Blood-oxygen transport in first trimester of diabetic pregnancy

Abnormal Placentation Associated with Infertility as a Marker of Overall Health

Infertility and fertility treatments utilized are associated with abnormal placentation leading to adverse pregnancy outcomes related to placentation, including preterm birth, low birth weight, placenta accrete, and placenta previa. This may be due to the underlying genetics predisposing to infertility or the epigenetic changes associated with the fertility treatments utilized, as specific disease states leading to infertility are at increased risk of adverse outcomes, including placental abruption, fetal loss, gestational diabetes mellitus, and outcomes related to placentation, as well as the treatments utilized including in vitro fertilization (IVF) and non-IVF fertility treatment. Placentation defects, leading to adverse maternal and fetal outcomes, which are more pronounced in the infertile population, occur due to changes in trophoblast invasion, vascular defects, changes in the environmental milieu, chronic inflammation, and oxidative stress. These similar processes are recognized as major contributors to lifelong risk of cardiovascular and metabolic disease for both the mother and her offspring. Thus, abnormal placentation, found to be more prevalent in the infertile population, may be the key to better understand how infertility affects overall and long-term health.

Associations of FPG, A1C and disease duration with protein markers of oxidative damage and antioxidative defense in type 2 diabetes and diabetic retinopathy

PURPOSE

To investigate the role of protein oxidative damage and antioxidant defense in relationship to hyperglycemia measured as fasting plasma glucose (FPG), glycated hemoglobin (A1C), and duration of disease in type 2 diabetes mellitus (DM) and diabetic retinopathy (DR).

METHODS

This study recruited 23 non-diabetic subjects, 16 DM patients without any complications and 18 DR patients. The serum ischemia modified albumin (IMA) and glutathione (GSH) levels were measured. The IMA results were corrected for serum albumin. Between-group differences were studied by analysis of variance and between-variable associations were studied by Spearman's and partial correlations.

RESULTS

IMA and cIMA values were elevated, whereas GSH was decreased in both patient groups vs controls (P<0.05), and the increase in IMA formation is not related to serum albumin changes. DR patients have much severe oxidative stress (OS) status with high IMA and cIMA, and low GSH than in the DM group (P<0.05). Both FPG and A1C levels were positively associated with IMA in DM group, while in the DR group, duration of disease too had a positive association with IMA. The antioxidant GSH had negative correlations with FPG (r=-0.52, P=0.02) and IMA (r=-0.49, P=0.03) in the DR group. Partial correlation analyses predicted mutual or independent associations among parameters.

CONCLUSIONS

Severe OS in DR has been associated with increased FPG, A1C, and disease duration. Both hyperglycemia and elevated oxidative damage detected as IMA are collectively associated with depleted GSH status. Our study unravels the need for monitoring of OS in addition to standard glycemic management in DR.

Obstetric conditions and the placental weight ratio

INTRODUCTION

To elucidate how obstetric conditions are associated with atypical placental weight ratios (PWR)s in infants born: (a) ≥37 weeks gestation; (b) at ≥33 but <37 weeks gestation; and (c) <33 weeks gestation.

METHODS

The study included all in-hospital singleton births in London, Ontario between June 1, 2006 and March 31, 2011. PWR was assessed as <10th or >90th percentile by gestational age-specific local population standards. Multivariable analysis was carried out using multinomial logistic regression with blockwise variable entry in order of temporality.

RESULTS

Baseline factors and maternal obstetric conditions associated with PWR <10th percentile were: increasing maternal height, overweight and obese body mass indexes (BMI), large for gestational age infants, smoking, and gestational diabetes. Obstetric factors associated with PWR >90th percentile were: underweight, overweight and obese BMIs, smoking, preeclampsia, placenta previa, and placental abruption. In particular, indicators of hypoxia and altered placental function were generally associated with elevated PWR at all gestations.

DISCUSSION

An association between obstetric conditions associated with fetal hypoxia and PWR ≥90th percentile was illustrated.

CONCLUSIONS

The multivariable findings suggest that the PWR is similarly increased regardless of the etiology of the hypoxia.

Consequences of gestational and pregestational diabetes on placental function and birth weight

Maternal diabetes constitutes an unfavorable environment for embryonic and fetoplacental development. Despite current treatments, pregnant women with pregestational diabetes are at increased risk for congenital malformations, materno-fetal complications, placental abnormalities and intrauterine malprogramming. The complications during pregnancy concern the mother (gravidic hypertension and/or preeclampsia, cesarean section) and the fetus (macrosomia or intrauterine growth restriction, shoulder dystocia, hypoglycemia and respiratory distress). The fetoplacental impairment and intrauterine programming of diseases in the offspring’s later life induced by gestational diabetes are similar to those induced by type 1 and type 2 diabetes mellitus. Despite the existence of several developmental and morphological differences in the placenta from rodents and women, there are similarities in the alterations induced by maternal diabetes in the placenta from diabetic patients and diabetic experimental models. From both human and rodent diabetic experimental models, it has been suggested that the placenta is a compromised target that largely suffers the impact of maternal diabetes. Depending on the maternal metabolic and proinflammatory derangements, macrosomia is explained by an excessive availability of nutrients and an increase in fetal insulin release, a phenotype related to the programming of glucose intolerance. The degree of fetal damage and placental dysfunction and the availability and utilisation of fetal substrates can lead to the induction of macrosomia or intrauterine growth restriction. In maternal diabetes, both the maternal environment and the genetic background are important in the complex and multifactorial processes that induce damage to the embryo, the placenta, the fetus and the offspring. Nevertheless, further research is needed to better understand the mechanisms that govern the early embryo development, the induction of congenital anomalies and fetal overgrowth in maternal diabetes.

Exposure to maternal diabetes is associated with altered fetal growth patterns: A hypothesis regarding metabolic allocation to growth under hyperglycemic-hypoxemic conditions

The prevalence of diabetes is rising worldwide, including women who grew poorly in early life, presenting intergenerational health problems for their offspring. It is well documented that fetuses exposed to maternal diabetes during pregnancy experience both macrosomia and poor growth outcomes in birth size. Less is known about the in utero growth patterns that precede these risk factor expressions. Fetal growth patterns and the effects of clinical class and glycemic control were investigated in 37 diabetic pregnant women and their fetuses and compared to 29 nondiabetic, nonsmoking maternal/fetal pairs who were participants in a biweekly longitudinal ultrasound study with measurements of the head, limb, and trunk dimensions. White clinical class of the diabetic women was recorded (A2-FR) and glycosylated hemoglobin levels taken at the time of measurement assessed glycemic control (median 6.9%, interquartile range 5.6-9.2%). No significant difference in fetal weight was found by exposure. The exposed sample had greater abdominal circumferences from 21 weeks (P < or = 0.05) and shorter legs, but greater upper arm and thigh circumferences accompanied increasing glycemia in the second trimester. In the third trimester, exposed fetuses had a smaller slope for the occipital frontal diameter (P = 0.00) and were brachycephalic. They experienced a proximal/distal growth gradient in limb proportionality with higher humerus / femur ratios (P = 0.04) and arms relatively long by comparison with legs (P = 0.02). HbA1c levels above 7.5% accompanied shorter femur length for thigh circumference after 30 gestational weeks of age. Significant effects of diabetic clinical class and glycemic control were identified in growth rate timing. These growth patterns suggest that hypoxemic and hyperglycemic signals cross-talk with their target receptors in a developmentally regulated, hierarchical sequence. The increase in fetal fat often documented with diabetic pregnancy may reflect altered growth at the level of cell differentiation and proximate mechanisms controlling body composition. These data suggest that the maternal-fetal interchange circuit, designed to share and capture resources on the fetal side, may not have had a long evolutionary history of overabundance as a selective force, and modern health problems drive postnatal sequelae that become exacerbated by increasing longevity.

Audit on stillbirths in women with pregestational type 1 diabetes

OBJECTIVE

To audit stillbirth cases in women with type 1 diabetes to search for specific characteristics in order to improve antenatal care and treatment.

RESEARCH DESIGN AND METHODS

Retrospectively identified cases of stillbirths in women with type 1 diabetes during 1990-2000 were analyzed regarding characteristics of the mother, the pregnancy, glycemic control, and the stillborn. The cause of stillbirth was categorized as explainable, likely, or without obvious cause.

RESULTS

We found 22 women with 25 stillbirths among 1,361 singleton births by women with type 1 diabetes. In seven stillbirths the cause was categorized as explainable and in six as likely. In 12 cases no obvious cause was found; however, glycemic control was suboptimal in 9 of these cases. A total of 14 women reported daily smoking, and 10 of 19 with low education were unemployed.

CONCLUSIONS

Women experiencing stillbirth were characterized by a high incidence of suboptimal glycemic control, diabetic nephropathy, smoking, and low social status.

Outcome of pregnancy in diabetic mothers

OBJECTIVE

To study complications seen among newborns of gestational diabetic mothers versus nondiabetics, and to compare the pattern of distribution of those complications to similar reports form Western populations.

METHOD

Prospective case controlled study of 384 newborns, (191 of diabetic and 193 of nondiabetic mothers) delivered at the King Abdulaziz University Hospital, Jeddah.

RESULTS

The overall rate of infant morbidity was greater among newborns of diabetic mothers, especially those who required insulin for metabolic control. The major complications were those associated with increased incidence of large birth weight infants. Complications such as congenital malformations, intrauterine growth retardation and other severe forms of morbidity often associated with insulin-dependent diabetes were rarely seen.

CONCLUSION

Fetal and neonatal risks associated with diabetes in pregnancy depend not only on the severity, but also on the type of diabetes. In modern societies fetal complications associated with diabetes are mainly those due to hyperglycemia in the second half of gestation. The results also emphasize the fact that perinatal morbidity rather than mortality should be the yardstick for the efficacy of management of diabetes in pregnancy.

Fetal acidosis and hyperlacticaemia diagnosed by cordocentesis in pregnancies complicated by maternal diabetes mellitus

Fetal blood samples were obtained by cordocentesis (ultrasound guided needle aspiration) from 28 pregnant Type 1 diabetic women between 20 and 40 weeks' gestation. Analysis of the deviations from normal values of blood pH and plasma lactate showed significant acidosis (p less than 0.001) and hyperlacticaemia (p less than 0.01) in the third trimester, but not in the second trimester. Blood PO2 and PCO2 levels did not differ significantly from normal values. The pH showed significant correlations with PO2 (r = 0.54; p less than 0.01) PCO2 (r = -0.70; p less than 0.001), lactate (r = -0.46; p less than 0.05), fetal glycosylated haemoglobin (r = -0.53; p less than 0.01), and maternal glycosylated haemoglobin (r = -0.57; p less than 0.01). Plasma lactate showed significant correlations with PO2 (r = -0.54; p less than 0.01), PCO2 (r = 0.50; p less than 0.05), and pH (r = -0.46; p less than 0.05). Neither pH nor lactate showed significant correlations with birthweight. These observations suggest that some fetuses of diabetic women are significantly acidotic and hyperlacticaemic in the third trimester. This may provide a possible explanation for the phenomenon of late intrauterine fetal death in pregnancies complicated by maternal diabetes mellitus.

2,3-diphosphoglycerate in normal and pathologic pregnancy: relationship to neonatal weight

2,3-Diphosphoglycerate levels were assayed in 154 pregnant women in third trimester (61 normal, 52 diabetic, 19 with gestational hypertension, 7 with fetal macrosomia, and 15 with idiopathic fetal underdevelopment). A correlation was found between 2,3-diphosphoglycerate levels and birth weight (absolute and relative birth weight or birth weight expressed as percentile), which was negative in normal patients evaluated in the last 7 days before delivery (r = 0.38; p = 0.04) and positive in diabetic patients (evaluated in the third trimester and in the last 7 days before delivery) and in patients with gestational hypertension (evaluated in the third trimester) (r and p values differ according to whether birth weight is expressed as absolute, relative, or a percentile). No correlation was found between 2,3-diphosphoglycerate levels and birth weight in patients with neonatal underdevelopment or macrosomia of unknown origin. On the basis of these results we hypothesize that in some conditions the fetus can influence maternal 2,3-diphosphoglycerate levels and hence its own oxygen supply and growth in utero.