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

Large for Gestational Age and Adverse Outcomes: Stratified By Diabetes Status

OBJECTIVE

 To examine the association of adverse outcomes among parturients with large for gestational age (LGA; birth weight ≥ 90th) newborns, stratified by diabetes status. Additionally, we described the temporal trends of adverse outcomes among LGA neonates.

STUDY DESIGN

 This retrospective cohort study used the U.S. Vital Statistics dataset between 2014 and 2020. The inclusion criteria were singleton, nonanomalous LGA live births who labored and delivered at 24 to 41 weeks with known diabetes status. The coprimary outcomes were composite neonatal adverse outcomes of the following: Apgar score < 5 at 5 minutes, assisted ventilation > 6 hours, seizure, or neonatal or infant mortality, and maternal adverse outcomes of the following: maternal transfusion, ruptured uterus, unplanned hysterectomy, admission to intensive care unit, or unplanned procedure. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CI). Average annual percent change (AAPC) was calculated to assess changes in rates of LGA and morbidity over time.

RESULTS

 Of 27 million births in 7 years, 1,843,467 (6.8%) met the inclusion criteria. While 1,656,888 (89.9%) did not have diabetes, 186,579 (10.1%) were with diabetes. Composite neonatal adverse outcomes (aRR = 1.48, 95% CI = 1.43, 1.52) and composite maternal adverse outcomes (aRR = 1.37, 95% CI = 1.36, 1.38) were significantly higher among individuals with diabetes, compared with those without diabetes. From 2014 to 2020, the LGA rate was stable among people without diabetes. However, there was a downward trend of LGA in people with diabetes (AAPC = - 2.4, 95% CI = - 3.5, -1.4).

CONCLUSION

 In pregnancies with LGA newborns, composite neonatal and maternal morbidities were higher in those with diabetes, compared with those without diabetes.

KEY POINTS

· Large for gestational age stratified by diabetes status.. · Composite neonatal and maternal adverse outcomes are worse among individuals with diabetes as compared to those without.. · During 2014 to 2020, the trend of LGA in individuals without diabetes increased..

Association between maternal hyperglycemia in pregnancy and offspring anthropometry in early childhood: the pandora wave 1 study

BACKGROUND

In-utero hyperglycemia exposure influences later cardiometabolic risk, although few studies include women with pre-existing type 2 diabetes (T2D) or assess maternal body mass index (BMI) as a potential confounder.

OBJECTIVE

To explore the association of maternal T2D and gestational diabetes mellitus (GDM) with childhood anthropometry, and the influence of maternal BMI on these associations.

METHODS

The PANDORA cohort comprises women (n = 1138) and children (n = 1163). Women with GDM and T2D were recruited from a hyperglycemia in pregnancy register, and women with normoglycemia from the community. Wave 1 follow-up included 423 children, aged 1.5-5 years (median follow-up age 2.5 years). Multivariable linear regression assessed associations between maternal antenatal variables, including BMI and glycemic status, with offspring anthropometry (weight, height, BMI, skinfold thicknesses, waist, arm and head circumferences).

RESULTS

Greater maternal antenatal BMI was associated with increased anthropometric measures in offspring independent of maternal glycemic status. After adjustment, including for maternal BMI, children exposed to maternal GDM had lower mean weight (-0.54 kg, 95% CI: -0.99, -0.11), BMI (-0.55 kg/m2, 95% CI: -0.91, -0.20), head (-0.52 cm, 95% CI: -0.88, -0.16) and mid-upper arm (-0.32 cm, 95% CI: -0.63, -0.01) circumferences, and greater mean suprailiac skinfold (0.78 mm, 95% CI: 0.13, 1.43), compared to children exposed to normoglycemia. Adjustment for maternal BMI strengthened the negative association between GDM and child weight, BMI and circumferences. Children exposed to maternal T2D had smaller mean head circumference (-0.82 cm, 95% CI: -1.33, -0.31) than children exposed to normoglycemia. Maternal T2D was no longer associated with greater child mean skinfolds (p = 0.14) or waist circumference (p = 0.18) after adjustment for maternal BMI.

CONCLUSIONS

Children exposed to GDM had greater suprailiac skinfold thickness than unexposed children, despite having lower mean weight, BMI and mid-upper arm circumference, and both GDM and T2D were associated with smaller mean head circumference. Future research should assess whether childhood anthropometric differences influence lifetime cardiometabolic and neurodevelopmental risk.

Association between hyperglycaemia in pregnancy and growth of offspring in early childhood: The PANDORA study

BACKGROUND

Few studies have assessed whether children exposed to in utero hyperglycaemia experience different growth trajectories compared to unexposed children.

OBJECTIVES

To assess association of type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) with early childhood weight, length/height and body mass index (BMI) trajectories, and with timing and magnitude of peak BMI in infancy.

METHODS

PANDORA is a birth cohort recruited from an Australian hyperglycaemia in pregnancy register, and women with normoglycaemia recruited from the community. Offspring growth measures were obtained from health records over a median follow-up of 3.0 years (interquartile range 1.9-4.0). This analysis included children born to Aboriginal mothers with in utero normoglycaemia (n = 95), GDM (n = 228) or T2D (n = 131). Growth trajectories (weight, length/height and BMI) were estimated using linear mixed models with cubic spline functions of child age.

RESULTS

After adjustment for maternal factors (age, BMI, parity, smoking, and socioeconomic measures) and child factors (age, gestational age at birth, and sex), children born to mothers with T2D or GDM had lower weight, length/height and BMI trajectories in infancy than children born to mothers with normoglycaemia, but similar weight and BMI by completion of follow-up. Children exposed to T2D had lower mean peak BMI 17.6 kg/m² (95% confidence interval [CI] 17.3-18.0) than children exposed to normoglycaemia (18.6 kg/m² [18.1-18.9]) (p = 0.001).

CONCLUSIONS

Maternal hyperglycaemia was associated with differences in early childhood growth trajectories after adjustment for maternal BMI. Exploration of associations between in utero hyperglycaemia exposure and growth trajectories into later childhood is required.

Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review

In spite of the huge progress in the treatment of diabetes mellitus, we are still in the situation that both pregestational (PGDM) and gestational diabetes (GDM) impose an additional risk to the embryo, fetus, and course of pregnancy. PGDM may increase the rate of congenital malformations, especially cardiac, nervous system, musculoskeletal system, and limbs. PGDM may interfere with fetal growth, often causing macrosomia, but in the presence of severe maternal complications, especially nephropathy, it may inhibit fetal growth. PGDM may also induce a variety of perinatal complications such as stillbirth and perinatal death, cardiomyopathy, respiratory morbidity, and perinatal asphyxia. GDM that generally develops in the second half of pregnancy induces similar but generally less severe complications. Their severity is higher with earlier onset of GDM and inversely correlated with the degree of glycemic control. Early initiation of GDM might even cause some increase in the rate of congenital malformations. Both PGDM and GDM may cause various motor and behavioral neurodevelopmental problems, including an increased incidence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Most complications are reduced in incidence and severity with the improvement in diabetic control. Mechanisms of diabetic-induced damage in pregnancy are related to maternal and fetal hyperglycemia, enhanced oxidative stress, epigenetic changes, and other, less defined, pathogenic mechanisms.

Association between pregestational diabetes and mortality among appropriate-for-gestational age birthweight infants

BACKGROUND/OBJECTIVE

Existing studies have shown that pregestational diabetes is a significant risk factor for adverse birth outcomes. However, it is unclear, whether pregestational diabetes and neonatal birthweight that is appropriate for the gestational age (AGA), a proxy for overall adequate glycemic control, is associated with higher infant mortality. To address this controversy, this study investigated the relationship between pregestational diabetes and infant mortality in appropriate-for-gestational age infants in the United States.

METHODS

Data from the National Vital Statistics System-Linked Birth-Infant Death dataset, including 6,962,028 live births between 2011 and 2013 were analyzed. The study was conducted in the US and data were analyzed in Milwaukee, Wisconsin. The outcome was mortality among AGA newborns, defined as annual deaths per 1000 live births with birthweights between the 10th and 90th percentiles for gestational age delivering at ≥37 weeks. The exposure was pregestational diabetes. Covariates were maternal demographics, behavioral/clinical, and infant factors. Logistic regression was used with p values <.05 considered statistically significant.

RESULTS

A total of 6,962,028 live births met inclusion criteria. Of these, a total of 11,711 (1.0%) term AGA birthweight infants died before their first birthday. About 35,689 (0.5%) mothers were diagnosed with pregestational diabetes prior to pregnancy with 0.3% of infants whose mothers had diabetes dying in their first year of life. In the unadjusted model, pregestational diabetes had a significant association with increased odds of mortality in term AGA infants (OR: 1.9, 95% CI: 1.6 - 2.3). AGA mortality remained significantly higher for women with pregestational diabetes compared to controls, after adjusting for maternal demographics (OR: 1.9, 95% CI: 1.6-2.3), behavioral/clinical characteristics (OR: 1.6, 95% CI: 1.3-2.0), and infant factors (OR: 1.3, 95% CI: 1.1-1.6).

CONCLUSIONS

In term pregnancies, pregestational diabetes was significantly associated with 30% higher mortality among AGA birthweight infants. Our study is innovative in its focus on AGA infants that overall is associated with good maternal glycemic control during pregnancy and in theory should confer a risk for infant mortality that is similar to pregnancies not complicated by pregestational diabetes. Despite this, we still found that even term AGA infants have higher risk of mortality in the setting of maternal pregestational diabetes. Implications of our findings underscore the importance of close antepartum surveillance and optimization of glycemic control preconception, identification of treatment targets, and health policies to reduce infant mortality. The results from this study may assist other researchers and clinicians understand how best to target future interventions to reduce term infant mortality and the burden of pregestational diabetes in the United States.

Adipose tissue development and lipid metabolism in the human fetus: The 2020 perspective focusing on maternal diabetes and obesity

During development, the human fetus accrues the highest proportion of fat of all mammals. Precursors of fat lobules can be found at week 14 of pregnancy. Thereafter, they expand, filling with triacylglycerols during pregnancy. The resultant mature lipid-filled adipocytes emerge from a developmental programme of embryonic stem cells, which is regulated differently than adult adipogenesis. Fetal triacylglycerol synthesis uses glycerol and fatty acids derived predominantly from glycolysis and lipogenesis in liver and adipocytes. The fatty acid composition of fetal adipose tissue at the end of pregnancy shows a preponderance of palmitic acid, and differs from the mother. Maternal diabetes mellitus does not influence this fatty acid profile. Glucose oxidation is the main source of energy for the fetus, but mitochondrial fatty acid oxidation also contributes. Indirect evidence suggests the presence of lipoprotein lipase in fetal adipose tissue. Its activity may be increased under hyperinsulinemic conditions as in maternal diabetes mellitus and obesity, thereby contributing to increased triacylglycerol deposition found in the newborns of such pregnancies. Fetal lipolysis is low. Changes in the expression of genes controlling metabolism in fetal adipose tissue appear to contribute actively to the increased neonatal fat mass found in diabetes and obesity. Many of these processes are under endocrine regulation, principally by insulin, and show sex-differences. Novel fatty acid derived signals such as oxylipins are present in cord blood with as yet undiscovered function. Despite many decades of research on fetal lipid deposition and metabolism, many key questions await answers.

Developmental origins of variability in pelvic dimensions: Evidence from nulliparous South Asian women in the United Kingdom

OBJECTIVES

Pelvic growth may be sensitive to early-life nutrition, with implications for maternal risk of obstructed labor. However, the "developmental origins" of adult pelvic variability require further investigation. We tested whether adult pelvic dimensions are associated with two components of height, indexing different periods of linear growth: tibia length, a proxy for early postnatal growth, and height-residual (height regressed on tibia length), a proxy for later growth. We also tested whether adult pelvic dimensions are associated with birth weight, a marker of nutritional investment in utero.

METHODS

In this cross-sectional study, data were obtained on 68 nulliparous young women of South Asian ancestry. Pelvic dimensions (bi-iliac and bi-acetabular breadth, anteroposterior pelvic inlet and outlet, interspinous and intertuberous diameter) were measured using magnetic resonance imaging. Height and tibia length were measured manually. Birth weight and gestational age were obtained by recall. Multivariable regression models were fitted with a given pelvic dimension regressed on height-residual, tibia, and birth weight, with the latter adjusted for gestational age.

RESULTS

Controlling for birth weight, height-residual was predictive of bi-acetabular breadth, bi-iliac breadth, and the pelvic inlet, while tibia length significantly predicted all dimensions except interspinous diameter. Controlling for the linear growth variables, birth weight was predictive of bi-iliac breadth only.

CONCLUSIONS

Markers of linear growth during both early and later development were associated with adult pelvic dimensions, whereas size at birth was poorly predictive. Efforts to reduce stunting in early life may facilitate the attainment of maximum potential growth for both height and the pelvis.

Developmental overnutrition and obesity and type 2 diabetes in offspring

Childhood obesity has reached pandemic proportions, and youth-onset type 2 diabetes is following suit. This review summarises the literature on the influence of developmental overnutrition, resulting from maternal diabetes, obesity, maternal dietary intake during pregnancy, excess gestational weight gain, and infant feeding practices, on the aetiology of obesity and type 2 diabetes risk during childhood and adolescence. Key goals of this review are: (1) to summarise evidence to date on consequences of developmental overnutrition; (2) describe shared and distinct biological pathways that may link developmental overnutrition to childhood obesity and youth-onset type 2 diabetes; and (3) to translate current knowledge into clinical and public health strategies that not only target primary prevention in youth, but also encourage primordial prevention during the perinatal period, with the aim of breaking the intergenerational cycle of obesity and diabetes.

Sex-dependent effect of post-migration adaptation on height and relative lower leg length in Polish youth

BACKGROUND

Growth in tibia length is considered to be particularly sensitive to environmental stress.

AIM

To estimate the effect of parental migration status on the relative length of the tibia in their school-age children.

SUBJECTS AND METHODS

Data included a nationwide random sample of 17,155 schoolchildren, 7-18 years of age, examined between 1966 and 1969 in Poland who provided information on anthropometric measurements and demographic and social characteristics. Parental migration status was based on paternal migration history. After standardisation by LMS method, z-scores of relative tibia length and z-scores of height were used for analysis. Three-way ANOVA was used to evaluate the influence of migration on tibia length-to-height ratio.

RESULTS

Sons of migrants have a significantly higher tibia length-to-height ratio compared to sons of non-migrants. Children of non-migrants were taller than children of migrants among boys in medium SES and among girls in high and low SES. Relative tibia length indicated significant effects of migration among boys in all age categories and in late adolescent girls: sons of migrants had a higher ratio and daughters of migrants had a lower tibia length-to-height ratio.

CONCLUSION

It is possible that migration experiences of the parents may have influenced the growth of their offspring. The results emphasise the potential importance of research addressing the impact of different types of migration on growth of children.

Higher Cord Blood Levels of Fatty Acids in Pregnant Women With Type 1 Diabetes Mellitus

CONTEXT

Type 1 diabetes mellitus (T1DM) is associated with a disturbance of carbohydrate and lipid metabolism.

OBJECTIVE

To determine whether T1DM alters maternal and neonatal fatty acid (FA) levels.

DESIGN

Observational study.

SETTING

Academic hospital.

PATIENTS

Sixty pregnant women (30 women with T1DM with good glycemic control and 30 healthy women) were included in the study. Maternal blood, umbilical vein, and artery blood samples were collected immediately upon delivery. Following lipid extraction, the FA profiles of the total FA pool of maternal serum and umbilical vein and artery serum were determined by gas chromatography.

RESULTS

Total FA concentration in maternal serum did not differ between the study groups; it was significantly higher in umbilical vein serum of the T1DM group compared with that in the control group [median (interquartile range)]: T1DM 2126.2 (1446.4 to 3181.3) and control 1073.8 (657.5 to 2226.0; P < 0.001), and in umbilical artery vein serum: T1DM 1805.7 (1393.1 to 2125.0) and control 990.0 (643.3 to 1668.0; P < 0.001). Composition of FAs in umbilical vein serum showed significantly higher concentrations of saturated, monounsaturated, and polyunsaturated FAs (SFAs, MUFAs, and PUFAs, respectively) in the T1DM group than compared with those in the control group (P = 0.001). Furthermore, cord blood levels of leptin (P < 0.001), C-peptide (P < 0.001), and insulin resistance (P = 0.015) were higher in the T1DM group compared with controls.

CONCLUSION

The neonates born to mothers with T1DM had higher concentrations of total FAs, SFAs and MUFAs, as well as PUFAs, compared with control newborns.

The Human Placenta in Diabetes and Obesity: Friend or Foe? The 2017 Norbert Freinkel Award Lecture

The placenta plays a key role in sustaining fetal growth and development. Due to its position between mother and fetus, it is exposed to changes in the intrauterine environment in both circulations. The relative influence of changes in those circulations depends on the period of gestation. Early in pregnancy, maternal influences prevail and may affect the complex biological processes characteristic for this pregnancy period, such as placentation, early cell differentiation, and spiral artery remodeling. It is still unclear whether the placenta early in pregnancy is a friend or foe for the fetus. Later in pregnancy, when the fetal circulation is gradually establishing, fetal signals gain importance in regulating placental structure and function. Many of the placental alterations seen at term of pregnancy are the result of fetoplacental interactions often driven by fetal signals associated with maternal diabetes or obesity. These alterations, such as hypervascularization or enhanced cholesterol removal from placental endothelial cells, can be regarded as adaptations to maintain homeostasis at the fetoplacental interface and, thus, to protect the fetus. However, extreme conditions such as poorly controlled diabetes or pronounced obesity may exceed placental homeostatic capacity, with potentially adverse consequences for the fetus. Thus, in late pregnancy, the placenta acts mostly as a friend as long as the environmental perturbations do not exceed placental capacity for mounting adaptive responses.

Effect of maternal diabetes on the embryo, fetus, and children: congenital anomalies, genetic and epigenetic changes and developmental outcomes

INTRODUCTION

Pregestational and gestational diabetes mellitus (PGDM; GDM) are significant health concerns because they are associated with an increased rate of malformations and maternal health complications.

METHODS

We reviewed the data that help us to understand the effects of diabetes in pregnancy.

RESULTS

Diabetic embryopathy can affect any developing organ system, but cardiovascular and neural tube defects are among the most frequent anomalies. Other complications include preeclampsia, preterm delivery, fetal growth abnormalities, and perinatal mortality. Neurodevelopmental studies on offspring of mothers with diabetes demonstrated increased rate of Gross and Fine motor abnormalities, of Attention Deficit Hyperactivity Disorder, learning difficulties, and possibly also Autism Spectrum Disorder. The mechanisms underlying the effects of maternal hyperglycemia on the developing fetus may involve increased oxidative stress, hypoxia, apoptosis, and epigenetic changes. Evidence for epigenetic changes are the following: not all progeny are affected and not to the same extent; maternal diet may influence pregnancy outcomes; and maternal diabetes alters embryonic transcriptional profiles and increases the variation between transcriptomic profiles as a result of altered gene regulation. Research in animal models has revealed that maternal hyperglycemia is a teratogen, and has helped uncover potential therapeutic targets which, when blocked, can mitigate or ameliorate the negative effects of diabetes on the developing fetus.

CONCLUSIONS

Tight metabolic control, surveillance, and labor management remain the cornerstone of care for pregnant women with diabetes, but advances in the field indicate that new treatments to protect the mother and baby are not far from becoming clinical realities.

Relationships between neonatal weight, limb lengths, skinfold thicknesses, body breadths and circumferences in an Australian cohort

Background

Low birth weight has been consistently associated with adult chronic disease risk. The thrifty phenotype hypothesis assumes that reduced fetal growth impacts some organs more than others. However, it remains unclear how birth weight relates to different body components, such as circumferences, adiposity, body segment lengths and limb proportions. We hypothesized that these components vary in their relationship to birth weight.

Methods

We analysed the relationship between birth weight and detailed anthropometry in 1270 singleton live-born neonates (668 male) from the Mater-University of Queensland Study of Pregnancy (Brisbane, Australia). We tested adjusted anthropometry for correlations with birth weight. We then performed stepwise multiple regression on birth weight of: body lengths, breadths and circumferences; relative limb to neck-rump proportions; or skinfold thicknesses. All analyses were adjusted for sex and gestational age, and used logged data.

Results

Circumferences, especially chest, were most strongly related to birth weight, while segment lengths (neck-rump, thigh, upper arm, and especially lower arm and lower leg) were relatively weakly related to birth weight, and limb lengths relative to neck-rump length showed no relationship. Skinfolds accounted for 36% of birth weight variance, but adjusting for size (neck-rump, thigh and upper arm lengths, and head circumference), this decreased to 10%. There was no evidence that heavier babies had proportionally thicker skinfolds.

Conclusions

Neonatal body measurements vary in their association with birth weight: head and chest circumferences showed the strongest associations while limb segment lengths did not relate strongly to birth weight. After adjusting for body size, subcutaneous fatness accounted for a smaller proportion of birth weight variance than previously reported. While heavier babies had absolutely thicker skinfolds, this was proportional to their size. Relative limb to trunk length was unrelated to birth weight, suggesting that limb proportions at birth do not index factors relevant to prenatal life.

Gestational Diabetes Independently Increases Birth Length and Augments the Effects of Maternal BMI on Birth Weight: A Retrospective Cohort Study

OBJECTIVE

To investigate the effect of the interaction between gestational diabetes mellitus (GDM) and maternal body mass index (BMI) on the individual neonatal growth parameters.

DESIGN

Retrospective cohort study.

SETTING

A tertiary maternity service in Sydney, Australia, between 2005 and 2009.

POPULATION

A cohort of 8859 women.

METHODS

Generalized linear models.

MAIN OUTCOME MEASURES

Neonatal growth parameters, represented by z-scores for infant birth weight (BW), birth length (BL), and head circumference (HC) in GDM and non-GDM groups.

RESULTS

Only GDM alone had an independent and positive effect on BL (p = 0.02) but not on BW or HC. In addition, in pregnancies complicated with GDM, the association between maternal weight and BW was significantly stronger (p < 0.001). In combination, GDM and maternal BMI significantly affected z-score differences between BW and BL (p < 0.001), in that underweight mothers had babies that were lighter relative to their length and inversely obese mothers had babies that were heavier relative to their length.

CONCLUSION

GDM independently influences BL and increases the association between maternal BMI and BW. In accordance with the hypothesis of the fetal origins of health and disease, the pronounced effects of GDM on fetal growth patterns demonstrated in this study are likely to influence long-term health outcomes in children.

Transgenerational Consequences of Racial Discrimination for African American Health

Disparities in African American health remain pervasive and persist transgenerationally. There is a growing consensus that both structural and interpersonal racial discrimination are key mechanisms affecting African American health. The Biopsychosocial Model of Racism as a Stressor posits that the persistent stress of experiencing discrimination take a physical toll on the health of African Americans and is ultimately manifested in the onset of illness. However, the degree to which the health consequences of racism and discrimination can be passed down from one generation to the next is an important avenue of exploration. In this review, we discuss and link literature across disciplines demonstrating the harmful impact of racism on African American physical health and the health of their offspring.

Increased risk of very low birth weight, rapid postnatal growth, and autism in underweight and obese mothers

PURPOSE

To determine whether prepregnancy weight was associated with children's birth weight, early physical growth, and autism diagnosis.

DESIGN

Early Childhood Longitudinal Study-Birth Cohort data.

SETTING

United States.

SUBJECTS

Representative sample of U.S. children followed from birth through kindergarten (n = 4800). Also, a subpopulation of the very low birth weight children was examined (n = 500).

MEASURES

Maternal variables included age and prepregnancy body mass index. Changes in children's height, weight, and head circumference between 9 months and 2 years were used as growth metrics. Children's sex, age, birth weight, and reported autism were also considered.

ANALYSIS

Logistic and multinomial logistic models assessed the impact of prepregnancy weight on birth weight and children's subsequent rate of physical growth and autism.

RESULTS

Children born to underweight or obese mothers had increased odds of very low birth weight. Very low birth weight was related to rapid height and weight growth and more than twice the likelihood to subsequently be diagnosed with autism. For the subgroup of very low birth weight children, rapid head growth was related to a fivefold increase in the odds of autism. After accounting for the impact birth weight and growth rates, we found prepregnancy weight indirectly impacted autism risk.

CONCLUSION

Being underweight or obese during prepregnancy indirectly increased risk for autism from increased odds of low birth weight and accelerated postnatal growth.

Classification of diabetes in pregnancy: time to reassess the alphabet

The White classification is a system of alphabetically designated categories of diabetes in pregnancy based on age at onset, duration of disease, and the presence or absence of vascular complications. The original classification system underwent several revisions, each progressively increasing in detail and complexity. Individual authors and institutions have modified the classes, resulting in identically lettered classes having different definitions. Some publications make reference to the class of diabetes by letter without providing a reference defining that class. Despite a 1994 American College of Obstetricians and Gynecologists Bulletin, which suggested that the White classification system was less helpful, publications still appear using lettered designations with and without modifications and with and without attendant definitions of terms. A clinically useful system of disease classification should consist of clearly defined, mutually exclusive, easily remembered categories. The current American Diabetes Association classification of diabetes fulfills these requirements and is applicable to diabetes during pregnancy. Adoption of such a system by the obstetrics community in verbal and written medical communication will likely enhance patient care and facilitate accurate data collection and comparison.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of maternal diabetes on epigenetic modifications leading to diseases in the offspring

Gestational diabetes, occurring during the hyperglycemic period of pregnancy in maternal life, is a pathologic state that increases the incidence of complications in both mother and fetus. Offspring thus exposed to an adverse fetal and early postnatal environment may manifest increased susceptibility to a number of chronic diseases later in life. Compelling evidence for the role of epigenetic transmission in these complications has come from comparison of siblings born before and after the development of maternal diabetes, exposure to this intrauterine diabetic environment being shown to cause alterations in fetal growth patterns which predispose these infants to developing overweight and obesity later in life. Diabetes of the offspring is also mainly the consequence of exposure to the diabetic intrauterine environment, in addition to genetic susceptibility. Since obesity and diabetes are known to increase the risk of cardiovascular disease, cardiovascular sequelae in the offspring of diabetic mothers are virtually inevitable. Research data also suggest that exposure to a diabetic intrauterine environment during pregnancy is associated with an increase in dyslipidemia, subclinical vascular inflammation, and endothelial dysfunction processes in the offspring, all of which are linked with development of cardiovascular disease later in life. The main underlying mechanisms involve persistent hyperglycemia hyperinsulinemia and leptin resistance.

Excess gestational weight gain is associated with child adiposity among mothers with normal and overweight prepregnancy weight status

There are inconsistencies in the literature regarding the association between gestational weight gain (GWG) and child adiposity. GWG is hypothesized to act on child adiposity directly through intrauterine programming and indirectly through birth weight. It is unclear if the relative importance of these pathways differs by prepregnancy BMI status. We analyzed data from 3600 participants of the nationally representative Early Childhood Longitudinal Study-Birth Cohort. Child BMI Z-score was calculated from height and weight measured at 5 y. Using linear regression, controlling for sociodemographics and family lifestyle, we examined prepregnancy BMI-specific associations between GWG and child BMI Z-score. There was a nonlinear association among normal (P < 0.001) and overweight mothers only (P = 0.013), such that GWG beyond the midpoint of the 2009 Institute of Medicine recommendations was associated with a significant increase in child BMI Z-score. After the addition of birth-weight-for-gestational-age and breastfeeding to the model, the association remained among normal-weight mothers (P = 0.005) and was slightly attenuated among overweight mothers (P = 0.09). No significant association was observed between GWG and child BMI Z-score among underweight or obese mothers. We used path analysis to decompose the total effect into direct and indirect effects. This indicated the presence of a stronger direct than indirect effect. In conclusion, low GWG is not associated with BMI Z-score among any prepregnancy BMI group. Excess GWG is associated with an increase in child BMI Z-score among normal and overweight mothers only. Prevention of excess GWG may be a strategy to prevent childhood obesity.

Differential expression of placental 11β-hydroxysteroid dehydrogenases in pregnant women with diet-treated gestational diabetes mellitus

Fetal exposure to excess glucocorticoid is one of the critical factors for the fetal origins of adult diseases. However, the mechanism of the local regulation of glucocorticoid activity in the human placenta of pregnancies complicated with gestational diabetes mellitus (GDM) has not been fully understood. We investigated placental 11β-hydroxysteroid dehydrogenases (11β-HSDs) expression, and analyzed their relationship with cortisol levels in maternal and umbilical vein. Pregnant women with GDM after diet intervention (n=23) or normal glucose tolerance (NGT, n=22) were studied at the community-based hospital. We collected maternal and umbilical venous cord blood and placental tissues from both groups. Explanted placentas from NGT were cultured with palmitic acid, dexamethasone, insulin or their mixture for 24-h. We examined plasma cortisol, cortisone to cortisol ratio, insulin, the homeostasis model assessment of insulin resistance index (HOMA-IR) and the insulin secretion index. Quantitative real-time PCR, Western blot and immunohistochemical assay were applied for the measurement of 11β-HSD1 and 11β-HSD2 mRNA and protein. GDM had higher maternal cortisol levels, HOMA-IR, insulin secretion index and higher cortisone to cortisol ratio in umbilical vein. No significant change in cortisol levels in umbilical vein and newborn weight was found. GDM placental 11β-HSD1 levels decreased while 11β-HSD2 increased. Treatment of placenta explants from NGT with palmitic acid, dexamethasone, insulin or their combination resulted in a significant drop of 11β-HSD1 and increase in 11β-HSD2. Differential expression of 11β-HSDs in diet-treated GDM placenta provides a protective mechanism for the fetus throughout the adverse environment of pregnancy by limiting excessive exposure of the fetus to glucocorticoid.

Developmental programming of the metabolic syndrome - critical windows for intervention

Metabolic disease results from a complex interaction of many factors, including genetic, physiological, behavioral and environmental influences. The recent rate at which these diseases have increased suggests that environmental and behavioral influences, rather than genetic causes, are fuelling the present epidemic. In this context, the developmental origins of health and disease hypothesis has highlighted the link between the periconceptual, fetal and early infant phases of life and the subsequent development of adult obesity and the metabolic syndrome. Although the mechanisms are yet to be fully elucidated, this programming was generally considered an irreversible change in developmental trajectory. Recent work in animal models suggests that developmental programming of metabolic disorders is potentially reversible by nutritional or targeted therapeutic interventions during the period of developmental plasticity. This review will discuss critical windows of developmental plasticity and possible avenues to ameliorate the development of postnatal metabolic disorders following an adverse early life environment.

Fetal growth trajectories in Type-1 diabetic pregnancy

OBJECTIVE

To describe the individual intrauterine growth patterns of fetuses of insulin-dependent (Type-1) diabetic women and to examine determinants of overgrowth (macrosomia) and its timing.

METHODS

This retrospective longitudinal study examined the developmental trajectories of fetal abdominal circumference (AC) and biparietal diameter in 76 Type-1 diabetic women with singleton pregnancies. Latent class analysis was used to identify subgroups of patients with a shared fetal AC growth trajectory. Subsequently, maternal factors, including glycemic control as assessed by glycosylated hemoglobin (HbA1c), were examined to see whether they had any effect on fetal growth.

RESULTS

Four subgroups with different AC growth patterns were identified. Differences in birth weight between the distinct subgroups were related to the shape of the AC growth velocity curve over gestation. Acceleration of AC growth commencing before or after 25 weeks' gestation was associated with the birth of a heavy or large-for-dates baby in 94 and 56% of cases, respectively. Poor glycemic control (HbA1c > 7.0%) during the periconception period or before 12 weeks' gestation was a modest predictor of midtrimester growth in AC. Other diabetes-related factors, fetal sex, parity, or maternal weight/obesity were unrelated to the fetal growth pattern.

CONCLUSION

The findings suggest that an individual fetus's growth trajectory is set early in gestation and that the contemporaneous degree of maternal glycemia plays a role in determining birth weight.

Early rapid growth, early birth: accelerated fetal growth and spontaneous late preterm birth

The past two decades in the United States have seen a 24% rise in spontaneous late preterm delivery (34-36 weeks) of unknown etiology. This study tested the hypothesis that fetal growth was identical prior to spontaneous preterm (n = 221, median gestational age at birth 35.6 weeks) and term (n = 3706) birth among pregnancies followed longitudinally in Santiago, Chile. The hypothesis was not supported: Preterm-delivered fetuses were significantly larger than their term-delivered peers by mid-second trimester in estimated fetal weight, head, limb, and abdominal dimensions, and they followed different growth trajectories. Piecewise regression assessed time-specific differences in growth rates at 4-week intervals from 16 weeks. Estimated fetal weight and abdominal circumference growth rates slowed at 20 weeks among the preterm-delivered, only to match and/or exceed their term-delivered peers at 24-28 weeks. After an abrupt growth rate decline at 28 weeks, fetuses delivered preterm did so at greater population-specific sex and age-adjusted birth weight percentiles than their peers from uncomplicated pregnancies (P < 0.01). Growth rates predicted birth timing: one standard score of estimated fetal weight increased the odds ratio for late preterm birth from 2.8 prior to 23 weeks, to 3.6 (95% confidence interval, 1.82-7.11, P < 0.05) between 23 and 27 weeks. After 27 weeks, increasing size was protective (OR: 0.56, 95% confidence interval, 0.38-0.82, P = 0.003). These data document, for the first time, a distinctive fetal growth pattern across gestation preceding spontaneous late preterm birth, identify the importance of mid-gestation for alterations in fetal growth, and add perspective on human fetal biological variability.

High D-glucose reduces SLC29A1 promoter activity and adenosine transport involving specific protein 1 in human umbilical vein endothelium

High D-glucose reduces human equilibrative nucleoside transporter 1 (hENT1)-mediated adenosine uptake involving endothelial nitric oxide synthase (eNOS), mitogen-activated protein (MAP) kinase kinases 1 and 2/MAP kinases p42/44 (MEK/ERKs), and protein kinase C (PKC) activation in human umbilical vein endothelium (HUVEC). Since NO represses SLC29A1 gene (hENT1) promoter activity we studied whether D-glucose-reduced hENT1-adenosine transport results from lower SLC29A1 expression in HUVEC primary cultures. HUVEC incubation (24 h) with high D-glucose (25 mM) reduced hENT1-adenosine transport and pGL3-hENT1(-1114) construct SLC29A1 reporter activity compared with normal D-glucose (5 mM). High D-glucose also reduced pGL3-hENT1(-1114) reporter activity compared with cells transfected with pGL3-hENT1(-795) construct. N(G)-nitro-L-arginine methyl ester (L-NAME, NOS inhibitor), PD-98059 (MEK1/2 inhibitor), and/or calphostin C (PKC inhibitor) blocked D-glucose effects. Insulin (1 nM) and phorbol 12-myristate 13-acetate (PMA, 100 nM, PKC activator), but not 4alpha-phorbol 12,13-didecanoate (4alphaPDD, 100 nM, PMA less active analogue) reduced hENT1-adenosine transport. L-NAME and PD-98059 blocked insulin effects. L-NAME, PD-98059, and calphostin C increased hENT1 expression without altering protein or mRNA stability. High D-glucose increased Sp1 transcription factor protein abundance and binding to SLC29A1 promoter, phenomena blocked by L-NAME, PD-98059, and calphostin C. Sp1 overexpression reduced SLC29A1 promoter activity in normal D-glucose, an effect reversed by L-NAME and further reduced by S-nitroso-N-acetyl-L,D-penicillamine (SNAP, NO donor) in high D-glucose. Thus, reduced hENT1-mediated adenosine transport in high D-glucose may result from increased Sp1 binding to SLC29A1 promoter down-regulating hENT1 expression. This phenomenon depends on eNOS, MEK/ERKs, and PKC activity, suggesting potential roles for these molecules in hyperglycemia-associated endothelial dysfunction.

Insulin and carbohydrate metabolism

Fetal glucose exposure and consequent fetal insulin secretion is normally tightly regulated by glucose delivery from the mother during pregnancy. Maternal hyperglycaemia and gestational diabetes (GDM) are known to be detrimental to offspring, although defining the criteria for diagnosis of GDM is controversial. Recent data suggest that the risk of poor fetal outcome appears to be a continuous variable across the range of glucose control, and that the level of maternal blood glucose for a diagnosis of gestational diabetes needs to be reviewed. After birth, rapid adaptation is necessary for infants to be able to maintain independent glucose homeostasis. This adaptation is compromised in infants who are small for gestational age (SGA), premature, or large for gestational age (LGA). Interestingly, the infants who are born at the extremes of birth weight are also at increased risk of impaired glucose tolerance and diabetes in later life.

Tradeoffs between oxygen and energy in tibial growth at high altitude

Some studies of high altitude populations argue that stature reduction results from caloric, rather than hypoxic, stress. However, tradeoff models of oxygen and glucose metabolism predict that in hypoxemia, glucose metabolism will be downregulated. We used tradeoff assumptions in two hypotheses: First, that hypoxia targets leg segment growth differentially, and second, that proportions of leg segments partition the impact of high altitude into hypoxemic and energetic components. A group of 113 Han and Tibetan middle school children at 3100 m aged 8 to 11 were measured for segment anthropometries, skinfolds, vital capacity, blood oxygen saturation, and percent body fat. MANOVA showed that Tibetan children were significantly larger and fatter than Han children. Independent of ethnicity or caloric status, absolute and relative tibia length was significantly reduced in children with lower blood oxygen saturation. Height, chest circumference, sitting height, tibia length, and ankle diameter were greatest in fatter children, independent of ethnicity or blood oxygen. For children of either ethnicity with the lowest blood oxygen, size as well as proportion was impacted. These results support the tradeoff model. Caloric reserves and ethnicity independently affect total skeletal size. Oxygen saturation and ethnicity affect leg proportions. In hypoxemia, body fat has less impact on growth than when ample oxygen is present. Therefore, we should qualify the claim that size in high altitude populations stems from nutritional stress. The findings also suggest that decanalization may have different meanings and outcomes depending on which body segments contribute to the effect.

Relative leg length as a biological marker to trace the developmental history of individuals and populations: growth delay and increased body fat

The purpose of this study was to determine whether differences in leg length index are related to differences in body fat. The study included a cross-sectional sample of 21,021 subjects ranging in age from 2 to 90 years who had anthropometric information and poverty income ratio that participated in the third National Health and Nutrition Survey (NHANES III) of the United Stated conducted during 1988-1994. Of the total 21,021 participants, 7,810 were non-Hispanic white (3,900 men and 3,910, women), 8,134 were African-American black (3,127 men and 2,889 women) and 6,237 were Mexican-American (3,221 and 3,016 women). In both males and females and in all three ethnic groups and across socio-economic status (measured by the poverty income ratio) a low leg length index is associated with increased body fat (measured by skinfold thickness) when compared with those with high leg length index. It is postulated that a low leg length index reflects the consequence of negative environmental conditions leading to growth delay. Previous studies indicate that individuals exposed both during development and adulthood to under-nutrition respond through inter-related physiological mechanisms oriented at improving energetic efficiency and low oxidation of fat. These interrelated compensatory physiological adjustments work together to promote fat storage among growth delayed individuals or populations.

Genomic imprinting, growth control and the allocation of nutritional resources: consequences for postnatal life

PURPOSE OF REVIEW

Genes subject to genomic imprinting are predominantly expressed from one of the two parental chromosomes, are often clustered in the genome, and their activity and repression are epigenetically regulated. The role of imprinted genes in growth control has been apparent since the discovery of imprinting in the early 1980s.

RECENT FINDINGS

Drawing from studies in the mouse, we propose three distinct classes of imprinted genes - those expressed, imprinted and acting predominantly within the placenta, those with no associated foetal growth effects that act postnatally to regulate metabolic processes, and those expressed in the embryo and placenta that programme the development of organs participating in metabolic processes. Members of this latter class may interact in functional networks regulating the interaction between the mother and the foetus, affecting generalized foetal well-being, growth and organ development; they may also coordinately regulate the development of particular organ systems.

SUMMARY

The mono-allelic behaviour and sensitivity to changes in regional epigenetic states renders imprinted genes adaptable and vulnerable; in all cases, their perturbed dosage can compromise prenatal and/or postnatal control of nutritional resources. This finding has implications for understanding the relationships between prenatal events and diseases later in life.

Beneficial Effect of Supplemental Lipoic Acid on Diabetes-Induced Pregnancy Loss in the Mouse

Uncontrolled diabetes mellitus (DM) is an etiological factor for recurrent pregnancy loss, fetal growth disorders, and major congenital malformations in the offspring. Antioxidant therapy has been advocated to overcome the oxidant-antioxidant disequilibrium inherent in diabetes. The objective of this article was to evaluate the beneficial effects of alpha-lipoic acid (LA) on fetal outcome in a mouse model of streptozotocin (STZ)-induced DM. Timed pregnant mice were made diabetic by intraperitoneal (IP) injection of a single dose of STZ (200 mg/kg) on gestation day (GD) 2. Diabetic animals were supplemented daily with an IP injection of 15 mg/kg of LA starting on GD 4 and continued through GD 12. Fetuses were examined on GD 18 for malformations and growth restriction. Some diabetic mice injected with Evans blue were examined on GD 3.5 and GD 6.5 to evaluate frequency of implantations. STZ-treated mice had all cardinal signs of DM. LA treatment did not normalize blood glucose levels of DM mice. Rates of pregnancy in saline control, DM, and DM + LA groups were 90%, 28%, and 64%, respectively, indicating that LA promotes pregnancy in DM animals. However, postimplantation resorption showed a threefold increase in the DM + LA group. Rates of intrauterine growth restriction and major congenital malformations were also augmented thus indicating that the interaction between DM and LA has deleterious effects on postimplantation embryos.

Maternal obesity, metabolism, and pregnancy outcomes

About one third of all pregnant women in the United States are obese. Maternal obesity at conception alters gestational metabolic adjustments and affects placental, embryonic, and fetal growth and development. Neural tube defects and other developmental anomalies are more common in infants born to obese women; these defects have been linked to poor glycemic control. Preeclampsia, a gestational disorder occurring more frequently in obese women, appears to be due to a subclinical inflammatory state that impairs early placentation and development of its blood supply. Fetal growth and development during the last half of pregnancy depends on maternal metabolic adjustments dictated by placental hormones and the subsequent oxygen and nutrient supply. Maternal obesity affects these metabolic adjustments as well. Basal metabolic rates are significantly higher in obese women, and maternal fat gain is lower, possibly in response to altered leptin function. The usual increase in insulin resistance seen in late pregnancy is enhanced in obese mothers, causing marked postprandial increases in glucose, lipids, and amino acids and excessive fetal exposure to fuel sources, which in turn increases fetal size, fat stores, and risk for disease postnatally. Impaired glucose tolerance, gestational diabetes, and hyperlipidemia are more common among obese mothers. To date, little attention has been given to the role of diet among obese women in preventing these problems. However, studies of women with impaired glucose tolerance show that replacing refined carbohydrates and saturated fat with complex, low-glycemic carbohydrates and polyunsaturated fatty acids improves metabolic homeostasis and pregnancy outcomes. Thus, current dietary guidelines regarding the amount and type of carbohydrates and fat for nonpregnant women seem appropriate for pregnant women as well.

Cellular life histories and bow tie biology

Considering the life-long influences of fetal growth biology, it is of interest to further elucidate the nature of the fetal growth process itself. Previous analyses of longitudinal fetal ultrasound data led to the hypothesis that hypoxia signals were important aspects of normal growth biology and directed attention to the place of oxygen as a basic nutrient. From the perspective of the cell, both hypoxia and lack of energy substrate trigger a common adaptive pathway through their effects on ATP availability. Comparative data from animal studies and cell culture provide evidence for an integrated energy/oxygen signaling system that acts redundantly and hierarchically with cellular differentiation programs, providing opportunities for developmental flexibility in response to variable ecologic or environmental challenge. The multinodal and interactive design of the fetal growth process suggests that it follows what has been described as the "bow tie" model of metabolism, with implications for robust and inventive approaches to cell, organ, and whole organism construction.