the Northwestern investigators said they had treated 300 patients with cantharidin and later interviewed their parents. The researchers said that, with an average of two treatments, 90% of the patients were cleared of their lesions. Another 8% had improvement but were not cleared by the treatment, although their lesions resolved afterward (J. Am. Acad. Dermatol. 2000;43:503–7).

About 92% of the patients experienced blistering, and 37% reported erythema at the site after treatment, which lasted for up to 3 weeks. A total of 14% reported mild to moderate pain after treatment and 10% reported a transient burning sensation. Other adverse events—including pruritus (6%) and bleeding (1%)—occurred less frequently. There were no serious events.

When the parents were interviewed, 95% said they would have their child treated the same way again. Of the 14 who said they would not, three gave their child's blistering as the reason and one mentioned pain. The others said they did not find the multiple visits convenient or did not give a reason.

In the Northwestern method used by Dr. Eichenfield, the cantharidin (0.7% concentration) is daubed on the lesions with the wooden end of a cotton-swab, sparing the surrounding skin. He treats no more than 20 lesions at a time; he does not treat facial lesions with this method.

The sites are not occluded afterward, and the agent is washed off with soap and water 4–6 hours later, Dr. Eichenfield said.

The treatment is relatively safe, but he recommends physicians be trained before using cantharidin. “If not done appropriately, you can get very severe blisters.”

Cantharidin 'is much less painful and traumatizing than either curettage or liquid nitrogen. DR. EICHENFIELD