Association of Maternal History of Spontaneous Abortion and Stillbirth With Risk of Congenital Heart Disease in Offspring of Women With vs Without Type 2 Diabetes

IMPORTANCE

The associations of maternal history of spontaneous abortion (SA) and stillbirth with congenital heart disease (CHD) remain elusive.

OBJECTIVE

To evaluate the associations of maternal history of pregnancy loss with CHD in offspring and the role of maternal type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included singleton live offspring born between January 1, 1977, and December 31, 2016, identified through Danish national health registries. Statistical analysis was performed from October 1, 2019, through September 1, 2021.

EXPOSURES

Maternal history of SA, with frequency varying from 1 or 2 to 3 or more episodes, and maternal history of single and multiple stillbirths.

MAIN OUTCOMES AND MEASURES

Overall CHD identified by hospital diagnosis. Cox proportional hazard regression was used to estimate the hazard ratio (HR) of CHD. Diabetes was evaluated as a potential confounder and a potential effect modifier.

RESULTS

Among 1 642 534 included offspring (mean [SD] age, 14.11 [8.39] years; 843 265 male [51.35%]), 246 669 (15.02%) were born to mothers with a history of SA and 9750 (0.59%) were born to mothers with a history of stillbirth. The HRs of CHD were 1.16 (95% CI, 1.13-1.20) for offspring with a maternal history of SA and 1.49 (95% CI, 1.32-1.68) for offspring with a maternal history of stillbirth. Significant dose-response associations were observed among offspring with a maternal history of 3 or more episodes of SA (HR, 1.60; 95% CI, 1.39-1.84) and those with maternal history of multiple stillbirths (HR, 2.75; 95% CI, 1.63-4.65). If only inpatient CHD cases were included, the risk of CHD was higher than that found in the main analysis, with HRs of 1.24 (95% CI, 1.19-1.30) for maternal history of SA and 1.78 (95% CI, 1.51-2.11) for maternal history of stillbirth. The observed associations were strengthened by maternal prepregnancy type 2 diabetes (HR for maternal history of SA, 1.65 [95% CI, 1.37-1.97]; HR for maternal history of stillbirth, 1.74 [95% CI, 1.06-2.85]).

CONCLUSIONS AND RELEVANCE

These findings suggest that offspring born to mothers with a previous SA or stillbirth, especially multiple episodes, or with prepregnancy type 2 diabetes were at a higher risk of being diagnosed with CHD. These findings may help identify women at increased risk in whom detailed fetal heart assessment may be cost-effective and highlight the importance of screening for type 2 diabetes in women of reproductive age.

Monogenic diabetes caused by GCK gene mutation is misdiagnosed as gestational diabetes - A multicenter study in Portugal

AIMS

Monogenic diabetes is an underdiagnosed type of diabetes mellitus, which can be harmful in pregnancy. We aim to estimate the prevalence of diabetes caused by the mutation of the glucokinase gene (GCK-MODY) in pregnant women diagnosed with gestational diabetes mellitus (GDM) and to characterize pregnant women with this suspicion.

METHODS

A multicenter observational study with data prospectively collected from pregnancies with GDM was conducted. Two groups of pregnant women were considered: those with GCK-MODY criteria and those without those criteria.

RESULTS

Of 18421 women with GDM, 3.6% (n = 730) had the GCK-MODY clinical criteria. A prevalence of 1.5% of GCK-MODY is estimated in women with GDM in Portugal, which is higher than in Northern European countries. Suspected GCK-MODY women had statistically higher odds of having neonates below the 25th percentile (OR = 1.23, 95%CI = 1.04-1.46, p = 0.016) and having prediabetes and diabetes in postpartum reclassification (OR = 2.11, 95%CI = 1.55-2.82, p < 0.001 and OR = 5.96, 95%CI = 3.38-10.06, p < 0.001, respectively).

CONCLUSIONS

Higher odds of neonates below the 25th percentile was probably due to excessive insulin treatment in cases where both the mother and the fetus have the mutation. It is essential to consider the diagnosis of GCK-MODY in all women with GDM criteria for better management of diabetes in pregnancy.

Maternal diet modulates placental nutrient transporter gene expression in a mouse model of diabetic pregnancy

Diabetes in the mother during pregnancy is a risk factor for birth defects and perinatal complications and can affect long-term health of the offspring through developmental programming of susceptibility to metabolic disease. We previously showed that Streptozotocin-induced maternal diabetes in mice is associated with altered cell differentiation and with smaller size of the placenta. Placental size and fetal size were affected by maternal diet in this model, and maternal diet also modulated the risk for neural tube defects. In the present study, we sought to determine the extent to which these effects might be mediated through altered expression of nutrient transporters, specifically glucose and fatty acid transporters in the placenta. Our results demonstrate that expression of several transporters is modulated by both maternal diet and maternal diabetes. Diet was revealed as the more prominent determinant of nutrient transporter expression levels, even in pregnancies with uncontrolled diabetes, consistent with the role of diet in placental and fetal growth. Notably, the largest changes in nutrient transporter expression levels were detected around midgestation time points when the placenta is being formed. These findings place the critical time period for susceptibility to diet exposures earlier than previously appreciated, implying that mechanisms underlying developmental programming can act on placenta formation.

Turning conceptual systems maps into dynamic simulation models: An Australian case study for diabetes in pregnancy

BACKGROUND

System science approaches are increasingly used to explore complex public health problems. Quantitative methods, such as participatory dynamic simulation modelling, can mobilise knowledge to inform health policy decisions. However, the analytic and practical steps required to turn collaboratively developed, qualitative system maps into rigorous and policy-relevant quantified dynamic simulation models are not well described. This paper reports on the processes, interactions and decisions that occurred at the interface between modellers and end-user participants in an applied health sector case study focusing on diabetes in pregnancy.

METHODS

An analysis was conducted using qualitative data from a participatory dynamic simulation modelling case study in an Australian health policy setting. Recordings of participatory model development workshops and subsequent meetings were analysed and triangulated with field notes and other written records of discussions and decisions. Case study vignettes were collated to illustrate the deliberations and decisions made throughout the model development process.

RESULTS

The key analytic objectives and decision-making processes included: defining the model scope; analysing and refining the model structure to maximise local relevance and utility; reviewing and incorporating evidence to inform model parameters and assumptions; focusing the model on priority policy questions; communicating results and applying the models to policy processes. These stages did not occur sequentially; the model development was cyclical and iterative with decisions being re-visited and refined throughout the process. Storytelling was an effective strategy to both communicate and resolve concerns about the model logic and structure, and to communicate the outputs of the model to a broader audience.

CONCLUSION

The in-depth analysis reported here examined the application of participatory modelling methods to move beyond qualitative conceptual mapping to the development of a rigorously quantified and policy relevant, complex dynamic simulation model. The analytic objectives and decision-making themes identified provide guidance for interpreting, understanding and reporting future participatory modelling projects and methods.

Maternal Lipids May Predict Fetal Growth in Type 2 Diabetes Mellitus and Gestational Diabetes Mellitus Pregnancies

AIM

During diabetic pregnancy, complex metabolic changes occur in the lipid profile. The aim of the study was to determine the predictive values of maternal serum lipid levels on large-for-gestational age newborns during the third trimester in pregnancies of women with type 2 diabetes mellitus (DM2) and gestational diabetes mellitus (GDM).

MATERIAL AND METHODS

Data of forty three pregnancies of women with DM2 and two hundred women with GDM were analyzed. The analysis encompassed the following parameters: age, body mass index (BMI), lipid parameters, HbA1c in first, second and third trimester of pregnancy, preeclampsia and baby birth weight.

RESULTS

DM2 and GDM groups showed statistically significant differences in the following variables: total lipids, triglycerides, total cholesterol, BMI, age, baby birth weight, incidence of SGA and preterm delivery (9.4 ± 2.3 vs. 11.0 ± 2.3 mmol/L, 2.4 ± 1.4 vs. 3.4 ± 1.6 mmol/L, 5.5 ± 1.2 vs. 6.4 ± 1.4 mmol/L, 30.6 ± 5.4 vs. 26.9 ± 5.2 kg/m2, 34 ± 7.8 vs. 31.5 ± 5.6 years, 3183 ± 972 vs. 3533 ± 699 g., 20% vs. 7.5%, 27.9 vs. 14%, respectively, p < 0.05). Linear multiple regression analysis demonstrated that triglycerides, LDL-C and total cholesterol were independent predictors of LGA (p < 0.05).

CONCLUSION

Triglycerides and LDL-C in the third trimester of pregnancy are independent predictors for fetal macrosomia in DM2 and GDM pregnancies. Thus, the maternal serum triglycerides and LDL-C levels determined in the maternal blood taken in the third trimester of pregnancy may indentify women who will give birth to LGA newborns.

Factors Associated with Periodontal Disease in Pregnant Diabetic Women

There have been an association between systemic diseases and hormonal changes particularly diabetes which has been cited as a risk factor in the progression of periodontitis in pregnant women. The incidence and severity of periodontal diseases are increasing at a higher rate and a common condition in pregnant diabetic women among Bangladeshi population. This cross sectional study included 200 pregnant women who were selected from gynecological department and examined at the dental unit. The clinical parameters used were the Silness and Loe plaque index (PI), gingival scores and periodontal status and any relationship to socio demographic variables (age, occupation, level of education and urban or rural residence) and clinical variables (gestation period, previous pregnancy, type of diabetes and periodontal maintenance) were evaluated. The results showed that these clinical parameters increased concomitantly with an increase in the stage of pregnancy and in women with multiple pregnancies. Increased age, lower level of education, unemployment and patients residing in rural areas were associated with significantly higher gingival scores and periodontal measures. Women with increased age and multiple pregnancies usually have less interest to frequent periodontal maintenance showing a significant statistical relation between an increased age and changes in gingival and periodontal status; however no significant association was found between increased age and plaque index. It is concluded that gingival inflammatory symptoms are aggravated during pregnancy in diabetic women and are related to different clinical and demographic variables.

Gestational diabetes: a red flag for future Type 2 diabetes in pregnancy? A retrospective analysis

AIMS

This study sought to understand the relationship between Type 2 diabetes in pregnancy and previous gestational diabetes (GDM), and determine whether a previous pregnancy with GDM was associated with subsequent better pregnancy planning.

METHODS

A retrospective review of medical records of women with Type 2 diabetes in pregnancy was conducted at three teaching hospitals to ascertain whether they had earlier GDM, and to determine whether this is associated with differences in measures of pregnancy planning and diabetes management.

RESULTS

Of 172 index pregnancies affected by Type 2 diabetes, in 76 (44%) cases, the mother had a previous history of GDM. Within this cohort, a diagnosis of 'overt diabetes in pregnancy', made on the basis of a GTT result during pregnancy in the WHO diabetic range with persistent diabetes post partum, was more common among women who had previous GDM than women who had not had GDM (20% vs 7%, P = 0.02). Women who previously had GDM did not exhibit a higher incidence of preconception planning or folate supplementation.

CONCLUSIONS

It is common for women with Type 2 diabetes in pregnancy to have had GDM previously. The diagnosis of GDM is an opportunity to improve future pregnancy planning and outcomes for women with Type 2 diabetes in pregnancy. This goal is yet to be realized.

GLP-1 agonist treatment: implications for diabetic retinopathy screening

Rapid improvement in glycaemic control induced by GLP-1 agonist therapy could be yet another illustration of transient or permanent progression of diabetic retinopathy, similar to documented examples such as pregnancy and continuous subcutaneous insulin infusion. Specific guidelines would be needed to monitor this paradoxical phenomenon during treatment with GLP-1 agonists.

Production of a type 2 maternal diabetes rodent model using the combination of high-fat diet and moderate dose of streptozocin

INTRODUCTION

Pregnancy may be complicated by maternal diabetes. The following experiments were performed in an attempt to produce mouse models of insulin-resistant maternal diabetes.

METHODS

CD1 females received 200 mg/kg streptozocin (STZ) to model insulin-dependent diabetes (T1 group). Another group of females (T2 group) was put on a HFD 4 weeks before receiving 100 mg/kg STZ. After 4 additional weeks of HFD, hyperglycemic females were separated and bred. In another experiement, CD1 females were fed a HFD for 4 weeks before receiving an intravenous (GDM1 group) or intraperitoneal (GDM2 group) injection of 100 mg/kg STZ. Females from GDM2 group were bred at the same day of the STZ injection. Females from GDM1 group were bred 4 weeks after the STZ injection.

RESULTS AND CONCLUSION

About 25% of the females from T2 group became hyperglycemic after 4 weeks of the injection of STZ. Fifty percent of the females from GDM1 group reached hyperglycemic levels greater than 250 mg/dl during pregnancy. The combination of HFD and moderate STZ in CD1 mice therefore produced hyperglycemic females; however numbers of these mice were somewhat low.

[Diabetus mellitus and pregnancy]

OBJECTIVE

The evaluation of diabetic retinopathy during pregnancy.

MATERIAL AND METHODS

Retrospective study regarding 16 pregnant patients, with type 1 diabetes mellitus and variable retinal changes before the pregnancy: without retinal changes (5 cases), minimal diabetic retinopathy (7 cases), severe diabetic retinopathy (3 cases), proliferative diabetic retinopathy with panphotocoagulation before the pregnancy (1 case). The patients had a complete general and ocular investigation.

RESULTS

The patients without retinal changes were not influenced by pregnancy; the patients with minimal changes presented an aggravation of the diabetic retinopathy with an amelioration post-partum in 3 from the 7 cases; the patients with severe diabetic retinopathy suffered an aggravation in 1 from the 3 cases; the patients with proliferative diabetic retinopathy with panphotocoagulation before the pregnancy did not present any important changes during pregnancy.

CONCLUSIONS

The pregnancy represents a risk factor in the evolution of retinal changes in diabetic patients. The monitoring of the retinal changes and of the patients during the pregnancy is strongly recommended.

Pre-conception care and support for women with diabetes

This article discusses the National Service Framework for Diabetes: Standards (Department of Health, 2001), with the main focus on Standard 9: diabetes and pregnancy. It concentrates on pre-conception care and support for women with pre-existing diabetes to optimize the outcome of their pregnancy. The rationale for this is the need to understand how this standard affects women with diabetes during childbearing age. Following an introduction to aetiology and epidemiology of diabetes, the author examines the importance of pre-conception care for women with diabetes. An acknowledgement of the deficits within the clinical environment aids recommendations on improvement of education and knowledge for nurses. Health promotion and patient support is emphasized to facilitate an understanding of the impact of diabetes on pregnancy and the necessity of the multidisciplinary team involvement before, during and after birth.

Type 1 diabetes associated with asymptomatic acromegaly successfully treated with surgery after pregnancy: a case report

We report a rare case of type 1 diabetes in a woman associated with acromegaly who was treated with surgery after pregnancy. An 18-year-old woman came to our hospital in April, 1998, complaining of thirst, polydipsia, polyuria, appetite loss, body weight loss of 8 kg in a month, and amenorrhea beginning 2 months earlier. Based on laboratory data, she was diagnosed as having type 1 diabetes mellitus. Although we suspected her of having acromegaly because of high growth hormone (GH) levels (6.9 or 8.5 ng/ml), blood levels of insulin-like growth factor 1 (IGF-1) and IGF-binding protein-3 (IGFBP-3) were within normal range and the circadian rhythm of her blood GH levels was normally maintained. Her blood GH level was elevated to 12.6 ng/ml 15 minutes after a TRH administration. Blood GH levels were suppressed from 49 ng/ml to 1.5 ng/ml 4 hours after an oral administration of 2.5 mg of bromocriptine. A magnetic resonance images (MRIs) showed pituitary swelling, but no nodules were found in the pituitary. Therefore, we diagnosed her as having acromegaly and observed her without surgery, while prescribing diet therapy and intensive insulin therapy for diabetes. We started a treatment of oral administration of 7.5 mg of bromocriptine per day for the acromegaly from April 28, 2000, because her elevated GH was suspected of causing her diabetes to be poorly controlled. During a pregnancy from October, 2000 to September, 2001, diabetic control was improved with increased administration of insulin under a constant dose of bromocriptine. She delivered a normal full-term infant. After the bromocriptine therapy was stopped as she hoped to breastfeed, blood levels of GH and IGF-1 became elevated and her diabetic control deteriorated. As her pituitary tumor observed in pituitary MRIs became larger during the course, a transsphenoidal surgery was performed on March 8, 2002. After the surgery, blood levels of GH and IGF-1 lowered and diabetic control improved again. We concluded as follows: to rule out acromegaly in patients with poorly controlled diabetes, 1) measurements of serum GH and IGF-1 should be performed, and 2) pituitary MRIs should be performed if blood levels of GH or IGF-1 are high.

Maternal obesity and complications during pregnancy

Obesity has become a major health problem all over the world and during pregnancy is associated with an increased risk of complications, including gestational diabetes, preeclampsia, and delivery complications such as macrosomia, shoulder dystocia and higher rates of cesarean sections and infections. Maternal obesity may also be an independent risk factor for neural tube defects and fetal mortality. This review focuses on the consequences of maternal obesity during pregnancy.

Animal models of diabetes mellitus

Animal models have been used extensively in diabetes research. Early studies used pancreatectomised dogs to confirm the central role of the pancreas in glucose homeostasis, culminating in the discovery and purification of insulin. Today, animal experimentation is contentious and subject to legal and ethical restrictions that vary throughout the world. Most experiments are carried out on rodents, although some studies are still performed on larger animals. Several toxins, including streptozotocin and alloxan, induce hyperglycaemia in rats and mice. Selective inbreeding has produced several strains of animal that are considered reasonable models of Type 1 diabetes, Type 2 diabetes and related phenotypes such as obesity and insulin resistance. Apart from their use in studying the pathogenesis of the disease and its complications, all new treatments for diabetes, including islet cell transplantation and preventative strategies, are initially investigated in animals. In recent years, molecular biological techniques have produced a large number of new animal models for the study of diabetes, including knock-in, generalized knock-out and tissue-specific knockout mice.

Preconception care in managed care: the translating research into action for diabetes study

OBJECTIVES

This study was undertaken to examine the rates of preconception counseling in managed care for women with diabetes and associated patient and physician characteristics.

STUDY DESIGN

Participants included women aged 18 to 45 years enrolled in a study of diabetes care in managed care. Women were asked if they recalled discussions regarding glucose control before conception (n = 236) and use of family planning until glucose control was achieved (n = 227). Hierarchical logistic regression models accounted for patient and physician characteristics.

RESULTS

Fifty-two percent of women recalled being counseled about glucose control and 37% recalled family planning advice. In adjusted models, patient age (years) (odds ratio [OR] 0.91, 95% CI 0.86-0.96) and body mass index (BMI) (kg/m2) (OR 0.96, 95% CI 0.93-0.99) remained significant predictors of glucose control counseling. Similarly, patient age (years) (OR 0.94, 95% CI 0.89-0.99) and BMI (kg/m2) (0.96, 95% CI 0.93-0.99) remained significant predictors of family planning counseling.

CONCLUSIONS

Preconception counseling rates for diabetic women are low and associated with younger age and lower BMI.

Gestational Diabetes

Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. GDM is becoming an increasing health problem worldwide and one of the most common complications of pregnancy. The prevalence of GDM in Central Europe is 5-7%. GDM is associated with increased feto-maternal morbidity as well as long-term complications in mothers and offspring. The key symptom of GDM is the development of diabetic fetopathy. Fetal hyperinsulinism is associated with macrosomia and a higher rate of birth injuries and caesarean sections, neonatal hypoglycemia, respiratory distress and due to fetal programming the development of the sequelae of the metabolic syndrome in childhood or adolescence. GDM is commonly diagnosed by an oral glucose tolerance test (OGTT) between gestational weeks 24 and 28. In addition, in case of a high risk of GDM (history of poor obstetric outcome: stillbirth, congenital malformation, birth weight > or = 4500 g or a history of impaired glucose tolerance or impaired fasting glucose) impaired glucose metabolism or diabetes should be excluded in the first trimester. GDM shares the same pathophysiology and clinical signs as diabetes mellitus type 2. Thus maternal obesity, higher age, hypertension as well as a positive family history of type 2 diabetes are high risk factors for the development of GDM. If GDM is diagnosed, a strict metabolic control is mandatory. All women should receive nutritional counseling and be instructed in blood glucose self-monitoring. If blood glucose levels cannot be maintained in the normal range (fasting < 95 mg/dl and 1 h after meals < 130 mg/dl), insulin therapy should be initiated. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery, all women with GDM have to be reevaluated as to their glucose tolerance by a 75 gOGTT (WHO criteria). While 85% of these women will return to normal glucose tolerance 8 weeks postpartum, those with persisting impaired glucose tolerance are at particularly high risk for diabetes.

Topographic change in the central macula coupled with contrast sensitivity loss in diabetic pregnancy

PURPOSE

To study macular topography and contrast sensitivity (CS) in diabetic and nondiabetic women during pregnancy and post partum.

METHODS

A prospective study of 46 pregnant women with insulin-dependent diabetes and 11 nondiabetic pregnant controls. Macular surface topography was analyzed by Heidelberg Retinal Tomograph. Volume above the reference plane (VARP) was measured with 1.0-, 1.5-, 2.0-, and 3.0-mm-diameter circles. CS was measured with the Vistech 6500 Contrast Test System.

RESULTS

The diabetic women had greater VARP than the controls measured with the 1.5-mm diameter circle. In diabetic women, the mean VARP was 0.084+/-0.064 mm(3) (mean +/- SD) in the first trimester, 0.080 +/- 0.056 mm(3) in the third trimester, and 0.087 +/- 0.067 mm(3) 3 months post partum compared with the values of 0.069+/-0.043, 0.054+/-0.024, and 0.036+/-0.020 mm(3) in the controls ( P=0.036 between groups). In diabetic women requiring laser treatment, the difference from controls was more significant ( P<0.001). CS at 3 cpd and 6.0 cpd was lower in diabetic women than in controls throughout pregnancy and post partum ( P=0.012 and P=0.043). A statistically significant negative correlation appeared between macular topography and CS during the third trimester; between cpd 6 and VARP 1.5 mm ( r=-0.471, P=0.001), and between cpd 6 and VARP 2.0 mm ( r=-0.446, P=0.002).

CONCLUSIONS

In the diabetic women, especially in those with clear progression of retinopathy during pregnancy and post-partum, the macula seemed to be slightly more elevated than in the controls, and CS was lower at mid-range spatial frequencies. CS loss in the diabetic women correlated with macular elevation during the third trimester.

Use of antidiabetes agents in pregnancy: current practice and controversy

Prior to the discovery of insulin, the combination of diabetes and pregnancy was considered potentially lethal. Advances in the care of diabetes, combined with advances in antepartum fetal testing, have reduced maternal and perinatal mortality outcomes to levels expected in nondiabetic pregnancies. As new oral antidiabetes medications are introduced, the safety and efficacy of using them during pregnancy are under investigation. This article describes the oral medications currently available to treat diabetes, reviews the body of research available on these agents, and discusses current recommendations and controversies.

Maternal and paternal family history of diabetes in women with gestational diabetes or insulin-dependent diabetes mellitus type I

Animal studies have shown that prenatal exposure to a diabetic intrauterine milieu leads to an increased risk in the female offspring of developing gestational diabetes (GD). In the present study, the family history of non-insulin-dependent diabetes mellitus type II (NIDDM) and insulin-dependent diabetes mellitus type I (IDDM) was evaluated in 106 women with GD, as compared to 189 women with IDDM. In GD patients, the prevalence of diabetes was significantly greater in mothers than in fathers (p = 0.03). This was mainly due to a greater prevalence of NIDDM in the mothers (p = 0.05). Furthermore, a significant aggregation of NIDDM was also observed in the maternal-grandmaternal line of GD women, as compared to the paternal-grandpaternal side (p = 0.02). In patients with IDDM no significant difference concerning the prevalence of any type of diabetes between mothers and fathers was observed. In conclusion, an aggregation of NIDDM in mothers and grandmothers of women with GD is reported here. A history of NIDDM on the maternal side of pregnant women should be considered as a particular risk factor for GD and, hence, for intergenerative transmission of NIDDM, which therefore might be prevented, at least in part, by strict avoidance of GD.

[Diabetes and pregnancy: physio-pathogenetic and epidemiologic aspects]

Diabetes mellitus is one of the most common maternal illnesses resulting in congenital malformations. All complications of pregnancy, either with diabetes pregestational or gestational, are directly or indirectly related to the degree of metabolic control. If it is not treated properly, diabetes in pregnancy causes major problems for both mother and fetus. The only way to reduce complications to the minimum and locate them near to those of the normal population, is to achieve a good metabolic control. Multi-disciplinary approach in which obstetricians, physicians, paediatricians are involved, combined with intensive monitoring and therapy throughout pregnancy, could achieve successful results in women with complicated diabetes. This objective is subordinate to early diagnosis for gestational diabetes and planning of pregnancy for diabetic women.

TRIPOD (TRoglitazone In the Prevention Of Diabetes): a randomized, placebo-controlled trial of troglitazone in women with prior gestational diabetes mellitus

The TRoglitazone In the Prevention Of Diabetes (TRIPOD) trial is a single-center, randomized, placebo-controlled, double-masked study. The primary aim of the TRIPOD trial is to test the hypothesis that chronic administration of troglitazone to nondiabetic women with prior gestational diabetes mellitus (GDM) will improve whole-body insulin sensitivity and reduce the incidence of non-insulin-dependent diabetes (NIDDM). Because troglitazone is already known to lower blood glucose concentrations in persons who have developed NIDDM, an additional aim of the project will be to determine whether early intervention with troglitazone will achieve better final glycemic control than can be achieved by later intervention. In addition, since troglitazone treatment is expected to improve insulin sensitivity and may prevent or delay a decline in glucose tolerance, we also plan to determine whether long-term troglitazone treatment alters the development or progression of atherosclerosis. In this article we describe the experiment's design, the study's endpoints and methods for determining those endpoints, methods for assessing quality of life, and proposed methods for statistical analyses. The unique two-phase study design of the TRIPOD trial will permit testing not only of the biological question about reversal of insulin resistance and prevention of diabetes, but also of the clinical question about whether early intervention is superior to late intervention. Results from this trial will have an important impact on the monitoring and treatment of patients at high risk for NIDDM.

Influence of postnatal overnutrition and pregnancy on non-insulin dependent diabetes induced in Wistar rats by neonatal streptozotocin

Wistar rats with non-insulin dependent diabetes induced by neonatal streptozotocin (STZ) administration were raised either in large or in small litters. The STZ-treated rats from small litters showed a higher body weight as well as increased blood glucose levels compared with vehicle- and STZ-treated rats reared in large nests at an age of 8 weeks. The higher body weight of these rats was maintained until an age of 15 weeks, whereas the basal blood glucose was normalized. However, both STZ-treated groups exhibited an impaired glucose tolerance. During pregnancy only the glucose tolerance of the STZ-treated animals from large nests was improved although not normalized. The STZ-treated rats from small nests failed to adapt to pregnancy because the blood glucose levels after glucose load were similar to values found in the virgin state. The body weight of pregnant STZ treated rats raised in small litters was significantly lower than in vehicle- or STZ-terated rats from large nests. The number of fetuses per litter was similar in all groups tested. Compared with the vehicle-treated rats from large litters the fetal body weight of STZ-treated rats from small nests was decreased and that of STZ rats raised in large litters was increased. These results suggest that the rats with the more impaired glucose tolerance produce growth-retarded pups and, conversely, rats with rather mild impairment have bigger fetuses than the vehicle-treated ones. In the present study we have examined for the first time the combined effects of postnatal overnutrition and pregnancy on glucose homeostasis of rats treated neonatally with STZ. Our data demonstrate that postnatal overnutrition is an aggravating factor in the development of a diabetic state in these rats, especially at times when the insulin requirement is higher such as puberty and pregnancy.

Transient diabetes insipidus in pregnancy--a consequence of enhanced placental clearance of arginine vasopressin

We report a patient who presented with transient diabetes insipidus in pregnancy on a background of previous postoperative diabetes insipidus following surgical excision of a prolactinoma. The patient illustrates how the complex changes in water homeostasis occurring during normal pregnancy may unmask latent diabetes insipidus. The major factors operating appear to be a physiological reduction in the thresholds for thirst and arginine vasopressin secretion coupled with a substantial increase in placental clearance of arginine vasopressin. Reversal of these changes after delivery results in normalization of the disordered water homeostasis, with consequent resolution of the diabetes insipidus.

Assessing the risk of gestational diabetes in twin gestation

This study examines the hypothesis that twin gestation is a risk factor for gestational diabetes. In a retrospective analysis, the incidence of gestational diabetes in twin and singleton pregnancies was determined in groups matched for maternal age, weight, and parity. One-hour oral glucose challenge tests (50 g) were used to screen 9185 pregnant women. Gestational diabetes was diagnosed when abnormal screens (> or = 130 mg/dL) were followed by two or more abnormal values on a 3-hour (100 g) glucose tolerance test using National Diabetes Data Group (NDDG) criteria. A twin gestation was identified in 1.5% (138/9185) of the pregnancies. Gestational diabetes was diagnosed in 5.8% (8/138) and 5.4% (439/9047) of the twin and singleton pregnancies, respectively. The incidence of gestational diabetes is similar for singleton and twin gestations.

Gestational diabetes and neonatal macrosomia in the polycystic ovary syndrome

Since patients with polycystic ovary syndrome (PCOS) commonly have insulin resistance, albeit with normal glucose tolerance, we evaluated glucose tolerance in PCOS patients exposed to the diabetogenic effect of pregnancy. The clinical material was obtained from two centers, in Springfield, Illinois (22 patients), and New York, New York (31 patients), and the results were compared with a control population with 2,306 consecutive general pregnancies. There were no differences between PCOS patients from the two centers in regard to age or ponderal index (P greater than .1). A review of the medical records showed that the incidence of gestational diabetes in the PCOS patients was 7.5%, similar (P greater than .1) to the 6.6% frequency of gestational diabetes in the controls. The overall incidence of neonatal macrosomia (birth weight greater than 4,000 g) was 7% (4 of 57) among infants born to PCOS women. That was similar to the 12.4% incidence of neonatal macrosomia among infants born to women with normal glucose tolerance and to the 14.5% incidence among infants born to women with gestational diabetes. Preexisting PCOS does not appear to increase the risk of developing gestational diabetes or neonatal macrosomia.

Insulin-dependent diabetes mellitus and immunogenetics: maternal and fetal considerations

It has now become clear that certain HLA antigens are associated with disease susceptibility more than any other genetic markers. Insulin-dependent diabetes mellitus (IDDM or type I) is an HLA-associated condition. Moreover, there is evidence to show that IDDM is a genetically programmed autoimmune disease. Studies of the HLA-DR region have shown a strong association with IDDM, with over 90 per cent of IDDM patients possessing DR3 and/or DR4. Although the HLA-DR region is a major component in the inherited disease susceptibility, it is not the only gene region involved. Recent studies demonstrated that HLA-DQ may be more closely linked to the disease locus than HLA-DR. Sequence analysis of the HLA-DQ3 gene products suggest that a single amino acid (aspartic acid) at position 57 is uniquely important for determining susceptibility or resistance to IDDM. Although there is a strong association of certain HLA loci with IDDM, it may not explain nor account for all the genetic susceptibility to the disease. It seems that 60 per cent of the genetic basis of IDDM is related to the HLA gene (chromosome 6) and another 40 per cent is non-HLA-associated (i.e., chromosomes 2, 7, 11, and 14). Even though great progress has been made in the understanding of the genetics of IDDM, the mode of inheritance of the disease remains controversial. The present review discusses various aspects of the autoimmune process believed to be involved in pancreatic beta cell destruction in individuals genetically susceptible to IDDM. The possible modes of inheritance and new data regarding estimated risks of transmitting the disease are presented.

Diet composition modifies embryotoxic effects induced by experimental diabetes in rats

Despite improvements in prenatal care, the incidence of congenital malformations in diabetic pregnancies is still 3-4 times higher than in normal pregnancies. These defects could be attributed to alterations of intrauterine environment due to disorder of the maternal metabolism. If this were true, the quality of food could play a role in diabetes-induced embryotoxicity. To check this hypothesis, female CD rats were made diabetic by injecting intravenously 50 mg/kg of streptozotocin 2 weeks before mating. From the first day of pregnancy they were divided into three groups and maintained on the following diets: (1) standard diet (Italiana Mangimi); (2) purified high protein diet (protein 55%, carbohydrates 25.5%, fat 7.5%, fiber 4.5%, ash 7.5%); (3) purified normoprotein diet (protein 19%, carbohydrates 62.5%, fat 7.5%, fiber 4%, ash 7%). Nondiabetic pregnant females fed with standard diet served as negative control. No significant differences were observed in blood glucose levels among the groups (range 410-500 mg/dl). The group fed on normoprotein diet showed at term of pregnancy: (1) higher rate of resorptions; (2) lower fetal weight; (3) higher frequency of major malformations than the groups fed standard and hyperproteic diets. Although we are not able at this time to discriminate between a protective effect of a diet with a high protein content and a disruptive effect of a diet containing high quantity of carbohydrates, the results of this trial support the hypothesis of a fuel-mediated teratogenesis in diabetic pregnancy.

Risk factors for gestational diabetes in black population

In a long-term longitudinal study of gestational diabetes mellitus in Black women, risk factors that were identified were age, obesity, a family history of diabetes, and the presence of hypertension. Poor predictors were a history of a previous large-for-date infant, parity, and age at first pregnancy. The prevalence of smooth muscle and nuclear autoantibodies was higher in gestational diabetic subjects. Gestational diabetic subjects who required insulin for glycemic control were more obese, had a lower frequency of the Bf-F phenotype and a higher frequency of the Bf-F1 phenotype, and had a lower frequency of the type 2 allele at the polymorphic locus adjacent to the insulin gene. Restriction-fragment-length polymorphisms flanking the insulin and apolipoprotein A-I and C-III genes, although not associated with gestational diabetes mellitus, may be associated with hyperlipidemia and subsequent atherosclerosis.

[The role of insulin in reproductive endocrinology and perinatal medicine]

Soskin, in his 1946 textbook, stated that insulin may be regarded as the dominant instrument in the symphony of endocrine action that results in normal carbohydrate metabolism. After almost half a century, great progress in the medical field has revealed that insulin plays more than even he described. Some aspects of important actions of insulin in our field as investigated in our laboratory are summarized below. 1. Role of insulin in reproductive endocrinology. (1) Correlation of insulin and testosterone in normal young women and patients with polycystic ovary syndrome (PCO). The sum of serum insulin values during 75g OGTT and serum testosterone values were positively correlated in normal women and patients with PCO. Glucose transport activities in isolated adipocytes from a typical PCO patient were decreased, but insulin binding activities were not, which indicates that insulin resistance in this patients is due to some post-receptor defects. (2) Insulin may be a risk factor of endometrial carcinoma. It is well-recognized that several diseases associate with hyperinsulinemia, such as obesity, PCO, diabetes mellitus, and hypertension are risk factors for endometrial carcinoma. The sum of the insulin values during OGTT was significantly higher in patients with endometrial carcinoma than in those without. 2. Role of insulin in perinatal medicine. (1) Increase in insulin secretion during pregnancy. High serum insulin concentration during OGTT, increased secretion of urinary C-peptide, and enhanced staining of insulin in B cells by the PAP method suggest that insulin secretion is enhanced during pregnancy. (2) Insulin resistance during pregnancy. Glucose utilization rate in both pregnant and progesterone-treated rats, as assessed by a glucose clamp technique, is significantly decreased as compared to nonpregnant rats. The technique of 2-deoxyglucose injection revealed that whole body insulin resistance is due to insulin resistance in individual insulin-sensitive tissues. The activities of 3-0-methyl-D-glucose transport in isolated rat skeletal muscle and human adipocytes were found to decrease during late pregnancy, but insulin binding activities were not. These results suggest that insulin resistance during pregnancy is due to some post-receptor mechanisms. (3) Physiological meaning of insulin in fetal growth.(ABSTRACT TRUNCATED AT 250 WORDS)

[Adrenal adenoma disclosing after delivery]

Pregnancy and Cushing's syndrome are seldom found together (40 cases in the literature), since hyperadrenocorticism is often responsible for anovulation by gonadotropin suppression. We report the case of a 25-year old para II woman whose pregnancy was complicated by diabetes and arterial hypertension at 31 weeks and who received the conventional treatments (special diet, insulin therapy, pindolol). Caesarean section, motivated by premature rupture of the membranes, was performed at 37 weeks, delivering a healthy infant. The diagnosis of hypercortisolism with low ACTH level was made post partum. An adrenal tumour (the most frequent cause of Cushing's syndrome occurring during pregnancy) was removed after pre-operative treatment with ketoconazole, and endocrine functions returned to normal.

How reliable is the fifty-gram, one-hour glucose screening test?

The Second International Workshop-Conference on Gestational Diabetes recommended screening all pregnant women with a 1-hour 50 gm oral glucose screening test, given without regard to time of day or time elapsed from the last meal. This study was designed to evaluate the reproducibility of that test, given under those clinical conditions. Thirty women with gestational diabetes and 80 control volunteers between 24 and 28 weeks' gestation were tested at the same time of day on two successive days. Of the 30 women with diabetes, three (10%) had glucose screening test results below the 135 mg/dl threshold on both days and 10 (33%) had results that straddled the threshold on successive days. Test results of 11 control women also straddled the threshold. Among these 21 women with results that straddled the threshold, there was no difference in mean glucose screening test results in diabetic women compared with nondiabetic ones. We conclude that, as currently recommended, the 1-hour glucose screening test is moderately reproducible. Reliance should not be placed on a single normal test result, particularly among patients with risk factors.

Factors predisposing to and outcome of gestational diabetes

Two hundred thirteen women with abnormal glucose tolerance tests (GTTs) were diagnosed over 9 years by a screening program involving the total antenatal population. Each subject was matched for age, parity, and ethnic group with a control. The gestational diabetics were subdivided into classes A1 or A2 based on the fasting plasma glucose value of their GTT: A1 when below 6.0 mmol/L (108 mg/dL) and A2 when 6.0 mmol/L (108 mg/dL) or higher. All received treatment with dietary advice and some with insulin. Birth weight was not related to maternal age or severity of diabetes, but was related to maternal obesity. However, neonatal morbidity indices such as admission to the special care baby unit for longer than 48 hours and polycythemia (hematocrit above 65%) were related significantly to the severity of the diabetes and not to maternal age or obesity.

The course and outcome of pregnancy after ovarian electrocautery in women with polycystic ovarian syndrome: the influence of body-weight

In 89 women with polycystic ovary syndrome (PCOS) who conceived after ovarian electrocautery, the pregnancy continued beyond 31 weeks in 62. In this group the frequency of pre-eclampsia and diabetes was 12.9 and 8.1% respectively. The increased frequencies were confined to overweight women. The frequency of major and minor malformations was 1% and 3.8% respectively. The rate of early miscarriage of the first pregnancy after ovarian electrocautery was 15%, and when later pregnancies were included the rate reduced to 10.3%. These data do not indicate any impact upon the course or outcome of pregnancy from the state of PCOS per se or the ovarian electrocautery that induced ovulation in this series.

Should all pregnant women be screened for gestational glucose intolerance?

Although gestational glucose intolerance is associated with the remote development of diabetes mellitus, the risk to the mother during the index pregnancy and the risk to her fetus remain uncertain. Nevertheless, universal screening for gestational glucose intolerance has many strong advocates. The scientific data supporting a universal screening programme--showing that treatment of gestational glucose intolerance does more good than harm--are limited. Until the evidence can be extended beyond that on infant birthweight, a more restrained approach than universal screening may be appropriate.

[Risk factors for changes in glucose metabolism in pregnancy]

Eighty women were studied having between 20-25 weeks of gestation at the National Institute of Perinatology. Weight and height were taken, and they were questioned about the risk factors (positive family history of diabetes mellitus, age, overweight and number of gestations). Two hours postprandial glucose tests were carried out using 100 g glucose load. Plasma glucose values were determinated according to the glucose-oxidase technique. Results showed that 36% of the population had at least glucose metabolism alteration (GMA) (glucose value 120 mg/dL). No significant difference was found for the weeks of gestation, nor number of gestations to define any cut point. On the other hand, significant values were found for the other risk factors, such as being 35 years or older, having 119% and 103% or more of pregestational and gestational weight for height respectively and having positive maternal family history of diabetes mellitus. The risk factor that is more capable to identify the subjects with an GMA is age 35 years followed by positive maternal family history of diabetes mellitus; when the combination of 4 risk factors is observed (gestas factor is excluded because it is a confusion element), the pregestational and pregestational and gestational weights work more like secondary supplementary risk factors than like determinants of the metabolic process. In view of these facts, it was found that positive maternal history of diabetes mellitus and the age less than or equal to 35 years individually and the presence of 3-4 risk factors can be considered high risk characteristics to develop GMA.