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Wang J, Wang F, Gui YH. [Research advances in the mechanism of congenital heart disease induced by pregestational diabetes mellitus]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1297-1300. [PMID: 29237533 PMCID: PMC7389805 DOI: 10.7499/j.issn.1008-8830.2017.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/11/2017] [Indexed: 06/07/2023]
Abstract
Congenital heart disease (CHD) is the most common birth defect at present and has a complex etiology which involves the combined effect of genetic and environmental factors. Pregestational diabetes mellitus is significantly associated with the development of CHD, but the detailed mechanism remains unknown. This article reviews the research advances in the molecular mechanism of CHD caused by pregestational diabetes mellitus.
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Affiliation(s)
- Jie Wang
- Department of Cardiovascular Medicine, Children's Hospital of Fudan University, Shanghai 200023, China.
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52
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Wang J, Wang F, Gui YH. [Research advances in the mechanism of congenital heart disease induced by pregestational diabetes mellitus]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1297-1300. [PMID: 29237533 PMCID: PMC7389805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/11/2017] [Indexed: 08/01/2024]
Abstract
Congenital heart disease (CHD) is the most common birth defect at present and has a complex etiology which involves the combined effect of genetic and environmental factors. Pregestational diabetes mellitus is significantly associated with the development of CHD, but the detailed mechanism remains unknown. This article reviews the research advances in the molecular mechanism of CHD caused by pregestational diabetes mellitus.
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Affiliation(s)
- Jie Wang
- Department of Cardiovascular Medicine, Children's Hospital of Fudan University, Shanghai 200023, China.
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53
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Sousa RALDE, Torres YS, Figueiredo CP, Passos GF, Clarke JR. Consequences of gestational diabetes to the brain and behavior of the offspring. AN ACAD BRAS CIENC 2017; 90:2279-2291. [PMID: 28813108 DOI: 10.1590/0001-3765201720170264] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 05/30/2017] [Indexed: 01/11/2023] Open
Abstract
Gestational diabetes mellitus (GD) is a form of insulin resistance triggered during the second/third trimesters of pregnancy in previously normoglycemic women. It is currently estimated that 10% of all pregnancies in the United States show this condition. For many years, the transient nature of GD has led researchers and physicians to assume that long-term consequences were absent. However, GD diagnosis leads to a six-fold increase in the risk of developing type 2 diabetes (T2D) in women and incidence of obesity and T2D is also higher among their infants. Recent and concerning evidences point to detrimental effects of GD on the behavior and cognition of the offspring, which often persist until adolescence or adulthood. Considering that the perinatal period is critical for determination of adult behavior, it is expected that the intra-uterine exposure to hyperglycemia, hyperinsulinemia and pro-inflammatory mediators, hallmark features of GD, might affect brain development. Here, we review early clinical and experimental evidence linking GD to consequences on the behavior of the offspring, focusing on memory and mood disorders. We also discuss initial evidence suggesting that downregulation of insulin signaling cascades are seen in the brains of GD offspring and could contribute to the consequences on their behavior.
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Affiliation(s)
- Ricardo A L DE Sousa
- School of Pharmacy, Carlos Chagas Filho Street, 373, Building A, Underground, Room 024, Federal University of Rio de Janeiro, 21941-902 Rio de Janeiro, RJ, Brazil
| | - Yasmin S Torres
- School of Pharmacy, Carlos Chagas Filho Street, 373, Building A, Underground, Room 024, Federal University of Rio de Janeiro, 21941-902 Rio de Janeiro, RJ, Brazil
| | - Claudia P Figueiredo
- School of Pharmacy, Carlos Chagas Filho Street, 373, Building A, Underground, Room 024, Federal University of Rio de Janeiro, 21941-902 Rio de Janeiro, RJ, Brazil
| | - Giselle F Passos
- School of Pharmacy, Carlos Chagas Filho Street, 373, Building A, Underground, Room 024, Federal University of Rio de Janeiro, 21941-902 Rio de Janeiro, RJ, Brazil
| | - Julia R Clarke
- School of Pharmacy, Carlos Chagas Filho Street, 373, Building A, Underground, Room 024, Federal University of Rio de Janeiro, 21941-902 Rio de Janeiro, RJ, Brazil
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54
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ROCK1/p53/NOXA signaling mediates cardiomyocyte apoptosis in response to high glucose in vitro and vivo. Biochim Biophys Acta Mol Basis Dis 2017; 1863:936-946. [DOI: 10.1016/j.bbadis.2017.01.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/04/2017] [Accepted: 01/24/2017] [Indexed: 01/02/2023]
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55
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Harris BS, Bishop KC, Kemeny HR, Walker JS, Rhee E, Kuller JA. Risk Factors for Birth Defects. Obstet Gynecol Surv 2017; 72:123-135. [PMID: 28218773 DOI: 10.1097/ogx.0000000000000405] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Major congenital abnormalities, or birth defects, carry significant medical, surgical, cosmetic, or lifestyle consequences. Such abnormalities may be syndromic, involving multiple organ systems, or can be isolated. Overall, 2% to 4% of live births involve congenital abnormalities. Risk factors for birth defects are categorized as modifiable and nonmodifiable. Modifiable risk factors require thorough patient education/counseling. The strongest risk factors, such as age, family history, and a previously affected child, are usually nonmodifiable. Objective This review focuses on risk factors for birth defects including alcohol consumption, illicit drug use, smoking, obesity, pregestational diabetes, maternal phenylketonuria, multiple gestation, advanced maternal age, advanced paternal age, family history/consanguinity, folic acid deficiency, medication exposure, and radiation exposure. Evidence Acquisition Literature review via PubMed. Results There is a strong link between alcohol use, folic acid deficiency, obesity, uncontrolled maternal diabetes mellitus, uncontrolled maternal phenylketonuria, and monozygotic twins and an increased risk of congenital anomalies. Advanced maternal age confers an increased risk of aneuploidy, as well as nonchromosomal abnormalities. Some medications, including angiotensin converting enzyme inhibitors, retinoic acid, folic acid antagonists, and certain anticonvulsants, are associated with various birth defects. However, there are few proven links between illicit drug use, smoking, advanced paternal age, radiation exposure, and statins with specific birth defects. Conclusions and Relevance Birth defects are associated with multiple modifiable and nonmodifiable risk factors. Obstetrics providers should work with patients to minimize their risk of birth defects if modifiable risk factors are present and to appropriately counsel patients when nonmodifiable risk factors are present.
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Affiliation(s)
| | | | - Hanna R Kemeny
- Medical Student, Duke University School of Medicine, Durham
| | - Jennifer S Walker
- Research Librarian, Health Sciences Library, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Jeffrey A Kuller
- Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
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56
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Chen G, Chen J, Yan Z, Li Z, Yu M, Guo W, Tian W. Maternal diabetes modulates dental epithelial stem cells proliferation and self-renewal in offspring through apurinic/apyrimidinicendonuclease 1-mediated DNA methylation. Sci Rep 2017; 7:40762. [PMID: 28094306 PMCID: PMC5240105 DOI: 10.1038/srep40762] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/09/2016] [Indexed: 12/16/2022] Open
Abstract
Maternal gestational diabetes mellitus (GDM) has many adverse effects on the development of offspring. Aberrant DNA methylation is a potential mechanism associated with these effects. However, the effects of GDM on tooth development and the underlying mechanisms have not been thoroughly investigated. In the present study, a GDM rat model was established and incisor labial cervical loop tissue and dental epithelial stem cells (DESCs) were harvested from neonates of diabetic and control dams. GDM significantly suppressed incisor enamel formation and DESCs proliferation and self-renewal in offspring. Gene expression profiles showed that Apex1 was significantly downregulated in the offspring of diabetic dams. In vitro, gain and loss of function analyses showed that APEX1 was critical for DESCs proliferation and self-renewal and Oct4 and Nanog regulation via promoter methylation. In vivo, we confirmed that GDM resulted in significant downregulation of Oct4 and Nanog and hypermethylation of their promoters. Moreover, we found that APEX1 modulated DNA methylation by regulating DNMT1 expression through ERK and JNK signalling. In summary, our data suggest that GDM-induced APEX1 downregulation increased DNMT1 expression, thereby inhibiting Oct4 and Nanog expression, through promoter hypermethylation, resulting in suppression of DESCs proliferation and self-renewal, as well as enamel formation.
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Affiliation(s)
- Guoqing Chen
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China
| | - Jie Chen
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China
| | - Zhiling Yan
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China
| | - Ziyue Li
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China
| | - Mei Yu
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China
| | - Weihua Guo
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,Department of Pedodontics, West China College of Stomatology, Sichuan University, No. 14, 3rd Section, Renmin South Road, Chengdu 610041, P. R. China
| | - Weidong Tian
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,National Engineering Laboratory for Oral Regenerative Medicine, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China.,Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, 610041, P. R. China
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57
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Grewal DS, Khanna V, Saxena S, Chamoli SC. Sonographic diagnosis of transposition of great arteries in mid trimester: Our experience. Med J Armed Forces India 2016; 72:386-388. [PMID: 27843189 DOI: 10.1016/j.mjafi.2015.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- D S Grewal
- Classified Specialist (Radiodiagnosis), Military Hospital, Allahabad, India
| | - Vikram Khanna
- Senior Advisor (Radiodiagnosis), Military Hospital, Jabalpur, India
| | - Sudhir Saxena
- Consultant (Radiodiagnosis), Command Hospital (Central Command), Lucknow, India
| | - S C Chamoli
- Classified Specialist, 166 Military Hospital, C/o 56 APO, India
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58
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Cited2 participates in cardiomyocyte apoptosis and maternal diabetes-induced congenital heart abnormality. Biochem Biophys Res Commun 2016; 479:887-892. [DOI: 10.1016/j.bbrc.2016.09.101] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 01/18/2023]
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Dong D, Zhang Y, Reece EA, Wang L, Harman CR, Yang P. microRNA expression profiling and functional annotation analysis of their targets modulated by oxidative stress during embryonic heart development in diabetic mice. Reprod Toxicol 2016; 65:365-374. [PMID: 27629361 DOI: 10.1016/j.reprotox.2016.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/03/2016] [Accepted: 09/09/2016] [Indexed: 02/07/2023]
Abstract
Maternal pregestational diabetes mellitus (PGDM) induces congenital heart defects (CHDs). The molecular mechanism underlying PGDM-induced CHDs is unknown. microRNAs (miRNAs), small non-coding RNAs, repress gene expression at the posttranscriptional level and play important roles in heart development. We performed a global miRNA profiling study to assist in revealing potential miRNAs modulated by PGDM and possible developmental pathways regulated by miRNAs during heart development. A total of 149 mapped miRNAs in the developing heart were significantly altered by PGDM. Bioinformatics analysis showed that the majority of the 2111 potential miRNA target genes were associated with cardiac development-related pathways including STAT3 and IGF-1 and transcription factors (Cited2, Zeb2, Mef2c, Smad4 and Ets1). Overexpression of the antioxidant enzyme, superoxide dismutase 1, reversed PGDM-altered miRNAs, suggesting that oxidative stress is responsible for dysregulation of miRNAs. Thus, our study provides the foundation for further investigation of a miRNA-dependent mechanism underlying PGDM-induced CHDs.
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Affiliation(s)
- Daoyin Dong
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Yuji Zhang
- Division of Biostatistics and Bioinformatics, Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201 ,United States
| | - E Albert Reece
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine Baltimore, MD 21201, United States
| | - Lei Wang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Christopher R Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Peixin Yang
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine Baltimore, MD 21201, United States.
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60
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Type 2 diabetes mellitus induces congenital heart defects in murine embryos by increasing oxidative stress, endoplasmic reticulum stress, and apoptosis. Am J Obstet Gynecol 2016; 215:366.e1-366.e10. [PMID: 27038779 DOI: 10.1016/j.ajog.2016.03.036] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Maternal type 1 and 2 diabetes mellitus are strongly associated with high rates of severe structural birth defects, including congenital heart defects. Studies in type 1 diabetic embryopathy animal models have demonstrated that cellular stress-induced apoptosis mediates the teratogenicity of maternal diabetes leading to congenital heart defect formation. However, the mechanisms underlying maternal type 2 diabetes mellitus-induced congenital heart defects remain largely unknown. OBJECTIVE We aim to determine whether oxidative stress, endoplasmic reticulum stress, and excessive apoptosis are the intracellular molecular mechanisms underlying maternal type 2 diabetes mellitus-induced congenital heart defects. STUDY DESIGN A mouse model of maternal type 2 diabetes mellitus was established by feeding female mice a high-fat diet (60% fat). After 15 weeks on the high-fat diet, the mice showed characteristics of maternal type 2 diabetes mellitus. Control dams were either fed a normal diet (10% fat) or the high-fat diet during pregnancy only. Female mice from the high-fat diet group and the 2 control groups were mated with male mice that were fed a normal diet. At E12.5, embryonic hearts were harvested to determine the levels of lipid peroxides and superoxide, endoplasmic reticulum stress markers, cleaved caspase 3 and 8, and apoptosis. E17.5 embryonic hearts were harvested for the detection of congenital heart defect formation using India ink vessel patterning and histological examination. RESULTS Maternal type 2 diabetes mellitus significantly induced ventricular septal defects and persistent truncus arteriosus in the developing heart, along with increasing oxidative stress markers, including superoxide and lipid peroxidation; endoplasmic reticulum stress markers, including protein levels of phosphorylated-protein kinase RNA-like endoplasmic reticulum kinase, phosphorylated-IRE1α, phosphorylated-eIF2α, C/EBP homologous protein, and binding immunoglobulin protein; endoplasmic reticulum chaperone gene expression; and XBP1 messenger RNA splicing, as well as increased cleaved caspase 3 and 8 in embryonic hearts. Furthermore, maternal type 2 diabetes mellitus triggered excessive apoptosis in ventricular myocardium, endocardial cushion, and outflow tract of the embryonic heart. CONCLUSION Similar to those observations in type 1 diabetic embryopathy, maternal type 2 diabetes mellitus causes heart defects in the developing embryo manifested with oxidative stress, endoplasmic reticulum stress, and excessive apoptosis in heart cells.
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Abstract
Congenital heart defects are the most common malformations in humans, affecting approximately 1% of newborn babies. While genetic causes of congenital heart disease have been studied, only less than 20% of human cases are clearly linked to genetic anomalies. The cause for the majority of the cases remains unknown. Heart formation is a finely orchestrated developmental process and slight disruptions of it can lead to severe malformations. Dysregulation of developmental processes leading to heart malformations are caused by genetic anomalies but also environmental factors including blood flow. Intra-cardiac blood flow dynamics plays a significant role regulating heart development and perturbations of blood flow lead to congenital heart defects in animal models. Defects that result from hemodynamic alterations, however, recapitulate those observed in human babies, even those due to genetic anomalies and toxic teratogen exposure. Because important cardiac developmental events, such as valve formation and septation, occur under blood flow conditions while the heart is pumping, blood flow regulation of cardiac formation might be a critical factor determining cardiac phenotype. The contribution of flow to cardiac phenotype, however, is frequently ignored. More research is needed to determine how blood flow influences cardiac development and the extent to which flow may determine cardiac phenotype.
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Affiliation(s)
- Sandra Rugonyi
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave. M/C CH13B, Portland, OR 97239, USA
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62
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Nassr AA, El-Nashar SA, Shazly SA, White WM, Brost BC. Expected probability of congenital heart disease and clinical utility of fetal echocardiography in pregnancies with pre-gestational diabetes. Eur J Obstet Gynecol Reprod Biol 2016; 201:121-5. [DOI: 10.1016/j.ejogrb.2016.02.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 01/06/2016] [Accepted: 02/19/2016] [Indexed: 11/30/2022]
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63
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Mert MK, Satar M, Özbarlas N, Yaman A, Özgünen FT, Asker HS, Çekinmez EK, Tetiker T. Troponin T and NT ProBNP Levels in Gestational, Type 1 and Type 2 Diabetic Mothers and Macrosomic Infants. Pediatr Cardiol 2016; 37:76-83. [PMID: 26266327 DOI: 10.1007/s00246-015-1242-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Abstract
This study compares NT proBNP and troponin T levels in umbilical cord arterial blood and postnatal echocardiographic findings for infants of gestational and pregestational diabetic mothers and macrosomic infants. Twenty-seven infants of pregestational diabetic mothers, 61 infants of gestational diabetic mothers and 37 macrosomic infants of nondiabetic mothers were prospectively enrolled in this study along with a control group of 58 healthy infants of mothers without any pregestational or gestational disorders as the control group. All enrollees were born after 34 weeks of gestation. For this study, umbilical cord blood was drawn during delivery to determine NT proBNP and troponin T levels. Echocardiography was performed 24-72 h after the delivery. Umbilical cord troponin T and NT proBNP levels were found to be higher in the diabetic and macrosomic groups than in the control group (all of them p < 0.001). NT proBNP levels were positively correlated with interventricular septum thickness in the pregestational and gestational infants of diabetic mothers groups (r = 0.564 and r = 0.560, respectively, p < 0.01). Both pregestational and gestational diabetic mothers were divided into two groups according to HbA1c levels in the third trimester as good (<6.1 %) and suboptimal (>6.1 %) metabolic control. In the good and suboptimal metabolic control diabetic groups, NT proBNP levels were also positively correlated with interventricular septum thickness (r = 0.536 and r = 0.576, respectively, p < 0.01). In the suboptimal metabolic control diabetic group, NT proBNP was only found to be positively correlated with the left ventricular mass index (r = 0.586, p < 0.01). While there was no correlation in the myocardial performance index between infants of diabetic mothers and the control group, the myocardial performance index of macrosomic infants was lower than that of the control group (p = 0.017). Cardiac biomarkers (NT proBNP and troponin T) were elevated in infants of diabetic mothers and macrosomic infants. While there was a positive correlation between NT proBNP levels and cardiac structure in infants of pregestational and gestational diabetic mothers, there was no relationship between NT proBNP levels and cardiac function.
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Affiliation(s)
- Mustafa Kurthan Mert
- Department of Neonatology, Çukurova University Faculty of Medicine, Toros Mahallesi, 78050 Sok. Havuz Apt. Kat: 9 No: 9, 01170, Çukurova, Adana, Turkey.
| | - Mehmet Satar
- Department of Neonatology, Çukurova University Faculty of Medicine, Toros Mahallesi, 78050 Sok. Havuz Apt. Kat: 9 No: 9, 01170, Çukurova, Adana, Turkey
| | - Nazan Özbarlas
- Department of Pediatric Cardiology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Akgün Yaman
- Central Laboratory, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Fatma Tuncay Özgünen
- Department of Obstetrics and Gynecology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Hüseyin Selim Asker
- Department of Neonatology, Çukurova University Faculty of Medicine, Toros Mahallesi, 78050 Sok. Havuz Apt. Kat: 9 No: 9, 01170, Çukurova, Adana, Turkey
| | - Eren Kale Çekinmez
- Department of Neonatology, Çukurova University Faculty of Medicine, Toros Mahallesi, 78050 Sok. Havuz Apt. Kat: 9 No: 9, 01170, Çukurova, Adana, Turkey
| | - Tamer Tetiker
- Department of Endocrinology and Metabolism, Çukurova University Faculty of Medicine, Adana, Turkey
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64
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Gene expression profiling of changes induced by maternal diabetes in the embryonic heart. Reprod Toxicol 2015; 57:147-56. [DOI: 10.1016/j.reprotox.2015.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 05/07/2015] [Accepted: 06/03/2015] [Indexed: 01/04/2023]
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65
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Ketharnathan S, Koshy T, Sethuratnam R, Paul S, Venkatesan V. Investigation ofNKX2.5Gene Mutations in Congenital Heart Defects in an Indian Population. Genet Test Mol Biomarkers 2015; 19:579-83. [DOI: 10.1089/gtmb.2015.0112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
| | - Teena Koshy
- Department of Human Genetics, Sri Ramachandra University, Chennai, India
| | - Rajan Sethuratnam
- Institute of Cardio-Vascular Diseases, The Madras Medical Mission, Chennai, India
| | - Solomon Paul
- Department of Human Genetics, Sri Ramachandra University, Chennai, India
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Lopez KN, Marengo LK, Canfield MA, Belmont JW, Dickerson HA. Racial disparities in heterotaxy syndrome. ACTA ACUST UNITED AC 2015; 103:941-50. [PMID: 26333177 DOI: 10.1002/bdra.23416] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Heterotaxy syndrome (HTX) is a constellation of defects including abnormal organ lateralization and often including congenital heart defects. HTX has widely divergent population-based estimates of prevalence, racial and ethnic predominance, and mortality in current literature. METHODS The objective of this study was to use a population-based registry to investigate potential racial and ethnic disparities in HTX. Using the Texas Birth Defects Registry, we described clinical features and mortality of HTX among infants delivered from 1999 to 2006. We calculated birth prevalence and crude prevalence (cPR) ratios for infant sex, maternal diabetes, and sociodemographic factors. RESULTS A total of 353 HTX cases were identified from 2,993,604 births (prevalence ratio = 1.18 per 10,000 live births. HTX prevalence was approximately 70% higher among infants of Hispanic and non-Hispanic black mothers and 28% higher among female infants (cPR = 1.28; 95% confidence interval,1.04-1.59). There was a twofold higher female preponderance for infants of mothers who were non-Hispanic white or black. Mothers with diabetes were three times more likely to have a child with HTX compared with nondiabetics (cPR = 3.13; 95% confidence interval, 2.12-4.45). Among nondiabetics, HTX cases were 86% more likely to have a Hispanic mother and 72% a non-Hispanic black mother. First-year mortality for live born children with HTX was 30.9%. CONCLUSION This study represents one of the largest population-based studies of HTX to date, with a novel finding of higher rates of HTX among Hispanic infants of mostly Mexican origin, as well as among female infants of only non-Hispanic white and black mothers. These findings warrant further investigation.
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Affiliation(s)
| | - Lisa K Marengo
- Birth Defects Epidemiology and Surveillance Section, Texas Department of State Health Services, Austin, Texas
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Section, Texas Department of State Health Services, Austin, Texas
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Wang F, Wu Y, Quon MJ, Li X, Yang P. ASK1 mediates the teratogenicity of diabetes in the developing heart by inducing ER stress and inhibiting critical factors essential for cardiac development. Am J Physiol Endocrinol Metab 2015; 309:E487-99. [PMID: 26173459 PMCID: PMC4556884 DOI: 10.1152/ajpendo.00121.2015] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 07/13/2015] [Indexed: 12/30/2022]
Abstract
Maternal diabetes in mice induces heart defects similar to those observed in human diabetic pregnancies. Diabetes enhances apoptosis and suppresses cell proliferation in the developing heart, yet the underlying mechanism remains elusive. Apoptosis signal-regulating kinase 1 (ASK1) activates the proapoptotic c-Jun NH2-terminal kinase 1/2 (JNK1/2) leading to apoptosis, suggesting a possible role of ASK1 in diabetes-induced heart defects. We aimed to investigate whether ASK1 is activated in the heart and whether deleting the Ask1 gene blocks diabetes-induced adverse events and heart defect formation. The ASK1-JNK1/2 pathway was activated by diabetes. Deleting Ask1 gene significantly reduced the rate of heart defects, including ventricular septal defects (VSDs) and persistent truncus arteriosus (PTA). Additionally, Ask1 deletion diminished diabetes-induced JNK1/2 phosphorylation and its downstream transcription factors and endoplasmic reticulum (ER) stress markers. Consistent with this, caspase activation and apoptosis were blunted. Ask1 deletion blocked the increase in cell cycle inhibitors (p21 and p27) and the decrease in cyclin D1 and D3 and reversed diabetes-repressed cell proliferation. Ask1 deletion also restored the expression of BMP4, NKX2.5, and GATA5, Smad1/5/8 phosphorylation, whose mutations or deletion result in reduced cell proliferation, VSD, and PTA formation. We conclude that ASK1 may mediate the teratogenicity of diabetes through activating the JNK1/2-ER stress pathway and inhibiting cell cycle progression, thereby impeding the cardiogenesis pathways essential for ventricular septation and outflow tract development.
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MESH Headings
- Animals
- Apoptosis/genetics
- Bone Morphogenetic Protein 4/metabolism
- Cell Proliferation
- Cyclin D1/metabolism
- Cyclin D3/metabolism
- Cyclin-Dependent Kinase Inhibitor p21/metabolism
- Cyclin-Dependent Kinase Inhibitor p27/metabolism
- Endoplasmic Reticulum Stress/genetics
- Female
- GATA5 Transcription Factor/metabolism
- Heart/embryology
- Heart Defects, Congenital/etiology
- Heart Defects, Congenital/genetics
- Heart Defects, Congenital/metabolism
- Heart Septal Defects, Ventricular/etiology
- Heart Septal Defects, Ventricular/genetics
- Heart Septal Defects, Ventricular/metabolism
- Homeobox Protein Nkx-2.5
- Homeodomain Proteins/metabolism
- MAP Kinase Kinase Kinase 5/genetics
- Mice
- Mice, Knockout
- Mitogen-Activated Protein Kinase 8/metabolism
- Mitogen-Activated Protein Kinase 9/metabolism
- Phosphorylation
- Pregnancy
- Pregnancy in Diabetics/genetics
- Pregnancy in Diabetics/metabolism
- Signal Transduction
- Smad1 Protein/metabolism
- Smad5 Protein/metabolism
- Smad8 Protein/metabolism
- Teratogenesis/genetics
- Transcription Factors/metabolism
- Truncus Arteriosus, Persistent/etiology
- Truncus Arteriosus, Persistent/genetics
- Truncus Arteriosus, Persistent/metabolism
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Affiliation(s)
- Fang Wang
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | - Yanqing Wu
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | | | - Xuezheng Li
- Department of Obstetrics, Gynecology, and Reproductive Sciences
| | - Peixin Yang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, Maryland
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Wang F, Fisher SA, Zhong J, Wu Y, Yang P. Superoxide Dismutase 1 In Vivo Ameliorates Maternal Diabetes Mellitus-Induced Apoptosis and Heart Defects Through Restoration of Impaired Wnt Signaling. ACTA ACUST UNITED AC 2015; 8:665-76. [PMID: 26232087 DOI: 10.1161/circgenetics.115.001138] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 07/21/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oxidative stress is manifested in embryos exposed to maternal diabetes mellitus, yet specific mechanisms for diabetes mellitus-induced heart defects are not defined. Gene deletion of intermediates of Wingless-related integration (Wnt) signaling causes heart defects similar to those observed in embryos from diabetic pregnancies. We tested the hypothesis that diabetes mellitus-induced oxidative stress impairs Wnt signaling, thereby causing heart defects, and that these defects can be rescued by transgenic overexpression of the reactive oxygen species scavenger superoxide dismutase 1 (SOD1). METHODS AND RESULTS Wild-type (WT) and SOD1-overexpressing embryos from nondiabetic WT control dams and nondiabetic/diabetic WT female mice mated with SOD1 transgenic male mice were analyzed. No heart defects were observed in WT and SOD1 embryos under nondiabetic conditions. WT embryos of diabetic dams had a 26% incidence of cardiac outlet defects that were suppressed by SOD1 overexpression. Insulin treatment reduced blood glucose levels and heart defects. Diabetes mellitus increased superoxide production, canonical Wnt antagonist expression, caspase activation, and apoptosis and suppressed cell proliferation. Diabetes mellitus suppressed Wnt signaling intermediates and Wnt target gene expression in the embryonic heart, each of which were reversed by SOD1 overexpression. Hydrogen peroxide and peroxynitrite mimicked the inhibitory effect of high glucose on Wnt signaling, which was abolished by the SOD1 mimetic, tempol. CONCLUSIONS The oxidative stress of diabetes mellitus impairs Wnt signaling and causes cardiac outlet defects that are rescued by SOD1 overexpression. This suggests that targeting of components of the Wnt5a signaling pathway may be a viable strategy for suppression of congenital heart defects in fetuses of diabetic pregnancies.
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Affiliation(s)
- Fang Wang
- From the Departments of Obstetrics, Gynecology, and Reproductive Sciences (F.W., J.Z., Y.W., P.Y.), Medicine (S.A.F.), and Biochemistry and Molecular Biology (P.Y.), School of Medicine, University of Maryland, Baltimore
| | - Steven A Fisher
- From the Departments of Obstetrics, Gynecology, and Reproductive Sciences (F.W., J.Z., Y.W., P.Y.), Medicine (S.A.F.), and Biochemistry and Molecular Biology (P.Y.), School of Medicine, University of Maryland, Baltimore
| | - Jianxiang Zhong
- From the Departments of Obstetrics, Gynecology, and Reproductive Sciences (F.W., J.Z., Y.W., P.Y.), Medicine (S.A.F.), and Biochemistry and Molecular Biology (P.Y.), School of Medicine, University of Maryland, Baltimore
| | - Yanqing Wu
- From the Departments of Obstetrics, Gynecology, and Reproductive Sciences (F.W., J.Z., Y.W., P.Y.), Medicine (S.A.F.), and Biochemistry and Molecular Biology (P.Y.), School of Medicine, University of Maryland, Baltimore
| | - Peixin Yang
- From the Departments of Obstetrics, Gynecology, and Reproductive Sciences (F.W., J.Z., Y.W., P.Y.), Medicine (S.A.F.), and Biochemistry and Molecular Biology (P.Y.), School of Medicine, University of Maryland, Baltimore.
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69
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Liu S, Rouleau J, León JA, Sauve R, Joseph KS, Ray JG. Impact of pre-pregnancy diabetes mellitus on congenital anomalies, Canada, 2002-2012. Health Promot Chronic Dis Prev Can 2015; 35:79-84. [PMID: 26186019 PMCID: PMC4910455 DOI: 10.24095/hpcdp.35.5.01] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the impact of pre-pregnancy diabetes mellitus (DM) on the population birth prevalence of congenital anomalies in Canada. METHODS We carried out a population-based study of all women who delivered in Canadian hospitals (except those in the province of Quebec) between April 2002 and March 2013 and their live-born infants with a birth weight of 500 grams or more and/or a gestational age of 22 weeks or more. Pre-pregnancy type 1 or type 2 DM was identified using ICD-10 diagnostic codes. The association between DM and all congenital anomalies as well as specific congenital anomaly categories was estimated using adjusted odds ratios; the impact was calculated as a population attributable risk percent (PAR%). RESULTS There were 118,892 infants with a congenital anomaly among 2,839,680 live births (41.9 per 1000). While the prevalence of any congenital anomaly declined from 50.7 per 1000 live births in 2002/03 to 41.5 per 1000 in 2012/13, the corresponding PAR% for a congenital anomaly related to pre-pregnancy DM rose from 0.6% (95% confidence interval [CI]: 0.4-0.8) to 1.2% (95% CI: 0.9-1.4). Specifically, the PAR% for congenital cardiovascular defects increased from 2.3% (95% CI: 1.7-2.9) to 4.2% (95% CI: 3.5-4.9) and for gastrointestinal defects from 0.8% (95% CI: 0.2-1.9) to 1.4% (95% CI: 0.7-2.6) over the study period. CONCLUSION Although there has been a relative decline in the prevalence of congenital anomalies in Canada, the proportion of congenital anomalies due to maternal pre-pregnancy DM has increased. Enhancement of preconception care initiatives for women with DM is recommended.
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Affiliation(s)
- S Liu
- Maternal, Child & Youth Health Unit, Surveillance and Epidemiology Division, Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - J Rouleau
- Maternal, Child & Youth Health Unit, Surveillance and Epidemiology Division, Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - J A León
- Maternal, Child & Youth Health Unit, Surveillance and Epidemiology Division, Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - R Sauve
- Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - K S Joseph
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- Children's and Women's Hospital of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - J G Ray
- Departments of Medicine, Health Policy Management and Evaluation, and Obstetrics and Gynecology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
Pregestational diabetes currently complicates 4% of pregnancies, while gestational diabetes complicates approximately 8% of pregnancies. Increased risk of stillbirth in diabetic pregnancies has been a well-known and recognized complication for decades. While stillbirth rates for diabetic pregnancies have decreased due to screening, treatment, and antenatal surveillance of these patients, about 4% of all stillbirths remain attributable to diabetes, and diabetic pregnancies continue to be at increased risk for perinatal mortality. The purpose of this article is to review the literature on the epidemiology, pathophysiology, and prevention, as well as future research, of diabetes-associated perinatal mortality.
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Affiliation(s)
- Roman Starikov
- , 106 Irving Street Suite 108, Washington, DC, 20010, USA,
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71
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Aburawi EH, Aburawi HE, Bagnall KM, Bhuiyan ZA. Molecular insight into heart development and congenital heart disease: An update review from the Arab countries. Trends Cardiovasc Med 2014; 25:291-301. [PMID: 25541328 DOI: 10.1016/j.tcm.2014.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/14/2014] [Accepted: 11/14/2014] [Indexed: 02/07/2023]
Abstract
Congenital heart defect (CHD) has a major influence on affected individuals as well as on the supportive and associated environment such as the immediate family. Unfortunately, CHD is common worldwide with an incidence of approximately 1% and consequently is a major health concern. The Arab population has a high rate of consanguinity, fertility, birth, and annual population growth, in addition to a high incidence of diabetes mellitus and obesity. All these factors may lead to a higher incidence and prevalence of CHD within the Arab population than in the rest of the world, making CHD of even greater concern. Sadly, most Arab countries lack appropriate public health measures directed toward the control and prevention of congenital malformations and so the importance of CHD within the population remains unknown but is thought to be high. In approximately 85% of CHD patients, the multifactorial theory is considered as the pathologic basis. The genetic risk factors for CHD can be attributed to large chromosomal aberrations, copy number variations (CNV) of particular regions in the chromosome, and gene mutations in specific nuclear transcription pathways and in the genes that are involved in cardiac structure and development. The application of modern molecular biology techniques such as high-throughput nucleotide sequencing and chromosomal array and methylation array all have the potential to reveal more genetic defects linked to CHD. Exploring the genetic defects in CHD pathology will improve our knowledge and understanding about the diverse pathways involved and also about the progression of this disease. Ultimately, this will link to more efficient genetic diagnosis and development of novel preventive therapeutic strategies, as well as gene-targeted clinical management. This review summarizes our current understanding of the molecular basis of normal heart development and the pathophysiology of a wide range of CHD. The risk factors that might account for the high prevalence of CHD within the Arab population and the measures required to be undertaken for conducting research into CHD in Arab countries will also be discussed.
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Affiliation(s)
- Elhadi H Aburawi
- Department of Pediatrics, United Arab Emirates University, Al-Ain, UAE
| | - Hanan E Aburawi
- Department of Biology, Faculty of Sciences, United Arab Emirates University, Al-Ain, UAE
| | - Keith M Bagnall
- Department of Anatomy, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | - Zahurul A Bhuiyan
- Laboratoire de Diagnostic Moléculaire, Service de Génétique Médicale, BH19_512, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, Lausanne CH-1011, Switzerland.
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72
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Wei D, Loeken MR. Increased DNA methyltransferase 3b (Dnmt3b)-mediated CpG island methylation stimulated by oxidative stress inhibits expression of a gene required for neural tube and neural crest development in diabetic pregnancy. Diabetes 2014; 63:3512-22. [PMID: 24834974 PMCID: PMC4171658 DOI: 10.2337/db14-0231] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 05/10/2014] [Indexed: 12/31/2022]
Abstract
Previous studies have shown that diabetic embryopathy results from impaired expression of genes that are required for formation of embryonic structures. We have focused on Pax3, a gene that is expressed in embryonic neuroepithelium and is required for neural tube closure. Pax3 expression is inhibited in embryos of diabetic mice due to hyperglycemia-induced oxidative stress. DNA methylation silences developmentally expressed genes before differentiation. We hypothesized that hypomethylation of Pax3 upon neuroepithelial differentiation may be inhibited by hyperglycemia-induced oxidative stress. We tested this using embryos of pregnant hyperglycemic mice and mouse embryonic stem cells (ESC). Methylation of a Pax3 CpG island decreased upon neurulation of embryos and formation of neuronal precursors from ESC. In ESC, this was inhibited by oxidative stress. Use of short hairpin RNA in ESC demonstrated that DNA methyltransferase 3b (Dnmt3b) was responsible for methylation and silencing of Pax3 before differentiation and by oxidative stress. Although expression of Dnmt3b was not affected by oxidative stress, DNA methyltransferase activity was increased. These results indicate that hyperglycemia-induced oxidative stress stimulates Dnmt3b activity, thereby inhibiting chromatin modifications necessary for induction of Pax3 expression during neurulation and thus providing a molecular mechanism for defects caused by Pax3 insufficiency in diabetic pregnancy.
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Affiliation(s)
- Dan Wei
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, and Department of Medicine, Harvard Medical School, Boston, MA
| | - Mary R Loeken
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, and Department of Medicine, Harvard Medical School, Boston, MA
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73
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Abstract
The population of adults with CHD continues to expand,and thus the number of women with CHD who contemplate pregnancy or become pregnant is also growing. Mothers with low-risk defects can be managed by general cardiologist,whereas those with more complex defects should be managed by or with the assistance of ACHD cardiologists. It is important to acknowledge that all patients with CHD may have unique anatomy or physiology, despite their classification as having a simple, moderate, or complex defect. As such, clinicians evaluating these patients should have adequate knowledge and expertise when assessing patient's risk for pregnancy,when performing imaging or hemodynamic studies, and when managing these patients during pregnancy. The American Board of Medical Specialties has recently recognized ACHD as a subspecialty of cardiovascular disease to treat the specialized needs of these patients in adulthood. ACHD experts can provide expertise in the management of specific defects or lesions, imaging techniques, prepregnancy risk assessment,and can manage these patients or comanage them with other medical providers during their pregnancy. Because many of these ACHD patients are lost to follow-up in adulthood, pregnancy represents a time when these patients seek medical care(and for some, represents a time of vulnerability and increased risk). This represents an opportunity to establish or reestablish care with ACHD specialists and to reestablish continuing long-term care for their CHD. Pregnancy also provides an opportunity to create partnerships between primary care physicians,adult cardiologists, and ACHD specialists to provide optimal care for these women throughout their lives.
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Affiliation(s)
- M Elizabeth Brickner
- From the University of Texas Southwestern Medical Center, Division of Cardiology, Dallas.
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74
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Zhao Z. TGFβ and Wnt in cardiac outflow tract defects in offspring of diabetic pregnancies. ACTA ACUST UNITED AC 2014; 101:364-70. [PMID: 25231192 DOI: 10.1002/bdrb.21120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 07/29/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Diabetes mellitus in pregnancy causes defects in infant heart, including the outflow tracts (OFTs). Development of the aorta and pulmonary artery, which are derived from the common OFT in the embryo, is regulated by the transforming growth factor β (TGFβ) and Wnt families, and can be perturbed by hyperglycemia-generated intracellular stress conditions. However, the underlying cellular and molecular mechanisms remain to be delineated. METHODS Female mice were induced diabetic with streptozotocin. Embryonic and fetal OFTs were examined morphologically and histologically. Cell proliferation was assessed using 5'-bromo-2'-deoxyuridine incorporation assay. Oxidative and endoplasmic reticulum (ER) stress markers and TGFβ factors were detected using immunohistochemistry. The expression of genes in the Wnt-signaling system was assessed using real-time reverse transcription polymerase chain reaction array. The role of activin-A in cell proliferation was addressed by treating embryos cultured in high glucose with activin-A. RESULTS Maternal diabetes caused complex abnormalities in the OFTs, including aortic and pulmonary stenosis and persistent truncus arteriosus. The development of the endocardial cushions was suppressed, manifested with insufficient cellularization of the tissues. Cell proliferation was significantly decreased under oxidative and ER stress conditions. The expression of genes in the Wnt signaling was significantly altered. Activin-A and Smad3 were found to be expressed in the OFT. Treatment with activin-A rescued cell proliferation in the endocardial cushions. CONCLUSIONS Maternal diabetes generates oxidative and ER stress conditions, suppresses TGFβ and Wnt signaling, inhibits cell proliferation and cellularization of the endocardial cushions, leading to OFT septal defects. Activin-A plays a role in hyperglycemia-suppressed proliferation of the endocardial cells.
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Affiliation(s)
- Zhiyong Zhao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
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Lei L, Lin H, Zhong S, Zhang Z, Chen J, Li XX, Yu X, Liu X, Zhuang J. Analysis of mutations in 7 candidate genes for dextro-Transposition of the great arteries in Chinese population. J Thorac Dis 2014; 6:491-6. [PMID: 24822108 DOI: 10.3978/j.issn.2072-1439.2014.03.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/24/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Transposition of great arteries (TGA) represents the most frequent cyanotic heart defect diagnosed in the neonatal period. Several genes had been identified to be associated with the pathogenesis of dextro-transposition of the great arteries (d-TGA). These genes are located in different chromosomes and their mutations can only explain few clinical cases. Besides, no genetic scan for TGA has been implemented in China. METHODS To evaluate whether aberrations in any of the 13 reported mutations in seven genes (MED13L, ZIC3, CFC1, NODAL, FOXH1, GDF1 and NKX2-5) could completely or in part be the genetic component involved in TGA in Chinese population, we screened 102 Chinese patients with d-TGA by direct sequencing for mutations within the seven genes. RESULTS We found none of the reported 13 mutations in those 102 Chinese d-TGA patients. CONCLUSIONS These reported 13 mutations may not be a common cause of d-TGA in Chinese population due to racial variation and genetic heterogeneity of TGA. New approaches including the whole exome sequencing technology are required to effectively identify genetic variants in TGA patients in China.
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Affiliation(s)
- Liming Lei
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Haoming Lin
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Shilong Zhong
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zhiwei Zhang
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jimei Chen
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xin-Xin Li
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiyong Yu
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xaioqing Liu
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jian Zhuang
- 1 Department of Cardiovascular Surgery of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 2 Department of Hepatobiliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Medical Research Center of Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China ; 4 Department of Pediatrics of Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Moazzen H, Lu X, Ma NL, Velenosi TJ, Urquhart BL, Wisse LJ, Gittenberger-de Groot AC, Feng Q. N-Acetylcysteine prevents congenital heart defects induced by pregestational diabetes. Cardiovasc Diabetol 2014; 13:46. [PMID: 24533448 PMCID: PMC3942143 DOI: 10.1186/1475-2840-13-46] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 12/21/2013] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Pregestational diabetes is a major risk factor of congenital heart defects (CHDs). Glutathione is depleted and reactive oxygen species (ROS) production is elevated in diabetes. In the present study, we aimed to examine whether treatment with N-acetylcysteine (NAC), which increases glutathione synthesis and inhibits ROS production, prevents CHDs induced by pregestational diabetes. METHODS Female mice were treated with streptozotocin (STZ) to induce pregestational diabetes prior to breeding with normal males to produce offspring. Some diabetic mice were treated with N-acetylcysteine (NAC) in drinking water from E0.5 to the end of gestation or harvesting of the embryos. CHDs were identified by histology. ROS levels, cell proliferation and gene expression in the fetal heart were analyzed. RESULTS Our data show that pregestational diabetes resulted in CHDs in 58% of the offspring, including ventricular septal defect (VSD), atrial septal defect (ASD), atrioventricular septal defects (AVSD), transposition of great arteries (TGA), double outlet right ventricle (DORV) and tetralogy of Fallot (TOF). Treatment with NAC in drinking water in pregestational diabetic mice completely eliminated the incidence of AVSD, TGA, TOF and significantly diminished the incidence of ASD and VSD. Furthermore, pregestational diabetes increased ROS, impaired cell proliferation, and altered Gata4, Gata5 and Vegf-a expression in the fetal heart of diabetic offspring, which were all prevented by NAC treatment. CONCLUSIONS Treatment with NAC increases GSH levels, decreases ROS levels in the fetal heart and prevents the development of CHDs in the offspring of pregestational diabetes. Our study suggests that NAC may have therapeutic potential in the prevention of CHDs induced by pregestational diabetes.
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Affiliation(s)
- Hoda Moazzen
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario N6A 5C1, Canada
| | - Xiangru Lu
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario N6A 5C1, Canada
| | - Noelle L Ma
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario N6A 5C1, Canada
| | - Thomas J Velenosi
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario N6A 5C1, Canada
| | - Brad L Urquhart
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario N6A 5C1, Canada
- Department of Medicine, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Lambertus J Wisse
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Qingping Feng
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario N6A 5C1, Canada
- Department of Medicine, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
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Dowling D, Corrigan N, Horgan S, Watson CJ, Baugh J, Downey P, McAuliffe FM. Cardiomyopathy in offspring of pregestational diabetic mouse pregnancy. J Diabetes Res 2014; 2014:624939. [PMID: 25054159 PMCID: PMC4098888 DOI: 10.1155/2014/624939] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/17/2014] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To investigate cardiomyopathy in offspring in a mouse model of pregestational type 1 diabetic pregnancy. METHODS Pregestational diabetes was induced with STZ administration in female C57BL6/J mice that were subsequently mated with healthy C57BL6/J males. Offspring were sacrificed at embryonic day 18.5 and 6-week adolescent and 12-week adult stages. The size and number of cardiomyocyte nuclei and also the extent of collagen deposition within the hearts of diabetic and control offspring were assessed following cardiac tissue staining with either haematoxylin and eosin or Picrosirius red and subsequently quantified using automated digital image analysis. RESULTS Offspring from diabetic mice at embryonic day 18.5 had a significantly higher number of cardiomyocyte nuclei present compared to controls. These nuclei were also significantly smaller than controls. Collagen deposition was shown to be significantly increased in the hearts of diabetic offspring at the same age. No significant differences were found between the groups at 6 and 12 weeks. CONCLUSIONS Our results from offspring of type 1 diabetic mice show increased myocardial collagen deposition in late gestation and have increased myocardial nuclear counts (hyperplasia) as opposed to increased myocardial nuclear size (hypertrophy) in late gestation. These changes normalize postpartum after removal from the maternal intrauterine environment.
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Affiliation(s)
- Daniel Dowling
- UCD Obstetrics & Gynaecology, School of Medicine and Medical Science, National Maternity Hospital, University College Dublin, Dublin 2, Ireland
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - Niamh Corrigan
- UCD Obstetrics & Gynaecology, School of Medicine and Medical Science, National Maternity Hospital, University College Dublin, Dublin 2, Ireland
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - Stephen Horgan
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - Chris J. Watson
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - John Baugh
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - Paul Downey
- Pathology, National Maternity Hospital, Dublin 2, Ireland
| | - Fionnuala M. McAuliffe
- UCD Obstetrics & Gynaecology, School of Medicine and Medical Science, National Maternity Hospital, University College Dublin, Dublin 2, Ireland
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
- *Fionnuala M. McAuliffe:
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78
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Li R, Yang P, Chen X, Wang L. Maternal serum AGEs levels in pregnancies associated with neural tube defects. Int J Dev Neurosci 2013; 33:57-61. [PMID: 24345611 DOI: 10.1016/j.ijdevneu.2013.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 12/07/2013] [Accepted: 12/07/2013] [Indexed: 11/18/2022] Open
Abstract
Advanced glycation end products (AGEs) plays an important role in diabetic embryopathy. AGE-mediated DNA damage could be a significant factor in the teratogenicity. The aim of the present study was to evaluate the association between the AGEs level and neural tube defects (NTDs) occurrence risk. Forty-eight mothers with NTD-affected pregnancies and 50 normal mothers were selected in this study. Blood were collected from the mothers and were assayed for serum AGEs, malondiadehyde (MDA) and hemoglobin A1c (HbA1c). Data were analyzed by logistic regression method. The study indicated that there were significant but modest lower prevalence for cases mothers on age, BMI and glucose levels compared with controls. NTD-affected mothers were significantly more likely to have higher AGEs levels (5.6±0.48 AU vs. 4.6±0.68 AU ρ<0.01) than controls. The AGEs levels were not correlated with MDA and HbA1c in NTDs mothers (r(2)=0.0006 p=0.8691 and r(2)=0.001 p=0.8172, respectively). The conclusion is that AGEs might be associated with NTDs occurrence.
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Affiliation(s)
- Rulin Li
- Laboratory for Development, College of Life Sciences, Northwest University, Taibai west road 229#, Shaanxi, Xi'an 710068, People's Republic of China; National Engineering Research Center for Miniaturized Detection System, Northwest University, Shaanxi, Xi'an 710069, People's Republic of China.
| | - Peiyao Yang
- Laboratory for Development, College of Life Sciences, Northwest University, Taibai west road 229#, Shaanxi, Xi'an 710068, People's Republic of China
| | - Xuyang Chen
- College of Pharmaceutical sciences, Chongqing Medical University, Chongqing 401331, People's Republic of China
| | - Li Wang
- Department of Clinical Laboratory, Panyu central Hospital, Guang Zhou 511400, People's Republic of China
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79
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WANG XIKE, LI PINGJUAN, CHEN SUN, XI LILI, GUO YING, GUO AIHUA, SUN KUN. Influence of genes and the environment in familial congenital heart defects. Mol Med Rep 2013; 9:695-700. [DOI: 10.3892/mmr.2013.1847] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/28/2013] [Indexed: 11/06/2022] Open
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Tabib A, Shirzad N, Sheikhbahaei S, Mohammadi S, Qorbani M, Haghpanah V, Abbasi F, Hasani-Ranjbar S, Baghaei-Tehrani R. Cardiac malformations in fetuses of gestational and pre gestational diabetic mothers. IRANIAN JOURNAL OF PEDIATRICS 2013; 23:664-8. [PMID: 24910745 PMCID: PMC4025124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 10/10/2013] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In this study we aimed to determine the prevalence of cardiac malformations in fetuses of Iranian diabetic mothers with pre-gestational and gestational diabetes mellitus (GDM) and to find the patterns of different cardiac malformations. METHODS One-hundred and seventy diabetic pregnant women (68 preGDM and 102 GDM) (mean age: 32.17±4.8 years) and 85 healthy controls (mean age: 31.35±4.55 years) were recruited from September 2008 to July 2012. Fetal echocardiography was performed to assess cardiac malformation. In order to study major factors that may affect the results, a complete history was obtained. FINDINGS Fetal echocardiography was performed at mean gestational age of 24.7±5.4 and 20.27±3.9 weeks in diabetic patients and control group, respectively. Fifteen (8.8%) fetuses of diabetic mothers were detected to have cardiac malformations compared with 1 (1.17%) fetus in control group (OR: 8.13, 95%CI: 1.1-62.61, P-value=0.02). Hypertrophic cardiomyopathy noted as the most common cardiac malformation occurred in 6 out of 15 (40%) fetuses, and was found significantly more common in pre-GDM compared to GDM group (7.4% vs 1%, P-value =0.04). Despite the higher incidence of cardiac malformation in pre-GDM compared to GDM group, the difference was not significant. Further, no significant association was observed between the variables including; parity, diabetic regimen, parents' consanguinity, maternal history of hypertension or hypothyroidism and occurring cardiac malformations (P-value>0.05). CONCLUSION In this study we detected cardiac malformations in 8.8% of our diabetic referrals. The result of the present study shows that screening diabetic mothers for fetal cardiac malformations could be beneficial.
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Affiliation(s)
- Avisa Tabib
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Nooshin Shirzad
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Author:Address: Endocrinology and Metabolism Research Institute,Tehran University of Medical Sciences,Dr.Shariati Hospital,NorthKargar Ave., Tehran, Iran. E-mail:
| | - Sara Sheikhbahaei
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Mohammadi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Department of Public Health, Alborz University of Medical Sciences, Karaj, Iran,Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Haghpanah
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Abbasi
- Department of Cardiac Surgery, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shirin Hasani-Ranjbar
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramin Baghaei-Tehrani
- Department of Cardiac Surgery, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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81
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Zhao Z. Activin-A in diabetes-induced cardiac malformations in embryos. ACTA ACUST UNITED AC 2013; 98:260-7. [PMID: 23716477 DOI: 10.1002/bdrb.21060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/08/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND Heart defects are the most common abnormalities in infants of diabetic mothers. Cardiac malformation is associated with altered expression of the genes in the transforming growth factor β system, including inhibin βA, which forms activin-A as a homodimer and functions through its effectors, Smad2 and Smad3. This study aimed to investigate the role of activin-A in diabetes-induced cardiac malformations. METHODS Diabetes mellitus in female mice (C57BL/6J) was induced via intravenous injection of streptozotocin. The expression of inhibin βA protein and phosphorylation of Smad2 and Smad3 in the embryonic hearts were examined using immunohistochemical, in situ proximity ligation, and immunoblot assays. Embryos and endocardial cushions of nondiabetic mice were cultured in a high concentration of glucose and treated with activin-A. Mitosis was examined using BrdU incorporation assay and immunohistochemistry of phosphorylated histone H3. Migration of the endocardial cells was assessed using a collagen-based cell migration assay. RESULTS The levels of inhibin βA expression and Smad2 and Smad3 activation were significantly reduced by maternal diabetes. Treatment with activin-A significantly increased cell proliferation in the myocardium and migration of endocardial cells, compared with those in vehicle-treated high glucose group, to the level in the euglycemic control group. CONCLUSIONS Maternal diabetes suppresses the expression of inhibin βA protein, as well as the activation of Smad2 and Smad3. Activin-A rescues cell proliferation in the myocardium and migration of the endocardial cells suppressed by hyperglycemia. The activin-Smad2/3 signaling system appears to play a role in cardiac malformation in diabetic embryopathy.
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Affiliation(s)
- Zhiyong Zhao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
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82
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Bohuslavova R, Skvorova L, Sedmera D, Semenza GL, Pavlinkova G. Increased susceptibility of HIF-1α heterozygous-null mice to cardiovascular malformations associated with maternal diabetes. J Mol Cell Cardiol 2013; 60:129-41. [PMID: 23619295 DOI: 10.1016/j.yjmcc.2013.04.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Revised: 04/13/2013] [Accepted: 04/15/2013] [Indexed: 01/27/2023]
Abstract
Cardiovascular malformations are the most common manifestation of diabetic embryopathy. The molecular mechanisms underlying the teratogenic effect of maternal diabetes have not been fully elucidated. Using genome-wide expression profiling, we previously demonstrated that exposure to maternal diabetes resulted in dysregulation of the hypoxia-inducible factor 1 (HIF-1) pathway in the developing embryo. We thus considered a possible link between HIF-1-regulated pathways and the development of congenital malformations. HIF-1α heterozygous-null (Hif1a(+/-)) and wild type (Wt) littermate embryos were exposed to the intrauterine environment of a diabetic mother to analyze the frequency and morphology of congenital defects, and assess gene expression changes in Wt and Hif1a(+/-) embryos. We observed a decreased number of embryos per litter and an increased incidence of heart malformations, including atrioventricular septal defects and reduced myocardial mass, in diabetes-exposed Hif1a(+/-) embryos as compared to Wt embryos. We also detected significant differences in the expression of key cardiac transcription factors, including Nkx2.5, Tbx5, and Mef2C, in diabetes-exposed Hif1a(+/-) embryonic hearts compared to Wt littermates. Thus, partial global HIF-1α deficiency alters gene expression in the developing heart and increases susceptibility to congenital defects in a mouse model of diabetic pregnancy.
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Abstract
Diabetes mellitus is responsible for nearly 10% of fetal anomalies in diabetic pregnancies. Although aggressive perinatal care and glycemic control are available in developed countries, the birth defect rate in diabetic pregnancies remains higher than that in the general population. Major cellular activities (ie, proliferation and apoptosis) and intracellular metabolic conditions (ie, nitrosative, oxidative, and endoplasmic reticulum stress) have been shown to be associated with diabetic embryopathy using animal models. Translating advances made in animal studies into clinical applications in humans requires collaborative efforts across the basic research, preclinical, and clinical communities.
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Affiliation(s)
- Zhiyong Zhao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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84
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Abstract
Congenital heart disease (CHD) is the most common congenital anomaly in newborn babies. Cardiac malformations have been produced in multiple experimental animal models, by perturbing selected molecules that function in the developmental pathways involved in myocyte specification, differentiation, or cardiac morphogenesis. In contrast, the precise genetic, epigenetic, or environmental basis for these perturbations in humans remains poorly understood. Over the past few decades, researchers have tried to bridge this knowledge gap through conventional genome-wide analyses of rare Mendelian CHD families, and by sequencing candidate genes in CHD cohorts. Although yielding few, usually highly penetrant, disease gene mutations, these discoveries provided 3 notable insights. First, human CHD mutations impact a heterogeneous set of molecules that orchestrate cardiac development. Second, CHD mutations often alter gene/protein dosage. Third, identical pathogenic CHD mutations cause a variety of distinct malformations, implying that higher order interactions account for particular CHD phenotypes. The advent of contemporary genomic technologies including single nucleotide polymorphism arrays, next-generation sequencing, and copy number variant platforms are accelerating the discovery of genetic causes of CHD. Importantly, these approaches enable study of sporadic cases, the most common presentation of CHD. Emerging results from ongoing genomic efforts have validated earlier observations learned from the monogenic CHD families. In this review, we explore how continued use of these technologies and integration of systems biology is expected to expand our understanding of the genetic architecture of CHD.
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Affiliation(s)
- Akl C Fahed
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
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85
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Roodpeyma S, Rafieyian S, Khosravi N, Hashemi A. Cardiovascular Complications in Infants of Diabetic Mothers: An Observational Study in a Pediatric Cardiology Clinic in Tehran. ACTA ACUST UNITED AC 2013. [DOI: 10.17795/compreped-8432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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86
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Cardiovascular Complications in Infants of Diabetic Mothers: An Observational Study in a Pediatric Cardiology Clinic in Tehran. ACTA ACUST UNITED AC 2013. [DOI: 10.5812/jcp.8432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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87
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Appleton K, Barnard J, Jantz AK, Pooh R, Comas-Gabriel C. The Role of Ultrasound in the Diagnosis of Complications Associated with Maternal Diabetes. ACTA ACUST UNITED AC 2013. [DOI: 10.5005/jp-journals-10009-1325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT
Gestational diabetes mellitus (GDM) is defined as glucose intolerance that begins or is first recognized during pregnancy. Numerous clinical factors are associated with an increased likelihood of GDM, such as increasing age, obesity, ethnicity, family history of diabetes and past obstetric history. There is a well-documented relationship between maternal hyperglycemia and increased rate of macrosomia, cesarean section, stillbirth, fetal congenital malformations, shoulder dystocia, hypoglycemia, hyperbilirubinemia, pre-eclampsia, preterm delivery, childhood obesity, and increased risk of maternal development of type 2 DM later on in her life. This case-based review is designed to provide health care workers a framework on using various ultrasound imaging modalities in early detection of the effects of gestational diabetes, and the specific conditions and/or anomalies seen in diabetic pregnancies.
How to cite this article
Appleton K, Barnard J, Jantz AK, Pooh R, Comas-Gabriel C, Kupesic-Plavsic S. The Role of Ultrasound in the Diagnosis of Complications Associated with Maternal Diabetes. Donald School J Ultrasound Obstet Gynecol 2013;7(4):506-515.
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88
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Vijaya M, Manikandan J, Parakalan R, Dheen ST, Kumar SD, Tay SSW. Differential gene expression profiles during embryonic heart development in diabetic mice pregnancy. Gene 2012; 516:218-27. [PMID: 23287646 DOI: 10.1016/j.gene.2012.12.071] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 12/09/2012] [Indexed: 11/19/2022]
Abstract
Congenital heart defects (CHD) are one of the most common defects in offspring of diabetic mothers. There is a clear association between maternal diabetes and CHD; however the underlying molecular mechanism remains unknown. We hypothesized that maternal diabetes affects with the expression of early developmental genes that regulate the essential developmental processes of the heart, thereby resulting in the pathogenesis of CHD. We analyzed genome-wide expression profiling in the developing heart of embryos from diabetic and control mice by using the oligonucleotide microarray. Microarray analysis revealed that a total of 878 genes exhibited more than 1.5 fold changes in expression level in the hearts of experimental embryos in either E13.5 or E15.5 compared with their respective controls. Expression pattern of genes that is differentially expressed in the developing heart was further examined by the real-time reverse transcriptase-polymerase chain reaction. Several genes involved in a number of molecular signaling pathways such as apoptosis, proliferation, migration and differentiation in the developing heart were differentially expressed in embryos of diabetic pregnancy. It is concluded that altered expression of several genes involved in heart development may contribute to CHD in offspring of diabetic mothers.
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Affiliation(s)
- Murugaiyan Vijaya
- Department of Anatomy, National University of Singapore, Singapore 117597, Singapore
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89
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Sukanya S, Bay BH, Tay SSW, Dheen ST. Frontiers in research on maternal diabetes-induced neural tube defects: Past, present and future. World J Diabetes 2012; 3:196-200. [PMID: 23301121 PMCID: PMC3538985 DOI: 10.4239/wjd.v3.i12.196] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/02/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Diabetes mellitus rightly regarded as a silent-epidemic is continually on the rise and estimated to have a global prevalence of 6.4 % as of 2010. Diabetes during pregnancy is a well known risk factor for congenital anomalies in various organ systems that contribute to neonatal mortality, including cardiovascular, gastrointestinal, genitourinary and neurological systems, among which the neural tube defects are frequently reported. Over the last two to three decades, several groups around the world have focussed on identifying the molecular cues and cellular changes resulting in altered gene expression and the morphological defects and in diabetic pregnancy. In recent years, the focus has gradually shifted to looking at pre-programmed changes and activation of epigenetic mechanisms that cause altered gene expression. While several theories such as oxidative stress, hypoxia, and apoptosis triggered due to hyperglycemic conditions have been proposed and proven for being the cause for these defects, the exact mechanism or the link between how high glucose can alter gene expression/transcriptome and activate epigenetic mechanisms is largely unknown. Although preconceptual control of diabetes, (i.e., managing glucose levels during pregnancy), and in utero therapies has been proposed as an effective solution for managing diabetes during pregnancy, the impact that a fluctuating glycemic index can have on foetal development has not been evaluated in detail. A tight glycemic control started before pregnancy has shown to reduce the incidence of congenital abnormalities in diabetic mothers. On the other hand, a tight glycemic control after organogenesis and embryogenesis have begun may prove insufficient to prevent or reverse the onset of congenital defects. The importance of determining the extent to which glycemic levels in diabetic mothers should be regulated is critical as foetal hypoglycemia has also been shown to be teratogenic. Finally, the major question remaining is if this whole issue is negligible and not worthy of investigation as the efficient management of diabetes during pregnancy is well in place in many countries.
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Affiliation(s)
- Shyamasundar Sukanya
- Shyamasundar Sukanya, Boon Huat Bay, Samuel Sam Wah Tay, S Thameem Dheen, Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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90
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Wahabi HA, Alzeidan RA, Esmaeil SA. Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis. BMC Public Health 2012; 12:792. [PMID: 22978747 PMCID: PMC3575330 DOI: 10.1186/1471-2458-12-792] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/14/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-gestational diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. This systematic review was carried out to evaluate the effectiveness and safety of pre-pregnancy care in improving the rate of congenital malformations and perinatal mortality for women with pre-gestational diabetes mellitus. METHODS We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2011, without language restriction, for any pre-pregnancy care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women with type I or type II diabetes mellitus. Study design were trials (randomized and non-randomized), cohort and case-control studies. RESULTS Of the 2452 title scanned 54 full papers were retrieved of those 21 studies were included in this review. Twelve cohort studies at low and medium risk of bias, with 3088 women, were included in the meta-analysis. Meta-analysis suggested that pre-pregnancy care is effective in reducing congenital malformation, Risk Ratio (RR) 0.25 (95% CI 0.16-0.37), number needed to treat (NNT) 19 (95% CI 14-24), and perinatal mortality RR 0.34 (95% CI 0.15-0.75), NNT = 46 (95% CI 28-115). Pre-pregnancy care lowers glycosylated hemoglobin A1c (HbA1c) in the first trimester of pregnancy by an average of 1.92% (95% CI -2.05 to -1.79). However women who received pre-pregnancy care were at increased risk of hypoglycemia during the first trimester of pregnancy RR 1.51 (95% CI 1.15-1.99). CONCLUSION Pre-pregnancy care for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations, perinatal mortality and in reducing maternal HbA1C in the first trimester of pregnancy. Pre-pregnancy care might cause maternal hypoglycemia in the first trimester of pregnancy.
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Affiliation(s)
- Hayfaa A Wahabi
- Sheikh Bahmdan Chair of Evidence-based Healthcare and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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91
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Blue GM, Kirk EP, Sholler GF, Harvey RP, Winlaw DS. Congenital heart disease: current knowledge about causes and inheritance. Med J Aust 2012; 197:155-9. [DOI: 10.5694/mja12.10811] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Gillian M Blue
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW
| | - Edwin P Kirk
- Department of Medical Genetics, Sydney Children's Hospital, Sydney, NSW
| | - Gary F Sholler
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW
| | | | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW
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92
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El-Sayyad HI, Al-Haggar MS, El-Ghawet HA, Bakr IH. Cardiomyopathy and angiogenesis defects of Wistar rat fetuses of diabetic and hypercholesterolemic mothers. Nutrition 2012; 28:e33-43. [DOI: 10.1016/j.nut.2011.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 12/22/2011] [Accepted: 12/22/2011] [Indexed: 10/28/2022]
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93
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Disparate Cardiovascular and Diabetic Outcomes in Young Adult Black Women: Studies from across the Globe. CURRENT CARDIOVASCULAR RISK REPORTS 2012. [DOI: 10.1007/s12170-012-0229-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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94
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Gestational diabetes affects postnatal development of transport and enzyme functions in rat intestine. Mol Cell Biochem 2011; 361:71-7. [PMID: 21964563 DOI: 10.1007/s11010-011-1090-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 09/16/2011] [Indexed: 10/17/2022]
Abstract
The effect of alloxan-induced gestational diabetes on the postnatal development of brush border disaccharidases and D-glucose transport in rat intestine was studied. Pups born to diabetic mothers showed 92-22% increase in blood sugar levels compared with the controls. Western blot and RT-PCR analyses revealed that the activities of brush border sucrase, lactase and Sodium Glucose Co-transporter 1 (SGLT1) correlates with protein and mRNA levels in intestine of pups born to diabetic rat mothers after 5-45 days of birth. Intestinal histology in pups born to diabetic mothers at day 10 and 45 after birth showed distorted cellular organization of mucosa with a decrease in the number of secretary goblet cells and regression of tubular mass. These findings suggest that the genetic switch in utero regulates the postnatal expression of enzyme and transport functions in intestine of pups born to diabetic rat mothers. This may influence the growth and development of offsprings later in life.
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95
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Zhao Z. Endoplasmic reticulum stress in maternal diabetes-induced cardiac malformations during critical cardiogenesis period. ACTA ACUST UNITED AC 2011; 95:1-6. [PMID: 21922638 DOI: 10.1002/bdrb.20330] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 07/12/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cardiac abnormalities, including atrioventricular (AV) septal defects (AVSDs), are the most common birth defects in diabetic embryopathy. The AV septum is derived from the endocardial cushions, which undergo development and remodeling during septation. The impact of maternal diabetes on these processes needs to be identified. Maternal diabetes disturbs the function of the endoplasmic reticulum (ER). The role of ER stress in cardiac malformation remains to be delineated to gain information for developing therapy. METHODS Female mice were induced diabetic via intravenous injection of streptozotocin. Pregnant mice were made hyperglycemic at desired embryonic (E) days. AVSDs were examined histologically at E15.5. ER stress-associated factors were examined and quantified using immunohistochemical and immunoblot assays at E10.5. The role of ER stress in endocardial cell migration was investigated by treating endocardial cushion explants that were cultured in high glucose with an organic chaperone molecule, sodium 4-phenylbutyrate. RESULTS The rate of AVSDs in the embryos that were exposed to maternal hyperglycemia during the period of endocardial cushion development was significantly higher than that in those during endocardial cushion remodeling. ER stress was increased in the hearts. Amelioration of ER stress restored endocardial cell migration under hyperglycemic conditions. CONCLUSIONS The development, rather than remodeling, of the endocardial cushions is the cardiomorphogenic process that is susceptible to the insult of maternal hyperglycemia in the formation of AVSDs. Maternal diabetes increases ER stress in the developing heart. ER stress plays an essential role in mediating the effect of hyperglycemia on endocardial cell migration.
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Affiliation(s)
- Zhiyong Zhao
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Miller A, Riehle-Colarusso T, Siffel C, Frías JL, Correa A. Maternal age and prevalence of isolated congenital heart defects in an urban area of the United States. Am J Med Genet A 2011; 155A:2137-45. [DOI: 10.1002/ajmg.a.34130] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 05/01/2011] [Indexed: 11/05/2022]
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97
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Yang P, Reece EA. Role of HIF-1α in maternal hyperglycemia-induced embryonic vasculopathy. Am J Obstet Gynecol 2011; 204:332.e1-7. [PMID: 21345401 DOI: 10.1016/j.ajog.2011.01.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 01/03/2011] [Accepted: 01/11/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Maternal diabetes adversely impacts embryonic vasculogenesis, which results in embryonic vasculopathy. The purpose of our study is to determine whether hypoxia inducible factor (HIF)-1α plays a role in diabetic embryonic vasculopathy. STUDY DESIGN Levels of HIF-1α were determined in mouse conceptuses. Conceptuses on day 7 of pregnancy were cultured under euglycemic (150 mg/dL glucose) and hyperglycemic (300 mg/dL) conditions with or without AdCA5, or in the presence or absence of 2.0 μg/mL human recombinant thioredoxin, an endogenous antioxidant protein. AdCA5 is an adenovirus encoding a constitutively active form of HIF-1α. RESULTS Maternal diabetes significantly reduced HIF-1α protein expression. The administration of 1 μL (1 × 10(7) infectious units/mL) per 1 mL culture medium AdCA5 completely reversed hyperglycemia-reduced vasculature morphological scores and vascular endothelial growth factor expression. Thioredoxin treatment reversed hyperglycemia-reduced HIF-1α levels. CONCLUSION We conclude that reduced HIF-1α plays a critical role in the induction of diabetic embryonic vasculopathy, and that oxidative stress is implicated in hyperglycemia-induced HIF-1α reduction.
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Affiliation(s)
- Peixin Yang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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98
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Lale S, Yu S, Ahmed A. Complex congenital heart defects in association with maternal diabetes and partial deletion of the A2BP1 gene. Fetal Pediatr Pathol 2011; 30:161-6. [PMID: 21355681 DOI: 10.3109/15513815.2010.547555] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this article, we report a case of complex congenital heart disease in a female infant with maternal diabetes who eventually died of sepsis and post-surgical complications. The autopsy phenotypic findings and organ malformations are detailed. Genomic studies identified a 162 kb intragenic deletion of A2BP1 gene within chromosome band 16p13.2. To our knowledge, this is the first description of A2BP1 gene deletion in association with congenital heart anomalies. This case also demonstrates the effect of maternal diabetes on gene transcription and emphasizes the importance of scanning the human genome in neonates born with congenital anomalies.
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Affiliation(s)
- Seema Lale
- Department of Pathology, University of Missouri, Kansas City, Missouri, USA
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Abstract
About 3 to 10% of pregnancies are complicated by glycemic control abnormalities. Maternal diabetes results in significantly greater risk for antenatal, perinatal, and neonatal morbidity and mortality, as well as congenital malformations. The number of diabetic mothers is expected to rise, as more and more of the obese pediatric female population in developed and some developing countries progresses to childbearing age. Radiologists, being part of the teams managing such pregnancies, should be well aware of the findings that may be encountered in infants of diabetic mothers. Timely, accurate, and proper radiological evaluation can reduce morbidity and mortality in these infants. The purpose of this essay is to illustrate the imaging findings in the various pathological conditions involving the major body systems in the offspring of women with diabetes.
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Affiliation(s)
- Ibrahim A Alorainy
- Department of Diagnostic Radiology, King Saud University, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia
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100
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Kitzmiller JL, Wallerstein R, Correa A, Kwan S. Preconception care for women with diabetes and prevention of major congenital malformations. ACTA ACUST UNITED AC 2010; 88:791-803. [DOI: 10.1002/bdra.20734] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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