A pilot study of gestational diabetes mellitus not controlled by diet alone: First-line medical treatment with myoinositol may limit the need for insulin.

AIM: This study assessed whether myoinositol might be a first-line medical treatment for gestational diabetes mellitus (GDM). METHODS: For 12 months, women with GDM not controlled by diet (n=32) were prospectively treated with myoinositol 1200mg and folic acid 400µg/day, while consecutive women (n=28) with insulin-requiring GDM treated during the previous year at our centre constituted the control group. Baseline characteristics and care were similar in both groups. RESULTS: Insulin was required in eight women (25%) in the myoinositol group who, compared with the 24 who did not need insulin, were older (37±5 vs. 32±5 years, respectively; P=0.018) and had a larger percentage of high self-monitored glucose values (45±8% vs. 32±14%; P<0.0001) during the week prior to the introduction of myoinositol treatment. All of the women had similar pregnancy outcomes regardless of their GDM management, although less labour induction was required in the myoinositol group (OR: 0.22 [0.07-0.65]), which had no side effects. CONCLUSION: This pilot study suggests that myoinositol may be a safe first-line medical treatment for uncontrolled GDM.

Management of pregnancy in women with type 1 diabetes mellitus: guidelines of the French-Speaking Diabetes Society (Société francophone du diabète [SFD]).

AIM: The clinical guidelines reported by the French-Speaking Diabetes Society (Société francophone du diabète) include updated recommendations for preconceptual planning and care in the management of pregnancy in women with type 1 diabetes mellitus (T1DM). METHODS: The working group included diabetologists, as well as an obstetrician, a nurse and a dietician. A review of the literature was performed using PubMed and Cochrane databases. Guidelines published by foreign diabetes societies were also consulted. RESULTS: In women with T1DM, pregnancy increased the risks of hypoglycaemia, diabetic ketoacidosis, pregnancy-induced hypertension, infections and worsening of diabetic microvascular disease. Moreover, T1DM during pregnancy had an impact on the embryo and the fetus, and may have increased the risk of spontaneous miscarriages, malformations, premature births, and fetal and neonatal complications. However, intensive glycaemic control and preconceptual care have been shown to decrease the rate of fetal demise and malformations. Also, the use of insulin analogues during pregnancy is now regarded as safe. Tight glucose control and frequent follow-up are recommended throughout pregnancy in women with T1DM. Their obstetric management should take place in a maternity hospital with an appropriate perinatal environment and in close collaboration with diabetologists. CONCLUSION: Pregnancy planning and adequate management during pregnancy are mandatory for improving the outcomes of women with T1DM.

Adrenal insufficiency and diabetes mellitus secondary to the use of topical corticosteroids for cosmetic purpose.

We report a case of symptomatic topical corticosteroid-induced adrenal insufficiency and diabetes in a 46-yr old HIV 1 positive woman of African descent. Topical Betamethasone dipropionate 0.05%-containing creams were used for the purpose of bleaching over a 2 month period prior to the acute episode. She recovered from her acute onset diabetes with ketosis and adrenal insufficiency a few months after withdrawal of corticosteroids. Despite possible discussion about pathophysiology of diabetes because acute-onset remitting diabetes is not rare in patients of African descent, and diabetes may occur in patients taking anti-retroviral treatments, no other cause of a hypothalamo-pituitary-adrenal axis disorder was found. This case suggests that chronic use of high dose topical corticosteroid containing creams should be ruled out in patients presenting with Hypothalamo-Pituitary-Adrenal hypofunction.

The use of gonadotrophin-releasing hormone antagonists in polycystic ovarian disease.

Polycystic ovarian disease (PCOD) is characterized by anovulation, eventually high luteinizing hormone (LH) levels, with increased LH pulse frequency, and hyperandrogenism. As the aetiology of the disease is still unknown, gonadotrophin-releasing hormone (GnRH) antagonists, competitive inhibitors of GnRH for its receptor, are interesting tools in order to study and treat the role of increased LH levels and pulse frequency in this disease. Their administration provokes a rapid decrease in bioactive and immunoactive LH followed by a slower decrease in follicle-stimulating hormone (FSH). In patients with PCOD, the suppression of gonadotrophin secretion eradicates the symptoms of the disease as long as the treatment lasts. Several authors have suggested that increased plasma LH levels have deleterious effects on the fertility of women with PCOD. Indeed, fewer spontaneous pregnancies with more miscarriages are observed when plasma LH levels are high. Assisted reproduction techniques such as in vitro fertilization (IVF) have provided other clues to the role of the LH secretory pattern in women with PCOD. The number of oocytes retrieved, the fertilization rate and the cleavage rate are lower in PCOD patients undergoing IVF and this is inversely correlated with FSH:LH ratio. These abnormalities are corrected when endogenous secretion of LH is suppressed. On the other hand, implantation and pregnancy rates after IVF are similar to those observed in control women. New GnRH antagonists are devoid of side effects and suppress LH secretion within a few hours without a flare-up effect. This action lasts for 10-100 hours. When GnRH antagonists are associated with i.v. pulsatile GnRH, this combination both suppresses the effect of endogenous GnRH and because of the competition for GnRH receptors restores a normal frequency of LH secretion. We have studied two women with PCOD, administering first 10 mg s.c. every 72 hours for 7 days of the GnRH antagonist Nal-Glu, then adding on top i.v. pulsatile GnRH: 10 micrograms/pulse every 90 minutes for 15 days. We thus succeeded in normalizing LH secretion pattern and observed a significant decline in testosterone levels. We failed to induce appropriate ovarian response and ovulation. In conclusion, the combination of GnRH antagonist and GnRH pulsatile treatment can re-establish normal LH secretory pattern in patients with PCOD. The failure to induce ovulation with this regimen suggests the existence of an inherent ovarian defect in women with PCOD.