The overall incidence of gestational diabetes mellitus (GDM) is increasing worldwide. Preventing pathological hyperglycaemia during pregnancy could have several benefits: a reduction in the immediate adverse outcomes during pregnancy, a reduced risk of long-term sequelae and a decrease in the economic burden to healthcare systems. In this Review we examine the evidence supporting lifestyle modification strategies in women with and without risk factors for GDM, and the efficacy of dietary supplementation and pharmacological approaches to prevent this disease. A high degree of heterogeneity exists between trials so a generalised recommendation is problematic. In population studies of dietary or combined lifestyle measures, risk of developing GDM is not improved and those involving a physical activity intervention have yielded conflicting results. In pregnant women with obesity, dietary modification might reduce fetal macrosomia but in these patients, low compliance and no significant reduction in the incidence of GDM has been observed in trials investigating physical activity. Supplementation with probiotics or myoinositol have reduced the incidence of GDM but confirmatory studies are still needed. In randomized controlled trials, metformin does not prevent GDM in certain at-risk groups. Given the considerable potential for reducing disease burden, further research is needed to identify strategies that can be easily and effectively implemented on a population level.

Background Euglycaemic ketoacidosis (EKA) is an infrequent but serious condition which usually follows a period of starvation, severe vomiting or illness in individuals with or without diabetes. Ketoacidosis is associated with materno-fetal morbidity and mortality necessitating prompt diagnosis and management. Physiological increases in insulin resistance render pregnancy a diabetogenic state with increased susceptibility to ketosis. COVID-19 is associated with worse clinical outcomes in patients with diabetes and is an independent risk factor for ketoacidosis in normoglycaemic individuals. Case presentations We describe two cases of SARS-CoV-2 positive pregnant women presenting with normoglycaemic metabolic ketoacidosis. Both cases were associated with maternal and fetal compromise, requiring aggressive fluid and insulin resuscitation and early delivery. Conclusion We discuss possible physiology and propose a management strategy for euglycaemic ketoacidosis in pregnancy.

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Background and aims: Gestational diabetes is defined as 'carbohydrate intolerance first recognised in pregnancy'. The definition encompasses women diagnosed in early pregnancy. Concerns exist that such cases phenotypically resemble those with established pre-existing diabetes and therefore have a higher risk profile. We aim to evaluate women diagnosed with impaired carbohydrate intolerance in early pregnancy and compare them with those with established Type 2 diabetes and gestational diabetes diagnosed on routine screening (24À28 weeks' gestation). Methods: We retrospectively reviewed 84 women who attended our inner-city conjoint antenatal clinic (2009À2012). Baseline demographics, insulin therapy requirement and outcomes were compared in women with gestational diabetes diagnosed prior to routine screening (group 1, n = 18) and women with established Type 2 diabetes (group 2, n = 66). A separate cohort of age-matched controls with routinely diagnosed gestational diabetes was identified (group 3, n = 18). Results: Mean age (groups 1À3, 35.6 years, 32.6 years, 35.4 years respectively) and proportion of women originating from non-Caucasian ethnicities (72%, 74%, 78%) were similar across the groups. Women were significantly more likely to be multiparous in group 1 (85%, 15%, 13.6%). Mean booking body mass index (BMI) in groups 1 and 2 were similar: group 1 had a significantly higher booking BMI than group 3 (32.3kg/m 2 ; 30.4kg/m 2 ; 28.3kg/ m 2 ). Differences in HbA1c at booking/diagnosis displayed similar patterns [group 1, 61.4mmol/mol; group 2, 58.5mmol/mol (p = ns); group 3, 38.3mmol/mol (p < 0.005)], as did requirement for insulin therapy [group 1, 94%; group 2, 83.3% (p = ns); group 3, 27.8% (p = 0.04)]. Unplanned Caesarean section rates (33.3%, 28.8%, 38.9%), mean fetal birth weight (3,402g AE 767; 3,257g AE 690; 3,218g AE 503) and birth weight centile (60 AE 37; 59 AE 36; 45 AE 25) were similar across the groups. A higher proportion of infants were born large for gestational age in group 1 and group 2 (27.8%, 25.8%, 5.6%; p = ns). Conclusions: Our analysis has demonstrated that women with carbohydrate intolerance diagnosed early in pregnancy phenotypically resemble those with Type 2 diabetes both in terms of treatment required and outcomes. The role of HbA1c at booking could be investigated as a potential screening tool. A34 (P394)Fasting plasma glucose (FPG) alone will miss persisting postnatal glucose abnormalities in gestational diabetes Aims: To assess the utility of FPG in detecting persisting postnatal hyperglycaemia in gestational diabetes.Methods: Retrospective data were collected for all antenatal and postnatal oral glucose tolerance tests (OGTT) between January 2008 and 2013 across three centres in the West Midlands that used selective screening and WHO criteria. A descriptive study was undertaken comparing the utility of OGTT and FPG postnatally. Results: In all, 14,360 women were screened antenatally; 1,289 women had gestational diabetes and 632 (49%) had OGTT (mean AE SD: 9.4 AE 4.1 weeks). Mean...

Multiple organ dysfunction syndrome (MODS) is associated with a marked catabolic response. Although, initially, aspects of this response are likely to be advantageous, the relentless loss of lean tissue and protein-wasting soon become functionally important, leading to increases in morbidity and mortality. Because standard nutritional support does little to limit proteinwasting in patients with MODS, investigators have sought to develop alternative treatment strategies. Amongst the many factors implicated in the adverse effects of prolonged catabolism, the role of the hypothalamicÁanteriorÁpituitary axis has stimulated considerable research and debate. In view of the well-documented anabolic properties of growth hormone, the efficacy of treatment with recombinant human growth hormone (rhGH) has been extensively investigated in the critically ill. Results have been disappointing however, and prospective randomized controlled trials have clearly demonstrated the dangers of administering 'pharmacological' doses of rhGH to those with prolonged critical illness. More recently, the potential of growth hormone secretagogues, which can restore the natural pulsatility of the hypothalamicÁpituitary axis, has been explored.

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