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Introduction—Diabetes mellitus is an increasingly prevalent condition in New Zealand (as in the rest of the world). Women on the East Coast of New Zealand's North Island are at high risk of developing gestational diabetes (GDM) especially because of elevated BMI and a past history of GDM.The current recommendations for GDM at our hospital are that all patients are screened for diabetes between 24 and 28 weeks, some earlier depending on risk factors that are present. The aim is to identify potential foetal and maternal morbidity (hypertension, PET, Caesarean section rates, future diabetes, perinatal mortality/morbidity). The diagnosis of diabetes is made on the usual criteria which includes a blood glucose challenge (1 hour) with levels of >7.8 mmol/L, a 75 gm glucose tolerance test with fasting hyperglycaemia and a 2-hour postprandial level of >9 mmol/L.2 Table 1. Audit of diabetes mellitus in pregnancy at Gisborne Hospital Variables 2000-2004 2009-2010 Total number of pregnancies: 1505 (752 pa) 2832 (705 pa) Gisborne Census 2006 pop 44496 45900 Percentage Māori (M) 44% 42% Number of diabetics and prevalence 50 (3.3%) M 64% 59 (2.08%) M 58% Maternal gestation at first visit: 29 women >30 weeks 20 women >30 weeks Maternal age 42 women >30 years 23 >30 years Age range in years: , range 19-43 years range 8-41 yrs; mean 28 and average 29 Family history of diabetes ? 23 (46%) Previous GDM 33 women (56%) 26 women (52%) BMI kg/m2 34 >30 (58%) 6>40 (10%) 35>30 (70%) M 7 11>40 (22%) M 5 Type of diabetes mellitus 7 type 1 and 13 type 2 3 type 1 and 4 type 2 Hypertension 6 women (10%) 5 women (10%) Treated with insulin in pregnancy 19 (32%) 13 (26%) Treated with metformin ? 2 Compliance with treatment poor in 5 (10%) poor in 6 (10%) Cigarette smoker 31 (52%) 65% Māori 13 (26%) all Māori Pregnancy outcome C/section 28 (47%) 21 (42%) total 16 emergency Baby birth weight >4.0Kg 23 (38%) 7 (14%) Postnatal follow-up GTT None in 70% None in 60% The obstetric medical service at Gisborne Hospital consists of a Specialist Obstetrician, two Specialist Diabetic Nurses, the hospital Dietician, the Midwife Clinic Co-ordinator and a Specialist Physician. Patients are seen monthly at the clinic for assessment of weight, blood pressure, urine analysis and BM levels. Weight loss is encouraged before rather than during pregnancy. If haemoglobin A1c is elevated prior to the appointment, the test is monitored more frequently—at least 4 to 6 weekly. Pregnancy outcome measures included finding of macrosomnia, Caesarean section rate and foetal complication rate (see Table 1). All patients were given notice of a postnatal follow-up glucose tolerance test (or at least a HbA1c with or without a fasting hyperglycaemia) at 6 weeks. If this is negative, the test is done again in 2 or 3 years time. Special note was taken of the presence of acanthosis nigricans (see Table 2). Table 2. Presence of acanthosis nigricans Total number 13 women (26%) (M 11 and PI 2) Age >30 years >40 years 8 women 5 women Baby birth weight 2.79-3.9 kg 11 women >3.9 kg 2 women 5 women had previous GDM and one had PCOD 5 women were on insulin during pregnancy 5 had Caesarian section, 4 were emergencies Discussion—In the US, more than 23.6 million adults have diabetes (7.8%) and 57 million adults have pre-diabetes (blood sugars are higher than normal but not elevated enough to be diagnosed as diabetic). Pre-diabetes also raises the risk of Type II diabetes and heart disease (CDC Press Release Jan 2011). The US prevalence of GDM has gradually increased since 1989 from 1.9 to 4.2%.1 The incidence of GDM in South Auckland for women of European decent is 3% and this rises to 7.9% among Māori women and 8.1% among Pacific Island women.2 In comparison, the current overall incidence of diabetes in pregnancy in Gisborne, given the ethnicity and high rates of obesity, remains still rather low at 3.3%. However, we can verify that nearly all the patients have had either a polycose challenge or a glucose tolerance test or both from results available at the hospital laboratory. The present cohort comprised 32 Māori women (M), 2 of Pacific Island origin (PI), one Chinese and 15 of European descent (E). The aim of screening for GDM is to reduce maternal and foetal morbidity associated with increasing levels of maternal hyperglycaemia. Recurrence rate of GDM is estimated at 35-52% in subsequent pregnancies and as many as 20% of women with GDM will have an impaired glucose tolerance test during the early postpartum period and go on to develop type 2 diabetes.1 Women with GDM have a higher risk of cardiovascular disease at a younger age. It is reported that the strongest independent risk factors for GDM were a positive past history of GDM and a maternal age of more than 40 years.3 The presence of diabetes in pregnancy increases the risk of the baby developing obesity (and subsequent diabetes) by threefold and this can occur 6 to 7 years after delivery.4 In this regard, postnatal follow up (with GTT) will allow early recognition of diabetes and help guide a more aggressive approach to dietary modification (food low in high GI content and fast-foods, fizzy/pop drinks) promoting weight loss combined with exercise, which may prove valuable to both the young mother and a her child. Pre-conceptual guidance and counselling is also provided and midwives are encouraged to refer patients at risk much earlier in the gestational period. Conclusions—The prevalence of diabetes in pregnancy in the Gisborne district remains surprisingly low at 3.3%.7 Patients with GDM are still being referred late in gestation despite high risk. There appears to be a high incidence of acanthosis nigricans (AN) which is associated with obesity, the metabolic syndrome and Insulin resistance. Though weight and maternal age are known risk factors, it would appear that patients with a previous history of GDM also have a high risk of developing type 2 diabetes. Caesarian sections rates remain fairly high at 42% when 2009 NZ statistics show a rate of 25.1% and half were emergencies. Postnatal follow-up with GTT remains very disappointing. This greatly reduces the opportunity for early diagnosis, access to prenatal care and to help arrest the progression of morbidity, especially diabetes-associated disease in this group of young women. On the positive side, fewer pregnant women were smokers no doubt helped and encouraged by current public health measures. Prevalence of foetal macrosomia has also declined (in this small group) reflecting better glycaemic control. The presence of acanthosis nigricans appears to be a valuable clinical sign in determining high risk. This is a skin disorder characterised by thickened hyperpigmented velvety plaques in the body flexures and neck and is more commonly associated with obesity and insulin resistance including Type II diabetes, the metabolic syndrome, polycystic ovarian disease and hypertension. The condition is 25% more common in African-Americans and can be regarded as a clinical surrogate of hyperinsulinism.5,6 The metabolic syndrome present in some 34% of American adults increases the risk of the development of diabetes three to fivefold in 5 years. The baby born of a mother with GDM at term will have a risk of becoming an obese child at the age of 6 to 7 years.3 Babs J Reddy Consultant Physician for the Gisborne Hospital’s Medical Obstetric Service reddybj@xtra.co.nz

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Babs J Reddy, Consultant Physician for the Gisborne Hospitals Medical Obstetric Service

Acknowledgements

Correspondence

Correspondence Email

reddybj@xtra.co.nz

Competing Interests

Getahun D et al. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol 2010; 203:467. e1.Simmons D et al. Gestational diabetes: time for consensus on screening and diagnosis. N Z Med J 2006 Jan 27;119 (1228).Gillman MW et al. Effect of gestational diabetes mellitus on obesity in the next generation. Diabetes care 2010; 33:964.Teh WT et al. Risk factors for gestational diabetes mellitus: implications for the application of screening guidelines. Aust/NZ J Obstet Gynaecol. 2011 Feb;51(1):26-30Kong AS et al. Acanthosis Nigricans and Diabetes Risk Factors: Prevalence in Young Persons seen in Southwestern US primary Care Practices. Ann Fam Med. 2007 May-June;5(3):202-8.Higgins SP et al. Acanthosis nigricans: a practical approach to evaluation and management. Dermatol Online J. 2008 Sept 15;14(9):2.Reddy J. Medical audit of practice management of diabetes in pregnancy at Gisborne Hospitals Obstetric Medical Service. N Z Med J 2006 Jan 27;119(1228):U1831. http://journal.nzma.org.nz/journal/119-1228/1831/content.pdf

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Introduction—Diabetes mellitus is an increasingly prevalent condition in New Zealand (as in the rest of the world). Women on the East Coast of New Zealand's North Island are at high risk of developing gestational diabetes (GDM) especially because of elevated BMI and a past history of GDM.The current recommendations for GDM at our hospital are that all patients are screened for diabetes between 24 and 28 weeks, some earlier depending on risk factors that are present. The aim is to identify potential foetal and maternal morbidity (hypertension, PET, Caesarean section rates, future diabetes, perinatal mortality/morbidity). The diagnosis of diabetes is made on the usual criteria which includes a blood glucose challenge (1 hour) with levels of >7.8 mmol/L, a 75 gm glucose tolerance test with fasting hyperglycaemia and a 2-hour postprandial level of >9 mmol/L.2 Table 1. Audit of diabetes mellitus in pregnancy at Gisborne Hospital Variables 2000-2004 2009-2010 Total number of pregnancies: 1505 (752 pa) 2832 (705 pa) Gisborne Census 2006 pop 44496 45900 Percentage Māori (M) 44% 42% Number of diabetics and prevalence 50 (3.3%) M 64% 59 (2.08%) M 58% Maternal gestation at first visit: 29 women >30 weeks 20 women >30 weeks Maternal age 42 women >30 years 23 >30 years Age range in years: , range 19-43 years range 8-41 yrs; mean 28 and average 29 Family history of diabetes ? 23 (46%) Previous GDM 33 women (56%) 26 women (52%) BMI kg/m2 34 >30 (58%) 6>40 (10%) 35>30 (70%) M 7 11>40 (22%) M 5 Type of diabetes mellitus 7 type 1 and 13 type 2 3 type 1 and 4 type 2 Hypertension 6 women (10%) 5 women (10%) Treated with insulin in pregnancy 19 (32%) 13 (26%) Treated with metformin ? 2 Compliance with treatment poor in 5 (10%) poor in 6 (10%) Cigarette smoker 31 (52%) 65% Māori 13 (26%) all Māori Pregnancy outcome C/section 28 (47%) 21 (42%) total 16 emergency Baby birth weight >4.0Kg 23 (38%) 7 (14%) Postnatal follow-up GTT None in 70% None in 60% The obstetric medical service at Gisborne Hospital consists of a Specialist Obstetrician, two Specialist Diabetic Nurses, the hospital Dietician, the Midwife Clinic Co-ordinator and a Specialist Physician. Patients are seen monthly at the clinic for assessment of weight, blood pressure, urine analysis and BM levels. Weight loss is encouraged before rather than during pregnancy. If haemoglobin A1c is elevated prior to the appointment, the test is monitored more frequently—at least 4 to 6 weekly. Pregnancy outcome measures included finding of macrosomnia, Caesarean section rate and foetal complication rate (see Table 1). All patients were given notice of a postnatal follow-up glucose tolerance test (or at least a HbA1c with or without a fasting hyperglycaemia) at 6 weeks. If this is negative, the test is done again in 2 or 3 years time. Special note was taken of the presence of acanthosis nigricans (see Table 2). Table 2. Presence of acanthosis nigricans Total number 13 women (26%) (M 11 and PI 2) Age >30 years >40 years 8 women 5 women Baby birth weight 2.79-3.9 kg 11 women >3.9 kg 2 women 5 women had previous GDM and one had PCOD 5 women were on insulin during pregnancy 5 had Caesarian section, 4 were emergencies Discussion—In the US, more than 23.6 million adults have diabetes (7.8%) and 57 million adults have pre-diabetes (blood sugars are higher than normal but not elevated enough to be diagnosed as diabetic). Pre-diabetes also raises the risk of Type II diabetes and heart disease (CDC Press Release Jan 2011). The US prevalence of GDM has gradually increased since 1989 from 1.9 to 4.2%.1 The incidence of GDM in South Auckland for women of European decent is 3% and this rises to 7.9% among Māori women and 8.1% among Pacific Island women.2 In comparison, the current overall incidence of diabetes in pregnancy in Gisborne, given the ethnicity and high rates of obesity, remains still rather low at 3.3%. However, we can verify that nearly all the patients have had either a polycose challenge or a glucose tolerance test or both from results available at the hospital laboratory. The present cohort comprised 32 Māori women (M), 2 of Pacific Island origin (PI), one Chinese and 15 of European descent (E). The aim of screening for GDM is to reduce maternal and foetal morbidity associated with increasing levels of maternal hyperglycaemia. Recurrence rate of GDM is estimated at 35-52% in subsequent pregnancies and as many as 20% of women with GDM will have an impaired glucose tolerance test during the early postpartum period and go on to develop type 2 diabetes.1 Women with GDM have a higher risk of cardiovascular disease at a younger age. It is reported that the strongest independent risk factors for GDM were a positive past history of GDM and a maternal age of more than 40 years.3 The presence of diabetes in pregnancy increases the risk of the baby developing obesity (and subsequent diabetes) by threefold and this can occur 6 to 7 years after delivery.4 In this regard, postnatal follow up (with GTT) will allow early recognition of diabetes and help guide a more aggressive approach to dietary modification (food low in high GI content and fast-foods, fizzy/pop drinks) promoting weight loss combined with exercise, which may prove valuable to both the young mother and a her child. Pre-conceptual guidance and counselling is also provided and midwives are encouraged to refer patients at risk much earlier in the gestational period. Conclusions—The prevalence of diabetes in pregnancy in the Gisborne district remains surprisingly low at 3.3%.7 Patients with GDM are still being referred late in gestation despite high risk. There appears to be a high incidence of acanthosis nigricans (AN) which is associated with obesity, the metabolic syndrome and Insulin resistance. Though weight and maternal age are known risk factors, it would appear that patients with a previous history of GDM also have a high risk of developing type 2 diabetes. Caesarian sections rates remain fairly high at 42% when 2009 NZ statistics show a rate of 25.1% and half were emergencies. Postnatal follow-up with GTT remains very disappointing. This greatly reduces the opportunity for early diagnosis, access to prenatal care and to help arrest the progression of morbidity, especially diabetes-associated disease in this group of young women. On the positive side, fewer pregnant women were smokers no doubt helped and encouraged by current public health measures. Prevalence of foetal macrosomia has also declined (in this small group) reflecting better glycaemic control. The presence of acanthosis nigricans appears to be a valuable clinical sign in determining high risk. This is a skin disorder characterised by thickened hyperpigmented velvety plaques in the body flexures and neck and is more commonly associated with obesity and insulin resistance including Type II diabetes, the metabolic syndrome, polycystic ovarian disease and hypertension. The condition is 25% more common in African-Americans and can be regarded as a clinical surrogate of hyperinsulinism.5,6 The metabolic syndrome present in some 34% of American adults increases the risk of the development of diabetes three to fivefold in 5 years. The baby born of a mother with GDM at term will have a risk of becoming an obese child at the age of 6 to 7 years.3 Babs J Reddy Consultant Physician for the Gisborne Hospital’s Medical Obstetric Service reddybj@xtra.co.nz

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Babs J Reddy, Consultant Physician for the Gisborne Hospitals Medical Obstetric Service

Acknowledgements

Correspondence

Correspondence Email

reddybj@xtra.co.nz

Competing Interests

Getahun D et al. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol 2010; 203:467. e1.Simmons D et al. Gestational diabetes: time for consensus on screening and diagnosis. N Z Med J 2006 Jan 27;119 (1228).Gillman MW et al. Effect of gestational diabetes mellitus on obesity in the next generation. Diabetes care 2010; 33:964.Teh WT et al. Risk factors for gestational diabetes mellitus: implications for the application of screening guidelines. Aust/NZ J Obstet Gynaecol. 2011 Feb;51(1):26-30Kong AS et al. Acanthosis Nigricans and Diabetes Risk Factors: Prevalence in Young Persons seen in Southwestern US primary Care Practices. Ann Fam Med. 2007 May-June;5(3):202-8.Higgins SP et al. Acanthosis nigricans: a practical approach to evaluation and management. Dermatol Online J. 2008 Sept 15;14(9):2.Reddy J. Medical audit of practice management of diabetes in pregnancy at Gisborne Hospitals Obstetric Medical Service. N Z Med J 2006 Jan 27;119(1228):U1831. http://journal.nzma.org.nz/journal/119-1228/1831/content.pdf

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Introduction—Diabetes mellitus is an increasingly prevalent condition in New Zealand (as in the rest of the world). Women on the East Coast of New Zealand's North Island are at high risk of developing gestational diabetes (GDM) especially because of elevated BMI and a past history of GDM.The current recommendations for GDM at our hospital are that all patients are screened for diabetes between 24 and 28 weeks, some earlier depending on risk factors that are present. The aim is to identify potential foetal and maternal morbidity (hypertension, PET, Caesarean section rates, future diabetes, perinatal mortality/morbidity). The diagnosis of diabetes is made on the usual criteria which includes a blood glucose challenge (1 hour) with levels of >7.8 mmol/L, a 75 gm glucose tolerance test with fasting hyperglycaemia and a 2-hour postprandial level of >9 mmol/L.2 Table 1. Audit of diabetes mellitus in pregnancy at Gisborne Hospital Variables 2000-2004 2009-2010 Total number of pregnancies: 1505 (752 pa) 2832 (705 pa) Gisborne Census 2006 pop 44496 45900 Percentage Māori (M) 44% 42% Number of diabetics and prevalence 50 (3.3%) M 64% 59 (2.08%) M 58% Maternal gestation at first visit: 29 women >30 weeks 20 women >30 weeks Maternal age 42 women >30 years 23 >30 years Age range in years: , range 19-43 years range 8-41 yrs; mean 28 and average 29 Family history of diabetes ? 23 (46%) Previous GDM 33 women (56%) 26 women (52%) BMI kg/m2 34 >30 (58%) 6>40 (10%) 35>30 (70%) M 7 11>40 (22%) M 5 Type of diabetes mellitus 7 type 1 and 13 type 2 3 type 1 and 4 type 2 Hypertension 6 women (10%) 5 women (10%) Treated with insulin in pregnancy 19 (32%) 13 (26%) Treated with metformin ? 2 Compliance with treatment poor in 5 (10%) poor in 6 (10%) Cigarette smoker 31 (52%) 65% Māori 13 (26%) all Māori Pregnancy outcome C/section 28 (47%) 21 (42%) total 16 emergency Baby birth weight >4.0Kg 23 (38%) 7 (14%) Postnatal follow-up GTT None in 70% None in 60% The obstetric medical service at Gisborne Hospital consists of a Specialist Obstetrician, two Specialist Diabetic Nurses, the hospital Dietician, the Midwife Clinic Co-ordinator and a Specialist Physician. Patients are seen monthly at the clinic for assessment of weight, blood pressure, urine analysis and BM levels. Weight loss is encouraged before rather than during pregnancy. If haemoglobin A1c is elevated prior to the appointment, the test is monitored more frequently—at least 4 to 6 weekly. Pregnancy outcome measures included finding of macrosomnia, Caesarean section rate and foetal complication rate (see Table 1). All patients were given notice of a postnatal follow-up glucose tolerance test (or at least a HbA1c with or without a fasting hyperglycaemia) at 6 weeks. If this is negative, the test is done again in 2 or 3 years time. Special note was taken of the presence of acanthosis nigricans (see Table 2). Table 2. Presence of acanthosis nigricans Total number 13 women (26%) (M 11 and PI 2) Age >30 years >40 years 8 women 5 women Baby birth weight 2.79-3.9 kg 11 women >3.9 kg 2 women 5 women had previous GDM and one had PCOD 5 women were on insulin during pregnancy 5 had Caesarian section, 4 were emergencies Discussion—In the US, more than 23.6 million adults have diabetes (7.8%) and 57 million adults have pre-diabetes (blood sugars are higher than normal but not elevated enough to be diagnosed as diabetic). Pre-diabetes also raises the risk of Type II diabetes and heart disease (CDC Press Release Jan 2011). The US prevalence of GDM has gradually increased since 1989 from 1.9 to 4.2%.1 The incidence of GDM in South Auckland for women of European decent is 3% and this rises to 7.9% among Māori women and 8.1% among Pacific Island women.2 In comparison, the current overall incidence of diabetes in pregnancy in Gisborne, given the ethnicity and high rates of obesity, remains still rather low at 3.3%. However, we can verify that nearly all the patients have had either a polycose challenge or a glucose tolerance test or both from results available at the hospital laboratory. The present cohort comprised 32 Māori women (M), 2 of Pacific Island origin (PI), one Chinese and 15 of European descent (E). The aim of screening for GDM is to reduce maternal and foetal morbidity associated with increasing levels of maternal hyperglycaemia. Recurrence rate of GDM is estimated at 35-52% in subsequent pregnancies and as many as 20% of women with GDM will have an impaired glucose tolerance test during the early postpartum period and go on to develop type 2 diabetes.1 Women with GDM have a higher risk of cardiovascular disease at a younger age. It is reported that the strongest independent risk factors for GDM were a positive past history of GDM and a maternal age of more than 40 years.3 The presence of diabetes in pregnancy increases the risk of the baby developing obesity (and subsequent diabetes) by threefold and this can occur 6 to 7 years after delivery.4 In this regard, postnatal follow up (with GTT) will allow early recognition of diabetes and help guide a more aggressive approach to dietary modification (food low in high GI content and fast-foods, fizzy/pop drinks) promoting weight loss combined with exercise, which may prove valuable to both the young mother and a her child. Pre-conceptual guidance and counselling is also provided and midwives are encouraged to refer patients at risk much earlier in the gestational period. Conclusions—The prevalence of diabetes in pregnancy in the Gisborne district remains surprisingly low at 3.3%.7 Patients with GDM are still being referred late in gestation despite high risk. There appears to be a high incidence of acanthosis nigricans (AN) which is associated with obesity, the metabolic syndrome and Insulin resistance. Though weight and maternal age are known risk factors, it would appear that patients with a previous history of GDM also have a high risk of developing type 2 diabetes. Caesarian sections rates remain fairly high at 42% when 2009 NZ statistics show a rate of 25.1% and half were emergencies. Postnatal follow-up with GTT remains very disappointing. This greatly reduces the opportunity for early diagnosis, access to prenatal care and to help arrest the progression of morbidity, especially diabetes-associated disease in this group of young women. On the positive side, fewer pregnant women were smokers no doubt helped and encouraged by current public health measures. Prevalence of foetal macrosomia has also declined (in this small group) reflecting better glycaemic control. The presence of acanthosis nigricans appears to be a valuable clinical sign in determining high risk. This is a skin disorder characterised by thickened hyperpigmented velvety plaques in the body flexures and neck and is more commonly associated with obesity and insulin resistance including Type II diabetes, the metabolic syndrome, polycystic ovarian disease and hypertension. The condition is 25% more common in African-Americans and can be regarded as a clinical surrogate of hyperinsulinism.5,6 The metabolic syndrome present in some 34% of American adults increases the risk of the development of diabetes three to fivefold in 5 years. The baby born of a mother with GDM at term will have a risk of becoming an obese child at the age of 6 to 7 years.3 Babs J Reddy Consultant Physician for the Gisborne Hospital’s Medical Obstetric Service reddybj@xtra.co.nz

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Babs J Reddy, Consultant Physician for the Gisborne Hospitals Medical Obstetric Service

Acknowledgements

Correspondence

Correspondence Email

reddybj@xtra.co.nz

Competing Interests

Getahun D et al. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol 2010; 203:467. e1.Simmons D et al. Gestational diabetes: time for consensus on screening and diagnosis. N Z Med J 2006 Jan 27;119 (1228).Gillman MW et al. Effect of gestational diabetes mellitus on obesity in the next generation. Diabetes care 2010; 33:964.Teh WT et al. Risk factors for gestational diabetes mellitus: implications for the application of screening guidelines. Aust/NZ J Obstet Gynaecol. 2011 Feb;51(1):26-30Kong AS et al. Acanthosis Nigricans and Diabetes Risk Factors: Prevalence in Young Persons seen in Southwestern US primary Care Practices. Ann Fam Med. 2007 May-June;5(3):202-8.Higgins SP et al. Acanthosis nigricans: a practical approach to evaluation and management. Dermatol Online J. 2008 Sept 15;14(9):2.Reddy J. Medical audit of practice management of diabetes in pregnancy at Gisborne Hospitals Obstetric Medical Service. N Z Med J 2006 Jan 27;119(1228):U1831. http://journal.nzma.org.nz/journal/119-1228/1831/content.pdf

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