High amniotic fluid erythropoietin levels are associated with an increased frequency of fetal and neonatal morbidity in type 1 diabetic pregnancies

Hepatic and Pancreatic Cellular Response to Early Life Nutritional Mismatch

To determine the basis for perinatal nutritional mismatch causing metabolic dysfunction-associated steatotic liver disease and diabetes mellitus, we examined adult phenotype, hepatic transcriptome, and pancreatic β-islet function. In prenatal caloric-restricted rats with intrauterine growth restriction (IUGR) and postnatal exposure to high fat with fructose (HFhf) or high carbohydrate, we investigated male and female IUGR-HFhf and IUGR-high carbohydrate, vs HFhf and control offspring. Males more than females displayed adiposity, glucose intolerance, insulin resistance, hyperlipidemia, and hepatomegaly with hepatic steatosis. Male hepatic triglyceride synthesis, de novo lipogenesis genes increased, while female lipolysis, β-oxidation, fatty acid efflux, and FGF21 genes increased. IUGR-HFhf males demonstrated reduced β-islet insulin and humanin, and type 1 diabetes mellitus human amniotic fluid increased humanin. Humanin suppression disabled glucose stimulated insulin, ATP production, with apoptotic diminished β-islet viability. Humanin and FGF21 may reverse perinatal nutritional mismatched phenotype by restoring functional β islets and preventing metabolic dysfunction-associated steatotic liver disease and diabetes mellitus.

The effect of fetal hypoxia on myeloperoxidase levels in cord blood: a prospective study

BACKGROUND

We aimed to compare myeloperoxidase (MPO) levels in cord blood samples of mothers with and without perinatal hypoxia, since fetal hypoxia results in decreased pH, base excess, and an increase in pCO2 and lactate levels.

METHODS

We enrolled 42 pregnant women to this cross-sectional analytic study if they had met following criteria: uneventful gestational follow-ups, no known chronic or pregnancy-associated diseases, a BMI of <29.9, a singleton pregnancy, those with pregnancy over 34 weeks. The exclusion criteria for the study and control groups were as follows: presence of multiple pregnancies, fetal abnormality, any disease diagnosed before or during antenatal follow-up e.g., diabetes, hypertension, thyroid dysfunction, uncontrolled endocrine disease or abnormal kidney function, autoimmune disease, chronic inflammatory diseases, IUGR, preeclampsia), maternal age below 18 or above 35, intrauterine exitus, pregnancy with assisted reproductive technique, alcohol or smoking addiction, and any chronic drug use. The subjects were 1:1 randomized to either hypoxic newborns (N.=21) and those in the control group (N.=21) and their myeloperoxidase levels were measured from cord blood samples. Results were expressed as U/L. Patient data regarding age, gestation, parity, birth weight, birth length, APGAR scores, and neonatal complications were collected. All the women signed written informed consent forms and accepted verbal consent before being included in the study.

RESULTS

The mean age of the study population was 26.9±5.3 years. The mean BMI was 28.3±3.5 kg/m2. For the hypoxic group, 21 newborns with cord blood below 7.25 were included in the study group. The bloods with pH above 7.25 formed the control group. Mean pH and five (5) minute APGAR scores were found to be significantly lower in the study group, while base excess (BE) was found to be significantly higher. In this study, we compared the MPO levels of hypoxic newborns and those in the control group, and we did not find a significant difference between the two groups (P=0.147). Pearson Correlation Analysis is at -0.566 with P value (0.008) showing significant negative correlation between MPO and pH in the study group.

CONCLUSIONS

We found that MPO values are negatively correlated with cord blood pH among newborns diagnosed with fetal hypoxia.

The impact of maternal diabetes on the future health and neurodevelopment of the offspring: a review of the evidence

Maternal health during gestational period is undoubtedly critical in shaping optimal fetal development and future health of the offspring. Gestational diabetes mellitus is a metabolic disorder occurring in pregnancy with an alarming increasing incidence worldwide during recent years. Over the years, there is a growing body of evidence that uncontrolled maternal hyperglycaemia during pregnancy can potentially have detrimental effect on the neurodevelopment of the offspring. Both human and animal data have linked maternal diabetes with motor and cognitive impairment, as well as autism spectrum disorders, attention deficit hyperactivity disorder, learning abilities and psychiatric disorders. This review presents the available data from current literature investigating the relationship between maternal diabetes and offspring neurodevelopmental impairment. Moreover, possible mechanisms accounting for the detrimental effects of maternal diabetes on fetal brain like fetal neuroinflammation, iron deficiency, epigenetic alterations, disordered lipid metabolism and structural brain abnormalities are also highlighted. On the basis of the evidence demonstrated in the literature, it is mandatory that hyperglycaemia during pregnancy will be optimally controlled and the impact of maternal diabetes on offspring neurodevelopment will be more thoroughly investigated.

Risk of Stillbirth in Pregnancies Complicated by Diabetes, Stratified by Fetal Growth

OBJECTIVE

To compare stillbirth rates per week of expectant management stratified by birth weight in pregnancies complicated by gestational diabetes mellitus (GDM) or pregestational diabetes mellitus.

METHODS

A national population-based retrospective cohort study of singleton, nonanomalous pregnancies complicated by pregestational diabetes or GDM was performed using national birth and death certificate data from 2014 to 2017. Stillbirth rates per 10,000 patients (stillbirth incidence at gestational age week/ongoing pregnancies-[0.5×live births at gestational age week]) were determined for each week of pregnancy from 34 to 39 completed weeks of gestation. Pregnancies were stratified by birth weight, categorized as having small-for-gestational-age (SGA), appropriate-for-gestational-age (AGA), or large-for-gestational-age (LGA) fetuses, assigned by sex-based Fenton criteria. Relative risk (RR) and 95% CI for stillbirth were calculated for each gestational age week compared with the GDM-related AGA group.

RESULTS

We included 834,631 pregnancies complicated by either GDM (86.9%) or pregestational diabetes (13.1%) in the analysis, with a total of 3,033 stillbirths. Stillbirth rates increased with advancing gestational age for pregnancies complicated by both GDM and pregestational diabetes regardless of birth weight. Compared with pregnancies with AGA fetuses, those with both SGA and LGA fetuses were significantly associated with an increased risk of stillbirth at all gestational ages. Ongoing pregnancies at 37 weeks of gestation complicated by pregestational diabetes with LGA or SGA fetuses had respective stillbirth rates of 64.9 and 40.1 per 10,000 patients. Pregnancies complicated by pregestational diabetes had an RR of stillbirth of 21.8 (95% CI 17.4-27.2) for LGA fetuses and 13.5 (95% CI 8.5-21.2) for SGA fetuses compared with GDM-related AGA at 37 weeks of gestation. The greatest absolute risk of stillbirth was in pregnancies complicated by pregestational diabetes at 39 weeks of gestation with LGA fetuses (97/10,000).

CONCLUSION

Pregnancies complicated by both GDM and pregestational diabetes affected by pathologic fetal growth have an increased risk of stillbirth with advancing gestational age. This risk is significantly higher with pregestational diabetes, especially pregestational diabetes with LGA fetuses.

Increased variability of fetal heart rate during labour: a review of preclinical and clinical studies

Increased fetal heart rate variability (FHRV) in intrapartum cardiotocographic recording has been variably defined and poorly understood, limiting its clinical utility. Both preclinical (animal) and clinical (human) evidence support that increased FHRV is observed in the early stage of intrapartum fetal hypoxaemia but can also be observed in a subset of fetuses during the preterminal stage of repeated hypoxaemia. This review of available evidence provides data and expert opinion on the pathophysiology of increased FHRV, its clinical significance and a stepwise approach regarding the management of this pattern, and propose recommendations for standardisation of related terminology.

Stillbirth in women with diabetes: a retrospective analysis of fetal autopsy reports

INTRODUCTION

Diabetes in pregnancy is associated with an increased rate of stillbirth. There are a wide variety of factors that have been implicated including placental insufficiency, hypoxia, hyperinsulinemia and impaired cardiac function. Furthermore, there is evidence that diabetic pregnancies have an increased rate of fetal cardiomyopathy as compared to non-diabetic pregnancies. Prior studies have indicated that this association can also be an etiology for diabetic stillbirth. The purpose of this study was to determine if diabetic pregnancies have an increased risk of fetal cardiomyopathy identified on fetal autopsy as compared to non-diabetic women with a stillbirth in a cohort of pregnancies that had evaluation with a fetal autopsy.

MATERIALS AND METHODS

Retrospective cohort study of women with a stillbirth who consented to fetal autopsy at an academic medical center from 2011 to 2017. Stillbirth was defined as an intrauterine fetal demise at ≥20 weeks' gestation. Women with diabetes defined as pre-gestational diabetes type 1, pre-gestational diabetes type 2, and gestational diabetes were compared to women without diabetes. Primary outcome was fetal cardiomyopathy. Other etiologies for stillbirth were also evaluated and classified according to the Stillbirth Collaborative Research Network (SCRN) initial causes of fetal death. Fisher exact test, χ2 test, and Mann Whitney U tests were performed as appropriate, with p < .05 considered significant. Generalized linear models were performed for fetal organ weights controlling for gestational age of delivery, maternal chronic hypertension, delivery body mass index, and birthweight.

RESULTS

A total of 78 women elected to have fetal autopsy examinations during the study period. Of these, 75 had complete information available for review. A total of 60 women did not have diabetes and 15 women had diabetes. Of pregnancies complicated by diabetes, 11 had insulin dependent diabetes and 4 had non-insulin dependent diabetes. Fetal cardiomyopathy was diagnosed on autopsy for 7 (46.7%) of pregnancies with diabetes and 2 (3.3% of pregnancies without diabetes (RR 14.00 [95% CI 3.23-60.65], p < .001). These associations were still significant even when analyzing only those pregnancies without fetal congenital heart disease (7 [46.7%] diabetic pregnancies with cardiomyopathy versus 1 [2.0%] nondiabetic pregnancy with cardiomyopathy, RR 23.80 [95% CI 3.17-178.46], p < .001). There was no difference between diabetic and non-diabetic pregnancies in regards to other causes for stillbirth. Stillbirths in pregnancies with diabetes also had larger fetal heart, liver, and adrenal weights on fetal autopsy.

CONCLUSION

Women with diabetes have 14 times the risk of fetal cardiomyopathy identified at fetal autopsy as compared to women without diabetes. As the prediction and prevention of diabetic stillbirth is limited, information on potential causes of stillbirth may help future research identify those pregnancies at the greatest risk for adverse outcome.

Type 1 Diabetes in Pregnancy: A Review of Complications and Management

BACKGROUND

Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent's declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes.

OBJECTIVES

This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care.

METHODS

A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised.

RESULTS

One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised.

CONCLUSION

This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.

Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review

In spite of the huge progress in the treatment of diabetes mellitus, we are still in the situation that both pregestational (PGDM) and gestational diabetes (GDM) impose an additional risk to the embryo, fetus, and course of pregnancy. PGDM may increase the rate of congenital malformations, especially cardiac, nervous system, musculoskeletal system, and limbs. PGDM may interfere with fetal growth, often causing macrosomia, but in the presence of severe maternal complications, especially nephropathy, it may inhibit fetal growth. PGDM may also induce a variety of perinatal complications such as stillbirth and perinatal death, cardiomyopathy, respiratory morbidity, and perinatal asphyxia. GDM that generally develops in the second half of pregnancy induces similar but generally less severe complications. Their severity is higher with earlier onset of GDM and inversely correlated with the degree of glycemic control. Early initiation of GDM might even cause some increase in the rate of congenital malformations. Both PGDM and GDM may cause various motor and behavioral neurodevelopmental problems, including an increased incidence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Most complications are reduced in incidence and severity with the improvement in diabetic control. Mechanisms of diabetic-induced damage in pregnancy are related to maternal and fetal hyperglycemia, enhanced oxidative stress, epigenetic changes, and other, less defined, pathogenic mechanisms.

Late-Pregnancy Fetal Hypoxia Is Associated With Altered Glucose Metabolism and Adiposity in Young Adult Offspring of Women With Type 1 Diabetes

OBJECTIVE

To investigate associations between exposure to fetal hypoxia and indicators of metabolic health in young adult offspring of women with type 1 diabetes (OT1D).

METHODS

156 OT1D born between 7/1995 and 12/2000 at Helsinki University Hospital, Finland, were invited for follow-up between 3/2019 and 11/2019. A control group of 442 adults born from non-diabetic pregnancies, matched for date and place of birth, was obtained from the Finnish Medical Birth Register. In total, 58 OT1D and 86 controls agreed to participate. All OT1D had amniotic fluid (AF) sampled for erythropoietin (EPO) measurement within two days before delivery in order to diagnose fetal hypoxia. In total, 29 OTID had an AF EPO concentration <14.0 mU/l, defined as normal, and were categorized into the low EPO (L-EPO) group. The remaining 29 OT1D had AF EPO ≥14.0 mU/ml, defined as fetal hypoxia, and were categorized into the high EPO (H-EPO) group. At the age of 18-23 years, participants underwent a 2-h 75g oral glucose tolerance test (OGTT) in addition to height, weight, waist circumference, body composition, blood pressure, HbA_1c, cholesterol, triglyceride, high-sensitivity CRP and leisure-time physical activity measurements.

RESULTS

Two OT1D were diagnosed with diabetes and excluded from further analyses. At young adult age, OT1D in the H-EPO group had a higher BMI than those in the L-EPO group. In addition, among female participants, waist circumference and body fat percentage were highest in the H-EPO group. In the OGTTs, the mean (SD) 2-h post-load plasma glucose (mmol/L) was higher in the H-EPO [6.50 (2.11)] than in the L-EPO [5.21 (1.10)] or control [5.67 (1.48)] offspring (p=0.009). AF EPO concentrations correlated positively with 2-h post-load plasma glucose [r=0.35 (95% CI: 0.07 to 0.62)] and serum insulin [r=0.44 (95% CI: 0.14 to 0.69)] concentrations, even after adjusting for maternal BMI, birth weight z-score, gestational age at birth and adult BMI. Control, L-EPO and H-EPO groups did not differ with regards to other assessed parameters.

CONCLUSIONS

High AF EPO concentrations in late pregnancy, indicating fetal hypoxia, are associated with increased adiposity and elevated post-load glucose and insulin concentrations in young adult OT1D.

Could the E/A ratio be included in the cardiological evaluation of the offspring of diabetic mothers? A case-control study in South Sardinia

INTRODUCTION

Diabetes mellitus (DM) is a chronic disease widespread in the world. Sardinia represents, together with Finland, the region with the highest incidence of type 1 DM (DM1), as well as a high prevalence of gestational DM (GDM). Despite the improvement in obstetric surveillance, perinatal and long-term adverse outcomes are still frequent in the offspring of diabetic mothers. During gestations complicated by DM, fetal heart is one of the most affected organ potentially undergoing structural heart defects or several degrees of fetal myocardium hypertrophy and impaired cardiac function.

AIM

The aim of our study was to evaluate, through echocardiographic examination, cardiac features and performance in a South Sardinian population of newborns of diabetic mothers comparing them to a group of control subjects.

CONCLUSIONS

In our sample, the E/A ratio resulted a significant marker of early diastolic dysfunction in asymptomatic neonates born by diabetic mothers, even if such result should be confirmed on larger samples.

Predictors of emergency cesarean section in women with preexisting diabetes

OBJECTIVE

Preexisting diabetes in pregnancy is associated with a high risk of emergency cesarean section (CS), which is associated with increased risk of maternal and neonatal complications. Thus, the aim of this study was to identify possible predictors of emergency CS in women with preexisting diabetes.

STUDY DESIGN

This is a secondary analysis of a prospective observational study of 204 women with preexisting diabetes (118 with type 1 diabetes and 86 with type 2) with singleton pregnancies recruited at Rigshospitalet, Copenhagen, Denmark from August 2015 to February 2018. Mode of delivery (trial of labor or planned CS) was individually planned in late pregnancy based on clinical variables reflecting maternal and fetal health including glycemic control and ultrasonically estimated fetal weight. Univariate and multivariable analyses were performed to identify possible predictors of in labor emergency CS.

RESULTS

Trial of labor was planned in 79 % (n = 162) of the women of whom 65 % (n = 105) were delivered vaginally and 35 % (n = 57) by an emergency CS, while the remaining 21 % (n = 42) were offered a planned CS. Nulliparity (adjusted odds ratio (aOR) 5.6 95 % CI 1.7-18.8), presence of a hypertensive disorder (aOR 2.8, 95 % CI 1.2-6.7) and previous CS (aOR 6.7, 95 % CI 1.5-28.9) were independently associated with an emergency CS. Maternal height was inversely associated with emergency CS (aOR 0.6 95 %, CI 0.5-0.9 per 5 cm decrease). Neither maternal HbA1c nor ultrasonically estimated fetal size in late pregnancy were associated with emergency CS. Women scheduled for a planned CS were characterized by poorer glycemic control and higher estimated fetal size than those offered a trial of labor.

CONCLUSION

Nulliparity, presence of a hypertensive disorder, previous CS and shorter maternal height were predictors of emergency CS in women with a planned trial of labor, whereas this not was the case for late pregnancy maternal Hba1c or fetal size estimated by ultrasound.

Saltatory Pattern of Fetal Heart Rate during Labor Is a Sign of Fetal Hypoxia

BACKGROUND

While late decelerations and major bradycardia episodes in intrapartum cardiotocography (CTG) recordings are known to correlate with fetal distress,little is known of the importance of the saltatory pattern.

OBJECTIVE

The aim of the study was to examine whether the fetal heart rate (FHR) saltatory pattern in intrapartum CTG registration is associated with fetal hypoxia during the last 2 h of labor.

DESIGN

The study group consisted of CTG recordings from 194 births with a 1-min Apgar score of <8 (birth weight 3,614 ± 512 g; gestational age 40.6 ± 0.7 weeks). The comparison group included 51 infants with a 1-min Apgar score of ≥9 (birth weight 3,624 ± 400 g; gestational age 40.5 ± 0.4 weeks). FHR patterns were evaluated blindly by 2 experienced perinatologists. The pH, base excess (BE), pO2 and erythropoietin (EPO) were measured from umbilical cord blood at birth as outcome variables.

RESULTS

Saltatory pattern occurred in 31/194 (16.0%) of the study group and in 1/51 (2.0%) of the comparison group. Umbilical artery pH, BE, and pO2 were lower and umbilical vein (UV) EPO higher in the study group than in the comparison group. In the study group, UV EPO level was significantly higher in cases where the saltatory pattern was present (median 241 mU/mL, 95% CI 39.4-16,484), than in those without the saltatory pattern (median 39.4 mU/mL, 95% CI 11-282) (p < 0.0001, for difference). In the study group, no differences in EPO levels were found in cases where episodes of bradycardia, tachycardia, reduced variability, or uterine tachysystole were present or absent. In the study group, saltatory pattern preceded late decelerations in 82.8%.

CONCLUSION

Saltatory pattern in an intrapartum FHR recording is an early sign of fetal hypoxia.

Pregnancy-induced hypertension is an independent risk factor for meconium aspiration syndrome: A retrospective population based cohort study

OBJECTIVE

Meconium aspiration syndrome (MAS), possibly resulting from fetal hypoxia, is a respiratory distress disorder in the infant. Pregnancy-induced hypertension (PIH) can cause placental dysfunction and lead to fetal hypoxia, which may induce the development of MAS. Therefore, the aim of this study was to determine the association between PIH and MAS and to identify the predictive risk factors.

MATERIALS AND METHODS

This was a retrospective cohort study. We selected patients with newly diagnosed PIH and a matched cohort group from the Taiwan National Health Insurance Research Database (NHIRD), from January 1, 2000 till December 31, 2013. For each patient in the PIH cohort, 4 subjects without PIH, matched for age and year of delivery, were randomly selected as the comparison cohort. The incidence of meconium aspiration syndrome was assessed in both groups.

RESULTS

Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. Patients who experienced PIH had a higher incidence of MAS than did those without PIH. According to a multivariate analysis, PIH (odds ratio [OR] = 1.70, 95% confidence interval [CI] = 1.49-1.93, p < 0.0001) was independently associated with increased risk of MAS. Additionally, age ≥30 years (OR = 1.26, 95% CI = 1.12-1.42, p = 0.0001), nulliparity (OR = 1.13, 95% CI = 1.01-1.27, p = 0.0367) and patients with diabetes mellitus (OR = 3.09, 95% CI = 1.35-7.09, p = 0.0078) were also independent risk factors of MAS.

CONCLUSION

Patients with PIH obtained higher subsequent risk for the development of MAS than those without PIH. Besides, age ≥30 years, nulliparity and patients with diabetes mellitus are the independent risk factors of developing MAS.

Fetal chronic hypoxia and oxidative stress in diabetic pregnancy. Could fetal erythropoietin improve offspring outcomes?

Oxidative stress is responsible for microvascular complications (hypertension, nephropathy, retinopathy, peripheral neuropathy) of diabetes, which during pregnancy increase both maternal and fetal complications. Chronic hypoxia and hyperglycemia result in increased oxidative stress and decreased antioxidant enzyme activity. However, oxidative stress induces also anti-oxidative reactions both in pregnant diabetes patients and in their fetuses. Not all type 1 diabetes patients with long-lasting disease develop microvascular complications, which suggests that some of these patients have protective mechanisms against these complications. Fetal erythropoietin (EPO) is the main regulator of red cell production in the mother and in the fetus, but it has also protective effects in various maternal and fetal tissues. This dual effect of EPO is based on EPO receptor (EPO-R) isoforms, which differ structurally and functionally from the hematopoietic EPO-R isoform. The tissue protective effects of EPO are based on its anti-apoptotic, anti-oxidative, anti-inflammatory, cell proliferative and angiogenic properties. Recent experimental and clinical studies have shown that EPO has also positive metabolic effects on hyperglycemia and diabetes, although these have not yet been fully delineated. Whether the tissue protective and metabolic effects of EPO could have clinical benefits, are important topics for future research in diabetic pregnancies.

Mechanisms of death in structurally normal stillbirths

Objectives To investigate mechanisms of in utero death in normally formed fetuses by measuring amniotic fluid (AF) biomarkers for hypoxia (erythropoietin [EPO]), myocardial damage (cardiac troponin I [cTnI]) and brain injury (glial fibrillary acidic protein [GFAP]), correlated with risk factors for fetal death and placental histopathology. Methods This retrospective, observational cohort study included intrauterine deaths with transabdominal amniocentesis prior to induction of labor. Women with a normal pregnancy and an indicated amniocentesis at term were randomly selected as controls. AF was assayed for EPO, cTnI and GFAP using commercial immunoassays. Placental histopathology was reviewed, and CD15-immunohistochemistry was used. Analyte concentrations >90th centile for controls were considered "raised". Raised AF EPO, AF cTnI and AF GFAP concentrations were considered evidence of hypoxia, myocardial and brain injury, respectively. Results There were 60 cases and 60 controls. Hypoxia was present in 88% (53/60), myocardial damage in 70% (42/60) and brain injury in 45% (27/60) of fetal deaths. Hypoxic fetuses had evidence of myocardial injury, brain injury or both in 77% (41/53), 49% (26/53) and 13% (7/53) of cases, respectively. Histopathological evidence for placental dysfunction was found in 74% (43/58) of these cases. Conclusion Hypoxia, secondary to placental dysfunction, was found to be the mechanism of death in the majority of fetal deaths among structurally normal fetuses. Ninety-one percent of hypoxic fetal deaths sustained brain, myocardial or both brain and myocardial injuries in utero. Hypoxic myocardial injury was an attributable mechanism of death in 70% of the cases. Non-hypoxic cases may be caused by cardiac arrhythmia secondary to a cardiac conduction defect.

Robust increases in erythropoietin production by the hypoxic fetus is a response to protect the brain and other vital organs

Fetal erythropoietin (EPO), in addition to regulating erythropoiesis, has also tissue-protective properties based on its anti-inflammatory, anti-apoptotic, antioxidant, and neurotrophic effects. Notably, EPO concentrations needed for tissue protection are 100-1000 times higher than concentrations needed for regulating erythropoiesis. This dual effect of EPO is based on EPO-receptor (EPO-R) isoforms, which differ structurally and functionally. We hypothesize in this Integrated Mechanism Review that during severe fetal hypoxia the observed, but poorly understood, marked increases of fetal plasma EPO concentrations occur to protect the brain, heart, and other vital fetal organs. We further hypothesize that the concurrent marked increases of EPO in the amniotic fluid during fetal hypoxia, occur to protect newborn infants from necrotizing enterocolitis. This review presents experimental and clinical evidence in support of these hypotheses and points out unknown or poorly understood functions of EPO in the fetus. If these novel hypotheses are correct, the importance of fetal EPO as an antenatal hypoxia biomarker will become apparent. It will also likely point the way to important diagnostic and therapeutic fetal and neonatal interventions.

Peripartum fetal distress in diabetic women: a retrospective case-cohort study

Background

Major concerns of pregnancies complicated by diabetes mellitus are an increased risk of adverse perinatal outcome. The objective of this study was to analyse the rate of fetal distress during labor in women with type 1, type 2 and gestational diabetes compared to control women.

Methods

A retrospective case-cohort study was conducted at the VU University Medical Center, Amsterdam; a tertiary care hospital. 117 women with type 1 diabetes, 59 women with type 2 diabetes, 303 women with gestational diabetes and 15,260 control women were included, who delivered between March 2004 and February 2014. Linear and logistic regression analyses were used to compare maternal and pregnancy characteristics. Risk of fetal distress and perinatal asphyxia was assessed by multiple regression analyses, adjusted for confounding factors as age, smoking, parity, previous cesarean section, hypertensive disorder, pre-eclampsia, prematurity, induction of labor and macrosomia. Main outcome measure was fetal distress, defined either as clinical indication for instrumental or cesarean delivery; or low umbilical artery pH (UA pH), or admission to neonatal unit (NU).

Results

The indication for instrumental or cesarean delivery in women with type 1 and type 2 diabetes mellitus was more frequently based on fetal distress as compared to controls (adjusted OR 2.76 CI 1.74–4.40 and adjusted OR 2.31 CI 1.19–4.51, respectively). In comparison with the control group, infants of women with type 1 diabetes had an increased risk of UA pH < 7.20 (adjusted OR 1.88 CI 1.23–2.87) or UA pH < 7.10 (adjusted OR 3.35 CI 1.79–6.27). Also, infants of women with type 1 diabetes were at increased risk for admission to NU as compared to infants of control women (OR 8.07 CI 4.75–13.70).

Conclusions

Women with type 1 and type 2 diabetes are at increased risk of fetal distress during labor as compared to controls.

Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study

AIMS/HYPOTHESIS

The aim of this prospective nationwide study was to examine antenatal pregnancy care and pregnancy outcomes in women with type 1 and type 2 diabetes, and to describe changes since 2002/2003.

METHODS

This national population-based cohort included 3036 pregnant women with diabetes from 155 maternity clinics in England and Wales who delivered during 2015. The main outcome measures were maternal glycaemic control, preterm delivery (before 37 weeks), infant large for gestational age (LGA), and rates of congenital anomaly, stillbirth and neonatal death.

RESULTS

Of 3036 women, 1563 (51%) had type 1, 1386 (46%) had type 2 and 87 (3%) had other types of diabetes. The percentage of women achieving HbA1c < 6.5% (48 mmol/mol) in early pregnancy varied greatly between clinics (median [interquartile range] 14.3% [7.7-22.2] for type 1, 37.0% [27.3-46.2] for type 2). The number of infants born preterm (21.7% vs 39.7%) and LGA (23.9% vs 46.4%) were lower for women with type 2 compared with type 1 diabetes (both p < 0.001). The prevalence rates for congenital anomaly (46.2/1000 births for type 1, 34.6/1000 births for type 2) and neonatal death (8.1/1000 births for type 1, 11.4/1000 births for type 2) were unchanged since 2002/2003. Stillbirth rates are almost 2.5 times lower than in 2002/2003 (10.7 vs 25.8/1000 births for type 1, p = 0.0012; 10.5 vs 29.2/1000 births for type 2, p = 0.0091).

CONCLUSIONS/INTERPRETATION

Stillbirth rates among women with type 1 and type 2 diabetes have decreased since 2002/2003. Rates of preterm delivery and LGA infants are lower in women with type 2 compared with type 1 diabetes. In women with type 1 diabetes, suboptimal glucose control and high rates of perinatal morbidity persist with substantial variations between clinics.

DATA AVAILABILITY

Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from http://content.digital.nhs.uk/npid .

Fetal thymus size in pregnant women with diabetic diseases

AIM

The aim of our study was to assess fetal thymus size in diabetic pregnancies compared with normal pregnancies.

METHODS

Sonographic fetal thymus size was retrospectively assessed in 161 pregnancies with maternal diabetes and in 161 uncomplicated pregnancies matched by gestational age. The anteroposterior thymic and the intrathoracic mediastinal diameter were measured and the quotient was calculated [thymic-thoracic ratio (TT-ratio)]. In addition, we defined the quotient of the anteroposterior thymic diameter and the head circumference as thymus-head ratio (TH-ratio). The maternal diabetes cases were subdivided into three groups: (1) diet-controlled gestational diabetes, (2) insulin-dependent gestational diabetes and (3) preexisting maternal diabetes.

RESULTS

TT-ratio and TH-ratio were smaller in pregnancies with maternal diabetes (P<0.001 and P<0.001, respectively). In all three maternal diabetes subgroups, the TT-ratio and the TH-ratio were lower compared with the control group (P<0.001 for each group).

CONCLUSIONS

Reduced fetal thymus size seems to be associated with diabetic pregnancy. We introduce fetal thymus size as a new potential prognostic parameter for maternal diabetes.

Quantitative assessment of the effect of pre-gestational diabetes and risk of adverse maternal, perinatal and neonatal outcomes

Pregnancies complicated by pre-gestational diabetes (PGD) are associated with a higher rate of adverse outcomes, including an increased rage of preterm delivery, pregnancy-induced hypertension, pre-eclampsia, caesarean section, perinatal mortality, stillbirth, shoulder dystocia, macrosomia, small for gestational age, large for gestational age, low birth weight, neonatal hypoglycemia, neonatal death, low Apgar score, NICU admission, jaundice and respiratory distress. In the past two decades, numerous reports have been published regarding associations between PGD and risk of adverse outcomes. However, study results are inconsistent. To provide a synopsis of the current understanding of PGD for risk of adverse pregnancy outcomes, a random-effects meta-analysis over 40 million subjects from 100 studies was performed to calculate the pooled ORs. Potential sources of heterogeneity were systematically explored by multiple strata analyses and meta-regression. Overall, PGD were significantly associated with increased risk of preterm delivery (OR=3.48), LGA (OR=3.90), perinatal mortality (OR=3.39), stillbirth (OR=3.52), pre-eclampsia (OR=3.48), caesarean section (OR=3.52), NICU admission (OR=3.92), and neonatal hypoglycemia (OR=26.62). Significant results were also observed for 7 adverse outcomes with OR range from 1.54 to 2.82, while no association was found for SGA and respiratory distress after Bonferroni correction. We found that women with T1DM had higher risks for most of adverse pregnancy outcomes compared with women with T2DM. When stratified by study design, sample size, type of diabetes, geographic region, and study quality, significant associations remains. Our findings demonstrated that PGD is a strong risk-conferring factor for adverse maternal, perinatal and neonatal outcomes.

IGF-1 is associated with fetal growth and preterm delivery in type 1 diabetic pregnancy

AIM

No data on IGF-1 and either preterm or preeclampsia have been reported so far in diabetic pregnancies. We evaluated consecutive measurements of IGF-1 for preeclampsia, preterm delivery and birth weight in type 1 diabetic pregnancy.

SETTING

In an outpatient university clinic, 97 pregnant women were consecutively recruited for evaluation of indicators for deterioration of diabetes status and adverse perinatal outcome. At every visit, a blood sample for measurement of IGF-1 was drawn.

RESULTS

IGF-1 levels from week 14 to 32 was consistently lower in women who delivered preterm compared with women whose delivered after gestational week 36; the increase in 2nd and 3rd trimester was steeper in those delivering at term than in women delivering preterm (p = 0.032). IGF-1 in preeclampsia did not show the same relation in diabetic women (p = 0.74). The lowest tertile of birth weight ratio (0.8-1.2) was associated with lower IGF-1 from week 14 to 32 (p = 0.047, adjusted for preterm delivery and preeclampsia).

CONCLUSION

We found low IGF-1 levels associated with preterm delivery and low birth weight.

Regeneration in the nervous system with erythropoietin

Globally, greater than 30 million individuals are afflicted with disorders of the nervous system accompanied by tens of thousands of new cases annually with limited, if any, treatment options. Erythropoietin (EPO) offers an exciting and novel therapeutic strategy to address both acute and chronic neurodegenerative disorders. EPO governs a number of critical protective and regenerative mechanisms that can impact apoptotic and autophagic programmed cell death pathways through protein kinase B (Akt), sirtuins, mammalian forkhead transcription factors, and wingless signaling. Translation of the cytoprotective pathways of EPO into clinically effective treatments for some neurodegenerative disorders has been promising, but additional work is necessary. In particular, development of new treatments with erythropoiesis-stimulating agents such as EPO brings several important challenges that involve detrimental vascular outcomes and tumorigenesis. Future work that can effectively and safely harness the complexity of the signaling pathways of EPO will be vital for the fruitful treatment of disorders of the nervous system.

Proteomic-driven biomarker discovery in gestational diabetes mellitus: a review

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy and it affects 18% of pregnant women worldwide. GDM is considered a high-risk state which may lead to type II diabetes which is associated with an increase in a number of interrelated adverse perinatal outcomes. Given the fact that the progress of a successful pregnancy is dependent on the intricate communication between several biological molecules, identification of the proteomic profile perturbations in women with GDM is expected to help in understanding the disease pathogenesis and also discovery of clinical biomarker(s). In recent years, both gel-free and gel-based proteomics have been extensively investigated for improving maternal and child health. Although there are several reports integrating various aspects of proteomics in pregnancy related diseases such as preeclampsia, extensive Pubmed search shows no review so far on the application of proteomics in gestational diabetes. In this review, we focus on various high-throughput proteomic technologies for the identification of unique biosignatures and biomarkers responsible for the early prediction of GDM. Further, different analytical strategies and biological samples involved in proteomic analysis of this pregnancy-related disease are discussed.This article is part of a Special Issue entitled: Proteomics in India.

The relationship between the oxidative stress and the cardiac hypertrophy in infants of diabetic mothers

Recently, oxidative stress was suggested to play a role in maternal and fetal complications of diabetic pregnancies. The aim of this study is to evaluate the global oxidant and antioxidant status in infants of diabetic mothers (IDM) via measurement of total antioxidant capacity (TAC) and total oxidant status (TOS) and to determine their association with the clinical and cardiac manifestations of gestational diabetes on infants. Forty five infants constituted the IDM group, 51 infants born to non diabetic mothers served as the control group. Umbilical cord blood was drawn from IDM and controls for TAC and TOS measurement. Echocardiographic measurements were performed in the first three days of life. Infants of diabetic mother had significantly higher TAC (p=0.024), TOS (p=0.03) and oxidative stress index (OSI, p=0.04) levels compared to controls. Hemoglobin values were correlated to TOS (r=0.310, p=0.03) and OSI (r=0.310, p=0.03). Maternal HbA1c values were also correlated to TOS (r=0.576, p=0.001) and OSI (r=0.606, p<0.001). Systolic and diastolic interventicular septum measurements, and left ventricular mass were also correlated with TOS (r=0.330, p=0.02; r=0.453, p=0.002; r=0.404, p=0.006, respectively) and OSI (r=0.330, p=0.02; r=0.300, p=0.04, r=0.300; p=0.04, respectively). Oxidant-antioxidant balance is disturbed in favor of oxidants in IDM despite compensatory increase in TAC. The degree of oxidative stress is related to the severity of myocardial and hematological involvement in IDM in the first days of life and maternal glycemic control.

Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988-2011

AIMS/HYPOTHESIS

Our aim was to analyse possible changes in the glycaemic control, BP, markers of renal function, and obstetric and perinatal outcomes of parturients with diabetic nephropathy during 1988-2011.

METHODS

The most recent childbirth of 108 consecutive type 1 diabetes patients with diabetic nephropathy and a singleton pregnancy were studied. Two periods, 1988-1999 and 2000-2011, were compared.

RESULTS

The prepregnancy and the first trimester median HbA1c values persisted at high levels (8.2% [66 mmol/mol] vs 8.5% [69 mmol/mol], p = 0.16 and 8.3% [67 mmol/mol] vs 8.4% [68 mmol/mol], p = 0.67, respectively), but decreased by mid-pregnancy (6.7% [50 mmol/mol] vs 6.9% [52 mmol/mol], p = 0.11). Antihypertensive medication usage increased before pregnancy (34% vs 65%, p = 0.002) and in the second and third trimesters of pregnancy (25% vs 47%, p = 0.02, and 36% vs 60%, p = 0.01, respectively). BP exceeded 130/80 mmHg in 62% and 61% (p = 0.87) of patients in the first trimester, and in 95% and 93% (p = 0.69) in the third trimester, respectively. No changes were observed in the markers of renal function. Pre-eclampsia (52% vs 42%, p = 0.29) and preterm birth rates before 32 and 37 gestational weeks (14% vs 21%, p = 0.33, and 71% vs 77%, p = 0.49, respectively) remained high. The elective and emergency Caesarean section rates were 71% and 45% (p = 0.01) and 29% and 48% (p = 0.05), respectively. Neonatal intensive care unit admissions increased from 26% to 49% (p = 0.02).

CONCLUSIONS/INTERPRETATION

Early pregnancy glycaemic control and hypertension management were suboptimal in both time periods. Pre-eclampsia and preterm delivery rates remained high in patients with diabetic nephropathy.

Amniotic fluid erythropoietin and neonatal outcome in pregnancies complicated by intrauterine growth restriction before 34 gestational weeks

OBJECTIVE

High amniotic fluid erythropoietin concentration reflects chronic fetal hypoxia. Our aim was to study amniotic fluid erythropoietin concentration in relation to neonatal outcome in pregnancies complicated by intrauterine growth restriction.

DESIGN

Retrospective case series.

SETTING

Helsinki University Hospital, Finland.

SAMPLE

A total of 66 singleton pregnancies complicated by intrauterine growth restriction.

METHODS

Amniocentesis or amniotic fluid sampling at cesarean section was performed between 24 and 34 gestational weeks. Values of amniotic fluid erythropoietin were quantitated with immunochemiluminometric assay. Normal amniotic fluid erythropoietin was defined as <3 IU/L, intermediate as 3-27 IU/L, and abnormal as >27 IU/L.

MAIN OUTCOME MEASURES

Adverse neonatal outcome.

RESULTS

Abnormal biophysical profile and reversed end-diastolic flow in umbilical artery were associated with abnormal amniotic fluid erythropoietin (p < 0.001 and p = 0.042, respectively). Abnormal amniotic fluid erythropoietin was not associated with absent end-diastolic flow in umbilical artery or with oligohydramnios (p = 0.404 and p = 0.080, respectively). Decreased umbilical artery pH and base excess values were associated with abnormal amniotic fluid erythropoietin (p = 0.027 and p = 0.007, respectively). Composite adverse neonatal outcome defined as intraventricular hemorrhage, periventricular leukomalacia, cerebral infarction and/or necrotizing enterocolitis was associated with abnormal amniotic fluid erythropoietin (p < 0.001).

CONCLUSIONS

High amniotic fluid erythropoietin concentrations are associated with decreased umbilical artery pH and base excess and with adverse neonatal outcome in pregnancies complicated by intrauterine growth restriction before 34 gestational weeks. In selected pregnancies complicated by intrauterine growth restriction, determining amniotic fluid erythropoietin could be a useful additional tool in fetal surveillance and possibly in optimizing timing of delivery.

Glucose, insulin, and oxygen interplay in placental hypervascularisation in diabetes mellitus

The placental vasculature rapidly expands during the course of pregnancy in order to sustain the growing needs of the fetus. Angiogenesis and vascular growth are stimulated and regulated by a variety of growth factors expressed in the placenta or present in the fetal circulation. Like in tumors, hypoxia is a major regulator of angiogenesis because of its ability to stimulate expression of various proangiogenic factors. Chronic fetal hypoxia is often found in pregnancies complicated by maternal diabetes as a result of fetal hyperglycaemia and hyperinsulinemia. Both are associated with altered levels of hormones, growth factors, and proinflammatory cytokines, which may act in a proangiogenic manner and, hence, affect placental angiogenesis and vascular development. Indeed, the placenta in diabetes is characterized by hypervascularisation, demonstrating high placental plasticity in response to diabetic metabolic derangements. This review describes the major regulators of placental angiogenesis and how the diabetic environment in utero alters their expression. In the light of hypervascularized diabetic placenta, the focus was placed on proangiogenic factors.

Evaluating the fetus at risk for cardiopulmonary compromise

The in-utero environment is relatively hypoxic, but fetal physiologic adaptation assures adequate tissue oxygen supply. Fetal reactions to acute or chronic hypoxia are different and are modified by the preceding fetal condition. Acute fetal hypoxia episodes are often not preventable. By contrast, good obstetric care during labor may prevent poor fetal outcome in many cases of acute fetal hypoxia. The pathophysiology of chronic fetal hypoxia caused by placental insufficiency differs from chronic fetal hypoxia seen during the last weeks of diabetic pregnancies. The efficacy of antenatal fetal surveillance methods in preventing perinatal complications is different in these two conditions. Electronic fetal heart rate testing and Doppler flow assessment methods have been successful in detecting chronic fetal hypoxia caused by placental insufficiency. However, these methods have been unable to prevent chronic fetal hypoxia complications in diabetic pregnancies. Therefore, research to find new strategies and early and reliable biomarkers is necessary to assess fetal well-being and to decide when to deliver the fetus.

Erythropoietin in amniotic fluid as a potential marker in distinction between growth restricted and constitutionally small fetuses

OBJECTIVE

To determine if there is any difference in amniotic fluid erythropoietin (EPO) concentration between fetuses small for gestational age (SGA) and appropriate for gestational age (AGA), and between the constitutionally small (CSF) and growth-restricted (GRF) fetuses.

METHODS

EPO concentrations in the amniotic fluid samples were determined by EpoELISA test in 38 pregnancies with SGA and 15 pregnancies with AGA fetuses. In the SGA group we measured Ponderal index (PI) and skin-fold thickness (SFT). If PI and/or SFT were below 10th percentile the neonate was GRF. If both PI and SFT were above 10th percentile the neonate was CSF.

RESULTS

Higher levels of EPO were detected in the SGA in comparison to the AGA fetuses (p < 0.01). EPO concentration was higher in GRF compared to CSF (p < 0.05). The EPO cut-off level between SGA and AGA was 6.81 IU/L (sensitivity 92.3%; specificity 73.3%), and between GRF and CSF was 9.8 IU/L (sensitivity 81%; specificity 80%).

CONCLUSION

The preliminary results of this study suggest that amniotic fluid erythropoietin concentration is elevated in growth-restricted fetuses and could potentially be used for distinction between growth restricted and constitutionally small fetuses. Confirmation of these results on a larger group of pregnant women is needed.

Differences in post-mortem findings after stillbirth in women with and without diabetes

AIMS

The reason for the fivefold increased risk of stillbirth in women with diabetes is not known. Further understanding of the underlying mechanisms may facilitate identification of pregnancies at increased risk. We have compared post-mortem reports in matched pairs of stillbirths in women with and without diabetes.

METHODS

Post-mortem reports were provided by the Centre for Maternal and Child Enquiries. Stillbirths as a result of lethal congenital and genetic abnormalities were excluded. Whole body, placenta and organ weights and histo-pathological findings in cases and controls were compared and also related to published reference values.

RESULTS

We analysed post-mortem reports on 23 matched pairs of stillbirths from 2009 to 2010. Mean placental weight in women with diabetes was 75 g less than in control subjects (95% CI -143 to -7 g; P = 0.032). In maternal diabetes, the thymus was often small and showed a 'starry sky' pattern on histology in 11 of 20 cases compared with four of 22 controls (P = 0.03). This histological finding was associated with a particularly low mean placental weight z-score -2.1 (1.1) standard deviations below a reference population corrected for gestational age.

CONCLUSIONS

In over half of the stillbirths occurring in women with diabetes, there was a 'starry sky' appearance in the fetal thymus on histology, this being associated with a small placenta. These findings are consistent with a critical subacute metabolic disturbance being a prominent cause of the increased risk of stillbirth in pregnancies complicated by maternal diabetes.

Amniotic fluid oxidative and nitrosative stress biomarkers correlate with fetal chronic hypoxia in diabetic pregnancies

BACKGROUND

In spite of improvement in obstetrical care, pregnancy in women with type 1 diabetes mellitus is associated with increased perinatal morbidity and mortality. Hyperglycemia during pregnancy causes excessive fetal growth and chronic fetal hypoxia as reflected in increased erythropoietin (EPO) levels in amniotic fluid (AF).

OBJECTIVES

We hypothesized that the degree of fetal hypoxia would correlate with fetal oxidative and nitrosative stress as evidenced ty the concentration of specific biomarkers in AF.

MATERIAL AND METHODS

19 pregnant women with type 1 or insulin-treated gestational diabetes mellitus were studied. AF samples were collected and processed for EPO, meta-tyrosine, nitro-tyrosine and 8-hydroxy-2-deoxiguanosine by chemiluminescent immunoassay and high-performance liquid chromatography coupled to tandem mass spectrometry methods, respectively.

RESULTS

The mean (SD) of the last HbA1c concentration before delivery was 7.7% (1.1). Median gestational age was 258 days (range 231-268). Birth weight was 3,868 ± 695 g with a z-score >2 SD in 47% of the cases. A significant correlation was found between the concentrations of AF EPO and meta-tyrosine/phenylalanine ratio (p < 0.001), nitro-tyrosine (p < 0.01) and 8-oxo-dG/2dG ratio (p < 0.001).

CONCLUSIONS

We confirmed that fetuses of type 1 diabetes or insulin-treated gestational diabetes pregnancies experience chronic hypoxia as reflected by increased EPO concentrations in AF near term. Moreover, EPO levels significantly correlated with the concentration of oxidative and nitrosative stress biomarkers in AF. This pro-oxidant status may predispose newborn infants to poor postnatal adaptation and early neonatal complications.

Trends in maternal BMI, glycaemic control and perinatal outcome among type 1 diabetic pregnant women in 1989-2008

AIMS/HYPOTHESIS

Our objective was to examine the trends in prepregnancy BMI and glycaemic control among Finnish type 1 diabetic patients and their relation to delivery mode and perinatal outcome.

METHODS

We analysed the obstetric records of 881 type 1 diabetic women with a singleton childbirth during 1989-2008. Maternal prepregnancy weight and height were obtained from the maternity cards, where they are recorded as reported by the mother.

RESULTS

Maternal BMI increased significantly during 1989-2008 (p < 0.001). The mean HbA(1c) in the first trimester remained unchanged, but the midpregnancy and the last HbA(1c) before delivery increased (p = 0.009 and 0.005, respectively). Elective Caesarean sections (CS) decreased (p for trend <0.001), while emergency CS increased (p for trend <0.001). The mean umbilical artery (UA) pH decreased in vaginal deliveries (p for trend <0.001). The frequency of UA pH <7.15 and <7.05 increased (p for trend <0.001 and 0.008, respectively). The macrosomia rate remained at 32-40%. Neonatal intensive care unit (NICU) admissions increased (p for trend 0.03) and neonatal hypoglycaemia frequency decreased (p for trend 0.001). In multiple logistic regression analysis, maternal BMI was associated with macrosomia and NICU admission. The last HbA(1c) value before delivery was associated with delivery before 37 weeks' gestation, UA pH <7.15, 1 min Apgar score <7, macrosomia, NICU admission and neonatal hypoglycaemia.

CONCLUSIONS/INTERPRETATION

Self-reported pregestational BMI has increased and glycaemic control during the second half of pregnancy has deteriorated. Poor glycaemic control seems to be associated with the observed increases in adverse obstetric and perinatal outcomes.

Biomarkers of maternal diabetes and its complication in pregnancy

There are specific biomarkers - indicators of normal and abnormal processes - in diabetic pregnancies that predict the degree of diabetic control as well as embryonic and fetal growth and development. They can be detected in maternal blood, amniotic fluid or in the cord plasma of the newborn infant. While the cord plasma levels are of little clinical relevance because they do not allow us to interfere with the outcome of pregnancy, biomarkers in maternal blood or amniotic fluid may help us to better control the outcome of diabetic pregnancies. Important biomarkers in maternal blood are fasting glucose, HbA1c and IGFs. Relevant biomarkers in amniotic fluid are insulin, erythropoietin and markers of bone formation and resorption. Cord plasma biomarkers include IGFs, leptin, adiponectin, resistin, markers of oxidative stress and of hypoxia. Whether these biomarkers can be predictors of long term outcome in infants of diabetic mothers is yet to be determined.

Disproportionate body composition and perinatal outcome in large-for-gestational-age infants to mothers with type 1 diabetes

OBJECTIVE

To determine if disproportionate body composition is a risk factor for perinatal complications in large-for-gestational-age infants born to mothers with type 1 diabetes.

DESIGN

Population-based cohort study.

SETTING

Data from the Swedish Medical Birth Registry from 1998 to 2007.

POPULATION

National cohort of 3517 infants born to mothers with type 1 diabetes. Only singletons with gestational age 32-43 weeks were included.

METHODS

Large for gestational age (LGA) was defined as birthweight > 90th centile and appropriate for gestational age (AGA) as birthweight between 10th and 90th centiles. Disproportionate (D) infants were defined as having a ponderal index [PI: calculated as birthweight in grams/(length in cm)(3) > 90th centile] and proportionate (P) as PI ≤ 90th centile. LGA infants were classified as P-LGA or D-LGA. Odds ratios were calculated for D-LGA and P-LGA infants, with AGA infants as the reference category. Odds ratios were adjusted for mode of delivery, fetal distress and stratified by gestational age.

MAIN OUTCOME MEASURES

The primary outcome was a composite of neonatal morbidities, i.e. any of the following diagnoses: Apgar score < 7 at 5 minutes, birth trauma (Erb's palsy or clavicle fracture), respiratory disorder, hyperbilirubinaemia or hypoglycaemia requiring treatment.

RESULTS

Composite morbidity was significantly more frequent in LGA as opposed to AGA infants, but there was no difference in risk between P-LGA and D-LGA infants.

CONCLUSIONS

High birthweight, irrespective of body proportionality, is a risk factor for neonatal complications in offspring of women with type 1 diabetes.

Intrapartum cardiotocography (CTG) and ST-analysis of labor in diabetic patients

AIM

To determine the prevalence and types of intrapartum cardiotocography (CTG) patterns and investigate their relationship to moderate acidemia in term fetuses of diabetic mothers. Also, to assess if the combination of fetal electrocardiogram (FECG) and those CTG patterns strengthens the association with moderate acidemia.

MATERIAL AND METHODS

The material for this study is obtained from the Swedish randomized control trial and the European Union ST-analysis trial. We developed an analytical model for CTG patterns based on the progress in CTG changes, in a longitudinal periodic manner. The model was then combined with information regarding changes in ST interval that indicate threatening asphyxia, and the findings were analyzed to determine correlation with the presence of moderate acidemia at birth.

RESULTS

This study involved data of 413 diabetic mothers. A preterminal CTG was more common in the diabetes mellitus (DM) group (6/70, 8.6%) than in the gestational diabetes (GD) group (3/307, 1.0%; P=0.003). For diabetic mothers (i.e., DM+GD) with a normal CTG at the start of monitoring, the presence of FECG data indicating asphyxia significantly increased the likelihood of an umbilical artery pH<7.15 at birth [odds ratio (OR)=3.65, 95% confidence interval (CI)=1.33-10.05]. Among labors where the CTG was non-reassuring at the start of monitoring, no significant association was found between pH<7.15 and indication to intervene according to FECG information (OR=1.51, 95% CI=0.33-7.0).

CONCLUSIONS

A preterminal CTG is more common in the fetuses of DM than GD mothers during labor. When CTG was normal at the start of recording, the addition of FECG information gave a significant add on information to predict moderate acidemia.

Novel avenues of drug discovery and biomarkers for diabetes mellitus

Globally, developed nations spend a significant amount of their resources on health care initiatives that poorly translate into increased population life expectancy. As an example, the United States devotes 16% of its gross domestic product to health care, the highest level in the world, but falls behind other nations that enjoy greater individual life expectancy. These observations point to the need for pioneering avenues of drug discovery to increase life span with controlled costs. In particular, innovative drug development for metabolic disorders such as diabetes mellitus becomes increasingly critical given that the number of diabetic people will increase exponentially over the next 20 years. This article discusses the elucidation and targeting of novel cellular pathways that are intimately tied to oxidative stress in diabetes mellitus for new treatment strategies. Pathways that involve wingless, β-nicotinamide adenine dinucleotide (NAD(+)) precursors, and cytokines govern complex biological pathways that determine both cell survival and longevity during diabetes mellitus and its complications. Furthermore, the role of these entities as biomarkers for disease can further enhance their utility irrespective of their treatment potential. Greater understanding of the intricacies of these unique cellular mechanisms will shape future drug discovery for diabetes mellitus to provide focused clinical care with limited or absent long-term complications.

Stillbirth in diabetic pregnancies

Pregnancy in women with pregestational diabetes is associated with high perinatal morbidity and mortality. Stillbirth accounts for the majority of cases with perinatal death. Intrauterine growth restriction, pre-eclampsia, foetal hypoxia and congenital malformations may be contributing factors, but more than 50% of stillbirths are unexplained. Majority of stillbirths are characterised by suboptimal glycaemic control during pregnancy. Foetal hypoxia and cardiac dysfunction secondary to poor glycaemic control are probably the most important pathogenic factors in stillbirths among pregnant diabetic women. There is thus a need for new strategies for improving glycaemic control to near-normal levels throughout pregnancy and for preventing and treating hypertensive disorders in pregnancy. Antenatal surveillance tests including ultrasound examinations of the foetal growth rate, kick counting and non-stress testing of foetal cardiac function are widely used. However, future research should establish better antenatal surveillance tests to identify the infants susceptible to stillbirth before it happens.

Obstetric problems in diabetic pregnancy - The role of fetal hypoxia

Perinatal mortality has not decreased over the last two decades in pregestational diabetic pregnancies. Stillbirth rate is 4-6 times and neonatal mortality 2-4 times higher in diabetic than in non-diabetic pregnancies despite modern electronic fetal surveillance methods. Majority of late stillbirths are "unexplained", many of which are presumably caused by fetal hypoxia. Both experimental and clinical studies have shown that fetal hyperglycaemia and hyperinsulinaemia can independently cause fetal hypoxia, which ultimately can lead to fetal death. Poor glycaemic control is associated with perinatal complications. Sharp increases in amniotic fluid erythropoietin levels indicate fetal hypoxia in diabetic pregnancy. Fetal erythropoietin concentrations correlate directly with maternal HbA(1c) levels. It is therefore important to maintain near-normal glycaemic level throughout pregnancy. Measurement of amniotic fluid erythropoietin level is a new way to detect fetal hypoxia antenatally. Sufficiently large controlled studies are needed before definitive answer of the clinical utility of amniotic fluid erythropoietin measurements in diabetic pregnancies can be determined.

Diabetes mellitus: channeling care through cellular discovery

Diabetes mellitus (DM) impacts a significant portion of the world's population and care for this disorder places an economic burden on the gross domestic product for any particular country. Furthermore, both Type 1 and Type 2 DM are becoming increasingly prevalent and there is increased incidence of impaired glucose tolerance in the young. The complications of DM are protean and can involve multiple systems throughout the body that are susceptible to the detrimental effects of oxidative stress and apoptotic cell injury. For these reasons, innovative strategies are necessary for the implementation of new treatments for DM that are generated through the further understanding of cellular pathways that govern the pathological consequences of DM. In particular, both the precursor for the coenzyme beta-nicotinamide adenine dinucleotide (NAD(+)), nicotinamide, and the growth factor erythropoietin offer novel platforms for drug discovery that involve cellular metabolic homeostasis and inflammatory cell control. Interestingly, these agents and their tightly associated pathways that consist of cell cycle regulation, protein kinase B, forkhead transcription factors, and Wnt signaling also function in a broader sense as biomarkers for disease onset and progression.

Oxidative stress: Biomarkers and novel therapeutic pathways

Oxidative stress significantly impacts multiple cellular pathways that can lead to the initiation and progression of varied disorders throughout the body. It therefore becomes imperative to elucidate the components and function of novel therapeutic strategies against oxidative stress to further clinical diagnosis and care. In particular, both the growth factor and cytokine erythropoietin (EPO) and members of the mammalian forkhead transcription factors of the O class (FoxOs) may offer the greatest promise for new treatment regimens since these agents and the cellular pathways they oversee cover a range of critical functions that directly influence progenitor cell development, cell survival and degeneration, metabolism, immune function, and cancer cell invasion. Furthermore, both EPO and FoxOs function not only as therapeutic targets, but also as biomarkers of disease onset and progression, since their cellular pathways are closely linked and overlap with several unique signal transduction pathways. However, biological outcome with EPO and FoxOs may sometimes be both unexpected and undesirable that can raise caution for these agents and warrant further investigations. Here we present the exciting as well as complicated role EPO and FoxOs possess to uncover the benefits as well as the risks of these agents for cell biology and clinical care in processes that range from stem cell development to uncontrolled cellular proliferation.

Obstetric and perinatal outcomes in type 1 diabetic pregnancies: A large, population-based study

OBJECTIVE

To perform comparative analyses of obstetric and perinatal outcomes between type 1 diabetic pregnancies and the general obstetric population in Sweden between 1991 and 2003.

RESEARCH DESIGN AND METHODS

This was a population-based study. Data were obtained from the Medical Birth Registry, covering >98% of all pregnancies in Sweden. A total of 5,089 type 1 diabetic pregnancies and 1,260,207 control pregnancies were included. Odds ratios (ORs) were adjusted for group differences in maternal age, parity, BMI, chronic hypertensive disease, smoking habits, and ethnicity.

RESULTS

In type 1 diabetes, preeclampsia was significantly more frequent (OR 4.47 [3.77-5.31]) as was delivery by cesarean section (5.31 [4.97-5.69]) compared with results for the general population. Stillbirth (3.34 [2.46-4.55]), perinatal mortality (3.29 [2.50-4.33]), and major malformations (2.50 [2.13-2.94]) were more common in type 1 diabetic than in control pregnancies. The risk of very preterm birth (<32 gestational weeks) was also higher among type 1 diabetic women (3.08 [2.45-3.87]). The incidence of fetal macrosomia (birth weight >or=2 SD above the mean) was increased in the diabetic group (11.45 [10.61-12.36]).

CONCLUSIONS

Type 1 diabetes in pregnancy is still associated with considerably increased rates of adverse obstetric and perinatal outcomes. The eightfold increased risk for fetal macrosomia in type 1 diabetic pregnancies is unexpected and warrants further investigation.

Erythropoietin, forkhead proteins, and oxidative injury: biomarkers and biology

Oxidative stress significantly impacts multiple cellular pathways that can lead to the initiation and progression of varied disorders throughout the body. It therefore becomes imperative to elucidate the components and function of novel therapeutic strategies against oxidative stress to further clinical diagnosis and care. In particular, both the growth factor and cytokine erythropoietin (EPO), and members of the mammalian forkhead transcription factors of the O class (FoxOs), may offer the greatest promise for new treatment regimens, since these agents and the cellular pathways they oversee cover a range of critical functions that directly influence progenitor cell development, cell survival and degeneration, metabolism, immune function, and cancer cell invasion. Furthermore, both EPO and FoxOs function not only as therapeutic targets, but also as biomarkers of disease onset and progression, since their cellular pathways are closely linked and overlap with several unique signal transduction pathways. Yet, EPO and FoxOs may sometimes have unexpected and undesirable effects that can raise caution for these agents and warrant further investigations. Here we present the exciting as well as the complex role that EPO and FoxOs possess to uncover the benefits as well as the risks of these agents for cell biology and clinical care in processes that range from stem cell development to uncontrolled cellular proliferation.

Amniotic fluid S100B protein and erythropoietin in pregnancies at risk for fetal hypoxia

OBJECTIVE

S100B protein is a biochemical marker for brain injury, and high serum S100B levels have been observed in newborns with birth asphyxia. We hypothesized that the concentration of amniotic fluid erythropoietin, which increases in chronic fetal hypoxia, correlates with amniotic fluid S100B concentration.

STUDY DESIGN

Amniotic fluid samples in 35 pregnancies at high risk for chronic fetal hypoxia were obtained at cesarean section or by amniocentesis done within a median of 2 days before delivery. S100B and erythropoietin concentrations were measured by chemiluminescent immunoassays.

RESULTS

A positive correlation existed between the concentrations of S100B and erythropoietin in the amniotic fluid (r=0.57, p<0.0001). Amniotic fluid S100B concentration was higher (70 ng/l; 33-469, n=17) (median; range) in pregnancies with elevated amniotic fluid erythropoietin (>or= 50 IU/l) than in pregnancies with normal erythropoietin (34 ng/l; 20-340, n=18) (p<0.0001, Mann-Whitney U-test). S100B predicted an elevated amniotic fluid erythropoietin concentration in the study population with the sensitivity of 94% and specificity of 83%.

CONCLUSION

A strong positive correlation exists between amniotic fluid S100B and erythropoietin concentrations in pregnancies at high risk for chronic fetal hypoxia. This suggests that chronic fetal hypoxia increases the intrauterine release of S100B.

Increased fetal plasma and amniotic fluid erythropoietin concentrations: markers of intrauterine hypoxia

Tissue hypoxia is the major stimulus of erythropoietin (EPO) synthesis in fetuses and adults. Since EPO does not cross the placenta and is not stored, fetal plasma and amniotic fluid levels indicate EPO synthesis and elimination. Acutely, the rate and magnitude of the increase in plasma EPO levels correlate with the intensity of hypoxia. Amniotic fluid EPO levels correlate with cord plasma levels in normal and abnormal pregnancies, with fetal plasma EPO levels in humans averaging 2.6 times higher than the corresponding amniotic fluid EPO levels. Recent experimental and clinical studies demonstrate that EPO has neuroprotective effects related to its anti-apoptotic and vascular growth-promoting properties. Although under basal conditions the fetal kidneys are the main site of EPO production, during hypoxia recent experimental data indicate an important role of the placenta. Amniotic fluid EPO levels have been shown to increase exponentially during fetal hypoxia in preeclamptic, diabetic and Rh-immunized pregnancies, to correlate inversely with cord blood pH, pO(2) and base excess and to predict neonatal morbidities and NICU admission. As an indicator of chronic intrauterine hypoxia, fetal EPO measurements have increased our knowledge about the pathogenesis and importance of intrauterine growth restriction, macrosomia, diabetic pregnancy, prolonged pregnancy, meconium staining, fetal hemorrhage, fetal anemia, maternal smoking and alcohol consumption, abnormal fetal heart rate and abnormal Doppler flow patterns. While the clinical utility of fetal amniotic fluid and plasma EPO measurements in the management of high-risk pregnancies and their offspring is promising, adequately powered clinical trials are urgently needed.

Erythropoietin: elucidating new cellular targets that broaden therapeutic strategies

Given that erythropoietin (EPO) is no longer believed to have exclusive biological activity in the hematopoietic system, EPO is now considered to have applicability in a variety of nervous system disorders that can overlap with vascular disease, metabolic impairments, and immune system function. As a result, EPO may offer efficacy for a broad number of disorders that involve Alzheimer's disease, cardiac insufficiency, stroke, trauma, and diabetic complications. During a number of clinical conditions, EPO is robust and can prevent metabolic compromise, neuronal and vascular degeneration, and inflammatory cell activation. Yet, use of EPO is not without its considerations especially in light of frequent concerns that may compromise clinical care. Recent work has elucidated a number of novel cellular pathways governed by EPO that can open new avenues to avert deleterious effects of this agent and offer previously unrecognized perspectives for therapeutic strategies. Obtaining greater insight into the role of EPO in the nervous system and elucidating its unique cellular pathways may provide greater cellular viability not only in the nervous system but also throughout the body.