Pregnancy Gestational Diabetes Research Articles

SKRINING DAN PENGENDALIAN FAKTOR RISIKO IBU HAMIL DENGAN PELAYANAN ANTENATAL CARE TERPADU DI WILAYAH KERJA PUSKESMAS KECAMATAN MUARA KABUPATEN TAPANULI UTARA

Background: The maternal mortality rate (MMR) in Indonesia is still quite high, based on the results of SUPAS in 2015, the MMR was 305/ 100,000 live births. Efforts to decrease of MMR can be done by ensuring that every mother can access quality health services for pregnant women because every pregnancy has the risk of complications. Integrated antenatal services are carried out including health counseling, antenatal care, case management and follow-up, preparation for delivery and planning for referrals in case of pregnancy. In the initial research conducted in Hutaginjang Village, Muara, there were still pregnant women who did not have their pregnancy checked according to the minimum pregnancy standards. Purpose: Screening and pregnancy risk factors is indispensable for early pregnancy and the potential for emergency pregnancy. Methods: Activities carried out by integrated and free pregnancy examinations for pregnant women include measuring weight / height and arm circumference, vital signs, physical examination, Hb examination, urine protein and glucose, provision of IEC about nutritional fulfillment, overcoming complaints of pregnant women in trimester IIII, preparation for delivery and administration of iron supplements as well as preparation for referrals for mothers who experience complications in their pregnancy. Results: The activity was carried out without any obstacles, with 18 mothers having their pregnancies checked. The results of the examination found several risk factors for pregnancy, namely age under 20 years and above 35 years of parity, history of delivery by sectio, height below 145 cm, anemia, preeclampsia, breech location, hyperemesia gravidarum, gestational diabetes and gemelli pregnancy. Each mother received communication, information and education related to maintaining and improving health during pregnancy and giving iron tablets. Conclusion: Screening and control of pregnancy risk factors is needed to detect early whether the pregnancy is at risk and has the potential for emergency pregnancy, so that the mother can pass her pregnancy well and give birth to a healthy baby.

Comparison of factor XII levels in gestational diabetes, fetal macrosomia, and healthy pregnancies

BackgroundIf not detected and treated, gestational diabetes mellitus (GDM) can cause serious pregnancy complications such as macrosomia, preeclampsia, and fetal/neonatal mortality. Many studies have examined underlying contributing factors for GDM, including hypercoagulation. Factor XII (FXII) is a coagulation factor that increases throughout normal pregnancies, and we evaluated the relationship of GDM with FXII, FXIIa (activated FXII), and other coagulation parameter levels. GDM and macrosomia are closely related, but it is not known whether FXII could be an independent causal factor for macrosomia.MethodsIn this prospective study, blood samples were taken from 69 pregnant women at the time of term delivery to determine levels of FXII, FXIIa, and other coagulation parameters. Based on the results, pregnancies fell into GDM, non-diabetic with macrosomia (M), or healthy (C [control]).ResultsFXII concentration levels were significantly higher in GDM patients compared with the M and C groups. There were no significant differences when comparing FXIIa, activated partial thromboplastin time, prothrombin time (PT), and international normalized ratio. The GDM group saw a significant negative correlation between FXII concentrations and maternal pregestational body mass index (BMI) and BMI before delivery. In the M group, a positive correlation was observed between FXII concentrations and newborn weight and newborn weight percentile.ConclusionsAn increase in FXII levels was observed in patients with gestational diabetes. Associations between coagulation parameters and GDM should be further analyzed to define the mechanisms of GDM and possible treatment modalities.Trial registrationOur study has been registered at clinicaltrials.gov (NCT03583216). Registered on July 11, 2018,

Clinical implications of the glucokinase impaired function - GCK MODY today.

Heterozygous inactivating mutations of the glucokinase (GCK) gene are causing GCK-MODY, one of the most common forms of the Maturity Onset Diabetes of the Young (MODY). GCK-MODY is characterized by fasting hyperglycemia without apparent worsening with aging and low risk for chronic vascular complications. Despite the mild clinical course, GCK-MODY could be misdiagnosed as type 1 or type 2 diabetes. In the diagnostic process, the clinical suspicion is often based on the clinical diagnostic criteria for GCK-MODY and should be confirmed by DNA analysis. However, there are several issues in the clinical and also in genetic part that could complicate the diagnostic process. Most of the people with GCK-MODY do not require any pharmacotherapy. The exception are pregnant women with a fetus which did not inherit GCK mutation from the mother. Such a child has accelerated growth, and has increased risk for diabetic foetopathy. In this situation the mother should be treated with substitutional doses of insulin. Therefore, distinguishing GCK-MODY from gestational diabetes in pregnancy is very important. For this purpose, special clinical diagnostic criteria for clinical identification of GCK-MODY in pregnancy are used. This review updates information on GCK-MODY and discusses several currently not solved problems in the clinical diagnostic process, genetics, and treatment of this type of monogenic diabetes.

Exposure to environmental contaminants and risk of pregnancy induced hypertension and gestational diabetes mellitus

Introduction: Persistent organic pollutants (POPs), including polychlorinated biphenyls (PCBs) and hexachlorobenzene (HCB), are ubiquitously found in the environment and resistant to degradation. POPs, along with persistent organochlorine pesticides including p,p'-dichlorodiphenyl dichloroethylene (DDE) and heavy metals have been associated with various pregnancy outcomes but results are inconsistent.Objective: We assessed the associations between prenatal exposures to organochlorines and heavy metals and the development of gestational diabetes mellitus (GDM) and pregnancy induced hypertension (PIH). Methods: We used existing exposure models to predict prenatal levels of PCBs (using the sum of 4 prevalent congeners), DDE, HCB, lead (Pb) and mercury (Hg) for all pregnant women living in southeast Massachusetts between 1993-1998 (n=10,270). Outcome and covariate data were obtained from Massachusetts birth records. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for GDM and PIH were estimated using multivariable logistic regression models. Results: Approximately 1.8% of women in this study population developed GDM and 1.9% of women developed PIH. PCBs, DDE and HCB were strongly associated with the development of GDM, while no associations were observed for Pb and Hg exposure. After adjusting for weight gain during pregnancy, smoking during pregnancy, parity, race, and socioeconomic factors, the effects of PCBs (OR: 1.56; 95% CI: 1.10-2.22) and DDE (OR: 2.84; 95% CI: 1.90-4.25) on GDM remained. However, the risk associated with HCB exposure was no longer significant after adjusting for confounders. Associations with PIH were null.Conclusions: These results suggest that women with high prenatal levels of PCBs and DDE may have a higher risk of developing GDM. We found no associations between PIH and exposures to organochlorines and heavy metals.

A consumer co-created infographic improves short-term knowledge about physical activity and self-efficacy to exercise in women with gestational diabetes mellitus: a randomised trial.

In women with gestational diabetes mellitus, does the addition of a consumer co-created infographic to usual education about gestational diabetes mellitus improve knowledge about physical activity and self-efficacy to exercise? A randomised trial with concealed allocation, a blinded assessor and intention-to-treat analysis. Sixty-nine women diagnosed with gestational diabetes mellitus. In addition to gestational diabetes education, the experimental group received a paper copy of a consumer co-created infographic about physical activity during a gestational diabetes pregnancy. The control group received gestational diabetes education alone. Participants completed outcome measures at baseline and again 1 week later. Knowledge of physical activity in a gestational diabetes mellitus pregnancy was assessed using a 19-item questionnaire modified to reflect current physical activity guidelines, with a total score from 0% (worst) to 100% (best). Self-efficacy was measured using the nine-item Self-Efficacy for Exercise Scale, with a total score from 0 (not confident) to 10 (very confident). Provision of the infographic led to a clinically important between-group difference in knowledge (MD 12%, 95% CI 10 to 15) and self-efficacy (MD 2.5 units, 95% CI 1.9 to 3.0). In women with gestational diabetes mellitus, short-term knowledge about physical activity and self-efficacy to exercise were improved when usual education was supplemented with a consumer co-created infographic that provided specific and relevant information about physical activity during a gestational diabetes mellitus pregnancy. ACTRN12619001207101.

Compromised barrier integrity of human feto-placental vessels from gestational diabetic pregnancies is related to downregulation of occludin expression

Aims/hypothesisReduced occupancy of junctional occludin is a feature of human placental vessels in the diabetic milieu. However, the functional consequence of this and whether this loss is due to differential expression of occludin splice variants is not known. Our study aimed to investigate the effects of gestational diabetes mellitus (GDM), and its treatment, on endothelial junctional integrity, gene and protein expression of occludin splice variants, and potential regulation of expression by microRNAs (miRNAs).MethodsTerm placentas were obtained from normal pregnancies (n = 21), and pregnancies complicated by GDM where glucose levels were controlled by diet (n = 11) or metformin (n = 6). Gene and microRNA (miRNA) expression were determined by quantitative real-time PCR; protein expression by immunoblotting; endothelial junctional occupancy by fluorescence microscopy and systematic sampling; and paracellular leakage by perfusion of placental microvascular beds with 76 Mr dextran. Transfection studies of miRNAs that target OCLN were performed in HUVECs, and the trans-endothelial electrical resistance and tracer permeability of the HUVECs were measured.ResultsAll three predicted OCLN gene splice variants and two occludin protein isoforms were found in human placental samples. In placental samples from diet-controlled GDM (d-GDM) pregnancies we found a lower percentage of conduit vessels showing occludin immunoreactivity (12%, p < 0.01), decreased levels of the fully functional occludin isoform-A protein (29%), and differential gene expression of OCLN variant 2 (33% decrease), variant 3 (3.3-fold increase). These changes were not seen in samples from the group with metformin-controlled GDM. In d-GDM placentas, increased numbers of conduit microvessels demonstrated extravasation of 76 Mr dextran (2.0-fold). In d-GDM expression of one of the five potential miRNAs targeting OCLN, miR-181a-5p, expression was 2.1-fold that in normal pregnancies. Experimental overexpression of miR-181a-5p in HUVECs from normal pregnancies resulted in a highly significant downregulation of OCLN variant 1 (69%) and variant 2 (46%) gene expression, with decreased trans-endothelial resistance (78%) and increase in tracer permeability (1.3-fold).Conclusions/interpretationDownregulation of expression of OCLN variant 2 and the fully functional occludin isoform-A protein are a feature of placentas in d-GDM pregnancies. These may be behind the loss of junctional occludin and the increased extravasation of exogenous dextran observed. miR-181a-5p was in part responsible for the downregulation of occludin in placentas from d-GDM pregnancies. Induced overexpression of miR-181a-5p compromised the integrity of the endothelial barrier. Our data suggest that, despite good glucose control, the adoption of lifestyle changes alone during a GDM pregnancy may not be enough to prevent an alteration in the expression of occludin and the subsequent functional consequences in placentas and impaired vascular barrier function in offspring.Graphical abstract

Approaches to screening for hyperglycaemia in pregnant women during and after the COVID-19 pandemic.

AimTo evaluate the diagnostic and prognostic performance of alternative diagnostic strategies to oral glucose tolerance tests, including random plasma glucose, fasting plasma glucose and HbA1c, during the COVID‐19 pandemic.MethodsRetrospective service data (Cambridge, UK; 17 736 consecutive singleton pregnancies, 2004–2008; 826 consecutive gestational diabetes pregnancies, 2014–2019) and 361 women with ≥1 gestational diabetes risk factor (OPHELIA prospective observational study, UK) were included. Pregnancy outcomes included gestational diabetes (National Institute of Health and Clinical Excellence or International Association of Diabetes and Pregnancy Study Groups criteria), diabetes in pregnancy (WHO criteria), Caesarean section, large‐for‐gestational age infant, neonatal hypoglycaemia and neonatal intensive care unit admission. Receiver‐operating characteristic curves and unadjusted logistic regression were used to compare random plasma glucose, fasting plasma glucose and HbA1c performance.ResultsGestational diabetes diagnosis was significantly associated with random plasma glucose at 12 weeks [area under the receiver‐operating characteristic curve for both criteria 0.81 (95% CI 0.79–0.83)], fasting plasma glucose [National Institute of Health and Clinical Excellence: area under the receiver‐operating characteristic curve 0.75 (95% CI 0.65–0.85); International Association of Diabetes and Pregnancy Study Groups: area under the receiver‐operating characteristic curve 0.92 (95% CI 0.85–0.98)] and HbA1c at 28 weeks' gestation [National Institute of Health and Clinical Excellence: 0.83 (95% CI 0.75–0.90); International Association of Diabetes and Pregnancy Study Groups: 0.84 (95% CI 0.77–0.91)]. Each measure predicts some, but not all, pregnancy outcomes studied. At 12 weeks, ~5% of women would be identified using random plasma glucose ≥8.5 mmol/l (sensitivity 42%; specificity 96%) and at 28 weeks using HbA1c ≥39 mmol/mol (sensitivity 26%; specificity 96%) or fasting plasma glucose ≥5.2–5.4 mmol/l (sensitivity 18–41%; specificity 97–98%).ConclusionsRandom plasma glucose at 12 weeks, and fasting plasma glucose or HbA1c at 28 weeks identify women with hyperglycaemia at risk of suboptimal pregnancy outcomes. These opportunistic laboratory tests perform adequately for risk stratification when oral glucose tolerance testing is not available.

COVID-19 and self-care strategies for women with gestational diabetes mellitus

Background and aimThe outbreak of the emerging coronavirus disease 2019 (COVID-19) is a global public health emergency. According to the findings, women with gestational diabetes mellitus (GDM) are at increased risk of this virus. Due to the need for quarantine and social distancing in the current disease situation and need to receive repeated medical care in GDM patients, this review study aimed to evaluate the self-care strategies for women with GDM during COVID-19 pandemic. Methods25 related articles from 2011 to 2020 and 3 guidelines were reviewed with the keywords of gestational diabetes mellitus, diabetes, pregnancy and COVID-19 in combination with self-care and self-management in PubMed, Google Scholar, Scopus, Science Direct, Elsevier, Springer, Wiley Online Library and SID. ResultsAccording to the results of the studies, face-to-face visits should be limited and instead, telemedicine services recommended. Self-care throughout telemedicine services were improved maternal and neonatal outcomes in women with GDM. ConclusionAlthough self-care program through telemedicine services is beneficial for women with GDM, performing clinical trials are recommended to assess maternal and neonatal outcomes in this condition.

A Critical Review of Proteomic Studies in Gestational Diabetes Mellitus.

Gestational diabetes mellitus is a progressive and complex pregnancy complication, which threatens both maternal and fetal health. It is urgent to screen for specific biomarkers for early diagnosis and precise treatment, as well as to identify key moleculars to better understand the pathogenic mechanisms. In the present review, we comprehensively summarized recent studies of gestational diabetes using mass spectrometry-based proteomic technologies. Focused on the entire experimental design and proteomic results, we showed that these studies have covered a broad range of research contents in terms of sampling time, sample types, and outcome associations. Although most of the studies only stayed in the stage of initial discovery, several proteins were further verified to be efficient for disease diagnosis. Functional analysis of all the combined significant proteins also showed that a small number of proteins are known to be involved in the regulation of insulin or indirect signaling pathways. However, many factors such as diagnostic criteria, sample processing, proteomic method, and statistical method can greatly affect the identification of reproducible and reliable protein candidates. Thus, we further provided constructive suggestions and recommendations for carrying out proteomic or follow-up studies of gestational diabetes or other pregnancy complications in the future.

Association between levels of aquaporin 3 in the placenta and adiponectin in the umbilical cord blood with gestational diabetes mellitus and pregnancy outcome.

Pregnant women with gestational diabetes mellitus (GDM) may have adverse pregnancy outcomes, even if their blood glucose level is well-controlled. Aquaporin 3 (AQP3) and adiponectin (APN) serve important roles in fetal growth and development. However, the associations of AQP3 and APN with GDM and pregnancy outcome are not known. Therefore, the present study was performed to evaluate the expression of AQP3 in the placenta and APN in the umbilical artery blood, and the association of the two factors with GDM and pregnancy outcome. The patient cohort was divided into two groups: Pregnant women with GDM; and pregnant women with normal glucose tolerance (NGT). The expression levels of AQP3 in the placenta and APN in the umbilical artery blood were detected. Logistic regression was used to analyze the associations of AQP3 and APN with GDM and pregnancy outcome. The expression levels of AQP3 and AQP3 mRNA in the placenta of the GDM group were decreased compared with that of the NGT group, and the difference was statistically significant (P<0.05). The expression of APN in the umbilical artery blood of the GDM group was also decreased compared with that of the NGT group, and the difference was also statistically significant (P<0.05). Multivariate logistic regression analyses indicated that the AQP3 and APN levels were negatively correlated not only with the risk of developing GDM [AQP3 odds ratio (OR)=5.00 (P<0.01); APN OR=2.98 (P=0.01)], but also with abnormal pregnancy outcome [(AQP3 OR=4.64 (P<0.01); APN OR=5.41 (P<0.01)]. The levels of AQP3 in the placenta and APN in the umbilical cord blood were associated with GDM, and the risk of GDM was increased in pregnant women with decreased AQP3 and APN levels. The AQP3 and APN levels also had an effect on pregnancy outcome. The risk of abnormal pregnancy outcomes, including cesarean section, macrosomia, fetal distress and neonatal asphyxia, was increased in pregnant women with decreased AQP3 and APN levels.

Fetal-Maternal Exposure to Endocrine Disruptors: Correlation with Diet Intake and Pregnancy Outcomes.

Endocrine-disrupting chemicals (EDCs) are exogenous substances able to mimic or to interfere with the endocrine system, thus altering key biological processes such as organ development, reproduction, immunity, metabolism and behavior. High concentrations of EDCs are found in several everyday products including plastic bottles and food containers and they could be easily absorbed by dietary intake. In recent years, considerable interest has been raised regarding the biological effects of EDCs, particularly Bisphenol A (BPA) and phthalates, on human pregnancy and fetal development. Several evidence obtained on in vitro and animal models as well as by epidemiologic and population studies strongly indicated that endocrine disruptors could negatively impact fetal and placental health by interfering with the embryonic developing epigenome, thus establishing disease paths into adulthood. Moreover, EDCs could cause and/or contribute to the onset of severe gestational conditions as Preeclampsia (PE), Fetal Growth Restriction (FGR) and gestational diabetes in pregnancy, as well as obesity, diabetes and cardiovascular complications in reproductive age. Therefore, despite contrasting data being present in the literature, endocrine disruptors must be considered as a therapeutic target. Future actions aimed at reducing or eliminating EDC exposure during the perinatal period are mandatory to guarantee pregnancy success and preserve fetal and adult health.

1375-P: Gestational Diabetes–Associated Changes in the Circulating Exosomes in Fetal Circulation Revealed a Potential Role of These Nanovesicles in Fetal Growth and Metabolism

The link between metabolic disorders during pregnancy and high risk of developing chronic noncommunicable diseases in later life has been well established. However, why the fetuses exposed to GDM have a higher risk of abnormal glucose homeostasis in later life, is still not fully understood. Exosomes have been well characterised in maternal circulation in normal and gestational diabetes pregnancies, however, the little is known about the profile of exosomes in fetal circulation. In this study, we isolated exosomes from cord-blood from women with normal tolerance glucose (NGT, n=35) and GDM (n=40) at the time of delivery. The miRNA content of exosomes was determined using a small RNA sequencing. The levels of circulating exosomes were significantly higher in GDM compared to NGT (p&amp;lt;0.05). Linear regression analysis identified a positive association between fetal length, maternal BMI and the levels of circulating exosomes in GDM, while no significant association was observed for NGT. Analysis of the miRNA within exosomes identified a range of miRNAs differentially expressed between NGT and GDM samples. Principal component analysis reveals a separation of the groups based on their miRNA profile. The miRNA contributing the most to this separation between normal and GDM conditions is miR-22-3p, thus this miRNA may be a key candidate for future GDM diagnostic strategies. Gene Ontology analysis shows that the miRNAs identified in exosomes regulate genes involved in insulin secretion in response to glucose stimulus, insulin receptor signalling, and glucose homeostasis. Thus, these data suggest that exosomes may alter gene expression and ultimately the cell phenotype by transferring specific miRNAs to target cells. Disclosure V. Ormazabal: None. S. Nair: None. D. Guanzon: None. F. Zuniga: None. D. McIntyre: Other Relationship; Self; Novo Nordisk A/S. M. Lappas: None. C. Salomon: None. Funding Diabetes Australia; Fondo Nacional de Desarrollo Científico y Tecnológico (1170809, 1190522)

Differences in fetal fractional limb volume changes in normal and gestational diabetic pregnancies: an exploratory observational study.

Fetal fractional limb volume has been proposed as a useful measure for quantifying fetal soft tissue development. The aim of this study was to investigate the growth of fractional arm volume (AVol) and fractional thigh volume (TVol) of fetuses with maternal gestational diabetes (GDM) compared with those of fetuses with normal glucose tolerance (NGT). We hypothesised fetal fractional limb volume would be larger in the GDM group than in the NGT group in late gestation. Exploratory observational study. Saitama Municipal Hospital. A total of 165 (125 NGT and 40 GDM) singleton Japanese pregnant women. AVol and TVol were assessed between 20 and 37weeks' gestation as cylindrical limb volumes based on 50% of the fetal humeral or femoral diaphysis length. Women were diagnosed as GDM based on the criteria of the Japan Society of Obstetrics and Gynecology. AVol and TVol were compared between women with NGT and those with GDM at each gestational age period (2-week intervals from 20 to 37weeks' gestation). Overall, 287 ultrasound scans were performed (NGT group, 205 scans; GDM group, 82 scans). There was no significant difference of AVol between the groups before 32weeks' gestation. AVol was significantly larger in the GDM group than in the NGT group after 32weeks' gestation (P<0.05). TVol was not statistically different between the groups across gestation. Detection of variations in fetal AVol may provide greater insight into understanding the origins of altered fetal body proportion in GDM. AVol, but not TVol, is significantly larger in fetuses with GDM than in those with NGT after 32weeks' gestation.

The value of mid-trimester fetal liver length measurement in prediction of gestational diabetes in Iraqi women

Background. Gestational diabetes (GD) is a hyperglycaemic state specific to pregnancy. A well-tolerated, quick and minimally-invasive method for the early detection of GD in pregnancy is lacking. Objective. To evaluate the correlation between the mid-trimester length of the fetal liver and GD. Methods. A prospective study was conducted at the National Endocrine and Diabetic Center, College of Medicine, Al-Mustansiriya University, Iraq and the Obstetric and Gynecological Department at Al-Yarmouk Teaching Hospital, Iraq, from September 2016 to September 2018. One-hundred-and-twenty singleton pregnant women at high risk for gestational diabetes mellitus (GDM) were recruited. An ultrasound scan was performed at 23 weeks’ gestation followed by a 75 g oral glucose tolerance test (OGTT) at 24 weeks. A correlation was assessed between the mid-trimester fetal liver length (FLL) measurement and the OGTT. Results. Mean (SD) FLL values were significantly higher among GDM patients v. healthy pregnant females respectively: 37.2 (3.4) v. 33.1 (2.7); p &lt;0.001. Univariate analysis showed that FLL in GDM group was 1.6 times the non-GDM group (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.31 - 1.96). There was no significant change after adjustment for parity and cumulative risk factors. Based on the above, FLL is an independent predictor for GDM (OR 1.6; 95% CI 1.30 - 1.96; p &lt;0.05). Conclusion. FLL measurement by ultrasound at 23 weeks’ gestation is a feasible alternative to OGGT for the early detection of GDM in high-risk patients

Metabolic Adaptations to Pregnancy in Healthy and Gestational Diabetic Pregnancies: The Pancreas - Placenta Axis.

Normal pregnancy is associated with increased insulin resistance as a metabolic adaptation to the nutritional demands of the placenta and fetus, and this is amplified in obese mothers. Insulin resistance is normally compensated for by an adaptive increase in pancreatic β-cell mass together with enhanced glucose-stimulated insulin release. Placentally-derived hormones and growth factors are central to the altered pancreatic morphology and function. A failure of β-cells to undergo adaptive change after the first trimester has been linked with gestational diabetes. In the pregnant mouse, an increase in β-cell replication contributes to a 2-3-fold increase in mass peaking in late gestation, depending on the proliferation of existing β-cells, the differentiation of resident progenitor β-cells, or islet cell transdifferentiation. Using mouse models and human studies placenta- and islet of Langerhans-derived molecules have been identified that are likely to contribute to the metabolic adaptations to pregnancy and whose physiology is altered in the obese, glucose-intolerant mother. Maternal obesity during pregnancy can create a pro-inflammatory environment that can disrupt the response of the β-cells to the endocrine signals of pregnancy and limit the adaptive changes in β-cell mass and function, resulting in an increased risk of gestational diabetes.

Cardiac Doppler in poorly controlled gestational diabetics and its link to markers of intra-uterine hypoxia and adverse outcome

The aim of the study was to investigate foetal cardiac function using the modified myocardial performance index (Mod-MPI) in poorly controlled gestational diabetics and its link with intrauterine markers for hypoxia and to an adverse outcome. In a prospective, cross sectional study, 44 consecutive women with severe or poorly controlled gestational diabetic pregnancies in their third trimester on insulin therapy were recruited and matched with 44 women with normal pregnancies which served as the control group. Using Doppler echocardiography the foetal Mod-MPI was calculated. The foetal Mod-MPI was significantly higher in the diabetic group compared to the controls indicating significant myocardial dysfunction. The Mod-MPI served as an excellent marker of adverse outcomes. Foetal myocardial function was significantly impaired in poorly controlled gestational diabetics and there was a significant link of Mod-MPI to intrauterine markers of hypoxia, as well as to an adverse outcome. Mod-MPI has the potential to improve foetal surveillance in gestational diabetes. IMPACT STATEMENT What is already known on this subject? Abnormal foetal cardiac function, as reflected in the modified myocardial performance index, has been reported to be significantly increased in foetuses of poorly controlled diabetics managed on insulin. What do the results of this study add? There is a significant link between abnormal foetal cardiac function to intrauterine markers of hypoxia, as well as to an adverse outcome; and that development of myocardial dysfunction could be one of the main mechanisms, inducing foetal compromise in poorly controlled gestational diabetes. What are the implications of these findings for clinical practice and/or further research? This study explores an interesting concept of foetal pathophysiology in gestational diabetes, namely the concept of “pseudo-hypoxia” in a foetus of a gestational diabetic mother, and this intrauterine “hypoxic stress” in turn leading to myocardial dysfunction. The Mod-MPI, a clinical marker for cardiac dysfunction, can therefore be used in the clinical setting to track a deteriorating metabolic state.

Pregnancy outcomes in women with anorexia nervosa.

Birth outcomes of women with anorexia nervosa are poorly understood. We hypothesized that hospitalization for anorexia nervosa before or during pregnancy is associated with an elevated risk of adverse maternal and infant birth outcomes. We performed a retrospective cohort study of 2,134,945 pregnancies in Quebec, Canada, from 1989 to 2016. The main exposure measure was anorexia nervosa requiring hospital treatment before or during pregnancy. Outcome measures included stillbirth, preterm birth, low birth weight, small-for-gestational age birth, preeclampsia, gestational diabetes, cesarean delivery, and other pregnancy disorders. We computed risk ratios and 95% confidence intervals (CI) for the association between anorexia nervosa and birth outcomes adjusted for maternal characteristics. Compared with no hospitalization, anorexia nervosa hospitalization was associated with 1.99 times the risk of stillbirth (95% CI 1.20-3.30), 1.32 times the risk of preterm birth (95% CI 1.13-1.55), 1.69 times the risk of low birth weight (95% CI 1.44-1.99), and 1.52 times the risk of small-for-gestational age birth (95% CI 1.35-1.72). The associations with low birth weight and small-for-gestational age birth were more prominent in women hospitalized for anorexia nervosa during pregnancy or within 2 years of delivery. Hospitalization for anorexia nervosa was associated with certain maternal outcomes, including precipitate labor, acute liver failure, and admission to an intensive care unit. Hospitalization for anorexia nervosa before or during pregnancy is associated with adverse infant and maternal outcomes. Infants are primarily at risk of stillbirth, preterm birth, low birth weight, and small-for-gestational age birth.

Placental changes in diabetic pregnancies and the contribution of hypertension

Objective To evaluate placental abnormalities in pregnancies affected by diabetes compared to unaffected pregnancies from a single academic center. Methods This is a retrospective cohort study of women with singleton gestations delivered at the University of Arkansas for Medical Sciences from 2007 to 2016. Pathologic examination of placentas from pregestational and gestational diabetic pregnancies were compared to placentas from patients without diabetes using 12 histologic elements. Maternal and neonatal outcomes were extracted from the medical record and compared between groups. Findings were adjusted for hypertensive disorders of pregnancy. Placental lesions were also correlated with diabetic control. Results Pathology reports of 590 placentas along with corresponding medical records were reviewed. The diabetic group (N = 484) consisted of 188 patients with pregestational diabetes and 296 patients with gestational diabetes. The nondiabetic group consisted of 106 patients. The diabetic group was older, had a higher average BMI, and more hypertensive disorders (p < .0001). Out of the 12 histologic elements investigated, accelerated villous maturation (aOR = 8.45, 95%CI (1.13–62.95)) and increased placental weight (aOR = 3.131, 95% CI (1.558–6.293)) were noted to be significantly increased in placentas from diabetic pregnancies after controlling for hypertension. Intervillous thrombi were not significantly increased in pregnancies affected by diabetes. Neonates of the diabetic group were more likely to be large for gestational age (p < .0001) and had a higher rate of preterm delivery (p < .0001). Conclusions Accelerated villous maturation was found to be more frequent in pregnancies complicated by pregestational diabetes, even after controlling for hypertension. In pregnancies complicated by gestational diabetes, the placental findings were not significant after controlling for hypertension. In contrast with prior studies, there was no increase in thrombotic lesions of the placenta in patients with diabetes.

Perinatal outcomes in pregnancies complicated by type 1 diabetes mellitus

The aim of this study was to explore the risk of perinatal outcomes in pre-gestational type 1 diabetes mellitus (T1DM) compared to gestational diabetes mellitus (GDM) and pregnancy without diabetes and to examine the association of glycemic level of third-trimester gestation with perinatal outcomes in T1DM. We included 69 pre-gestational T1DM, 1398 cases of GDM, and 1304 control pregnancies and collected data regarding demographics, obstetric, and perinatal outcomes from the hospital discharge database. Relative to the pregnancies without diabetes, women with T1DM encountered increasing risk of polyhydramnios, preterm delivery, and cesarean section. These adverse outcomes were also common in GDM, although with relatively lower adjusted ORs. The weights of babies delivered by women with T1DM were more intend to be large for gestational age, as well as to be less than 2.5 kg relative to those without diabetes. Poorly controlled hemoglobin A1c in late pregnancy was significantly associated with an increased risk of preterm birth in T1DM (adjusted odds ratio 2.01, 95%confidence interval 1.1–3.6). Women with T1DM have considerably increased risks of adverse perinatal outcomes, which appear more prevalent than the perinatal outcomes in women with GDM. Thus, a specific routine is required for pregnancy in T1DM to improve the glycemic control and obstetric care.

First-trimester fasting glycemia as a predictor of gestational diabetes (GDM) and adverse pregnancy outcomes.

Studies to prevent gestational diabetes (GDM) have shown the best results when lifestyle measures have been applied early in pregnancy. We aimed to investigate whether first-trimester fasting plasma glucose (FPG) could predict GDM risk and adverse pregnancy outcomes. A retrospective analysis of prospectively collected data from singleton pregnancies who were attended at our hospital between 2008 and 2018 (n = 27,198) was performed. We included patients with a recorded first-trimester FPG and complete pregnancy data (n = 6845). Patients under 18, with pregestational diabetes or reproductive techniques, were excluded. First-trimester FPG was evaluated as a continuous variable and divided into quartiles. GDM was diagnosed by NDDG criteria. The relationship between first- and second-trimester glucose > 92mg/dL was also investigated. The relationship between FPG and pregnancy outcomes was assessed in 6150 patients who did not have GDM. Maternal age was 34.2 ± 3.9years, BMI 23.1 ± 3.7kg/m2 and mean FPG 83.0 ± 7.3mg/dL. Glucose quartiles were: ≤ 78, 79-83, 84-87 and ≥ 88mg/dL. First-trimester FPG predicted the risk of GDM (7%, 8%, 10.2% and 16% in each quartile, p < 0.001) and the risk of second-trimester glucose > 92mg/dL (2.6%, 3.8%, 6.3% and 11.4% in each quartile, p < 0.001). FPG was significantly associated with LGA (8.2%, 9.3%, 10% and 11.7% in each quartile, p = 0.011) but not with other obstetrical outcomes. In a multivariate analysis including age, BMI, tobacco use, number of pregnancies and weight gained during pregnancy, first-trimester FPG was an independent predictor of LGA. First-trimester FPG is an early marker of GDM and LGA.