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D R Coustan

Publications and source records attributed to D R Coustan.

At least 19 recordsLinked to original sources
PubMed1992

Financial implications of implementing standards of care for diabetes and pregnancy.

This article examines the financial implications of implementing standards of care for pregnancy among women with diabetes, including both the costs of enhanced treatment and the savings of avoided adverse outcomes. Numerous studies have demonstrated the harmful effects of poor blood glucose control for both mother and fetus. Standards set forth by the American Diabetes Association aim to reduce maternal complications and fetal adverse outcomes, such as congenital malformations. Because the precise configuration of resources required to meet these standards was not outlined in the American Diabetes Association statement, a panel of physicians (all specialists in pregnancy care for women with diabetes) was convened to develop a model program. Implementing such a program during the preconception and prenatal periods will represent an intensification of resource use in the outpatient setting. However, through these preventive measures, medical care costs for maternal and fetal complications can be avoided.

Female↗
PubMed1991

Does intensive glycemic control in diabetic pregnancies result in normalization of other metabolic fuels?

Intensive treatment of insulin-dependent diabetes mellitus during pregnancy often normalizes plasma glucose levels. However, it is unclear whether this adversely affects other metabolic fuels that are essential to normal fetal growth and development. Metabolic studies were conducted after the subjects ingested a standardized mixed meal during each trimester in 7 normal and 15 insulin-dependent diabetic pregnant women. The latter were treated with continuous subcutaneous insulin infusion or multiple injections, which were adjusted to achieve strict glucose control throughout pregnancy. Insulin, alanine, branched-chain amino acids, triglycerides, free fatty acids, and ketones were measured every 15 to 30 minutes before a standardized breakfast and for 150 minutes after the breakfast. Patients with insulin-dependent diabetes mellitus were studied while they received their unusual insulin dosages. Fasting glucose levels (87 +/- 7 mg/dl) and glucose levels 150 minutes after the meal (112 +/- 11 mg/dl) were near normal. However, normoglycemia was achieved at the expense of increased plasma insulin levels (area under insulin response curves, p less than 0.01, vs nondiabetic curves). Nevertheless, fasting and post-prandial plasma branched-chain amino acids, alanine, and free fatty acids were similar in both groups. Fasting cholesterol, triglyceride, and ketone levels were also normalized. We conclude that normalization of circulating amino acids and lipids in conjunction with correction of hyperglycemia may contribute to favorable outcomes in infants of intensively treated diabetic mothers.

Adult↗
PubMed1991

The role of repeat glucose tolerance tests in the diagnosis of gestational diabetes.

The diagnosis of gestational diabetes requires that two of the four 100 gm, 3-hour oral glucose tolerance test values be elevated. Our report evaluates the usefulness of repeating the oral glucose tolerance test in patients who have only one abnormal value. One hundred six patients who had abnormal results of diabetes screening tests (glucose level greater than or equal to 130 mg/dl) and whose glucose tolerance test had one abnormal value underwent repeat glucose tolerance testing at an average of 4.6 weeks later. Thirty-six patients (34%) had two abnormal values on the repeat test and were classified as having gestational diabetes. Our results indicate that the finding of one abnormal value on a glucose tolerance test denotes a significant risk for the development of gestational diabetes.

Diabetes, Gestational↗
PubMed1991

Screening and diagnosis of gestational diabetes.

This chapter discusses the evidence for the existence of an entity called 'gestational diabetes', suggesting that it can be understood in terms of risk to the pregnancy and/or risk to the mother. Various diagnostic criteria used in various parts of the world are described, and a rationale for using pregnancy-specific criteria is put forth. Universal screening approaches are also characterized. Barriers to the universal adoption of a single screening scheme and set of diagnostic criteria are outlined.

Diabetes, Gestational↗
PubMed1991

Maternal insulin to lower the risk of fetal macrosomia in diabetic pregnancy.

Fetal macrosomia is a well-recognized adverse outcome associated with gestational diabetes. Weekly measurement of fasting and postprandial glucose should identify those with fasting (greater than or equal to 100 or 105 mg/dl) or postprandial (greater than or equal to 120 mg/dl 2 hours after a meal) hyperglycemia who are at increased risk for perinatal mortality. If the prevention of macrosomia is desired, the use of prophylactic insulin, initiated as early as possible, but at the latest before 36 weeks' gestation, without regard to glycemia is effective. Alternatively, glucose self-monitoring (four to six times daily with institution of insulin treatment when fasting glucose exceeds some arbitrary threshold such as 90 mg/dl or postprandial values exceed a threshold such as 100 mg/dl) is likely to be equally effective with fewer patients requiring insulin injections.

Female↗
PubMed1991

Diagnosis of gestational diabetes. What are our objectives?

International agreement is lacking with regard to diagnostic criteria for gestational diabetes and its treatment. Consensus is not possible without agreement on the objectives in making the diagnosis. The most commonly used criteria in North America were validated by their predictive value for the subsequent development of overt diabetes in the years after affected pregnancies. The diagnosis is also deemed by many to be important as a risk factor for adverse perinatal outcome in the present pregnancy. Attempts have been made, in various parts of the world, to derive diagnostic criteria based on pregnancy outcome; unfortunately, these have not been so intensively studied as the standards cited above. There is also a lack of agreement on whether gestational diabetes should be considered a disease or merely a risk factor. In addition, consensus has not been reached on whether population-specific criteria should be used in each location or universally accepted diagnostic thresholds should be applied. Many philosophical questions remain unanswered, and numerous opportunities for investigation present themselves. Many of these are dealt with in this workshop-conference, whereas others remain as goals to be attained.

Diabetes, Gestational↗
PubMed1991

Management of gestational diabetes.

The treatment of gestational diabetes is based on maintaining near-normal maternal glucose levels. To accomplish this goal, dietary counseling is used. circulating glucose is measured regularly, and exogenous insulin is sometimes necessary. Early delivery is not routine. Cesarean section is reserved for obstetric indications, but the presence of fetal macrosomia may be responsible for increasing the overall cesarean section rate in individuals with this disorder. The most important component of the treatment of gestational diabetes is probably the identification of the individual with this condition.

Diabetes, Gestational↗
PubMed1991

Are the current ACOG Glucose Tolerance Test criteria sensitive enough?

One hundred three women with gestational diabetes diagnosed by the criteria used at Women and Infants' Hospital were followed through the prenatal course. Sixty-four also met the current ACOG criteria. Ten of the 39 (26%) who met only the hospital's criteria required insulin therapy, a proportion not different from that in the group who met the ACOG criteria (19 of 64, 30%). The degree of abnormality of the glucose tolerance test (GTT) did not predict subsequent need for insulin treatment. The ACOG GTT criteria may fail to detect a proportion of women with gestational diabetes whose carbohydrate metabolism abnormality is severe enough to require insulin therapy.

Adult↗
PubMed1991

The resolution of preeclampsia-related thrombocytopenia.

The average time until the resolution of thrombocytopenia, which as a part of HELLP syndrome accompanies 4-16% of cases of severe preeclampsia, has not been defined previously. We followed 25 patients with severe preeclampsia, platelet counts below 100,000/microL, and elevated liver enzymes until their platelet counts returned to levels above 100,000/microL. Among severe preeclamptics who did not receive platelet transfusions, the average time from delivery to the resolution of thrombocytopenia was 60 hours, and all had platelet counts above 100,000/microL by 95 hours. Seven patients were followed after their platelet counts exceeded 340,000/microL; all showed a rebound phenomenon, with platelet counts reaching values of 413,000-871,000/microL.

Adolescent↗
PubMed1990

Cardiovascular response to maximal cycle exercise during pregnancy and at two and seven months post partum.

We examined the cardiovascular response at rest and during upright cycle exercise in nine women during pregnancy (25.6 +/- 3.0 weeks' gestation) and at 2 months (8.8 +/- 1.8 weeks) and 7 months (30.0 +/- 2.5 weeks) post partum. Antepartum resting cardiac output, heart rate, and stroke volume were higher, whereas the arterial-venous oxygen difference was lower than both postpartum values. The antepartum resting oxygen uptake did not differ from 2 months post partum but was higher than at 7 months post partum. Cardiac output during submaximal exercise was greater antepartum than at both postpartum tests. Submaximal antepartum oxygen uptake, heart rate, and stroke volume were generally higher, and the arterial-venous oxygen difference was lower than at 7 months post partum. The slope of the antepartum cardiac output versus oxygen uptake relationship did not differ from the value at 2 months post partum, (6.16 +/- 1.38 and 5.84 +/- 1.34, p greater than 0.05) but was higher than at 7 months post partum (5.22 +/- 0.78, p less than 0.05). There were no significant differences in maximal oxygen uptake or heart rate among the three testing periods. Maximal cardiac output and stroke volume were higher antepartum than at 2 and 7 months post partum, whereas the arterial-venous oxygen difference was lower than at 7 months post partum. There were few significant differences in resting, submaximal, or maximal measurements between the two postpartum conditions. These data suggest that the augmented cardiac response to exercise during pregnancy is reduced by 2 months post partum but that additional time may be required for a complete resolution of the cardiovascular changes induced by pregnancy.

Adult↗
PubMed1990

Survival rates of monoamniotic twins do not decrease after 30 weeks' gestation.

A search of pathology records from the years 1967 to 1988 at Women and Infants' Hospital of Rhode Island (138,232 live births) revealed 24 sets of histologically confirmed monoamniotic twins. All records were available for review. Among the 17 sets of monoamniotic twins that reached 30 weeks' gestation with at least one twin still alive, there were no further fetal deaths. The risks of early delivery in these pregnancies appear to outweigh the risk of fetal death as a result of monoamniotic status alone. These data do not show an advantage to early delivery.

Female↗
PubMed1990

Absence of evidence of pulmonary maturity at amniocentesis in term infants of diabetic mothers.

A total of 153 patients' charts were reviewed over a 6-year period to assess the results of the practice of amniocentesis for diabetic mothers at term (greater than or equal to 37 weeks' gestation) before elective induction/delivery. The number of cases with absent phosphatidylglycerol were determined at each specific gestational age at or near term. Phosphatidylglycerol was present in 130, and phosphatidylglycerol was absent in 23 at first amniocentesis sampling. A significant proportion (approximately 21%) of those with gestational diabetes were phosphatidylglycerol-negative as late as 38 weeks' gestation. A similar proportion of overt diabetic patients were phosphatidylglycerol-negative as late as 39 weeks' gestation. These figures give the clinician some estimate of the likelihood of the absence of phosphatidylglycerol at or near term if amniocentesis is used before elective delivery in these patients.

Amniocentesis↗
PubMed1990

Effect of maternal weight gain during pregnancy on exercise performance.

We examined the effect of maternal weight gain during pregnancy on exercise performance. Ten women performed submaximal cycle (up to 60 W) and treadmill (4 km/h, up to 10% grade) exercise tests at 34 +/- 1.5 (SD) wk gestation and 7.6 +/- 1.7 wk postpartum. Postpartum subjects wearing weighted belts designed to equal their body weight during the antepartum tests performed two additional treadmill tests. Absolute O2 uptake (VO2) at the same work load was higher during pregnancy than postpartum during cycle (1.04 +/- 0.08 vs. 0.95 +/- 0.09 l/min, P = 0.014), treadmill (1.45 +/- 0.19 vs. 1.27 +/- 0.20 l/min, P = 0.0002), and weighted treadmill (1.45 +/ 0.19 vs. 1.36 +/- 0.20 l/min, P = 0.04) exercise. None of these differences remained, however, when VO2 was expressed per kilogram of body weight. Maximal VO2 (VO2max) estimated from the individual heart rate-VO2 curves was the same during and after pregnancy during cycling (1.96 +/- 0.37 to 1.98 +/- 0.39 l/min), whereas estimated VO2max increased postpartum during treadmill (2.04 +/- 0.38 to 2.21 +/- 0.36 l/min, P = 0.03) and weighted treadmill (2.04 +/- 0.38 to 2.19 +/- 0.38 l/min, P = 0.03) exercise. We conclude that increased body weight during pregnancy compared with the postpartum period accounts for 75% of the increased VO2 during submaximal weight-bearing exertion in pregnancy and contributes to reduced exercise capacity. The postpartum increase in estimated VO2max during weight-bearing exercise is the result of consistently higher antepartum heart rates during all submaximal work loads.

Adult↗
PubMed1990

Screening measure to assess knowledge of diabetes in pregnancy.

The purpose of this study was to develop a brief measure to assess knowledge regarding diabetes in pregnancy (Diabetes in Pregnancy Knowledge Screen [DPKS]). A test-retest design was used for subjects enrolled in a diabetes in pregnancy program at a university hospital. There were 58 women with overt diabetes (OD; insulin dependent and non-insulin dependent) and 67 women with gestational diabetes (GD). Three forms of the DPKS scale were developed for use with women with OD and women with GD treated or not treated with insulin. Adequate readability, internal consistency (r = 0.71), and test-retest reliability (r = 0.76) were demonstrated with the DPKS. Initial support for the validity of the measure is suggested by its ability to differentiate women with GD versus OD, women on insulin versus those who are diet controlled, and women with shorter versus longer duration of illness. The DPKS may prove a useful clinical tool for diabetes educators working with pregnant women.

Adult↗
PubMed1989

Cardiovascular response to cycle exercise during and after pregnancy.

Our purpose was to determine if pregnancy alters the cardiovascular response to exercise. Thirty-nine women [29 +/- 4 (SD) yr], performed submaximal and maximal exercise cycle ergometry during pregnancy (antepartum, AP, 26 +/- 3 wk of gestation) and postpartum (PP, 8 +/- 2 wk). Neither maximal O2 uptake (VO2max) nor maximal heart rate (HR) was different AP and PP (VO2 = 1.91 +/- 0.32 and 1.83 +/- 0.31 l/min; HR = 182 +/- 8 and 184 +/- 7 beats/min, P greater than 0.05 for both). Cardiac output (Q, acetylene rebreathing technique) averaged 2.2 to 2.8 l/min higher AP (P less than 0.01) at rest and at each exercise work load. Increases in both HR and stroke volume (SV) contributed to the elevated Q at the lower exercise work loads, whereas an increased SV was primarily responsible for the higher Q at higher levels. The slope of the Q vs. VO2 relationship was not different AP and PP (6.15 +/- 1.32 and 6.18 +/- 1.34 l/min Q/l/min VO2, P greater than 0.05). In contrast, the arteriovenous O2 difference (a-vO2 difference) was lower at each exercise work load AP, suggesting that the higher Q AP was distributed to nonexercising vascular beds. We conclude that Q is greater and a-vO2 difference is less at all levels of exercise in pregnant subjects than in the same women postpartum but that the coupling of the increase in Q to the increase in systemic O2 demand (VO2) is not different.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗