Previous gestational diabetes mellitus and markers of cardiovascular risk

Cardiac Imaging in Women with Ischemic Heart Disease

Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.

Differential Expression of FXR and Genes Involved in Inflammation and lipid Metabolism Indicate Adipose Tissue Dysfunction in Gestational Diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) is the most frequent metabolic alteration in pregnancy. Several abnormalities in visceral adipose tissue (VAT) have been described as part of its pathophysiology including hypertrophy, inflammation and altered lipid metabolism. Farnesoid X receptor (FXR) is involved in adipocyte physiology and inflammation, so its expression may correlate with the expression of tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), lipoprotein lipase (LPL), and two fatty acid transporters (SLC27A2, and SLC27A4).

AIM

To compare the FXR, LPL, SLC27A2, SLC27A4, TNF-α, and IL-10 mRNA expression in VAT between women with GDM and healthy pregnant (HP) women. Secondarily, to evaluate the potential correlation between these expression levels.

MATERIALS AND METHODS

Cross-sectional study of 50 GDM and 50 HP women. Conventional biochemical tests were performed and relative mRNA expression in VAT was measured by RT-qPCR.

RESULTS

Gene expression levels of FXR and IL-10 were lower, whereas those of LPL, as well as the TNF-α/IL-10 ratio, were higher in women with GDM compared to HP. Pre-pregnancy BMI was the main significant independent variable for FXR levels in VAT from women with GDM. In all women, LPL expression levels correlated positively with those of SLC27A2. Only in women with GDM, IL-10 expression levels correlated negatively with those of SLC27A2, and SLC27A4.

CONCLUSIONS

GDM is associated with decreased expression of FXR and IL-10 and increased expression of LPL, as well as a higher TNF/IL-10 ratio in VAT. These results suggest increased lipid storage and pro-inflammatory state indicating VAT dysfunction in this metabolic disorder.

Potential mechanisms and modulators of food intake during pregnancy

Dietary choice during pregnancy is crucial not only for fetal development, but also for long-term health outcomes of both mother and child. During pregnancy, dramatic changes in endocrine, cognitive, and reward systems have been shown to take place. Interestingly, in different contexts, many of these mechanisms play a key role in guiding food intake. Here, we review how food intake may be impacted as a function of pregnancy-induced changes across species. We first summarize changes in endocrine and metabolic signaling in the course of pregnancy. Then, we show how these may be related to cognitive function and reward processing in humans. Finally, we link these to potential drivers of change in eating behavior throughout the course of pregnancy.

Obesity Affects Maternal and Neonatal HDL Metabolism and Function

Pregravid obesity is one of the major risk factors for pregnancy complications such as gestational diabetes mellitus (GDM) and an increased risk of cardiovascular events in children of affected mothers. However, the biological mechanisms that underpin these adverse outcomes are not well understood. High-density lipoproteins (HDLs) are antiatherogenic by promoting the efflux of cholesterol from macrophages and by suppression of inflammation. Functional impairment of HDLs in obese and GDM-complicated pregnancies may have long-term effects on maternal and offspring health. In the present study, we assessed metrics of HDL function in sera of pregnant women with overweight/obesity of the DALI lifestyle trial (prepregnancy BMI ≥ 29 kg/m2) and women with normal weight (prepregnancy BMI < 25 kg/m2), as well as HDL functionalities in cord blood at delivery. We observed that pregravid obesity was associated with impaired serum antioxidative capacity and lecithin−cholesterol acyltransferase activity in both mothers and offspring, whereas maternal HDL cholesterol efflux capacity was increased. Interestingly, functionalities of maternal and fetal HDL correlated robustly. GDM did not significantly further alter the parameters of HDL function and metabolism in women with obesity, so obesity itself appears to have a major impact on HDL functionality in mothers and their offspring.

Long-term cardiovascular outcomes of gestational diabetes mellitus: a prospective UK Biobank study

BACKGROUND

Previous studies showed that gestational diabetes mellitus (GDM) can be a risk factor for subsequent atherosclerotic cardiovascular disease. However, there is a paucity of information regarding diverse cardiovascular outcomes in elderly women after GDM. In the current study, we examined whether women with a history of GDM have an increased risk for long-term overall cardiovascular outcomes.

METHODS

Among the UK participants, we included 219,330 women aged 40 to 69 years who reported at least one live birth. The new incidence of diverse cardiovascular outcomes was compared according to GDM history by multivariable Cox proportional hazard models. In addition, causal mediation analysis was performed to examine the contribution of well-known risk factors to observed risk.

RESULTS

After enrollment, 13,094 women (6.0%) developed new overall cardiovascular outcomes. Women with GDM history had an increased risk for overall cardiovascular outcomes [adjusted HR (aHR) 1.36 (95% CI 1.18-1.55)], including coronary artery disease [aHR 1.31 (1.08-1.59)], myocardial infarction [aHR 1.65 (1.27-2.15)], ischemic stroke [aHR 1.68 (1.18-2.39)], peripheral artery disease [aHR 1.69 (1.14-2.51)], heart failure [aHR 1.41 (1.06-1.87)], mitral regurgitation [aHR 2.25 (1.51-3.34)], and atrial fibrillation/flutter [aHR 1.47 (1.18-1.84)], after adjustment for age, race, BMI, smoking, early menopause, hysterectomy, prevalent disease, and medication. In mediation analysis, overt diabetes explained 23%, hypertension explained 11%, and dyslipidemia explained 10% of the association between GDM and overall cardiovascular outcome.

CONCLUSIONS

GDM was associated with more diverse cardiovascular outcomes than previously considered, and conventional risk factors such as diabetes, hypertension, and dyslipidemia partially contributed to this relationship.

The influence of inflammation on cardiovascular disease in women

The onset of cardiovascular disease in women is almost a decade later than men, partly due to the protective effect of estrogen prior to menopause. Recently, it was noted that while there have been advances in improving the morbidity and mortality from CVD in women older than 55 years, the improvement in younger women has been stagnant. The mechanism behind this lag is unclear. This manuscript reviews the literature available on the sex-specific inflammatory response in the context of traditional and non-traditional cardiovascular disease risk factors. Our review suggests that women have a differential inflammatory response to various disease states that increases their risk for CVD and warrants a distinct prioritization from men when calculating cardiovascular disease risk.

Gender gap in annual preventive care services in France

BACKGROUND

In France, screening for cardiovascular risk factors is recommended during annual preventive visits. However, data are lacking on the temporal trend in women's uptake to preventive care services, and in cardiovascular and mortality outcomes. The aim of the study was to investigate the participation and mortality of women in annual preventive care services in a major preventive medicine center in France.

METHOD

Ee conducted repeated cross-sectional studies including a total of 366,270 individuals who had a first examination at the Centre d'Investigations Préventives et Cliniques, France, between January 1992 and December 2011.

FINDINGS

Women's participation was low below 50 years of age, then increases from 50 to 70 years, and is lower for women older than 70 years. The gap in female participation was more pronounced among individuals with high education, low social deprivation, and no depressive symptoms. Compared with the general population, the screened population had significantly lower standardized mortality ratios (SMRs) among both men and women, for all age ranges. Screened women aged 18-49 years showed a lower mortality gain compared with men of the same age; SMRs did not differ significantly by sex for individuals over 50 years.

INTERPRETATION

In this community-based sample, compared with men, women's participation to annual preventive care services was lower, and screened women had a lower mortality gain. Despite the demonstrated benefit of annual check-ups on health, there is a gender gap in adherence to preventive programs and in efficiency of screening programs, especially in the young age range. This gap in cardiovascular disease prevention may result in poorer cardiovascular health in women. Urgent adaptations to overcome this gender gap in preventive screening in France are warranted.

FUNDING

Bamba Gaye is supported by the Fondation Recherche Médicale grant.

New Insights into Adipokines in Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is the most common metabolic disorder of pregnancy and has considerable short- and long-term consequences for the health of both the mother and the newborn. Within its pathophysiology, genetic, nutritional, epigenetic, immunological, and hormonal components have been described. Within the last two items, it is known that different hormones and cytokines secreted by adipose tissue, known collectively as adipokines, are involved in the metabolic alterations underlying GDM. Although the maternal circulating profile of adipokines in GDM has been extensively studied, and there are excellent reviews on the subject, it is in recent years that more progress has been made in the study of their expression in visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), placenta, and their concentrations in the umbilical circulation. Thus, this review compiles and organizes the most recent findings on the maternal and umbilical circulating profile and the levels of expression of adipokines in VAT, SAT, and placenta in GDM.

Cardiovascular Disease in Older Women

Cardiovascular disease is the major cause of death in women. Older women remain at risk for coronary artery disease/cardiovascular disease, but risk-modifying behavior can improve outcomes. Women have a different symptom profile and have been underdiagnosed and undertreated as compared with men. Although older women are underrepresented in trials, clinicians should be more attuned to the prevention, diagnosis, and treatment of cardiovascular disease in older women.

Cardiovascular risk in menopausal women and our evolving understanding of menopausal hormone therapy: risks, benefits, and current guidelines for use

Women are at increased risk for cardiovascular disease (CVD) compared with men. While traditional risk factors for CVD seem to disproportionately affect women and contribute to this disparity, increased prevalence of CVD at midlife calls into question the contribution of menopause. Given the potential role that declining hormone levels play in this transition, menopause hormone therapies (MHT) have been proposed as a strategy for risk factor reduction. Unfortunately, trials have not consistently shown cardiovascular benefit with use, and several describe significant risks. Notably, the timing of hormone administration seems to play a role in its relative risks and benefits. At present, MHT is not recommended for primary or secondary prevention of CVD. For women who may benefit from the associated vasomotor, genitourinary, and/or bone health properties of MHT, CVD risks should be taken into account prior to administration. Further research is needed to assess routes, dosing, and formulations of MHT in order to elucidate appropriate timing for administration. Here, we aim to review both traditional and sex-specific risk factors contributing to increased CVD risk in women with a focus on menopause, understand cardiovascular effects of MHT through a review of several landmark clinical trials, summarize guidelines for appropriate MHT use, and discuss a comprehensive strategy for reducing CV risk in women.

Fetal High-Density Lipoproteins: Current Knowledge on Particle Metabolism, Composition and Function in Health and Disease

Cholesterol and other lipids carried by lipoproteins play an indispensable role in fetal development. Recent evidence suggests that maternally derived high-density lipoprotein (HDL) differs from fetal HDL with respect to its proteome, size, and function. Compared to the HDL of adults, fetal HDL is the major carrier of cholesterol and has a unique composition that implies other physiological functions. Fetal HDL is enriched in apolipoprotein E, which binds with high affinity to the low-density lipoprotein receptor. Thus, it appears that a primary function of fetal HDL is the transport of cholesterol to tissues as is accomplished by low-density lipoproteins in adults. The fetal HDL-associated bioactive sphingolipid sphingosine-1-phosphate shows strong vasoprotective effects at the fetoplacental vasculature. Moreover, lipoprotein-associated phospholipase A2 carried by fetal-HDL exerts anti-oxidative and athero-protective functions on the fetoplacental endothelium. Notably, the mass and activity of HDL-associated paraoxonase 1 are about 5-fold lower in the fetus, accompanied by an attenuation of anti-oxidative activity of fetal HDL. Cholesteryl ester transfer protein activity is reduced in fetal circulation despite similar amounts of the enzyme in maternal and fetal serum. This review summarizes the current knowledge on fetal HDL as a potential vasoprotective lipoprotein during fetal development. We also provide an overview of whether and how the protective functionalities of HDL are impaired in pregnancy-related syndromes such as pre-eclampsia or gestational diabetes mellitus.

Racial and ethnic disparities in chronic health conditions among women with a history of gestational diabetes mellitus

Background: This study aims to examine and determine the role of race/ethnicity in chronic conditions in women diagnosed with gestational diabetes mellitus (GDM) during any of their previous pregnancies. Methods: We used the National Health and Nutrition Examination Survey (NHANES) from2007-2016 to identify women who self-reported prior GDM and chronic disease diagnoses such as cardiovascular disease, hypertension, depression, and type 2 diabetes mellitus (T2DM).We used bivariate analysis using the chi-square test (χ²) and multiple logistic regressions to perform statistical test for associations, taking into consideration design and sample weight. Results: Among participants with prior GDM diagnoses, black women had a 74.4% prevalence of chronic disease, followed by Whites, 58.5% Hispanics, 58.0%, and Asians, 51.9% (P=0.009).Black women with prior GDM diagnoses had 2.4 odds of having chronic conditions compared to Whites (adjusted odds ratio [AOR]=2.40, 95% confidence interval [CI] = 1.28-4.50). In addition, they had higher odds of being former smokers (AOR=1.73, 95% CI=1.01-2.96),current smokers (AOR=1.96, 95% CI=1.06-3.61), having a body mass index (BMI) of 25-29.9(AOR=2.55, 95% CI=1.10-5.87), or a BMI ≥30 (AOR=4.09, 95% CI = 2.05-8.17) compared to their White counterparts. Hispanic women had lower odds of being diagnosed with GDM and associated chronic diseases. Conclusion: Black women with GDM were disproportionally affected and at higher risk to be diagnosed with chronic conditions. Smoking and obesity were strongly associated with chronic disease diagnoses. Our findings also suggest a 'Hispanic Paradox', requiring further study. These findings inform primary care clinicians and Obstetricians, and Gynecologists of at-risk patients who could benefit from lifestyle modification recommendations and counseling.

Metabolic syndrome markers and risk of hyperglycemia in pregnancy: a cross-sectional cohort study

The aim was to assess the role of Metabolic Syndrome (MetS) diagnostic markers, recommended by three different guidelines, in the prediction of hyperglycemia in pregnancy. This cross-sectional cohort study included 506 non-diabetic women, with a singleton pregnancy, who underwent a diagnostic test for hyperglycemia at 24-28 weeks. Clinical, anthropometric, and laboratory data were obtained. The relationship between MetS markers and the risk of hyperglycemia was evaluated by backward stepwise logistic regression analysis (OR, 95% CI). The limit of statistical significance was 95% (p < 0.05). Triglycerides (TG) ≥ 150 mg/dL, blood pressure (BP) ≥ 130/85 mmHg, fasting glucose (FG) ≥ 100 mg/dL, and waist circumference (WC) > 88 cm were identified as independent risk factors for hyperglycemia in pregnancy. These results might help the selective screening of hyperglycemia in pregnancy.

Maternal factors associated with hyperglycemia in pregnancy and perinatal outcomes: a Brazilian reference center cohort study

BACKGROUND

While sufficient evidence supporting universal screening is not available, it is justifiable to look for specific risk factors for gestational diabetes mellitus (GDM) or hyperglycemia in pregnancy (HIP). The objective of this study is to identify independent risk factors for HIP and its adverse perinatal outcomes in a Brazilian public referral center.

METHODS

We included 569 singleton pregnant women who were split into three groups by glucose status: GDM (n = 207), mild gestational hyperglycemia (MGH; n = 133), and control (n = 229). Women who used corticosteroids or had a history of DM were excluded. HIP comprised both GDM and MGH, diagnosed by a 100 g- or 75 g-oral glucose tolerance test (OGTT) and a glucose profile at 24-28 weeks. Maternal characteristics were tested for their ability to predict HIP and its outcomes. Bivariate analysis (RR; 95% CI) was used to identify potential associations. Logistic regression (RRadj; 95% CI) was used to confirm the independent risk factors for HIP and its perinatal outcomes (p < 0.05).

RESULTS

Age ≥ 25 years [1.83, 1.12-2.99], prepregnancy BMI ≥ 25 kg/m2 [2.88, 1.89-4.39], family history of DM [2.12, 1.42-3.17] and multiparity [2.07, 1.27-3.37] were independent risk factors for HIP. Family history of DM [169, 1.16-2.16] and hypertension [2.00, 1.36-2.98] were independent risk factors for C-section. HbA1c ≥ 6.0% at birth was an independent risk factor for LGA [1.99, 1.05-3.80], macrosomia [2.43, 1.27-4.63], and birthweight Z-score > 2.0 [4.17, 1.57-11.10].

CONCLUSIONS

MGH presents adverse pregnancy outcomes similar to those observed in the GDM group but distinct from those observed in the control (no diabetes) group. In our cohort, age ≥ 25 years, prepregnancy BMI ≥ 25 kg/m2, family history of DM, and multiparity were independent risk factors for HIP, supporting the use of selective screening for this condition. These results should be validated in populations with similar characteristics in Brazil or other low- and middle-income countries.

Obesity and cardiovascular disease in women

As the prevalence of obesity continues to grow worldwide, the health and financial burden of obesity-related comorbidities grows too. Cardiovascular disease (CVD) is clearly associated with increased adiposity. Importantly, women are at higher risk of CVD when obese and insulin resistant, in particular at higher risk of developing heart failure with preserved ejection fraction and ischemic heart disease. Increased aldosterone and mineralocorticoid receptor activation, aberrant estrogenic signaling and elevated levels of androgens are among some of the proposed mechanisms explaining the heightened CVD risk. In addition to traditional cardiovascular risk factors, understanding nontraditional risk factors specific to women, like excess weight gain during pregnancy, preeclampsia, gestational diabetes, and menopause are central to designing personalized interventions aimed to curb the epidemic of CVD. In the present review, we examine the available evidence supporting a differential cardiovascular impact of increased adiposity in women compared with men and the proposed pathophysiological mechanisms behind these differences. We also discuss women-specific cardiovascular risk factors associated with obesity and insulin resistance.

Postpartum C-Reactive Protein: A limited value to detect infection or inflammation

BACKGROUND

During pregnancy the maternal immune system adjusts to preserve the foetoplacental unit. These adjustments lead to an increase in CRP, continuing into the postpartum. The objective of this study was to determineantepartal, peripartal and postpartal factors associated with an elevated CRP on the second postpartum day.

METHODS

A retrospective quantitative, monocentric file analysis in which antepartal, peripartal and postpartal factors were collected from a convenience sample was performed. On the second day postpartum CRP was taken according to local protocol. Uni- and multi-variate analysis was performed to determine factors that are related to postpartum level of CRP. The total sample size consisted of 1400 patients.

RESULTS

Multiple regression analysis indicated 11 factors related to increased CRP on the second day postpartum: gestational age (p=0.002), maternal blood leukocyte count on day 2 postpartum (p<0.001), artificial rupture of the membranes (p<0.001), fever during labor (p<0.001), indwelling urinary catheter (p=0.008), epidural anesthesia (p<0.001), fetal scalp electrode (p<0.001), primary planned caesarean (p=0.019), secondary caesarean h (p<0.001), formula feeding (p=0.030) and fever during postpartum (p=0.001).

CONCLUSION

This research indicates that many antepartal, peripartal and postpartal factors are related to high postpartum CRP. CRP can not be used as a screening test test in the postpartum to discriminate between normal and pathologic inflammatory/infectious changes.

Decreased maternal serum cortistatin levels in pregnancies with gestational diabetes mellitus

Objective: To investigate serum cortistatin levels in women with gestational diabetes mellitus (GDM) and women with uncomplicated pregnancies.Material and methods: This case-control study consisted of 40 pregnancies with GDM and 41 healthy singleton pregnancies matched for maternal and gestational age. The maternal serum levels of cortistatin were measured with enzyme-linked immunosorbent assay and compared between groups.Results: Cortistatin levels were significantly lower in GDM group (48.85 ± 20.18 versus 65.84 ± 33.98 ng/ml, p = .008). There was a statistically significant difference in cortistatin levels between different treatment modalities and control group (χ²(2) = 8.828, p = .012). Pairwise comparisons showed that diet group had significantly lower CST levels than control group (p = .012). Serum cortistatin levels were negatively correlated with serum insulin and glucose levels and HOMA-IR (r = -0.358, p = .001; r = -0.303, p = .006; r = -0.444, p < .001, respectively).Conclusion: Cortistatin levels were significantly lower in GDM pregnancies and related to serum insulin and glucose levels and HOMA-IR in pregnancy. This may help to better clarify the mechanism of GDM pathogenesis.

Recognition and treatment of ischemic heart diseases in women

Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.

Significance of Obstetrical History with Future Cardiovascular Disease Risk

The maternal cardiovascular system undergoes profound changes to support the increasing demands of fetal growth during pregnancy. An accumulating body of evidence has shown that common pregnancy complications, including gestational diabetes mellitus, preeclampsia, low birth weight, and preterm delivery, can be associated with future cardiovascular adverse events in mothers. Factors such as glucose metabolism, hyperlipidemia, inflammatory markers, and large- and small-vessel stiffness/functionality have been linked with these pregnancy conditions. Critically, there are no established guidelines to account for these maternal factors when considering future cardiovascular disease risk, one of the leading causes of female mortality. This article reviews the study of cardiovascular disease and pregnancy, and proposes possible connections that should spur future investigation in an area of medicine that requires significant research.

High-glucose concentrations change DNA methylation levels in human IVM oocytes

STUDY QUESTION

What are the effects of high-glucose concentrations on DNA methylation of human oocytes?

SUMMARY ANSWER

High-glucose concentrations altered DNA methylation levels of Peg3 and Adiponectin in human in vitro maturation oocytes.

WHAT IS KNOWN ALREADY

Maternal diabetes has a detrimental influence on oocyte quality including epigenetic modifications, as shown in non-human mammalian species.

STUDY DESIGN, SIZE, DURATION

Immature metaphase I (MI) stage oocytes of good quality were retrieved from patients who had normal ovarian potential and who underwent ICSI in the Reproductive Medicine Center of People's Hospital of Zhengzhou University. MI oocytes were cultured in medium with different glucose concentrations (control, 10 mM and 15 mM) in vitro and 48 h later, oocytes with first polar body extrusion were collected to check the DNA methylation levels.

PARTICIPANTS/MATERIALS, SETTING, METHODS

MI oocytes underwent in vitro maturation (IVM) at 37°C with 5% mixed gas for 48 h. Then the mature oocytes were treated with bisulfite buffer. Target sequences were amplified using nested or half-nested PCR and the DNA methylation status was tested using combined bisulfite restriction analysis (COBRA) and bisulfite sequencing (BS).

MAIN RESULTS AND THE ROLE OF CHANCE

High-glucose concentrations significantly decreased the first polar body extrusion rate. Compared to controls, the DNA methylation levels of Peg3 in human IVM oocytes were significantly higher in 10 mM (P < 0.001) and 15 mM (P < 0.001) concentrations of glucose. But the DNA methylation level of H19 was not affected by high-glucose concentrations in human IVM oocytes. We also found that there was a decrease in DNA methylation levels in the promoter of adiponectin in human IVM oocytes between controls and oocytes exposed to 10 mM glucose (P = 0.028).

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

It is not clear whether the alterations are beneficial or not for the embryo development and offspring health. The effects of high-glucose concentrations on the whole process of oocyte maturation are still not elucidated. Another issue is that the number of oocytes used in this study was limited.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first time that the effects of high-glucose concentration on DNA methylation of human oocytes have been elucidated. Our result indicates that in humans, the high risk of chronic diseases in offspring from diabetic mothers may originate from abnormal DNA modifications in oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the fund of National Natural Science Foundation of China (81401198) and Doctor Foundation of Qingdao Agricultural University (1116008).The authors declare that there are no potential conflicts of interest relevant to this article.

Increased risk of cardiovascular disease in women with prior gestational diabetes: A systematic review and meta-analysis

This study aims to investigate the effect of gestational diabetes mellitus (GDM) on the long-term risk of cardiovascular disease (CVD). PubMed and other databases were searched up to August 31, 2017. Cohort studies evaluating risk of CVD postpartum in women with and without prior GDM were included. Random-effect model was used to estimate the pooled relative risk of CVD. Sensitivity and subgroup analyses were performed to check the consistency of the effect size and to explore sources of heterogeneity. Multivariable logistic regression was used to control for high heterogeneity. Seven cohort studies with 3,417,020 pregnant women including 14,146 incident CVD events were retrieved. In the pooled analysis, women with previous GDM had a higher risk of CVD than those without (RR: 1.74, 95%CI: 1.28-2.35, I² = 95.7%). Four studies reported the event of coronary artery disease (CAD) and two studies reported stroke. The overall RR for CAD was 2.09 (95%CI: 1.56-2.80, I² = 91.2%) and that for stroke was 1.25 (95%CI: 1.07-1.48). In view of the high level of heterogeneity, adjustments were made for this, with the resulting adjusted OR for CVD and CAD being 1.95 (95%CI: 1.83-2.08) and 1.59 (95%CI: 1.30-1.94). Women with prior GDM have increased risk of CVD.

Subclinical inflammation associated with prolonged TIMP-1 upregulation and arterial stiffness after gestational diabetes mellitus: a hospital-based cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) has significant implications for the future health of the mother. Some clinical studies have suggested subclinical inflammation and vascular dysfunction after GDM. We aimed to study whether concentrations of high-sensitivity C-reactive protein (hsCRP), tissue inhibitor of metalloproteinase-1 (TIMP-1), matrix metalloproteinase-8 (MMP-8) and -9, as well as values of arterial stiffness differ between women with and without a history of GDM a few years after delivery. We also investigated possible effects of obesity on the results.

METHODS

We studied two cohorts-120 women with a history of GDM and 120 controls-on average 3.7 years after delivery. Serum concentrations of hsCRP were determined by immunonephelometric and immunoturbidimetric methods, MMP-8 by immunofluorometric assay, and MMP-9 and TIMP-1 by enzyme-linked immunosorbent assays. Pulse wave velocity (PWV) was determined using the foot-to-foot velocity method from carotid and femoral waveforms by using a SphygmoCor device. Arterial compliance was measured non-invasively by an HDI/PulseWave™CR-2000 arterial tonometer. All 240 women were also included in subgroup analyses to study the effect of obesity on the results. Multiple linear regression analyses were performed with adjustment for confounding factors.

RESULTS

PWV after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 6.44 ± 0.83 (SD) vs. 6.17 ± 0.74 m/s (p = 0.009). Previous GDM was also one of the significant determinants of PWV in multiple linear regression analyses. On the other hand, compliance indices of both large (p = 0.092) and small (p = 0.681) arteries did not differ between the study cohorts. Serum TIMP-1 levels were significantly increased after previous GDM (p = 0.020). However, no differences were found in the serum levels of MMP-8, MMP-9 or hsCRP. In subgroup analyses, there were significantly higher concentrations of hsCRP (p = 0.015) and higher PWV (p < 0.001) among obese women compared with non-obese ones.

CONCLUSIONS

PWV values were significantly higher after GDM compared with normoglycemic pregnancies and were associated with prolonged TIMP-1 upregulation. Cardiovascular risk factors were more common in participants with high BMI than in those with previous GDM.

Elevated iron status and risk of gestational diabetes mellitus: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis of observational studies was to assess the relationship between elevated iron status, measured as hemoglobin and ferritin levels, and the risk of gestational diabetes mellitus (GDM). The present study was recorded in PROSPERO (2013:CRD42013005717). The selected studies were identified through a systematic review of scientific literature published in The Cochrane Library and PubMed/MEDLINE databases from their inception until March 10, 2016, in addition to citation tracking and hand-searches. The search strategy of original articles combined several terms for hemoglobin, ferritin, pregnancy, and GDM. OR and 95% CI of the selected studies were used to identify associations between hemoglobin and/or ferritin levels with the risk of GDM. Summary estimates were calculated by combining inverse-variance using fixed-effects model. 2468 abstracts were initially found during the search. Of these, 11 with hemoglobin and/or ferritin data were selected for the meta-analyses. We observed that high hemoglobin (OR = 1.52; 95% CI: 1.23-1.88), as well as ferritin (OR = 2.09; 95% CI: 1.48-2.96) levels were linked to an increased risk of GDM. Low heterogeneity was observed in hemoglobin (I²  = 33.3%, P = 0.151) and ferritin (I²  = 0.7%, P = 0.418) meta-analyses, respectively. Publication bias was not appreciated. High hemoglobin or ferritin levels increase the risk of GDM by more than 50% and more than double, respectively, in the first and third trimester. Therefore, determining of hemoglobin or ferritin concentration in early pregnancy might be a useful tool for recognizing pregnant women at risk of GDM.

Maternal serum ADAMTS-9 levels in gestational diabetes: a pilot study

OBJECTIVE

Gestational diabetes mellitus (GDM) is characterized with insulin resistance which is diagnosed during pregnancy. Although pregnancy is a diabetogenic state, not all women develop GDM. Genetic factors together with enviromental factors cause the maladaptation of maternal pancreas to this diabetogenic state and GDM develops. ADAMTS-9 is a recently recognized molecule whose genetic variants have risk of GDM. Decreased levels have already been shown in fetal membranes. Maternal serum levels of this protein have not been studied yet. We hypothesized that the alteration of ADAMTS-9 expression should cause changes in maternal serum levels which further could help to identify the disease and develop new treatment strategies.

MATERIALS AND METHODS

This prospective case-control study is consisted of 27 pregnancies with GDM and 30 healthy singleton pregnancies matched for matenal age, gestational week, and maternal weight. GDM diagnosis was made with 2-h 75 g oral glucose tolerance test. ADAMTS-9 levels were compared between groups.

RESULTS

ADAMTS levels were 3.62 ± 0.33 ng/dL (range: 3.04-4.23) in GDM group and 4.65 ± 1.70 ng/dL (range: 3.07-8.21) in control group (p < 0.001). ADAMTS levels were not affected by maternal age, gestational age, and maternal weight.

CONCLUSION

ADAMTS-9 levels were significantly lower in GDM pregnancies. This may help to understand the mechanism of GDM pathogenesis. In future, target treatments with ADAMTS proteins may help to improve the severity of diabetes pathogenesis.

Postpartum dyslipidaemia in women diagnosed with gestational diabetes mellitus

BACKGROUND

Diabetes mellitus is a known risk factor for cardiovascular disease which should prompt screening for other cardiovascular risk factors, including dyslipidaemia. Women diagnosed with gestational diabetes mellitus (GDM) are not routinely screened for cardiovascular risk factors.

AIMS

The objective of this study was to determine the prevalence of dyslipidaemia postpartum in women with GDM.

METHODS

The study was performed in a large university hospital. Women with GDM had a fasting lipid profile performed 6 weeks postnatally. Clinical details were obtained from the medical records. Lipid results in our cohort were compared with healthy women of the same age.

RESULTS

The overall prevalence of postpartum dyslipidaemia was 52 % (n = 51). Total cholesterol was raised in 44 % (n = 43), low-density lipoprotein was raised in 33 % (n = 32) and triglycerides were raised in 16 % (n = 16). Of the 51 women with dyslipidaemia, 73 % (n = 37) had more than one abnormality in their lipid profile. Four of the five women with an abnormal postpartum GTT had an abnormal lipid profile. Compared with healthy women of the same age, women with GDM had higher total cholesterol (p = 0.04), higher LDL (p = 0.003), higher triglycerides (p < 0.001) and lower HDL (p < 0.04).

CONCLUSIONS

Women with GDM should be screened for dyslipidaemia postpartum and protective cardiovascular interventions offered where appropriate.

Review of gestational diabetes mellitus effects on vascular structure and function

Vascular dysfunction has been described in women with a history of gestational diabetes mellitus. Furthermore, previous gestational diabetes mellitus increases the risk of developing Type 2 diabetes mellitus, a risk factor for cardiovascular disease. Factors contributing to vascular changes remain uncertain. The aim of this review was to summarize vascular structure and function changes found to occur in women with previous gestational diabetes mellitus and to identify factors that contribute to vascular dysfunction. A systematic search of electronic databases yielded 15 publications from 1998 to March 2014 that met the inclusion criteria. Our review confirmed that previous gestational diabetes mellitus contributes to vascular dysfunction, and the most consistent risk factor associated with previous gestational diabetes mellitus and vascular dysfunction was elevated body mass index. Heterogeneity existed across studies in determining the relationship of glycaemic levels and insulin resistance to vascular dysfunction.

Cardiovascular Disease in Women: Clinical Perspectives

Cardiovascular disease continues to be the leading cause of death among women in the United States, accounting for ≈1 of every 3 female deaths. Sex-specific data focused on cardiovascular disease have been increasing steadily, yet is not routinely collected nor translated into practice. This comprehensive review focuses on novel and unique aspects of cardiovascular health in women and sex differences as they relate to clinical practice in the prevention, diagnosis, and treatment of cardiovascular disease. This review also provides current approaches to the evaluation and treatment of acute coronary syndromes that are more prevalent in women, including myocardial infarction associated with nonobstructive coronary arteries, spontaneous coronary artery dissection, and stress-induced cardiomyopathy (Takotsubo Syndrome). Other cardiovascular disease entities with higher prevalence or unique considerations in women, such as heart failure with preserved ejection fraction, peripheral arterial disease, and abdominal aortic aneurysms, are also briefly reviewed. Finally, recommendations for cardiac rehabilitation are addressed.

Identifying Key Intervention Opportunities During a Pregnancy Complicated by Diabetes: a Review of Acute Complications of Diabetes During Pregnancy

Diabetes in pregnancy is associated with significant and sometimes devastating acute complications. It is important that all health care providers are aware of possible complications at each stage of pregnancy so that we can prevent these complications whenever possible and reduce morbidity when they do occur. Most complications associated with diabetes during pregnancy have reduced incidence when blood glucose and blood pressure are optimally controlled. Yet, it is always best to try to optimize diabetes and any comorbidities prior to conception.

Serum homocysteine level and gestational diabetes mellitus: A meta-analysis

Aims/Introduction

Homocysteine levels during pregnancy in women with gestational diabetes mellitus (GDM) have been studied; however, it remains unclear whether hyperhomocysteinemia is a useful predictor of insulin resistance. The present study aimed to evaluate the relationship between homocysteine level and GDM.

Materials and Methods

PubMed, Elsevier, Web of Science and CNKI were searched for relevant studies published up to January 2015. Manual searches of references of the relevant original studies were carried out. Meta‐analysis was used to assessed the relationship between homocysteine level and GDM using the stata 12.0 software.

Results

Homocysteine levels were significantly elevated in women with GDM compared with those without GDM (weighted mean difference 0.77, 95% confidence interval 0.44–1.10). This evidence was more consistent during the second trimester measurement of homocysteine (weighted mean difference 0.95, 95% confidence interval 0.67–1.23) and for women aged older than 30 years (weighted mean difference 0.90, 95% confidence interval 0.63–1.17).

Conclusions

The present meta‐analysis shows that homocysteine level is significantly elevated among women with GDM compared with women with normal glucose tolerance, and this finding persists more during the second trimester.

Zinc supplementation and the effects on metabolic status in gestational diabetes: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

To the best of our knowledge, no reports are available indicating the effects of zinc supplementation on metabolic status in women with gestational diabetes (GDM). This study was designed to determine the effects of zinc supplementation on glucose homeostasis parameters and lipid concentrations in GDM women.

METHODS

This randomized, double-blind, placebo-controlled trial was performed among 58 women diagnosed with GDM, primigravida and aged 18-40years old. Patients were randomly divided into two groups to receive 233mg zinc gluconate (containing 30mg zinc) supplements (n=29) or placebo (n=29) per day for 6weeks. Fasting blood samples were taken at the beginning and end of the trial to quantify glucose, insulin and lipid concentrations.

RESULTS

Patients who received zinc supplements had significantly higher serum zinc concentrations (+6.9±13.2 vs. -1.5±16.5mg/dL, P=0.03) than those received the placebo. In addition, zinc-supplemented patients had reduced fasting plasma glucose (FPG) (-6.6±11.2 vs. +0.6±6.7mg/dL, P=0.005), serum insulin levels (-1.3±6.6 vs. +6.6±12.2μIU/mL, P=0.003), homeostasis model of assessment-insulin resistance (HOMA-IR) (-0.5±1.6 vs. +1.5±2.7, P=0.001), homeostatic model assessment-Beta cell function (HOMA-B) (-0.7±25.0 vs. +26.5±49.5, P=0.01) and increased quantitative insulin sensitivity check index (QUICKI) (+0.01±0.01 vs. -0.01±0.02, P=0.004) compared with the placebo. Additionally, significant differences in serum triglycerides (+13.6±61.4 vs. +45.9±36.5mg/dL, P=0.01) and VLDL-cholesterol concentrations (+2.7±12.3 vs. +9.2±7.3mg/dL, P=0.01) were observed following the administration of zinc supplements compared with the placebo.We did not observe any significant effects of taking zinc supplements on other lipid profiles.

CONCLUSIONS

Taken together, 30mg zinc supplementation per day for 6weeks among GDM women had beneficial effects on metabolic profiles.

Relationship between mean platelet volume and vitamin D deficiency in gestational diabetes mellitus

OBJECTIVE

To investigate whether vitamin D deficiency is associated with high mean platelet volume (MPV) in pregnancies diagnosed with gestational diabetes mellitus (GDM) compared to healthy pregnancies.

SUBJECTS AND METHODS

This study included 200 pregnant women. 25-hydroxyvitamin D3(25(OH)D3) and MPV values were monitored between pregnant women with GDM and normal glucose metabolism. Correlation between 25(OH)D3 and MPV was calculated both in GDM and healthy pregnancies. Both 25(OH)D3 level in different MPV percentile (≤ 50, 50-75, 75-90, ≥ 90 percentile) and MPV value in different 25(OH)D3 level (≤ 10, 10-20, ≥ 20 ng/mL) were calculated.

RESULTS

Low 25(OH)D3 level and high MPV were observed both in GDM group (p = 0.007, p = 0.06, respectively) and in glucose metabolism disorders (GMD) group (p = 0.03, p = 0.04, respectively). There was no significant relationship between 25(OH)D3 and MPV in healthy pregnancies. Whereas, it is observed that there is a negative, but statistically insignificant correlation between MPV and 25(OH)D3 pregnant women with GMD (r = 0.1, r = -0.7, respectively). MPV values had significantly higher in vitamin D deficient group than pregnant women with normal 25(OH)D3 level in GMD group (p = 0.04). The optimal 25(OH)D3 cut off point for predicting future cardiovascular risk was 10.4 ng/ mL (area under curve (AUC) = 0.58).

CONCLUSIONS

Vitamin D deficiency may contribute to an increased risk for future cardiovascular diseases and a risk of thrombotic complications in pregnant women with GDM.

Predictors of type 2 diabetes among Taiwanese women with prior gestational diabetes mellitus

AIM

The aims of this study were to determine the blood glucose screening rate of Taiwanese post-partum women with gestational diabetes (GDM) and to identify the predictors of type 2 diabetes among Taiwanese women with GDM.

METHODS

The medical records of 130 women with GDM, who were delivered at a hospital in southern Taiwan between 1997 and 2010, were retrospectively reviewed. The GDM diagnosis was performed according to the National Diabetes Data Group and Expert Committee Criteria. The 2010 American Diabetes Association diabetes diagnosis criteria were used to determine whether post-partum women subsequently developed type 2 diabetes.

RESULTS

In total, 71 records (54.6%) included blood glucose testing after childbirth between the first month and the ninth year, and 29 records (22.3%) documented subsequent type 2 diabetes. In a multiple logistic regression analysis, the patients' pre-pregnancy body mass indices and insulin use during pregnancy were independently associated with subsequent type 2 diabetes.

CONCLUSION

In this study, documentation during pregnancy, which could have provided beneficial insights, was limited. Healthcare professionals should develop a program to improve the post-partum follow-up of women diagnosed with GDM.

Maternal lipid levels during pregnancy and gestational diabetes: a systematic review and meta-analysis

BACKGROUND

Lipid levels during pregnancy in women with gestational diabetes mellitus (GDM) have been extensively studied; however, it remains unclear whether dyslipidaemia is a potential marker of preexisting insulin resistance.

OBJECTIVE

To evaluate the relationship between lipid measures throughout pregnancy and GDM.

SEARCH STRATEGY

We searched PubMed-MedLine and SCOPUS (inception until January 2014) and reference lists of relevant studies.

SELECTION CRITERIA

Publications describing original data with at least one raw lipid (total cholesterol, high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], or triglyceride) measurement during pregnancy in women with GDM and healthy pregnant controls were retained.

DATA COLLECTION AND ANALYSIS

Data extracted from 60 studies were pooled and weighted mean difference (WMD) in lipid levels was calculated using random effects models. Meta-regression was also performed to identify sources of heterogeneity.

MAIN RESULTS

Triglyceride levels were significantly elevated in women with GDM compared with those without GDM (WMD 30.9, 95% confidence interval [95% CI] 25.4-36.4). This finding was consistent in the first, second and third trimesters of pregnancy. HDL-C levels were significantly lower in women with GDM compared with those without GDM in the second (WMD -4.6, 95% CI -6.2 to -3.1) and third (WMD -4.1, 95% CI -6.5 to -1.7) trimesters of pregnancy. There were no differences in aggregate total cholesterol or LDL-C levels between women with GDM and those without insulin resistance.

AUTHOR'S CONCLUSIONS

Our meta-analysis shows that triglycerides are significantly elevated among women with GDM compared with women without insulin resistance and this finding persists across all three trimesters of pregnancy.

The risk of metabolic syndrome after gestational diabetes mellitus - a hospital-based cohort study

BACKGROUND

Women with gestational diabetes mellitus (GDM) are at an increased risk of developing metabolic syndrome (MetS) after delivery. Recently, the prevalence of both GDM and MetS has increased worldwide, in parallel with obesity. We investigated whether the presentation of MetS and its clinical features among women with previous GDM differs from that among those with normal glucose tolerance during pregnancy, and whether excess body weight affects the results.

METHODS

This hospital-based study of two cohorts was performed in Kanta-Häme Central Hospital, Finland. 120 women with a history of GDM and 120 women with a history of normal glucose metabolism during pregnancy, all aged between 25 and 46 were enrolled. They all underwent physical examination and had baseline blood samples taken. All 240 women were also included in subgroup analyses to study the effect of excess body weight on the results.

RESULTS

Although the groups did not differ in body mass index (BMI; p = 0.069), the risk of developing MetS after pregnancy complicated by GDM was significantly higher than after normal pregnancy, 19 vs. 8 cases (p  =  0.039). Fasting glucose (p < 0.001) and triglyceride levels (p < 0.001) were significantly higher in women affected. In subgroup analysis, cardiovascular risk factors were more common in participants with high BMI than in those with previous gestational diabetes.

CONCLUSIONS

The risk of MetS was 2.4-fold higher after GDM than after normal pregnancy. Cardiovascular risk factors were more common in participants with high BMI than in those with previous GDM. Multivariate analysis supported the main findings. Weight control is important in preventing MetS after delivery.

The long-term effects of stillbirth on women with and without gestational diabetes: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this study was to estimate the incidence of type 2 diabetes (primary objective) and hospitalisation for cardiovascular events (secondary objective) in women with previous gestational diabetes mellitus (GDM) and in those with normal glucose tolerance (NGT) in pregnancy, and to evaluate the role of stillbirth in differentiating the risks.

METHODS

This was a population-based cohort study using administrative data and involving 12 local health authorities. Women with GDM (n = 3,851) during the index period from 2002 to 2010 were propensity matched with women with NGT (n = 11,553). Information was collected on type 2 diabetes development and hospitalisation for cardiovascular events.

RESULTS

During a median follow-up of 5.4 years, the incidence rate per 1,000 person-years of type 2 diabetes was 2.1 (95% CI 1.8, 2.5) in women without GDM and 54.0 (95% CI 50.2, 58.0) among women with GDM and pregnancy at term (incidence rate ratio [IRR] 26.9; 95% CI 22.1, 32.7 compared with NGT and pregnancy at term). A history of stillbirth increased the risk of type 2 diabetes development by about twofold, irrespective of GDM status. No significant interaction between stillbirth and GDM on type 2 diabetes risk was found. GDM was associated with a significantly higher risk of cardiovascular events compared with NGT (IRR 2.4; 95% CI 1.5, 3.8).

CONCLUSIONS/INTERPRETATION

Pregnancy complicated by GDM and ending in stillbirth represents an important contributory factor in determining type 2 diabetes development. Women with GDM are at a high risk of future cardiovascular events. Women with pregnancy complicated by GDM and stillbirth deserve careful follow-up.

Preterm birth and long-term maternal cardiovascular health

PURPOSE

To investigate whether preterm birth (PTB) is associated with greater cardiovascular disease (CVD) risk in a longitudinal cohort.

METHODS

We examined differences in systolic blood pressure (SBP), diastolic blood pressure, insulin resistance (Homeostatic model assessment of insulin resistance), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein, triglycerides, C-reactive protein, and interleukin 6 at 3 years postpartum between women who delivered preterm (gestation <37 weeks; n = 54) versus term (≥37 weeks; n = 751) using multivariable linear regression. We also assessed relations with body mass index, weight change from prepregnancy, and waist circumference at 3 and 7 years postpartum.

RESULTS

Median age at enrollment was 33.9 years (range: 16.4-44.9). After adjusting for age, race, prepregnancy body mass index, parity, marital status, education, and SBP during early pregnancy, women with PTB had 3.99 mm Hg (95% confidence interval, 0.82-7.16) higher SBP and 7.01 mg/dL (1.54-12.50) lower HDL than those who delivered at term. The association with SBP was attenuated after accounting for hypertension before or during pregnancy (2.78 mm Hg [-0.30 to 5.87]). PTB was not related to other postpartum outcomes.

CONCLUSIONS

PTB is related to greater CVD risk by 3 years postpartum as indicated by higher SBP and lower HDL. Although these associations may be due to preexisting conditions exacerbated during pregnancy, PTB may flag high-risk women for more vigilant CVD monitoring and lifestyle interventions.

Recurrent pregnancy loss: a risk factor for long-term maternal atherosclerotic morbidity?

OBJECTIVE

We sought to investigate whether patients with a history of recurrent pregnancy loss (RPL) have an increased risk for future maternal atherosclerotic morbidity.

STUDY DESIGN

A population-based study compared the incidence of long-term atherosclerotic morbidity (renal and cardiovascular) in a cohort of women with and without a diagnosis of RPL. Patients had a mean follow-up duration of more than a decade. Women with known atherosclerotic disease were excluded from the study. Cardiovascular morbidity was divided into 4 categories according to severity and type including simple and complex cardiovascular events and invasive and noninvasive cardiac procedures. Kaplan-Meier survival curves were used to estimate cumulative incidence of cardiovascular and renal hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazard ratios for cardiovascular and renal morbidity.

RESULTS

During the study period 99,285 patients were included; of these 6.7% (n = 6690) had a history of RPL. Patients with RPL had higher rates of renal and cardiovascular morbidity including cardiac invasive and noninvasive diagnostic procedures, simple as well as complex cardiovascular events, and hospitalizations due to cardiovascular causes. Using Kaplan-Meier survival curves, patients with a previous diagnosis of RPL had a significantly higher cumulative incidence of cardiovascular but not renal hospitalizations. Using a Cox proportional hazards model, adjusted for confounders such as preeclampsia, diabetes mellitus, obesity, and smoking, a history of RPL remained independently associated with cardiovascular hospitalizations (adjusted hazard ratio, 1.6; 95% confidence interval, 1.4-1.8; P = .001).

CONCLUSION

RPL is an independent risk factor for long-term maternal cardiovascular complications.

Adipokines in gestational diabetes

Gestational diabetes is characterised by glucose intolerance with onset or first recognition during pregnancy. The disease shows facets of the metabolic syndrome including obesity, insulin resistance, and dyslipidaemia. Adipokines are a group of proteins secreted from adipocytes, which are dysregulated in obesity and contribute to metabolic and vascular complications. Recent studies have assessed the role of various adipokines including leptin, adiponectin, tumour necrosis factor α (TNFα), adipocyte fatty acid-binding protein (AFABP), retinol-binding protein 4 (RBP4), resistin, NAMPT, SERPINA12, chemerin, progranulin, FGF-21, TIMP1, LCN2, AZGP1, apelin (APLN), and omentin in gestational diabetes. This Review provides an overview of these key adipokines, their regulation in, and potential contribution to gestational diabetes. Based on the evidence so far, the adipokines adiponectin, leptin, TNFα, and AFABP seem to be the most probable candidates involved in the pathophysiology of gestational diabetes.

Metabolic syndrome risk after gestational diabetes: a systematic review and meta-analysis

BACKGROUND

A number of studies have been conducted to investigate the risk of metabolic syndrome (MS) after gestational diabetes mellitus (GDM), but the results are contradictory. Accordingly, we performed a systematic review and meta-analysis to assess the association between these two conditions. The aim was to better understand the risks of MS with prior gestational diabetes.

METHODS

Pubmed, ISI Web of Science, and Cochrane databases from September 1, 1979 to July 11, 2013 were searched to identify relevant studies. 17 studies containing 5832 women and 1149 MS events were included. We calculated the odds ratio (OR) with 95% confidence interval (CI) in analysis for each study using a random-effect or fixed-effect model. We also determined heterogeneity among these 17 articles and their publication bias.

RESULTS

Women with a history of gestational diabetes had a significantly higher risk of MS than those who had a normal pregnancy (OR, 3.96; 95% CI, 2.99 to 5.26), but had significant heterogeneity (I (2) = 52.6%). The effect remained robust (OR, 4.54; 95% CI, 3.78-5.46) in the subgroup of Caucasians, but no association (OR, 1.28; 95% CI, 0.64-2.56) was found in Asians. Heterogeneity was reduced (body mass index (BMI) matched group I (2) = 14.2%, BMI higher in the GDM group I (2) = 13.2%) in the subgroup of BMI. In addition, mothers with higher BMI in the GDM group had higher risk of MS than those in the BMI matched group (BMI higher in GDM group OR, 5.39; 95% CI, 4.47-6.50, BMI matched group OR, 2.53; 95% CI, 1.88-3.41).

CONCLUSIONS

This meta-analysis demonstrated increased risk of MS after gestational diabetes. Therefore, attention should be given to preventing or delaying the onset of MS in GDM mothers, particularly in Caucasian and obese mothers.

Metabolic syndrome risk after gestational diabetes: a systematic review and meta-analysis

BACKGROUND

A number of studies have been conducted to investigate the risk of metabolic syndrome (MS) after gestational diabetes mellitus (GDM), but the results are contradictory. Accordingly, we performed a systematic review and meta-analysis to assess the association between these two conditions. The aim was to better understand the risks of MS with prior gestational diabetes.

METHODS

Pubmed, ISI Web of Science, and Cochrane databases from September 1, 1979 to July 11, 2013 were searched to identify relevant studies. 17 studies containing 5832 women and 1149 MS events were included. We calculated the odds ratio (OR) with 95% confidence interval (CI) in analysis for each study using a random-effect or fixed-effect model. We also determined heterogeneity among these 17 articles and their publication bias.

RESULTS

Women with a history of gestational diabetes had a significantly higher risk of MS than those who had a normal pregnancy (OR, 3.96; 95% CI, 2.99 to 5.26), but had significant heterogeneity (I (2) = 52.6%). The effect remained robust (OR, 4.54; 95% CI, 3.78-5.46) in the subgroup of Caucasians, but no association (OR, 1.28; 95% CI, 0.64-2.56) was found in Asians. Heterogeneity was reduced (body mass index (BMI) matched group I (2) = 14.2%, BMI higher in the GDM group I (2) = 13.2%) in the subgroup of BMI. In addition, mothers with higher BMI in the GDM group had higher risk of MS than those in the BMI matched group (BMI higher in GDM group OR, 5.39; 95% CI, 4.47-6.50, BMI matched group OR, 2.53; 95% CI, 1.88-3.41).

CONCLUSIONS

This meta-analysis demonstrated increased risk of MS after gestational diabetes. Therefore, attention should be given to preventing or delaying the onset of MS in GDM mothers, particularly in Caucasian and obese mothers.

Gestational diabetes and risk of cardiovascular disease: a scoping review

BACKGROUND

Gestational diabetes mellitus is associated with an increased risk of incident type 2 diabetes and has deleterious effects on other cardiovascular risk factors. However, the effect of gestational diabetes on the risk of cardiovascular disease remains unclear. We conducted a scoping review of the literature to examine the association between these 2 conditions.

METHODS

We systematically searched the PubMed and Embase databases for studies examining the association between gestational diabetes and cardiovascular disease. We restricted our search to studies involving humans that were published in English or French. Outcomes of interest included acute coronary syndromes, angina, arrhythmia, coronary artery disease, heart failure, myocardial infarction, stroke, and composite end points with these outcomes.

RESULTS

A total of 11 publications (3 cohort studies [1 published as an abstract], 2 cross-sectional studies, 1 case-control study [published as an abstract], 4 narrative reviews, and 1 editorial) met our inclusion criteria. The 2 cohort studies published as full manuscripts were conducted in overlapping populations. The included studies reported a range of adjusted relative risks for incident cardiovascular disease, from not significant to 1.85 (95% confidence interval [CI] 1.21 to 2.82). Adjustment for subsequent type 2 diabetes mellitus attenuated the effects but with wide 95% CIs that spanned unity (range 1.13 [95% CI 0.67 to 1.89] to 1.56 [95% CI 1.00 to 2.43]).

INTERPRETATION

Available data suggest that gestational diabetes is associated with an increased risk of cardiovascular disease. However, these data are limited, and evidence regarding this association independent of the increased risk due to subsequent type 2 diabetes and other risk factors for cardiovascular disease remains inconclusive.

Prediction of gestational diabetes early in pregnancy: targeting the long-term complications

Gestational diabetes (GD), defined as carbohydrate intolerance with onset or first recognition during pregnancy, has a prevalence of 7% and is a growing problem worldwide. Infants born to mothers with GD are more likely to be large for gestational age, incur traumatic birth injury, require a stay in the intensive care unit and develop postnatal metabolic disturbances. As the worldwide epidemic of obesity worsens, more women are entering pregnancy with metabolic alterations and preexisting insulin resistance, which is heightened by the hormonal milieu of pregnancy. The Hyperglycemia Adverse Pregnancy Outcome (HAPO) study has clearly shown that GD-related complications correlate with glycemic control. We will review the current understanding of the physiology of GD and the screening and treatment guidelines that are commonly utilized in clinical care. In addition, we will discuss the need for development of multiparametric models combining maternal clinical risk factors and biomarkers early in pregnancy to better stratify and predict risk of GD-related complications and offer targeted intervention.

An association between preterm delivery and long-term maternal cardiovascular morbidity

OBJECTIVE

The purpose of this study was to investigate whether a history of preterm delivery (PTD) poses a risk for subsequent maternal long-term cardiovascular morbidity.

STUDY DESIGN

A population-based study compared the incidence of cardiovascular morbidity in a cohort of women who delivered preterm (<37 weeks' gestation) and those who gave birth at term at the same period. Deliveries occurred during the years 1988-1999 with follow up until 2010. Kaplan-Meier survival curves were used to estimate cumulative incidence of cardiovascular hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazard ratios for cardiovascular hospitalizations.

RESULTS

During the study period 47,908 women met the inclusion criteria; 12.5% of the patients (n = 5992) delivered preterm. During a follow-up period of >10 years, patients with PTD had higher rates of simple and complex cardiovascular events and higher rates of total cardiovascular-related hospitalizations. A linear association was found between the number of previous PTD and future risk for cardiovascular hospitalizations (5.5% for ≥2 PTDs; 5.0% for 1 PTD vs 3.5% in the comparison group; P < .001). The association remained significant for spontaneous vs induced PTD and for early (<34 weeks) and late (34 weeks to 36 weeks 6 days' gestation) PTD. In a Cox proportional hazards model that adjusted for pregnancy confounders such as labor induction, diabetes mellitus, preeclampsia, and obesity, PTD was associated independently with cardiovascular hospitalizations (adjusted hazard ratio, 1.4; 95% confidence interval, 1.2-1.6).

CONCLUSION

PTD is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than a decade.

Correlation of serum homocysteine and previous history of gestational diabetes mellitus

Background

Gestational diabetes mellitus (GDM) is a common pregnancy condition. In this study, the risk of having a history of previous GDM (pGDM) on serum homocysteine level was assessed

Methods

Biomedical parameters, serum homocysteine, Insulin, homeostatic model assessment (HOMA) in women with (n = 52) and without pGDM (n = 51) were assessed. According to their current status of Oral Glucose Tolerance Test (GTT), the participants in each group were divided into two subgroups of normal or impaired GTT.

Results

Mean serum homocysteine in normal women was 8.56 ± 3.19 vs 11.44 ± 7.34 μmol/L (p < 0.01) in women with pGDM. Two groups had significant differences in respect to serum insulin levels (8.35 ± 5.12 vs 12.48 ± 5.44, p < 0.002), and HOMA-IR (1.90 ± 1.30 vs 2.91 ± 1.30, p < 0.002). In women without pGDM, serum homocysteine in normal and impaired GTT were 7.60 ± 1.69 and 10.52 ± 3.65 μmol/L (p = 0.03), respectively, while in women with pGDM, the figures were 8.38 ± 2.52 and 14.00 ± 10.17 (p < 0.01), respectively. In multi regression analysis an association between history of GDM and homocysteine levels was presented (OR: 7.71, 95% CI: 1.67-35.42, p < 0.001).

Conclusion

A trend of elevation of homocysteine is presented in women with pGDM, that is more prominent in women with impaired GTT, and shows a significant correlation with history of GDM. Further studies with larger sample size are suggested.

An association between gestational diabetes mellitus and long-term maternal cardiovascular morbidity

OBJECTIVE

To investigate whether a diagnosis of gestational diabetes mellitus (GDM) is a risk factor for subsequent long-term cardiovascular morbidity.

DESIGN

A population-based study.

SETTING

Soroka University Medical Center, a tertiary centre in the southern region of Israel.

PATIENTS

A cohort of women with and without a diagnosis of GDM who delivered during the years 1988-1999 with a follow-up period until 2010.

INTERVENTIONS

A comparison of the incidence of cardiovascular morbidity.

RESULTS

Of 47 909 deliveries that met the inclusion criteria, 4928 (10.3%) occurred in patients who were diagnosed with GDM. During a follow-up period of more than 10 years, compared with women who gave birth at the same time period, after adjustment for age and ethnicity, patients with GDM had higher rates of cardiovascular morbidity including non-invasive cardiac diagnostic procedures (OR=1.8; 95% CI 1.4 to 2.2), simple cardiovascular events (OR=2.7; 95% CI 2.4 to 3.1) and total cardiovascular hospitalisations (OR=2.3; 95% CI 2.0 to 2.5). In a Cox proportional hazards model, adjusted for comorbidities such as pre-eclampsia and obesity, GDM was independently associated with cardiovascular hospitalisations (adjusted HR 2.6, 95% CI 2.3 to 3).

CONCLUSIONS

GDM is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than a decade.

Osteoprotegerin as a marker of atherosclerosis in diabetic patients

Atherosclerosis is the principal cause of cardiovascular disease (CVD) and has many risk factors, among which is diabetes. Osteoprotegerin (OPG) is a soluble glycoprotein, involved in bone metabolism. OPG is also found in other tissues, and studies have shown that it is expressed in vascular smooth muscle cells. OPG has been implicated in various inflammations and also has been linked to diabetes mellitus. Increased serum OPG levels were found in patients with diabetes and poor glycemic control. Furthermore, prepubertal children with type 1 diabetes have significantly increased OPG levels. Receptor activator of nuclear factor kappa-B ligand (RANKL) is not found in the vasculature in normal conditions, but may appear in calcifying areas. OPG and RANKL are important regulators of mineral metabolism in both bone and vascular tissues. Few data are available on the relationship between plasma OPG/RANKL levels and endothelial dysfunction as assessed using noninvasive methods like ultrasound indexes, neither in the general population nor, more specifically, in diabetic patients. The aim of our review study was to investigate, based on the existing data, these interrelationships in order to identify a means of predicting, via noninvasive methods, later development of endothelial dysfunction and vascular complications in diabetic patients.