Effect of maternal ketoacidemia on the pregnant ewe and the fetus

Determinants for Perinatal Mortality in South China: A Prospective Cohort Study

OBJECTIVE

To estimate the association of selected maternal and fetal characteristics with the risk of perinatal mortality in South China.

METHODS

A prospective cohort study was conducted from March 2013 to December 2019. The exposures of interest were maternal sociodemographic characteristics, lifestyle and habits during early pregnancy, and complications of pregnancy. Their effects on the development of perinatal death were analyzed in our study.

RESULTS

A total of 44,048 eligible pregnant women were included in the analysis. Of these, 596 fetuses were perinatal deaths (perinatal mortality was 13.5 per 1,000 births). After adjustment, maternal obesity, being employed, history of gestational hypertension, taking antidepressants during early pregnancy, history of gestational diabetes mellitus, gestational diabetes mellitus, infertility drug treatment and assisted reproductive techniques, history of neonatal death, preterm birth, and congenital malformations all significantly increased the risk of perinatal death. Ethnic minority, income > 5,000, multiparous women, and cesarean section associated with reduced risk of perinatal death.

CONCLUSION

Some factors of maternal sociodemographic characteristics, abnormal pregnancy history, lifestyle and habits during early pregnancy, and complications of pregnancy were associated with the risk of perinatal death.

Evaluation of the Precision Xtra meter for monitoring blood β-hydroxybutyrate concentrations in late-gestation ewes

Blood samples were collected from late-gestation ewes to determine the agreement of a point-of-care (POC) Precision Xtra meter and a standard laboratory test for β-hydroxybutyrate (BHBA). Fresh whole blood samples were immediately tested with the POC instrument, and serum samples were analyzed with a standard commercial biochemical analyzer. Ewes were classified as having ketonemia if their BHBA concentrations were ≥800 µmol/L. Scatter plots, paired t-tests, Bland-Altman limits of agreement, and Gwet AC1 tests were used to compare results. The 2 tests had very good agreement. The values between instruments were not statistically different based on paired t-tests ( p = 0.312). The intercept and slope of a linear mixed model, containing the standard test results as an outcome and the POC meter results as a predictor, were 0.02 (95% CI: 0.00, 0.04) and 0.98 (95% CI: 0.96, 1.01), respectively. When the samples were classified into ketonemic classes (non-ketonemic and ketonemic) based on BHBA concentrations obtained from each test, the Gwet AC1 statistic was 0.94 (95% CI: 0.91, 0.97; p < 0.001). The ketosis classification agreed in 95% of samples. Based on the Bland-Altman plot and limits of agreement, the optimal cutoff to diagnose ketonemia with the POC meter was 1,000 µmol/L, which is 200 µmol/L higher than the laboratory BHBA medical decision limit. The Precision Xtra meter provided excellent correlation and substantial agreement with the standard laboratory technique for measuring blood BHBA in late-gestation ewes.

Detection of elevated ketone bodies by postmortem 1H-MRS in a case of fetal ketoacidosis

We report a fetal loss following maternal ketoacidosis in a case of cryptic pregnancy. Biochemical analysis of peripheral blood revealed highly elevated levels of beta-hydroxybutyrate (BHB) in the mother (9.2 mmol/l) and the fetus (4.2 mmol/l). Fetal ketoacidosis with hypoxic-ischemic brain damage was determined to be the cause of death. ¹H-MRS of the right cerebral hemisphere presented with distinctive resonances of BHB and acetone. Acetoacetate and glucose were not detected. Due to reported chronic abuse of ethanol and a period of fasting, alcoholic ketoacidosis was concluded to be the cause of the metabolic disorder. ¹H-MRS is a viable examination for the postmortem detection of ketone bodies and may be a key supplement to noninvasive fetal autopsy for the diagnosis of ketoacidosis.

Acute fetal asphyxia after gastric rupture in a pregnant patient with a gastric band

We report a 37-year-old primigravida with a gastric band who developed the clinical picture of abdominal pain, vomiting and regurgitation coexistent with a cardiotocogram with severe variable decelerations with absent variability at 33 weeks' gestation. After partial improvement with gastric band enlargement, new aggravation of symptoms and recurrence of a pathological cardiotocogram led to an emergency cesarean section. Intraoperatively, hemoperitoneum from gastric rupture was verified and partial gastrectomy was performed. After bariatric surgery, pregnant women are at increased risk of gastrointestinal complications, which may need prompt and multidisciplinary diagnosis and management in order to avoid maternal-fetal morbidity and mortality.

[Gestational diabetes mellitus: importance of blood glucose monitoring]

Gestational diabetes mellitus (GDM) is common during pregnancy, and is frequently associated with maternal and perinatal complications. Intensive treatment of hyperglycaemia during pregnancy has been shown to reduce perinatal morbidity. In women with pregestational type 1 or 2 diabetes, hyperglycaemia during labour and delivery is an important factor in the development of neonatal hypoglycaemia. There are no generally accepted recommendations for women with GDM. Recent studies evaluating patients with GDM show that peripartum glucose control can be achieved in these women without the need for insulin use in the majority of cases. Hyperglycaemia during labour is not related with treatment established during pregnancy but rather with non-compliance of endocrinological follow-up. Factors such as ethnic origin, neonatal hypoxaemia, and large for gestational age seem to play an important role in the development of neonatal hypoglycaemia.

Bilateral basal ganglia infarctions in a neonate born during maternal diabetic ketoacidosis

Diabetic ketoacidosis (DKA) during pregnancy carries significant risk of intrauterine fetal demise, but little is known about its postnatal sequelae in surviving neonates. We report here the case of an infant who was born to a mother with White's class C diabetes mellitus during an episode of DKA. Throughout pregnancy her glucose control was suboptimal, as evidenced by a predelivery glycosylated hemoglobin level of 8.1%. At 33 weeks' gestation, the mother presented with nausea and vomiting, a serum glucose concentration of 575 mg/dL, and other metabolic derangements consistent with DKA. Despite rehydration and insulin therapy, fetal distress necessitated cesarean delivery. At birth the infant required intubation, but her clinical status quickly improved and she was extubated within the first day of life. However, on day-of-life 4 she exhibited seizure-like activity, and subsequent brain MRI revealed bilateral basal ganglia infarctions. Previous research has revealed that the keto acid β-hydroxybutyrate (β-OHB) can cross the placenta into the fetal circulation and thereafter accumulate in the fetal brain, which leads to severe metabolic derangements. Furthermore, β-OHB accumulates rapidly in the basal ganglia of older children during episodes of DKA, wherein its presence is associated with neuronal injury. We suspect that transplacental transfer of maternal β-OHB led to an acquired ketoacidosis in the fetus and that accumulation of β-OHB contributed to neuronal injury and subsequent infarction of the basal ganglia. Further research is necessary to better characterize neonatal complications of maternal DKA, as well as the possible inclusion of β-OHB levels in the goal-directed treatment of this disease.

Perinatal mortality in diabetic pregnancy

Perinatal mortality rate (PMR) is one of the most important perinatal health indicators. PMR in diabetic pregnancies varies throughout the world and is higher than the background PMR. The prevalence of pregestational diabetes is increasing and is associated with an elevated risk of congenital malformations, macrosomia, preeclampsia, and preterm delivery. The incidence of PMR in preexisting diabetes mellitus ranges considerably, with congenital abnormalities and preterm labor the main factors contributing to the higher PMR. Women with gestational diabetes mellitus or impaired glucose tolerance are a mixed group that may have low to a high PMR, especially if they require insulin in their pregnancy. All the known diabetic women should plan their pregnancies and optimize glycemic control periconceptually and throughout pregnancy, as this reduces the frequency of congenital abnormalities, obstetric complications, and perinatal mortality.

Peripartum metabolic control in gestational diabetes

OBJECTIVE

We sought to evaluate intrapartum metabolic control in gestational diabetes mellitus (GDM) patients and maternal factors influencing intrapartum glycemic control and neonatal hypoglycemia risk.

STUDY DESIGN

A prospective observational study included 129 women with GDM admitted for delivery. Data collected included maternal intrapartum capillary blood glucose (CBG) and ketonemia, use of insulin, and neonatal hypoglycemia.

RESULTS

In all, 86% of maternal intrapartum CBG values fell within target range (3.3-7.2 mmol/L) without need for insulin use. There were no cases of maternal hypoglycemia or severe ketosis. Intrapartum CBG >7.2 mmol/L was associated with third-trimester glycated hemoglobin (P = .02) and lack of endocrinologic follow-up (P = .04). Risk of neonatal hypoglycemia was related with pregnancy insulin use compared with dietary control (60.5% vs 29.5%; P = .02).

CONCLUSION

Peripartum metabolic control in GDM patients was achieved without insulin in most cases. Intrapartum glycemic control was related with third-trimester glycated hemoglobin and with no endocrinologic follow-up. Neonatal hypoglycemia was associated with insulin use during pregnancy.

The differential effects of the timing of maternal nutrient restriction in the ovine placenta on glucocorticoid sensitivity, uncoupling protein 2, peroxisome proliferator-activated receptor-gamma and cell proliferation

Nutrient restriction (NR) during critical windows of pregnancy has differential effects on placento-fetal growth and development. Our study, therefore, investigated developmental and metabolic adaptations within the ovine placenta following NR at different critical windows during the first 110 days of gestation (term=147 days). Thus, the effects of NR on cell proliferation, glucocorticoid sensitivity, IGF1 and 2 receptor, peroxisome proliferator-activated receptor gamma (PPARG), and uncoupling protein (UCP)2 gene expression in the placenta were examined. Singleton bearing sheep (n=4-8 per group) were fed either 100% of their total metabolizable energy requirements throughout the study or 50% of this amount between 0-30, 31-65, 66-110, and 0-110 days gestation. A significant reduction in cell proliferation and increased gene expression for the glucocorticoid and IGF2 receptors, PPARG, and UCP2 were detected in placentae sampled from mothers who were nutrient restricted between days 66 and 110 of gestation, only, relative to controls. This window of gestation coincides with the maximum placental growth and the start of exponential growth of the fetus when there are substantially increased metabolic demands on the placenta compared with earlier in gestation. Consequently, increased glucocorticoid sensitivity and suppressed IGF2 action could contribute to a switch in the placenta from proliferation to differentiation, thereby improving its nutrient transfer capacity. Upregulation of PPARG and UCP2 would promote placental fatty acid metabolism thereby limiting glucose utilization. These compensatory placental responses may serve to maintain fetal growth but could result in adverse adaptations such as the early onset of the metabolic syndrome in later life.

Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip

OBJECTIVE

The purpose of this study was to determine whether continuous insulin infusion provides a greater degree of intrapartum maternal glycemic control than rotating between glucose and non-glucose containing intravenous fluids.

STUDY DESIGN

Laboring patients with pregestational or gestational diabetes were recruited and randomized to an "insulin drip" or "rotating fluids" protocol. The primary outcome measure was mean maternal capillary blood glucose (CBG) levels (mg/dL). Power analysis indicated that 16 patients were needed in each arm to find a difference of 10 mg/dL.

RESULTS

Fifteen patients were randomized to the rotating fluids protocol and 21 patients to an insulin drip. There was no difference in mean intrapartum maternal CBG levels (103.9 +/- 8.7 mg/dL and 103.2 +/- 17.9 mg/dL in the rotating fluids and insulin drip group, respectively, P = .89). Neonatal outcomes were also similar between the 2 treatment groups.

CONCLUSION

In patients with insulin requiring gestational diabetes, intrapartum glycemic control may be comparable with a standard adjusted insulin drip or a rotation of intravenous fluids between glucose and non-glucose containing fluids.

Lipid metabolism in pregnancy and its consequences in the fetus and newborn

During early pregnancy there is an increase in body fat accumulation, associated with both hyperphagia and increased lipogenesis. During late pregnancy there is an accelerated breakdown of fat depots, which plays a key role in fetal development. Besides using placental transferred fatty acids, the fetus benefits from two other products: glycerol and ketone bodies. Although glycerol crosses the placenta in small proportions, it is a preferential substrate for maternal gluconeogenesis, and maternal glucose is quantitatively the main substrate crossing the placenta. Enhanced ketogenesis under fasting conditions and the easy transfer of ketones to the fetus allow maternal ketone bodies to reach the fetus, where they can be used as fuels for oxidative metabolism as well as lipogenic substrates. Although maternal cholesterol is an important source of cholesterol for the fetus during early gestation, its importance becomes minimal during late pregnancy, owing to the high capacity of fetal tissues to synthesize cholesterol. Maternal hypertriglyceridemia is a characteristic feature during pregnancy and corresponds to an accumulation of triglycerides not only in very low-density lipoprotein but also in low- and high-density lipoprotein. Although triglycerides do not cross the placental barrier, the presence of lipoprotein receptors in the placenta, together with lipoprotein lipase, phospholipase A2, and intracellular lipase activities, allows the release to the fetus of polyunsaturated fatty acids transported as triglycerides in maternal plasma lipoproteins. Normal fetal development needs the availability of both essential fatty acids and long chain polyunsaturated fatty acids, and the nutritional status of the mother during gestation has been related to fetal growth. However, excessive intake of certain long chain fatty acids may cause both declines in arachidonic acid and enhanced lipid peroxidation, reducing antioxidant capacity.

The infant of the diabetic mother

The history of the medical success in treatment of the pregnant diabetic woman and her infant in the twentieth century illustrates how the combined efforts of dedicated clinicians and researchers have resulted in dramatic improvements in outcome for this patient group. This article discusses fetal growth, metabolic complications of the infant of the diabetic mother, risk of respiratory distress syndrome, hypertrophic cardiomyopathy, and congenital anomalies.

Fetal surveillance and timing of delivery in pregnancy complicated by diabetes mellitus

Protocols for antepartum fetal assessment in pregnancies complicated by diabetes mellitus are an important part of a care program that allows most of these pregnancies to reach term, ensuring fetal maturation. Maternal assessment of fetal activity serves as an efficient screening test in most surveillance programs. These programs have used primarily biophysical testing consisting of the nonstress test, cardiac stress test, or biophysical profile. Doppler studies have been investigated as an adjunct for identifying fetal compromise. These studies may prove most valuable in cases of maternal vascular disease. The success of these protocols continues to be predicated on careful regulation of maternal glycemia through aggressive therapy with insulin and diet. Reassuring tests of fetal condition are present in most diabetic women and, therefore, permit fetal maturation to occur prior to delivery.

Effects of beta-hydroxybutyrate infusion on hind limb metabolism in fetal sheep

OBJECTIVES

This study investigated the effects of high ketone levels on fetal carcass metabolism. Specifically, we aimed to determine whether beta-hydroxybutyrate was taken up by fetal muscle and whether lactate production by the fetal hind limb contributed to the raised circulating lactate levels seen in high ketone states.

STUDY DESIGN

Hind limb metabolism was studied in 10 chronically catheterized fetal sheep. Substrate/oxygen quotients were measured before and after 2 hour infusions of beta-hydroxybutyrate and compared with the Wilcoxon signed-rank test.

RESULTS

beta-Hydroxybutyrate was taken up by hind limb tissues in large amounts (butyrate/oxygen quotient = 1.02 +/- 0.40). Lactate was produced by the hind limb (lactate/oxygen quotient = -0.96 +/- 0.52) in amounts almost equivalent to glucose uptake (glucose/oxygen quotient = 1.32 +/- 0.29). Hind limb oxygen consumption increased 35% and fetal arterial oxygen content fell 16%.

CONCLUSION

beta-Hydroxybutyrate may be consumed by the fetal carcass in amounts sufficient to entirely substitute for glucose. Glucose may then be released as lactate for metabolism elsewhere. Ketones may be important fetal substrates during maternal starvation.

Neonatal hematocrit and maternal glycemic control in insulin-dependent diabetes

We hypothesized that in infants of diabetic women neonatal hematocrit would correlate with third-trimester maternal glycemic control. Neonatal hematocrit correlated with the maternal total glycosylated hemoglobin level at delivery (r = 0.36; p less than 0.05) but not at 36 weeks of gestation in 32 mother-infant pairs. Improved maternal glycemic control during late gestation may decrease the incidence of neonatal polycythemia.

Characterization of 1,25-dihydroxyvitamin D3 receptors and in vivo targeting of [3H]-1,25(OH)2D3 in the sheep placenta

We sought to detect the presence of receptors for 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] in placental tissues of five late gestational pregnant sheep and to quantitate their biochemical properties and abundance. Cytosol prepared from cotyledonary tissue was found to contain two [3H]-1,25(OH)2D3 binding macromolecules that sedimented at 3.2 S and 4.1 S, respectively, on linear (4-20 per cent) hypertonic sucrose gradients. The 4.1 S component cosedimented with serum that had been prelabelled with [3H]-25-hydroxyvitamin D3 (25-OHD3) and was present in cytosols despite extensive washing of the tissue prior to homogenization. Concurrent incubation of the cytosol with [3H]-1,25(OH)2D3 and a tenfold molar excess of radioinert 25-OHD3 resulted in complete resolution of the 3.2 S macromolecule and disappearance of the 4.1 S binding component. The binding of [3H]-1,25(OH)2D3 to the 3.2 S component was completely abolished by coincubation with a 100-fold molar excess of radioinert 1,25(OH)2D3 and was replaced by a well resolved peak in the 4.1 S region. Scatchard analysis of cytosol binding to [3H]-1,25(OH)2D3 in the presence of a tenfold molar excess of radioinert 25OHD3 revealed a single class of non-interacting saturable binding site in the cotyledon and the endometrium of high affinity and low capacity. The mean +/- s.e. of the dissociation constant of the cotyledonary receptor of 0.21 +/- 0.06 nM was not different from that of 0.16 +/- 0.03 nM for the endometrial receptor. However, the abundance of the cotyledonary receptor was fourfold higher than that in the endometrium (110 +/- 20 versus 28 +/- 7 fmol/mg protein). Since it is not possible to completely separate endometrial tissue from cotyledonary tissue, the low abundance of receptor in endometrial cytosols may merely represent contamination of endometrial tissue with cotyledonary tissue. Further analysis of the [3H]-1,25(OH)2D3 occupied receptor in cotyledonary cytosols showed that it bound to DNA cellulose and was eluted with 0.16 M KCl. This in vitro binding of [3H]-1,25(OH)2D3 to DNA was confirmed in vivo by the finding of preferential nuclear targetting of [3H]-1,25(OH)2D3 (56 per cent of total cellular activity), 4 h after fetal intravenous administration of [3H]-1,25(OH)2D3 to five chronically catheterized fetal sheep. Total placental uptake of [3H]-1,25(OH)2D3 at this time amounted to 3.7 +/- 0.9 per cent of the injected dose. Preliminary analysis of ovine placental cytosols revealed a calcium binding protein of similar molecular weight to that found in the ovine intestine and in the intestine and placenta of rodents.(ABSTRACT TRUNCATED AT 400 WORDS)

Fetal glucose utilization in response to maternal starvation and acute hyperketonemia

The effects of maternal hypoglycemia and/or hyperketonemia on glucose utilization by individual fetal rat tissues have been studied in vivo. To decrease blood glucose and to raise fetal blood ketone body concentrations, 19-day pregnant rats were submitted to 48 or 96 h of starvation. To differentiate between the effects of decreased blood glucose and increased ketone body concentrations, fed pregnant rats were infused for 2 h with DL-beta-hydroxybutyrate. After 96 h of maternal starvation, fetal 2-deoxy-D-glucose (2DG) uptake decreased from 13.6 +/- 0.5 to 8.6 +/- 1.15 micrograms.min-1.g-1. This was mainly due to a decrease in 2DG uptake by fetal hindlimb muscles and heart. By contrast, 2DG uptake in fetal liver and brain was not affected by maternal starvation. Acute hyperketonemia in fed pregnant rats induced a 23% decrease in 2DG uptake by the whole fetus mainly as the result of a lowered 2DG uptake in fetal hindlimb muscles. These data suggest that fetal 2DG uptake does not simply depend on lowered blood glucose level during maternal starvation but that other hormonal, cardiovascular, or metabolic adaptations are implicated. In the rat, most of the fetal tissues including brain are protected against maternal hypoglycemia.

Alloxan-induced diabetes mellitus in the pregnant ewe: metabolic and cardiovascular effects on the mother and her fetus

Diabetes mellitus was acutely produced in nine pregnant sheep by the intravenous administration of alloxan 40 mg/kg in the maternal inferior vena cava. Maternal and fetal plasma concentrations of glucose, lactate, beta-hydroxybutyrate, insulin, glucagon, and PaO2, oxygen content, and pH were determined before and at days 1, 3, and 5 after the injection of alloxan. Two animals aborted between days 1 and 3 after alloxan administration. In the other animals, significant changes occurred from baseline to day 5: maternal hyperglycemia (56.8 +/- 5.2 vs. 227.3 +/- 54.6 mg/dl; p less than 0.01), maternal hypoinsulinemia (6.2 +/- 3.5 vs. 1.0 +/- 0.4 microU/ml, p = 0.016); maternal hyperketonemia (beta-hydroxybutyrate: 0.79 +/- 0.27 vs. 4.69 +/- 2.64 mmol/L, p less than 0.01); fetal hyperglycemia (17.0 +/- 2.6 vs. 86.0 +/- 16.2 mg/dl, p less than 0.001); fetal hyperinsulinemia (8.4 +/- 4.5 vs. 19.2 +/- 6.4 microU/ml, p less than 0.001); fetal hyperketonemia (beta-hydroxybutyrate: 0.03 +/- 0.03 vs. 0.06 +/- 0.02 mmol/L, p less than 0.05); fetal hypoxemia (arterial PO2: 21.6 +/- 1.8 vs. 18.0 +/- 2.8 mm Hg, p less than 0.05, and oxygen content: 7.1 +/- 0.5 vs. 4.5 +/- 1.9 vol/dl, p less than 0.02). Thus alloxan administered in the pregnant ewe can produce major metabolic and endocrine derangements acutely simulating those occurring in human insulin-dependent diabetic pregnancy.

Diabetes and pregnancy

Prior to the introduction of insulin, a vast majority of pregnancies complicated by diabetes ended in perinatal death, with an associated risk of maternal death. Currently, virtually all diabetic women can undergo pregnancy with the expectation of good maternal and fetal outcome. However, many challenges still remain in preventing congenital anomalies and macrosomia.

Perinatal asphyxia in infants of insulin-dependent diabetic mothers

Infants of diabetic mothers are thought to be at risk for perinatal asphyxia. We hypothesized that the following are significant risk factors for perinatal asphyxia: poor third-trimester glycemic control, diabetic vascular disease (nephropathy, retinopathy) appearing in pregnancy, pregnancy-associated hypertension, smoking, prematurity, fetal macrosomia, and maternal hyperglycemia and hypoglycemia within 6 hours preceding delivery. We prospectively studied 162 infants born to 149 diabetic mothers (White classes B through R-T). Perinatal asphyxia was defined clinically as fetal distress during labor (late decelerations, persistent fetal bradycardia, or both), 1-minute Apgar score less than or equal to 6, or intrauterine fetal death. Forty-four infants (26.7%) had perinatal asphyxia. The presence of perinatal asphyxia did not correlate with third-trimester glycemic control, pregnancy-associated hypertension, smoking, fetal macrosomia, or maternal hypoglycemia before delivery, but it did correlate significantly with nephropathy appearing in pregnancy, maternal hyperglycemia before delivery, and prematurity. We speculate that (1) the appearance of diabetic vasculopathy (nephropathy) during pregnancy is accompanied by placental vascular disease and subsequently by fetal compromise and (2) in pregnancy complicated by diabetes, maternal and subsequently fetal hyperglycemia before delivery leads to fetal hypoxemia.

Beneficial effects of U-63,557A, a thromboxane synthetase inhibitor, in an ovine model of pregnancy-induced hypertension

Pregnancy-induced hypertension was induced in five ewes (gestational day 135; term 150 days) by 72 hours of food deprivation. Maternal arterial pressure, uterine blood flow, platelet function, renal function, and plasma levels of 6-ketoprostaglandin F1 alpha and thromboxane B2 were measured before and during hypertension and after three intravenous injections of U-63,557A; sodium 5-(3'-pyridinylmethyl) benzofuran-2-carboxylate, monohydrate (30 mg/kg every 8 hours). Blood pressure increased (p less than 0.03), and returned to normal after U-63,557A. Left uterine artery blood flow increased after U-63,557A (p less than 0.03). Creatinine clearance decreased during hypertension (p less than 0.03) and increased after U-63,557A. Urine protein increased during hypertension (p less than 0.03) and decreased after treatment. Platelet count dropped during hypertension (p less than 0.03) and was elevated after treatment. Collagen lag phase decreased during hypertension (p less than 0.03) and increased after treatment. After U-63,557A, 6-ketoprostaglandin F1 alpha levels were higher (p less than 0.04) than baseline or hypertensive values. Administration of a thromboxane synthetase inhibitor caused resolution of hemodynamic, renal, and coagulation dysfunctions that occurred in ovine pregnancy-induced hypertension.

Effect of maternal hyperketonemia in hyperglycemic pregnant ewes and their fetuses

The fetus of the pregnant diabetic woman is exposed to hyperglycemia frequently accompanied by ketoacidosis. Previous studies have demonstrated that beta-hydroxybutyrate, a major ketone body, crosses the ovine placenta in significant amounts, leading to significant reductions in fetal PaO2 and increased fetal heart rate. In the present study the pregnant ewe was used to evaluate the maternal and fetal cardiovascular and metabolic responses to hyperketonemia in the presence of hyperglycemia and to determine if the combined diabetic insults were more detrimental to the fetus than hyperketonemia alone. A glucose priming dose of 25 gm was administered in the maternal femoral vein followed by a continuous glucose infusion of 200 mg/min to achieve steady maternal plasma glucose levels of 180 mg/dl. Once glucose levels were stable, beta-hydroxybutyrate was infused for 2 hours at a rate of 0.39 mmol/100 ml of uterine blood flow into both left and right uterine arteries. Infusion of glucose alone did not significantly alter fetal cardiovascular and blood gas parameters but did increase the fetal glucose level from 17 +/- 4 to 58 +/- 8 mg/dl. The simultaneous infusion of beta-hydroxybutyrate and glucose produced significant decreases in fetal PaO2 and oxygen content as were reported for hyperketonemia alone and significant time-related increases in fetal lactate levels and fetal heart rate. These data suggest that hyperketonemia in the pregnant ewe leads to quantitatively similar changes in oxygenation in both normoglycemic and hyperglycemic fetuses. These observations may in part help explain the increased perinatal mortality in the pregnant woman with uncontrolled diabetes.

Relationship of prospective diabetes control in pregnancy to neonatal cardiorespiratory function

We evaluated two groups of diabetic women in pregnancy who differed primarily in the time of initiation of careful diabetes management. Group A (early) were entered in the first trimester (n = 35); group B (late) were entered in the late second or early third trimester (n = 28). Normal women delivering at the same period were used as controls (n = 23). All infants were evaluated by a thorough clinical and echocardiographic examination between 24 and 72 hours of life. Both groups of infants of diabetic mothers had mild increase in mean thickness of ventricular and septal walls compared with those of normal newborn infants, and both had a significant percentage with septal hypertrophy (43% vs 39%). None of the infants in the early group had respiratory symptoms requiring oxygen therapy, compared with 19% in the late group. The early group had significantly fewer infants with elevated right ventricular systolic time interval ratios than did the late group (20% vs 50%); none of the normal infants had elevated ratios. We conclude that careful management of diabetes in pregnancy reduces the severity of hypertrophic cardiomyopathy, although no advantage of early vs late management was obvious. Early management does significantly reduce the number of infants of diabetic mothers who develop respiratory symptoms requiring oxygen therapy.

Effects of chronic ethanol treatment on glucose tolerance, insulin response and circulating metabolites in the pregnant rat

The effects of chronic ethanol treatment on intravenous glucose tolerance and insulin response in non-pregnant and pregnant rats were studied. Basal circulating glucose, insulin, and ketone bodies levels were also determined during the treatment. Basal blood glucose concentration did not change during the ethanol treatment whereas plasma insulin levels were lower at the beginning of gestation and at the 15 and 18 days of pregnancy in ethanol-treated rats. Blood beta-OH-butyrate levels were higher and acetoacetate concentrations unchanged during the ethanol treatment, resulting in augmented beta-OH-butyrate/acetoacetate ratio. Intravenous glucose tolerance was not modified in ethanol-treated rats whilst the associated insulin response was lower in both non-pregnant and pregnant ethanol-treated rats. Data show that ethanol treatment during pregnancy alters glucose-insulin relationships despite being associated with unchanged maternal glycemia.

High malformation rates and decreased mortality in infants of diabetic mothers managed after the first trimester of pregnancy (1956-1978)

Over a period of 23 years we accumulated data on 182 pregnant juvenile diabetic subjects during pregnancy, labor, and delivery. Diabetic subjects were evaluated generally after the first trimester of pregnancy. Data examined included diabetic class, maternal complications of pregnancy, and infant morbidity and mortality. Data were analyzed in two periods-before and after 1970. In the second period, maternal polyhydramnios and acidosis rates improved, neonatal problems of homeostasis did not change significantly, and combined fetal and neonatal losses fell from 34.7% to 16.4%. The neonatal malformation rate, however, increased from 1.4% to 16.8% and was not influenced by maternal age or diabetic class.