Prediction of macrosomia at birth in type-1 and 2 diabetic pregnancies with biomarkers of early placentation

Demethylase FTO-mediated m6A modification of SIK1 modulates placental cytotrophoblast syncytialization in type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) represents a common complication during pregnancy that affects fetoplacental development. We demonstrated the existence of impaired trophoblast syncytialization under hyperglycemic conditions. However, the exact mechanism remains unknown. RNA N6-methyladenosine (m6A) is an emerging regulatory mechanism of mRNA and participates in various biological processes. We described the global m6A modification pattern in T2DM placenta by the combined analysis of methylated RNA immunoprecipitation sequencing (MeRIP-Seq) and RNA sequencing (RNA-Seq). Both the m6A modification and expression of SIK1, which is critical for syncytialization, were significantly decreased in trophoblast exposed to hyperglycemic conditions. In addition, the m6A demethylase fat mass and obesity-associated protein (FTO) affects the expression and mRNA stability of SIK1 by binding to its 3'-untranslated region (UTR) m6A site. This work reveals that the FTO-m6A-SIK1 axis plays critical roles in regulating syncytialization in the placenta.

Placental Growth Factor and Pregnancy-Associated Plasma Protein-A as Potential Early Predictors of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common pregnancy complications and one of the main causes of adverse pregnancy outcomes. An early diagnosis of GDM is of fundamental importance in clinical practice. However, the major professional organizations recommend universal screening for GDM, using a 75 g oral glucose tolerance test at 24-28 weeks of gestation. A selective screening at an early stage of pregnancy is recommended only if there are maternal risk factors for diabetes. As a result, the GDM diagnosis is often delayed and established after the appearance of complications. The manifestation of GDM is directly related to insulin resistance, which is closely associated with endothelial dysfunction. The placenta, the placental peptides and hormones play a pivotal role in the manifestation and progression of insulin resistance during pregnancy. Recently, the placental growth factor (PlGF) and plasma-associated protein-A (PAPP-A), have been shown to significantly affect both insulin sensitivity and endothelial function. The principal function of PAPP-A appears to be the cleavage of circulating insulin-like growth factor binding protein-4 while PlGF has been shown to play a central role in the development and maturation of the placental vascular system and circulation. On one hand, these factors are widely used as early predictors (11-13 weeks of gestation) of complications during pregnancy, such as preeclampsia and fetal aneuploidies, in most countries. On the other hand, there is increasing evidence for their predictive role in the development of carbohydrate disorders, but some studies are rather controversial. Therefore, this review aims to summarize the available literature about the potential of serum levels of PlGF and PAPP-A as early predictors in the diagnosis of GDM.

Secular trend for increasing birthweight in offspring of pregnant women with type 1 diabetes: is improved placentation the reason?

Despite enormous progress in managing blood glucose levels, pregnancy in women with type 1 diabetes still carries risks for the growing fetus. While, previously, fetal undergrowth was not uncommon in these women, with improved maternal glycaemic control we now see an increased prevalence of fetal overgrowth. Besides short-term implications, offspring of women with type 1 diabetes are more likely to become obese and to develop diabetes and features of the metabolic syndrome. Here, we argue that the increase in birthweight is paradoxically related to improved glycaemic control in the pre- and periconceptional periods. Good glycaemic control reduces the prevalence of microangiopathy and improves placentation in early pregnancy, which may lead to unimpeded fetal nutrition. Even mild maternal hyperglycaemia may then later result in fetal overnutrition. This notion is supported by circumstantial evidence that lower HbA_1c levels as well as increases in markers of placental size and function in early pregnancy are associated with large-for-gestational age neonates. We also emphasise that neonates with normal birthweight can have excessive fat deposition. This may occur when poor placentation leads to initial fetal undergrowth, followed by fetal overnutrition due to maternal hyperglycaemia. Thus, the complex interaction of glucose levels during different periods of pregnancy ultimately determines the risk of adiposity, which can occur in fetuses with both normal and elevated birthweight. Prevention of fetal adiposity calls for revised goal setting to enable pregnant women to maintain blood glucose levels that are closer to normal. This could be supported by continuous glucose monitoring throughout pregnancy and appropriate maternal gestational weight gain. Future research should consider the measurement of adiposity in neonates.

The impact of anti-hypertensive treatment on foetal growth and haemodynamics in pregnant women with pre-existing diabetes - An explorative study

OBJECTIVES

To explore the impact of anti-hypertensive treatment of pregnancy-induced hypertension on foetal growth and hemodynamics in women with pre-existing diabetes.

METHODS

A prospective cohort study of 247 consecutive pregnant women with pre-existing diabetes (152 type 1 diabetes; 95 type 2 diabetes), where tight anti-hypertensive treatment was initiated and intensified (mainly with methyldopa) when office blood pressure (BP) ≥135/85 mmHg and home BP ≥130/80 mmHg. Foetal growth was assessed by ultrasound at 27, 33 and 36 weeks and foetal hemodynamics were assessed by ultrasound Doppler before and 1-2 weeks after initiation of anti-hypertensive treatment.

RESULTS

In 215 initially normotensive women, anti-hypertensive treatment for pregnancy-induced hypertensive disorders was initiated in 42 (20%), whilst 173 were left untreated. Chronic hypertension was present in 32 (13%). Anti-hypertensive treatment for pregnancy-induced hypertensive disorders was not associated with foetal growth deviation (linear mixed model, p = 0.681). At 27 weeks, mainly before initiation of anti-hypertensive treatment, the prevalence of small foetuses with an estimated foetal weight <10th percentile was 12% in women initiating anti-hypertensive treatment compared with 4% in untreated women (p = 0.054). These numbers were close to the prevalence of birth weight ≤10th percentile (small for gestational age (SGA)) (17% vs. 4%, p = 0.003). Pulsatility index in the umbilical and middle cerebral artery remained stable after the onset of anti-hypertensive treatment in a representative subgroup (n = 12, p = 0.941 and p = 0.799, respectively).

CONCLUSION

There is no clear indication that antihypertensive treatment causes harm in this particular at-high-risk group of pregnant women with diabetes, such that a larger well-designed study to determine the value of tight antihypertensive control would be worthwhile.

Galectins in Early Pregnancy and Pregnancy-Associated Pathologies

Galectins are a family of conserved soluble proteins defined by an affinity for β-galactoside structures present on various glycoconjugates. Over the past few decades, galectins have been recognized as important factors for successful implantation and maintenance of pregnancy. An increasing number of studies have demonstrated their involvement in trophoblast cell function and placental development. In addition, several lines of evidence suggest their important roles in feto-maternal immune tolerance regulation and angiogenesis. Changed or dysregulated galectin expression is also described in pregnancy-related disorders. Although the data regarding galectins' clinical relevance are still at an early stage, evidence suggests that some galectin family members are promising candidates for better understanding pregnancy-related pathologies, as well as predicting biomarkers. In this review, we aim to summarize current knowledge of galectins in early pregnancy as well as in pregnancy-related pathologies.

A first trimester prediction model for large for gestational age infants: a preliminary study

Background

Large for gestational age infants (LGA) have increased risk of adverse short-term perinatal outcomes. This study aims to develop a multivariable prediction model for the risk of giving birth to a LGA baby, by using biochemical, biophysical, anamnestic, and clinical maternal characteristics available at first trimester.

Methods

Prospective study that included all singleton pregnancies attending the first trimester aneuploidy screening at the Obstetric Unit of the University Hospital of Modena, in Northern Italy, between June 2018 and December 2019.

Results

A total of 503 consecutive women were included in the analysis. The final prediction model for LGA, included multiparity (OR = 2.8, 95% CI: 1.6–4.9, p = 0.001), pre-pregnancy BMI (OR = 1.08, 95% CI: 1.03–1.14, p = 0.002) and PAPP-A MoM (OR = 1.43, 95% CI: 1.08–1.90, p = 0.013). The area under the ROC curve was 70.5%, indicating a satisfactory predictive accuracy. The best predictive cut-off for this score was equal to − 1.378, which corresponds to a 20.1% probability of having a LGA infant. By using such a cut-off, the risk of LGA can be predicted in our sample with sensitivity of 55.2% and specificity of 79.0%.

Conclusion

At first trimester, a model including multiparity, pre-pregnancy BMI and PAPP-A satisfactorily predicted the risk of giving birth to a LGA infant. This promising tool, once applied early in pregnancy, would identify women deserving targeted interventions.

Trial registration

ClinicalTrials.gov NCT04838431, 09/04/2021.

Can placental growth factors explain birthweight variation in offspring of women with type 1 diabetes?

AIMS/HYPOTHESIS

Maternal hyperglycaemia alone does not explain the incidence of large offspring amongst women with type 1 diabetes. The objective of the study was to determine if there is an association between placental function, as measured by angiogenic factors, and offspring birthweight z score in women with type 1 diabetes.

METHODS

This cohort study included samples from 157 Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes (CONCEPTT) trial participants. Correlations were estimated between birthweight z score and placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1) levels measured at baseline and at 24 and 34 weeks of gestation. Linear regression was used to assess the relationship between birthweight z score and placental health, as measured by PlGF and sFlt-1/PlGF ratio, stratified by glycaemic status (continuous glucose monitoring and HbA_1c measures) and adjusted for potential confounders of maternal BMI, smoking and weight gain. Higher PlGF levels and lower sFlt-1/PlGF ratios represent healthy placentas, while lower PlGF levels and higher sFlt-1/PlGF ratios represent unhealthy placentas.

RESULTS

Among CONCEPTT participants, the slopes relating PlGF levels to birthweight z scores differed according to maternal glycaemia at 34 weeks of gestation (p = 0.003). With optimal maternal glycaemia (HbA_1c < 48 mmol/mol [6.5%]/ or continuous glucose monitoring time above range ≤ 30%), birthweight z scores were reduced towards zero (normal weight) with increasing PlGF values (representing a healthy placenta), and increased with decreasing PlGF values. With suboptimal glycaemic status (HbA_1c ≥ 48 mmol/mol [6.5%] or time above range > 30%), increasing PlGF values were associated with heavier infants. Those with a healthy placenta (PlGF > 100) and suboptimal glycaemic control had a higher mean z score (2.45) than those with an unhealthy placenta (mean z score = 1.86). Similar relationships were seen when using sFlt-1/PlGF ratio as a marker for a healthy vs unhealthy placenta.

CONCLUSIONS/INTERPRETATION

In women with type 1 diabetes, infant birthweight is influenced by both glycaemic status and placental function. In women with suboptimal glycaemia, infant birthweight was heavier when placentas were healthy. Suboptimal placental function should be considered in the setting of suboptimal glycaemia and apparently 'normal' birthweight.

First trimester combined screening test for aneuploidies in anti-Ro carriers pregnant women

INTRODUCTION

Anti-Ro/SSA and anti-La/SSB antibodies are associated with neonatal lupus and congenital heart block. Controversial results regarding perinatal outcomes are found and less is known about aneuploidy screening. The hypothesis is that the presence of anti-Ro and/or anti-La antibodies influences the levels of PAPP-A and ß-HCG, thus interfering in the calculation of risk of aneuploidies.

MATERIAL AND METHODS

Fifty-five anti-Ro/SSA positive pregnant women were included. The demographic characteristics and laboratory variables were studied. Data concerning chromosomopaties screening were also recorded.

RESULTS

PAPP-A and β-HCG levels were calculated (as well as NT and CRL) and compared with a healthy cohort of 12971 pregnant women. PAPP-A levels in mg/mL were lower significatively. In anti-La/SS-B cohort, significant differences were found in PAPP-A in mg/mL and in MoM. Combined risks for Down syndrome (DS) in both groups were higher but the differences were due to age.

CONCLUSIONS

Serum levels of PAPP-A were significative lower but not confirmed when adjusted to MoM. This will have to be confirmed in studies with a larger number of patients and to check whether there is an impact in the calculation of DS risk or not. They could represent a group of pregnant women with significantly a higher risk of adverse perinatal outcome. Key Points • Pregnant patients with anti-Ro/SS-A ant/or anti-La/SS-B antibodies have low PAPP-A levels compared with pregnant women without antibodies. • PAPP-A levels are used in obstetrics for aneuploidies screening in the first trimester, so in these patients, there could be more false positive screening. • In these findings are verified in trials with a larger number of patients, a correction variable would have to be applied for the aneuploidies screening calculation. • Also, low PAPP-A levels are correlated with poor placentation, that is to say, more risk of miscarriages, small fetus for gestational age, and preeclampsia. This is another topic to take into consideration in this population.

Fetal overgrowth in pregnancies complicated by diabetes: validation of a predictive index in an external cohort

PURPOSE

To assess validity of a fetal overgrowth index in an external cohort of women with diabetes in pregnancy METHODS: We performed a retrospective analysis of data derived from women with singleton gestations complicated by diabetes who delivered January 2015-June 2018. The following index variables were used to calculate risk of fetal overgrowth as defined by a customized birthweight ≥ 90th centile: age, history of fetal overgrowth in a prior pregnancy, gestational weight gain, fetal abdominal circumference measurement and fasting glucose between 24 and 30 weeks.

RESULTS

In our validation cohort, 21% of 477 pregnancies were complicated by fetal overgrowth. The predictive index had a bias-corrected bootstrapped area under receiver operating characteristic curve of 0.90 (95% CI 0.86-0.93). 55% of the cohort had a low-risk index (≤ 3) which had a negative predictive value of 97% (95% CI 94-98%), while 18% had a high-risk index (≥ 8) that had a positive predictive value of 74% (95% CI 66-81%).

CONCLUSION

The fetal overgrowth index incorporates five factors that are widely available in daily clinical practice prior to the period of maximum fetal growth velocity in the third trimester. Despite substantial differences between our cohort and the one studied for model development, we found the performance of the index was strong. This finding lends support for the general use of this tool that may aid counseling and allow for targeted allocation of healthcare resources among women with pregnancies complicated by diabetes.

Both glycaemic control and insulin dose during pregnancy in women with type 1 diabetes are associated with neonatal anthropometric measures and placental weight

BACKGROUND

To investigate longitudinal associations of maternal glucose/HbA_1c and insulin dose with birthweight-related outcomes in women with type 1 diabetes.

METHODS

We performed a cohort study including 473 pregnant women with type 1 diabetes with singleton pregnancies. We investigated maternal self-monitored blood glucose (SMBG, mmol/L), HbA_1c (%, mmol/mol) and insulin dose (IU/kg/day) in the three trimesters as potential independent variables, while adjusting for potential confounders. Outcomes of interest were birthweight, birthweight SD score, neonatal length, weight/length index, ponderal index and placental weight. Multiple linear regression analysis was performed with separate analyses for SMBG and HbA_1c .

RESULTS

Maternal glucose and insulin dose were independently associated with birthweight-related outcomes. In the main analysis, in the first trimester most associations were positive for insulin dose, in the second the associations were positive for glucose and inverse for insulin while in the third there were no associations. Most sensitivity analyses produced consistent results. In a sensitivity analysis splitting the first trimester in two periods, positive associations of maternal insulin with birthweight-related outcomes were observed in weeks 0+ to 6+.

CONCLUSIONS

Early in pregnancy in women with type 1 diabetes, maternal insulin dose is positively associated with birthweight-related outcomes, whereas in the second trimester, a positive association with SMBG emerges and the association with maternal insulin becomes inverse. If confirmed in other cohorts, these results would have implications in the management of women with type 1 diabetes.

Fibrin/fibrinogen degradation products in late pregnancy promote macrosomia prediction in normal uncomplicated pregnancy

OBJECTIVE

The purpose of this study was to explore the association of fibrin/fibrinogen degradation products (FDP) levels with the risk of macrosomia, and determine whether FDP, either alone or combined with traditional factors in late pregnancy, could be used to predict macrosomia at birth in healthy pregnancies.

METHODS

A total of 9464 health pregnant women with singleton pregnancy were recruited in this retrospective cohort study. Maternal plasma FDP levels at hospital admission and birth outcomes were obtained from laboratory system and hospital records, respectively.

RESULTS

FDP levels in late pregnancy were significant higher in women who delivered macrosomia than those who delivered infants with normal weight [median (interquartile range, IQR): 8.2 (5.8-11.9) vs. 6.6 (4.7-9.6) mg/L; P < 0.001]. Multivariable logistic regression analysis demonstrated that FDP levels were independently associated with macrosomia risk. Pregnant women in the highest quartile of FDP had a 2.99-fold higher risk of delivering macrosomia compared with those in the lowest (adjusted OR: 2.99; 95% CI: 2.27-3.93). In addition, the incorporation of FDP into the crude prediction model significantly improved the area under curve (AUC) for predicting macrosomia (0.774 vs. 0.787; P < 0.001).

CONCLUSION

Our findings suggest that maternal plasma FDP levels in late pregnancy are independently and significantly associated with risk of macrosomia. Combination of FDP levels and traditional risk factors could promote the prediction of macrosomia.

Are the first-trimester levels of PAPP-A and fb-hCG predictors for obstetrical complications in diabetic pregnancy?

Objective: To assess the levels of pregnancy-associated plasma protein-A (PAPP-A) and β-human chorionic gonadotropin (fb-hCG) in cases of diabetic pregnancy, to determine whether these biomarkers can be considered significant predictors for macrosomia, preeclampsia (PE), intrauterine growth restriction (IUGR), and preterm birth in mothers with different types of pregestational diabetes mellitus (DM).Methods: It was a retrospective cohort study. Study groups were presented: type 1 DM (n = 100), type 2 DM (n = 50), and controls (n = 25). At 11 + 0 to 13 + 6 week's gestation, we recorded maternal characteristics and medical history, and performed a combined test for the detection of risk of chromosomal abnormalities. To assess the performance of the markers in the prediction of the main obstetrical complications (PE, IUGR, preterm birth, and macrosomia), receiver-operating characteristic (ROC) curves were produced and area under the curves was calculated.Results: The study has shown that DM is associated with a high rate of perinatal complications: PE, IUGR, macrosomia, and preterm birth. The median level of PAPP-A was significantly lower in case of type 1 DM- 0.89 (inter quartile range (IQR), 0.51-1.1), and type 2 DM-0.88 (IQR, 0.42-1.15) compared to the unaffected group 1.03 (IQR, 0.96-1.12; p = .025). There were no significant differences in the fb-hCG multiples of the normal median (MoM; p = .14) between the diabetic and unaffected groups. More significant results were obtained when calculated by percentile: in diabetic pregnancies, PAPP-A and fb-hCG MoMs values were lower in the 5-10% ranges and higher in the 95% range, compared to the control group. ROC-analysis did not show any significant data that first-trimester PAPP-A and fb-hCG serum levels are predictors for PE, IUGR, macrosomia, and preterm birth.Conclusion: The routine first-trimester serum screening of fetal Down syndrome cannot be used as a tool of risk identification for PE, IUGR, macrosomia, and preterm birth in case of diabetic pregnancy.

The utility of pregnancy associated plasma protein-A MoM values in prediction of term respiratory distress syndrome

This study aimed to investigate if the pregnancy associated plasma Protein-A (PAPP-A) multiples of median (MoM) levels could be used as a marker for the early prediction of RDS. The present study was designed with data gathered from 1773 patients who were referred to our institution for first trimester fetal chromosomal anomaly screening. First trimester PAPP-A MoM values and postnatal RDS occurrences in these pregnancies were retrospectively analysed. Of the 1773 neonates that were included in the study, 28 were delivered at or beyond 37 weeks, and 42 were delivered less than 37 weeks of gestation. In the group of neonates at or beyond 37 weeks, the cut-off value for RDS prediction was determined as 1.02. For this cut-off value, sensitivity was 72.41% and specificity was 91.84%. The area under curve (AUC) was determined to be statistically significant (p < .01). In conclusion, it was determined that in neonates that were delivered at or beyond 37 weeks of gestation, RDS occurrence could be predicted at a significant rate by utilising PAPP-A MoM values.IMPACT STATEMENTWhat is already known on this subject? Respiratory distress syndrome (RDS) is one of the major global healthcare problems, and continues to effect newborns despite the improvements in diagnosis and treatments of the disease. Studies have shown that pregnancy associated plasma protein-A (PAPP-A) has a critical role in cellular proliferation and differentiation, and it is closely associated with many physiological and pathological processes via regulation of local insulin like growth factor (IGF) concentrations. In majority of the past studies in the literature regarding PAPP-A values in pregnancies, the association between low values of PAPP-A MoM and maternal-fetal complications were investigated.What do the results of this study add? This study retrospectively examines the PAPP-A MoM levels and the occurence of RDS. In neonates that were delivered at or beyond 37 weeks of gestation, RDS occurrence could be predicted at a significant rate by utilising PAPP-A MoM values which was measured at the first trimester fetal anomaly screening test.What are the implications of these findings for clinical practice and/or further research? In the light of these findings, in order to reduce RDS related neonatal morbidity and mortality, pregnancies with PAPP-A MoM values greater than 1.02 at the first trimester fetal anomaly screening should be more closely followed up and a higher rate of suspicion should be kept for RDS occurrence.

Expression profile of circular RNAs in placentas of women with gestational diabetes mellitus

Forty-five pregnant women who underwent cesarean section, including 30 cases of gestational diabetes mellitus (GDM) and 15 normal pregnant women, were enrolled in this study to examine the differential expression of circular RNAs (circRNAs) in the placentas of women with GDM by RNA sequencing (RNA-seq) analysis. The differentially expressed circRNAs were analyzed bioinformatically using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment and circRNA-microRNA (miRNA) interaction prediction. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to verify the results. A total of 8,321 circRNAs were identified in the human placenta, among which 46 were differentially expressed (fold change ≥2 and p < 0.05), including three that were upregulated and 43 that were downregulated. According to the GO and KEGG enrichment results, these circRNAs may be associated with vital biological processes, cellular components, molecular functions, and signaling pathways. In particular, KEGG analysis shown they may be involved in advanced glycation end products-receptor for advanced glycation end products (AGE-RAGE) signaling pathway in diabetic complications, indicating that these circRNAs might participate in the occurrence and pathogenesis of GDM. qRT-PCR verified that the expression of circ_5824, circ_3636, and circ_0395 was consistent with RNA-seq analysis; their expression levels were significantly lower in the GDM group than in the control group. The circRNA-miRNA interaction was analyzed according to the molecular sponge mechanism, and its potential function is discussed. These results shed light on future functional studies of circRNAs related to GDM.

Macrosomia. A Systematic Review of Recent Literature

Background and aims: The obesity and overweight rate among women of childbearing age and fetal macrosomia associated with different birth injuries are very frequent all over the world and with an increasing incidence. The huge amount of published literature on this topic in the last decade is putting the practioners in a very challenging position. Material and method: We have done a systematic review on the recent literature (last five years) based on science direct database. Results: A total of 5990 articles were identified and after successive exclusion of some of them, 48 were deeply analyzed. The results were grouped in following topics: risk factors for fetal macrosomia, the pathophysiology of macrosomia, prenatal clinical and lab diagnosis and prevention of macrosomia. Conclusions: Considering the maternal, fetal and neonatal complications of macrosomia, the counseling, and monitoring of the pregnant women risk group are of particular importance for adopting a low calorie / low glycemic diet and avoiding a sedentary behaviour. Long-term follow-up of the mother and the macrosomic baby is required because of the risk of obesity, diabetes, hypertension, and metabolic syndrome later in life.

Maternal diabetes alters the development of ductus venosus shunting in the fetus

INTRODUCTION

Despite adequate glycemic control, the risks of fetal macrosomia and perinatal complications are increased in diabetic pregnancies. Adjustments of the umbilical venous distribution, including increased ductus venosus shunting, can be important fetal compensatory mechanisms, but the impact of pregestational diabetes on umbilical venous and ductus venosus flow is not known.

MATERIAL AND METHODS

In this prospective study, 49 women with pregestational diabetes mellitus underwent monthly ultrasound examinations from gestational week 20 to 36. The blood velocity and the mean diameters of the umbilical vein and ductus venosus were used for calculating blood flow volumes. The development of the umbilical venous flow, ductus venosus flow and ductus venosus shunt fraction (% of umbilical venous blood shunted through the ductus venosus) was compared with a reference population, and the effect of HbA_1c on the ductus venosus flow was assessed.

RESULTS

The umbilical venous flow was larger in pregnancies with pregestational diabetes mellitus than in low-risk pregnancies (p < 0.001) but smaller when normalized for fetal weight (p = 0.036). The distributional pattern of the ductus venosus flow developed differently in diabetic pregnancies, particularly during the third trimester, being smaller (p = 0.007), also when normalized for fetal weight (p < 0.001). Correspondingly, the ductus venosus shunt fraction was reduced (p < 0.0001), most prominently at 36 weeks. There were negative relations between the maternal HbA_1c and the ductus venosus flow velocity, flow volume and shunt fraction.

CONCLUSIONS

In pregnancies with pregestational diabetes mellitus, prioritized umbilical venous distribution to the fetal liver and lower ductus venosus shunt capacity reduce the compensatory capability of the fetus and may represent an augmented risk during hypoxic challenges during late pregnancy and birth.

Continuous subcutaneous insulin infusion vs multiple daily injections in pregnant women with type 1 diabetes mellitus: a systematic review and meta-analysis of randomised controlled trials and observational studies

BACKGROUND

Randomised controlled trials (RCTs) have shown an advantage of continuous subcutaneous insulin infusion (CSII) over multiple daily injections (MDI) in the general type 1 diabetes mellitus (T1DM) population. RCT data on T1DM management in pregnancy remain limited.

OBJECTIVE

We performed a systematic review of both RCTs and non-RCTs evaluating CSII vs MDI in T1DM-complicated pregnancy.

STUDY DESIGN

Electronic databases were searched for studies comparing CSII with MDI in T1DM-complicated pregnancy.

METHODS

A meta-analysis provided point estimates with 95% confidence intervals (CI). Continuous outcomes were reported as weighted mean differences (WMD) or standardised mean differences (SMD), and dichotomous data as relative risk (RR).

RESULTS

The search identified 47 studies, including 43 non-RCTs, reporting on 7824 pregnancies. The meta-analysis showed a lower HbA1c level with CSII vs MDI in the first trimester (WMD: -0.45%; 95%CI: -0.62, -0.27). This difference decreased in subsequent trimesters. Compared to MDI, therapy with CSII resulted in higher gestational weight gain (GWG) (WMD: 1.02 kg; 95%CI: 0.41, 1.62), and lower daily insulin dose requirements in the first (SMD: -0.46; 95%CI: -0.68, -0.24) and subsequent trimesters. Moreover, infants from the CSII group were more likely to be large for gestational age (LGA) (RR: 1.16; 95%CI: 1.07, 1.24) and less likely to be small for gestational age (SGA) (RR: 0.66; 95%CI: 0.45; 0.97).

CONCLUSIONS

In T1DM-complicated pregnancy, CSII compared to MDI therapy resulted in better first trimester glycaemic control; this difference decreased in subsequent trimesters. CSII therapy was associated with lower insulin requirements, higher GWG and altered risk for infants being LGA and SGA.

First-trimester irisin and fetuin-A concentration in predicting macrosomia

Objective: We investigated the diagnostic value of first-trimester adipokines and placental markers in predicting macrosomia. Methods: Out of 328 women recruited during the prenatal diagnosis between 11th and 13th week of pregnancy and subjected to follow up until delivery, we selected 26 women who gave birth to macrosomic babies and 34 women who gave birth to normal weight neonates for the evaluation of first trimester serum levels of pregnancy associated plasma protein-A, free β-human chorionic gonadotropin, placental growth factor (PIGF), and selected adipokines. Results: The mothers of macrosomic infants had higher PIGF (p = .049) and irisin concentrations (p = .00003), and lower fetuin-A levels (p = .0002) than had the mothers of normal weight babies. Newborn's weight correlated positively with maternal irisin (R = 0.454, p = .0003) and negatively with fetuin-A concentrations (R = -0.497, p = .00005). Multiple regression analysis showed that only serum irisin concentration was a significant predictor of birth weight (β = 0.329, p = .03), explaining 14% of its variability. The sensitivity and the specificity of irisin concentration in predicting macrosomia were 0.769 and 0.794, respectively (AUC = 0.818 [95%CI: 0.708-0.928], p = .00001) with a proposed cut-off value of 1725.4 ng/ml. Conclusions: Our results suggest that mother's irisin may be an early biomarker of macrosomia.

Accelerated fetal growth in early pregnancy and risk of severe large-for-gestational-age and macrosomic infant: a cohort study in a low-risk population

INTRODUCTION

Our objective was to examine the association between fetal growth in early pregnancy and risk of severe large-for-gestational-age (LGA) and macrosomia at birth in a low-risk population.

MATERIAL AND METHODS

Cohort study that included 68 771 women with non-anomalous singleton pregnancies, without history of diabetes or hypertension, based on an electronic database on pregnancies and deliveries in Stockholm-Gotland Region, Sweden, 2008-2014. We performed multivariable logistic regression to estimate the association between accelerated fetal growth occurring in the first through early second trimester as measured by ultrasound and LGA and macrosomia at birth. Restricted analyses were performed in the groups without gestational diabetes and with normal body mass index (18.5-24.9 kg/m² ).

RESULTS

When adjusting for confounders, the odds of having a severely LGA or macrosomic infant were elevated in mothers with fetuses that were at least 7 days larger than expected as compared with mothers without age discrepancy at the second-trimester scan (adjusted odds ratio 1.80; 95% CI 1.23-2.64 and adjusted odds ratio 2.15; 95% CI 1.55-2.98, respectively). Additionally, mothers without gestational diabetes and mothers with normal weight had an elevated risk of having a severely LGA or macrosomic infant when the age discrepancy by second-trimester ultrasound was at least 7 days.

CONCLUSIONS

In a low-risk population, ultrasound-estimated accelerated fetal growth in early pregnancy was associated with an increased risk of having a severely LGA or macrosomic infant.

Fetal growth trajectories in pregnancies of European and South Asian mothers with and without gestational diabetes, a population-based cohort study

Objective

Our aim was to examine the impact of gestational diabetes (GDM), from before the GDM-diagnosis is made, on fetal growth trajectories, and to compare it in Europeans and South Asians; two ethnic groups with dissimilar fetal growth patterns.

Methods

We studied European (n = 349) and South Asian (n = 184) pregnant women, from the population-based STORK-Groruddalen cohort in Oslo, Norway. Mothers were enrolled in early pregnancy, screened for GDM in gestational week 28 ±2, and classified as “non-GDM”, “mild GDM” or “moderate/severe GDM”. We measured fetal head circumference, abdominal circumference and femur length by ultrasound, and estimated fetal weight in gestational week 24, 32 and 37, and performed corresponding measurements at birth.

Results

In non-GDM pregnancies, South Asian fetuses (n = 156) had a slower growth from gestational week 24, compared with Europeans (n = 310). More than two thirds of the European mothers later diagnosed with GDM were overweight or obese in early pregnancy, while this was not observed in South Asians. Fetuses of GDM mothers tended to be smaller than fetuses of non-GDM mothers in week 24, but thereafter grew faster until birth. This pattern was especially pronounced in fetuses of South Asian mothers with moderate/severe GDM. In week 24 these fetuses had a -0.95 SD (95% CI: -1.53, -0.36) lower estimated fetal weight than their non-GDM counterparts. In contrast, at birth they were 0.45 SD (0.09, 0.81) larger.

Conclusions

Offspring of GDM mothers were smaller in mid pregnancy, but subsequently grew faster until birth, compared with offspring of non-GDM mothers. This pattern was most prominent in South Asian mothers with moderate to severe GDM. However, the most remarkable characteristic of these fetuses was not a large size at birth, but the small size in mid pregnancy, before the GDM diagnosis was set.

Growth and BMI during the first 14 y of life in offspring from women with type 1 or type 2 diabetes mellitus

BACKGROUND

Infants of women with pregestational diabetes are at risk for developing obesity in later life. This study aimed to identify subgroups at highest risk, by studying growth profiles of offspring from women with type 1 or 2 diabetes mellitus (ODM1, ODM2) until the age of 14 y.

METHODS

Information from infant welfare centers was received for 78 ODM1 and 44 ODM2. Mean BMI SD scores (SDS) (based on 1980 nation-wide references) and height SDS (based on 2009 references) were calculated and included in a random-effects model. Values were compared to the 2009 Dutch growth study.

RESULTS

BMI SDS profiles differed between ODM1 and ODM2, with the highest mean BMI SDS profiles in ODM2. Other factors that affected growth profiles in these infants included the presence of maternal obesity, large for gestational age (LGA) at birth and in ODM2 a Dutch-Mediterranean origin.

CONCLUSION

Offspring of women with diabetes have higher BMI SDS profiles than observed in the 2009 Dutch growth study, with the highest BMI SDS in ODM2 who are LGA at birth and have obese mothers. Preventive strategies for offspring adiposity may include pursuing lower prepregnancy maternal BMI, prevention of LGA at birth, and prevention of increased weight gain during childhood.

Time-specific placental growth factor (PlGF) across pregnancy and infant birth weight in women with preexisting diabetes

OBJECTIVE

Determine the independent association between time-specific placental growth factor (PIGF)-a marker of placental vasculature-and infant birth weight in offspring of mothers with preexisting type 1 and 2 diabetes.

METHODS

A total of 150 women were recruited from Joslin Diabetes Center's/Beth Israel Deaconess Medical Center's Diabetes in Pregnancy Program. PlGF was measured up to four times during pregnancy. Infant birth weight and covariate data were collected from medical records. Hemoglobin A1c was assessed from drawn blood samples. We used generalized linear and log-binomial models to calculate the change in continuous birth weight, as well as macrosomia for every unit change in time-specific ln-transformed PlGF, respectively. Models were adjusted for potential confounders.

RESULTS

Approximately 75% of women had type 1 diabetes. Third trimester PlGF levels were significantly associated with infant birth weight (r = 0.24, p = 0.02 at 27-34 weeks; r = 0.26, p < 0.009 for 36-40 weeks). After full adjustment, there was a 6.1% and 6.6% increase in birth weight for gestational age percentile for each unit increase in ln-transformed PlGF level at 27-34 weeks and 35-40 weeks, respectively (95% CI for 27-34 weeks gestation: 1.1, 11.0, and 95% CI for 35-40 weeks gestation: 0.7%, 12.5%). We found a statistically significant increased risk of macrosomia among women with higher ln-transformed PlGF levels (RR: 1.72; 95% CI: 1.09, 2.70). Associations were not mediated by hemoglobin A1c.

CONCLUSIONS

Third trimester PlGF levels were associated with higher birth weight in women with preexisting diabetes. These findings may provide insight to the pathophysiology of fetal overgrowth in women with diabetes.

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.

Serum free β-human chorionic gonadotropin in the three trimesters of pregnancy: effects of maternal characteristics and medical history

OBJECTIVE

To define the contribution of maternal variables which influence the measured level of maternal serum free β-human chorionic gonadotropin (β-hCG) in screening for pregnancy complications.

METHODS

Maternal characteristics and medical history were recorded and serum free β-hCG was measured in women with a singleton pregnancy attending for three routine hospital visits at 11 + 0 to 13 + 6, 19 + 0 to 24 + 6 and 30 + 0 to 34 + 6 weeks' gestation. For pregnancies delivering phenotypically normal live births or stillbirths ≥ 24 weeks' gestation, variables from maternal demographic characteristics and medical history that are important in the prediction of free β-hCG were determined from a linear mixed-effects multiple regression.

RESULTS

Serum free β-hCG was measured in 94 985 cases in the first trimester, 7879 in the second trimester and 8424 in the third trimester. Significant independent contributions to serum free β-hCG were provided by gestational age, maternal weight, age and racial origin, cigarette smoking, method of conception, diabetes mellitus and family history of pre-eclampsia (PE) in the mother of the patient. The effects of some variables were similar and those for others differed in each trimester. Random-effects multiple regression analysis was used to define the contribution of maternal variables that influence the measured level of serum free β-hCG and express the values as multiples of the median (MoMs). The model was shown to provide an adequate fit of MoM values for all covariates both in pregnancies that developed PE and in those without this pregnancy complication.

CONCLUSIONS

A model was fitted to express measured serum free β-hCG across the three trimesters of pregnancy as MoMs after adjusting for variables from maternal characteristics and medical history that affect this measurement.

Comparison of different blood collection, sample matrix, and immunoassay methods in a prenatal screening setting

We compared how measurements of pregnancy-associated plasma protein A (PAPP-A) and the free beta subunit of human chorionic gonadotropin (fβ-hCG) in maternal blood are influenced by different methods for blood collection, sample matrix, and immunoassay platform. Serum and dried blood spots (DBS) were obtained by venipuncture and by finger prick of 19 pregnant women. PAPP-A and fβ-hCG from serum and from DBS were measured by conventional indirect immunoassay on an AutoDELFIA platform and by antibody microarray. We compared methods based on the recoveries for both markers as well as marker levels correlations across samples. All method comparisons showed high correlations for both marker concentrations. Recovery levels of PAPP-A from DBS were 30% lower, while those of fβ-hCG from DBS were 50% higher compared to conventional venipuncture serum. The recoveries were not affected by blood collection or immunoassay method. The high correlation coefficients for both markers indicate that DBS from finger prick can be used reliably in a prenatal screening setting, as a less costly and minimally invasive alternative for venipuncture serum, with great logistical advantages. Additionally, the use of antibody arrays will allow for extending the number of first trimester screening markers on maternal and fetal health.

Insulin pump use in pregnancy is associated with lower HbA1c without increasing the rate of severe hypoglycaemia or diabetic ketoacidosis in women with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this study was to compare glycaemic control and maternal-fetal outcomes in women with type 1 diabetes managed on insulin pumps compared with multiple daily injections of insulin (MDI).

METHODS

In a retrospective study, glycaemic control and outcomes of 387 consecutive pregnancies in women with type 1 diabetes who attended specialised clinics at three centres 2006-2010 were assessed.

RESULTS

Women using insulin pumps (129/387) were older and had a longer duration of diabetes, more retinopathy, smoked less in pregnancy, and had more preconception care (p < 0.01 for each). Among 113 pregnancies >20 weeks' gestation in women on insulin pumps and 218 in women on MDI, there was a significant difference in HbA1c in the first trimester (mean HbA1c 6.90 ± 0.71% (52 ± 7.8 mmol/mol) vs 7.60 ± 1.38% (60 ± 15.1 mmol/mol), p < 0.001), which persisted until the third trimester (mean HbA1c 6.49 ± 0.52% (47 ± 5.7 mmol/mol) vs 6.81 ± 0.85% (51 ± 9.3 mmol/mol), p = 0.002). Rates of diabetic ketoacidosis were similar in women on insulin pumps vs MDI (1.8% vs 3.0%, p = 0.72). Despite lower HbA1c, women on insulin pumps did not have an increased incidence of severe hypoglycaemia (8.0% vs 7.6%, p = 0.90) or more weight gain (16.3 ± 8.7 vs 15.2 ± 6.2 kg, p = 0.18). More large-for-gestational-age infants in the pump group (55.0% vs 39.2%, p = 0.007) may have resulted from confounding by parity.

CONCLUSIONS/INTERPRETATION

In this large multicentre study, women using insulin pumps in pregnancy had lower HbA1c without increased risk of severe hypoglycaemia or diabetic ketoacidosis but no improvement in other pregnancy outcomes. This information can help inform care providers and patients about the glycaemic effectiveness and safety of insulin pumps in pregnancy.

The association between gestational diabetes mellitus and first trimester aneuploidy screening markers

Objective

To establish whether maternal serum first trimester concentrations of PAPP-A and free hCGβ are altered in pregnancies that subsequently are diagnosed by an oral glucose tolerance test (OGTT) with gestational diabetes mellitus (GDM).

Methods

Over the period 2009 and 2011, the results for women who had first trimester screening for aneuploidy were matched with those having an oral glucose tolerance test at 22–26 weeks for suspected GDM. Free hCGβ, PAPP-A and NT MoMs were compared amongst the group having an OGTT with confirmed GDM and those in which GDM was not confirmed. A second comparison group consisted of all non-aneuploidy singleton pregnancies in which no OGTT was performed.

Results

During the three-year period, 27,660 singleton pregnancies were screened of which 7429 cases had an OGTT of which 870 cases were classed as GDM by WHO criteria. There was a significant 7–9% reduction in both PAPP-A and free hCGβ MoM in the GDM group compared with either the OGTT non-GDM group or the remaining pregnancies with no known risk factors for evidence of GDM. There was no difference in the NT measurements.

Conclusions

First trimester concentrations of PAPP-A and free hCGβ are reduced in pregnancies that subsequently are diagnosed with GDM and may be useful in further screening algorithms for this disorder although the sensitivity alone is quite poor.

Fractalkine (CX3CL1) and its receptor CX3CR1 may contribute to increased angiogenesis in diabetic placenta

Chemokine CX3CL1 is unique, possessing the ability to act as a dual agent: chemoattractant and adhesive compound. Acting via its sole receptor CX3CR1, CX3CL1 participates in many processes in human placental tissue, including inflammation and angiogenesis. Strongly upregulated by hypoxia and/or inflammation-induced inflammatory cytokines secretion, CX3CL1 may act locally as a key angiogenic factor. Both clinical observations and histopathological studies of the diabetic placenta have confirmed an increased incidence of hypoxia and inflammatory reactions with defective angiogenesis. In this study we examined comparatively (diabetes class C complicated versus normal pregnancy) the correlation between CX3CL1 content in placental tissue, the mean CX3CR1 expression, and density of the network of placental microvessels. A sandwich enzyme immunoassay was applied for CX3CL1 measurement in placental tissue homogenates, whereas quantitative immunohistochemical techniques were used for the assessment of CX3CR1 expression and the microvascular density. Significant differences have been observed for all analyzed parameters between the groups. The mean concentration of CX3CL1 in diabetes was increased and accompanied by augmented placental microvessel density as well as a higher expression of CX3CR1. In conclusion, we suggest involvement of CX3CL1/CX3CR1 signaling pathway in the pathomechanism of placental microvasculature remodeling in diabetes class C.

Fetal growth profiles of macrosomic and non-macrosomic infants of women with pregestational or gestational diabetes

OBJECTIVE

To assess fetal growth profiles in an unselected group of pregnant women with either type-1 diabetes (DM1), type-2 diabetes (DM2) or gestational diabetes (GDM), with emphasis on intergroup differences and development of disproportionate fetal growth and macrosomia.

METHODS

Second- and third-trimester longitudinal ultrasound measurements of fetal growth were made in 77 women with DM1, 68 women with DM2 and in 99 women with GDM. Altogether 897 ultrasound examinations were performed and 145 uncomplicated pregnancies with 843 ultrasound examinations were included as controls. Ultrasound data included head circumference (HC), abdominal circumference (AC), femur length (FL) and HC/AC ratio.

RESULTS

The AC, but not HC and FL, evolved differently in diabetic pregnancies, with a smaller AC in early pregnancy and larger AC at term (significant for DM1 and DM2). The most striking differences were found for the HC/AC ratio, especially in DM1 pregnancies. HC/AC growth trajectories of both macrosomic and non-macrosomic fetuses differed from that of the controls, and the HC/AC ratio at term was lower in all diabetic subgroups except in non-macrosomic DM2 cases.

CONCLUSION

We found altered (disproportionate) fetal growth in macrosomic and non-macrosomic fetuses of women with DM1, DM2 and GDM. This indicates that the abnormal intrauterine environment affects the majority of these infants. Growth profiles differed among these groups, the most prominent growth deviations being found in the fetuses of women with DM1. The latter was most probably caused by poor glucose control. In monitoring fetal growth in diabetic pregnancies the HC/AC ratio should be used to assess altered fetal growth.

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.