Showing papers by "Anny H. Xiang published in 1998"
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TL;DR: Progestin-only OCs were associated with an increased risk of diabetes in breast-feeding Latinas with recent GDM and probably should be prescribed with caution, if at all, in these women.
Abstract: Context.—Effective contraception is essential in women with prior gestational
diabetes mellitus (GDM) but should not increase their already substantial
risk of developing type 2 diabetes.Objective.—To determine whether exposure to low-dose oral contraceptives increases
the risk of developing type 2 diabetes mellitus in women with recent GDM.Design.—Retrospective cohort study of 904 Latinas with GDM who gave birth between
January 1987 and March 1994, in whom postpartum diabetes was excluded at 4
to 16 weeks post partum.Interventions.—At their initial postpartum visit, 443 women selected a nonhormonal
form of contraception, 383 received a low-dose, estrogen-progestin combination
oral contraceptive (OC), and 78 breast-feeding women received the progestin-only
OC. When breast-feeding ended, patients initially taking progestin-only OCs
were switched to combination OCs. Patients were followed up periodically with
oral glucose tolerance tests for up to 712 years.Main Outcome Measures.—Person time was used to compute unadjusted average annual incidence
rates of developing diabetes mellitus, as defined by the National Diabetes
Data Group Criteria. Survival analysis was used to compute the unadjusted
cumulative incidence rates and adjusted relative risks of diabetes mellitus.Results.—The unadjusted average annual incidence rates of type 2 diabetes mellitus
were 8.7%, 10.4%, and 26.5%, respectively, for patients using nonhormonal
forms of contraception, combination OCs, and progestin-only OCs. Cumulative
incidence rates were virtually identical for patients with uninterrupted use
of combination OCs and nonhormonal forms of contraception, but patients using
progestin-only OCs developed diabetes mellitus more rapidly during the first
2 years of use. After adjustment for potential confounding factors, the use
of progestin-only OCs almost tripled the risk of type 2 diabetes mellitus
compared with equivalent use of low-dose combination OCs (adjusted relative
risk, 2.87; 95% confidence interval, 1.57-5.27). The magnitude of this risk
increased with duration of uninterrupted use.Conclusion.—Progestin-only OCs were associated with an increased risk of diabetes
in breast-feeding Latinas with recent GDM and probably should be prescribed
with caution, if at all, in these women. Long-term use of low-dose combination
OCs did not increase the risk of type 2 diabetes compared with use of nonhormonal
contraception. Thus, combination OCs do not appear to increase the risk of
diabetes in non–breast-feeding women with recent GDM.
162 citations
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TL;DR: The unique two-phase study design of the TRIPOD trial will permit testing not only of the biological question about reversal of insulin resistance and prevention of diabetes, but also of the clinical question about whether early intervention is superior to late intervention.
151 citations
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TL;DR: The association of postpar-turn IGT with weight gain and an early gestational age at diagnosis of GDM suggests a role for chronic insulin resistance in mediating hyperglycemia outside the 3rd trimester in women with such a β-cell defect.
Abstract: We examined antepartum clinical characteristics along with measures of glucose tolerance, insulin sensitivity, pancreatic β-cell function, and body composition in Latino women with gestational diabetes mellitus (GDM) for their ability to predict type 2 diabetes or impaired glucose tolerance (IGT) within 6 months after delivery. A total of 122 islet cell antibody-negative women underwent oral and intravenous glucose tolerance tests (OGTT; IVGTT), hyperinsulinemic-euglycemic clamps, and measurement of body fat between 29 and 36 weeks' gestation and returned between 1 and 6 months postpartum for a 75-g OGTT. Logistic regression analysis was used to examine the relationship between antepartum variables and glucose tolerance status postpartum. At postpartum testing, 40% of the cohort had normal glucose tolerance, 50% had IGT, and 10% had diabetes by American Diabetes Association criteria. Independent antepartum predictors of postpartum diabetes were the 30-min incremental insulin:glucose ratio during a 75-g OGTT ( P = 0.0002) and the total area under the diagnostic 100-g glucose tolerance curve ( P = 0.003). Independent predictors of postpartum IGT were a low firstphase IVGTT insulin response ( P = 0.0001), a diagnosis of GDM before 22 weeks' gestation ( P = 0.003), and weight gain between prepregnancy and the postpartum examination ( P = 0.03). All subjects had low insulin sensitivity during late pregnancy, but neither glucose clamp nor minimal model measures of insulin sensitivity in the 3rd trimester were associated with the risk of IGT or diabetes within 6 months' postpartum. These results highlight the importance of pancreatic β-cell dysfunction, detectable under conditions of marked insulin resistance in late pregnancy, to predict abnormalities of glucose tolerance soon after delivery in pregnancies complicated by GDM. Moreover, the association of postpar-turn IGT with weight gain and an early gestational age at diagnosis of GDM suggests a role for chronic insulin resistance in mediating hyperglycemia outside the 3rd trimester in women with such a β-cell defect.
139 citations
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TL;DR: Management approaches that take into account not only maternal glycemia, but also fetal growth and metabolic parameters in selecting GDM pregnancies for intensive metabolic therapy can reduce the number of women with mild GDM who require self-monitoring of glucose and/or exogenous insulin therapy, thereby providing the potential to improve cost-effectiveness of antepartum management of GDM.
Abstract: The metabolic management of gestational diabetes mellitus (GDM) during pregnancy traditionally has focused on maintenance of circulating maternal glucose concentrations in all patients within a range that is associated with a low rate of perinatal morbidity, especially morbidity related to excessive fetal growth and macrosomia. Clinical data reviewed elsewhere in this supplement provide guidelines for glycemic targets that appear to eliminate the excess risk to the fetus. However, because only a minority of infants are at risk for perinatal morbidity over the range of glycemia generally encountered in patients with GDM, attainment of those strict glycemic targets in all women with GDM requires implementation of self-monitoring of glucose and exogenous insulin therapy in many pregnancies that are not at risk. In this article, we review management approaches that take into account not only maternal glycemia, but also fetal growth and metabolic parameters in selecting GDM pregnancies for intensive metabolic therapy. The approaches can reduce the number of women with mild GDM who require self-monitoring of glucose and/or exogenous insulin therapy, thereby providing the potential to improve cost-effectiveness of antepartum management of GDM.
46 citations
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TL;DR: In women with prior gestational diabetes, exposure to repeat pregnancy poses a greater risk for subsequent diabetes than does either an exposure to low-dose progestin and estrogen combination oral contraceptives or to postmenopausal hormonal therapy, both of which do not appear to increase the risk of diabetes.
Abstract: The effects of subsequent states of excess hormone exposure, for example, subsequent pregnancy, hormonal contraception, and hormonal replacement therapy, on the development of diabetes in women with prior gestational diabetes were assessed. Current literature examining the effect of parity, hormonal contraception, and hormonal replacement therapy in healthy women and women with previous gestational diabetes and current diabetes was reviewed. Subsequent pregnancy in women with prior GDM appears to triple the risk of subsequent diabetes. Low-dose progestin and estrogen combination oral contraceptives do not appear to clinically increase the risk of diabetes. Hormonal replacement therapy appears to provide the greatest reduction in coronary artery disease to women at greatest risk, i.e., those who have developed diabetes. Careful follow-up and metabolic surveillance should be provided when prescribing hormonal contraception or replacement therapy. In women with prior gestational diabetes, exposure to repeat pregnancy poses a greater risk for subsequent diabetes than does either an exposure to low-dose progestin and estrogen combination oral contraceptives or to postmenopausal hormonal therapy, both of which do not appear to increase the risk of diabetes.
12 citations