Gestationsdiabetes (GDM)

Exercise-Diet Therapy Combined with Insulin Aspart Injection for the Treatment of Gestational Diabetes Mellitus: A Study on Clinical Effect and Its Impact

Objective

To explore the clinical effect and impact of exercise-diet therapy combined with Insulin Aspart Injection on gestational diabetes mellitus (GDM).

Methods

The objects of study were patients with pregestational diabetes mellitus (PGDM) and 62 patients with GDM who were diagnosed by oral glucose tolerance test (OGTT) and insulin release test from February 2017 to February 2019. According to the severity of the disease, enrolled patients were informed to have appropriate exercise and diet control or Insulin Aspart Injection on this basis until the completion of delivery. By using 50 pregnant women with normal glucose as the control, the fasting plasma glucose (FPG), 1-hour postprandial glucose (1hPG), 2-hour postprandial glucose (2hPG), nocturnal glucose, and glycosylated hemoglobin (HbA1c) levels were compared between the PGDM group and the GDM group before and after treatment; besides, further comparison was made in terms of glucose compliance rate, islet B-cell secretory function, and insulin resistance after treatment. The pregnant women were examined by B-ultrasound at 24 and 26 weeks of gestation to check if the fetus had abnormalities in the central nervous system and the heart. Further B-ultrasound examination was performed at 32 and 37 weeks of gestation to check the problems such as polyhydramnios and stillbirth. In addition, a comparative analysis was carried out in terms of the adverse pregnancy outcomes and complications, associated with the comparison of the results after treatment with control group.

Results

After treatment, the levels of FPG, 1hPG, 2hPG, nocturnal glucose, and HbA1c were decreased in the PGDM group and GDM group than those before treatment, especially in the GDM group, with significant difference still when compared with the control group (P < 0.05). Statistical analysis revealed that the blood glucose compliance rate in the GDM group was higher than that in the PGDM group, showing a better therapeutic effect. Fasting insulin (FINS) and homeostasis model assessment index for insulin resistance (HOMA-IR) in the GDM group were significantly higher than those in control group, but lower than those in the PGDM group (P < 0.01), while the level of HOMA-β was lower in the GDM group than that in the control group and higher than that in PGDM (P < 0.01). Further ultrasound examination revealed the presence of fetal cardiac abnormality, polyhydramnios, stillbirth, and problems, showing a higher incidence in the PGDM group but almost nonexistence in the control group. In addition, the incidence of hypertension, macrosomia, premature rupture of membranes, postpartum hemorrhage, and infection were obviously higher in the PGDM group than those in the GDM group and control group (P < 0.05).

Conclusion

Exercise-diet therapy combined with Insulin Aspart Injection can effectively control the blood glucose level of pregnant patients with GDM, improve the pregnancy outcome to a certain extent, and ensure the health of pregnant women and fetus, which is worthy of clinical application.

Placental neurotrophin levels in gestational diabetes mellitus

OBJECTIVE

Neurotrophins are known to influence the development and maturation of the feto-placental unit and affect fetal growth trajectories. This study reports the levels of nerve growth factor (NGF) and brain-derived growth factor (BDNF) in the placenta of women with gestational diabetes mellitus (GDM).

METHODS

A total number of 60 women with GDM and 70 women without GDM (non-GDM) were included in the study. Placental NGF and BDNF levels were measured using commercially available ELISA kits.

RESULTS

Placental NGF levels were lower (p < .05) in women with GDM compared to non-GDM women. Maternal body mass index (BMI), mode of delivery, and the gender of the baby influenced the placental NGF levels. Placental BDNF levels were similar in GDM and non-GDM women. There was an influence of baby gender on the placental BDNF levels while maternal BMI and mode of delivery did not show any effect. In regression models adjusted for maternal age at delivery, gestational age, maternal BMI, mode of delivery, and baby gender, the placental NGF levels in the GDM group were lower (-0.144 pg/ml [95% CI -0.273, 22120.016] p = .028) as compared to the non-GDM group. However, there was no difference in the BDNF levels between the groups.

CONCLUSION

This study for the first time demonstrates differential effects on neurotrophic factors such as BDNF and NGF in the placenta in pregnancies complicated by GDM. Alterations in the levels of placental neurotrophins in GDM deliveries may affect placental development and fetal brain growth. This has implications for increased risk for neurodevelopmental pathologies in later life.

Gestational diabetes mellitus

Hyperglycaemia that develops during pregnancy and resolves after birth has been recognized for over 50 years, but uniform worldwide consensus is lacking about threshold hyperglycaemic levels that merit a diagnosis of 'gestational diabetes mellitus' (GDM) and thus treatment during pregnancy. GDM is currently the most common medical complication of pregnancy, and prevalence of undiagnosed hyperglycaemia and even overt diabetes in young women is increasing. Maternal overweight and obesity, later age at childbearing, previous history of GDM, family history of type 2 diabetes mellitus and ethnicity are major GDM risk factors. Diagnosis is usually performed using an oral glucose tolerance test (OGTT), although a non-fasting, glucose challenge test (GCT) is used in some parts of the world to screen women for those requiring a full OGTT. Dietary modification and increased physical activity are the primary treatments for GDM, but pharmacotherapy, usually insulin, is used when normoglycaemia is not achieved. Oral hypoglycaemic agents, principally metformin and glibenclamide (glyburide), are also used in some countries. Treatment improves immediate pregnancy outcomes, reducing excess fetal growth and adiposity and pregnancy-related hypertensive disorders. GDM increases the risk of long-term complications, including obesity, impaired glucose metabolism and cardiovascular disease, in both the mother and infant. Optimal management of mother and infant during long-term follow-up remains challenging, with very limited implementation of preventive strategies in most parts of the world.

The participation rate of migrant women in gestational diabetes screening in Austria: a retrospective analysis of 3293 births

Purpose

This study evaluated the extent to which migrant women participate in the mandatory oral glucose tolerance test (OGTT) for gestational diabetes mellitus (GDM) screening in Austria.

Methods

A retrospective data analysis was carried out of births at an obstetrics unit in a university hospital between January 2013 and December 2015. The inclusion criteria were singleton pregnancies, live births, birth weight ≥ 3500, and no preexisting diabetes mellitus. The patient’s extramurally obtained OGTT values and history of GDM were checked. If the mother’s country of birth was not Austria, the woman was classified as a migrant. Three groups were defined: group 1—women with normal OGTT; group 2—women with pathological OGTT; and group 3—women without OGTT or with an incomplete OGTT.

Main outcome measures: Numbers of complete and incomplete OGTTs and rate of women with pathological OGTTs not treated in accordance with the guidelines among mothers born in Austria or migrants. The groups were compared using the t-test, chi-squared test, or Fisher’s exact test.

Results

A total of 3293 births met the inclusion criteria, and 43.52% of all mothers were migrants; 16.8% of all women had pathological OGTT findings. Only 60.1% of the latter received treatment in accordance with the guidelines. The proportion of mothers born in Austria who did not have OGTTs, or only incomplete ones, was 5.4%. In the group of migrant women, the corresponding figure was 10.5% (P < 0.01).

Conclusions

Migrant women have significantly lower rates of participation in GDM screening.

Comparison of umbilical artery Doppler and non-stress test in assessment of fetal well-being in gestational diabetes mellitus: A prospective cohort study

Background

Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy and is related to poor perinatal outcomes. Reduction of neonatal complications of GDM is feasible by assessment of fetal well-being. Both fetal Doppler and NST are used for the screening of high-risk pregnancies.

Objective

We aimed to compare the non-stress test (NST) and umbilical artery (UA) Doppler assessments for evaluation of the adverse perinatal outcomes in GDM.

Methods

We conducted a prospective cohort study on 50 pregnant women with GDM in Jame Zanan Hospital, Tehran, Iran, from Oct 2014 to Sep 2015. A convenient sampling method was used for patient recruitment. Inclusion criteria were women with GDM, singleton pregnancies, and gestational age>32 weeks who had neither medical conditions nor fetal anomalies. Adverse perinatal outcomes were defined as Apgar scores at 1-min and 5-min <7, hypoglycemia (blood glucose <45 mg/dl), neonatal acidosis (PH<7.2), hypocalcemia (Ca<8 mg/dl), admission to the NICU for more than 24 hours, and perinatal death. Statistical analyses were performed with SPSS version 16 using Chi-square, Fisher's exact test, and independent-samples t-test. The significance level was considered at 0.05.

Results

Totally, 22% and 12% of women had an abnormal UA Doppler and a non-reactive NST respectively. Poor outcomes were detected in 13 women. The most frequent poor outcomes were hypoglycemia (n=9), Apgar 1-min <7 (n=8), neonate admitted in NICU (n=6), and respiratory distress syndrome (n=6). Poor outcome was more prevalent in women with non-reactive NST (p<0.001), abnormal UA Doppler (p=0.033), and those with infant birth weight >4000 gram (p=0.033). Sensitivity and specificity of the NST in predicting different poor outcomes were 76.9% and 97.3% respectively. Sensitivity and specificity of UA Doppler in predicting different poor outcomes were 30.8% and 94.6% respectively.

Conclusion

NST is a better predictor of adverse perinatal outcomes in GDM patients.

Screening of gestational diabetes mellitus in early pregnancy by oral glucose tolerance test and glycosylated fibronectin: study protocol for an international, prospective, multicentre cohort trial

INTRODUCTION

As the accurate diagnosis and treatment of gestational diabetes mellitus (GDM) is of increasing importance; new diagnostic approaches for the assessment of GDM in early pregnancy were recently suggested. We evaluate the diagnostic power of an 'early' oral glucose tolerance test (OGTT) 75 g and glycosylated fibronectin (glyFn) for GDM screening in a normal cohort.

METHODS AND ANALYSIS

In a prospective cohort study, 748 singleton pregnancies are recruited in 6 centres in Switzerland, Austria and Germany. Women are screened for pre-existing diabetes mellitus and GDM by an 'early' OGTT 75 g and/or the new biomarker, glyFn, at 12-15 weeks of gestation. Different screening strategies are compared to evaluate the impact on detection of GDM by an OGTT 75 g at 24-28 weeks of gestation as recommended by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). A new screening algorithm is created by using multivariable risk estimation based on 'early' OGTT 75 g and/or glyFn results, incorporating maternal risk factors. Recruitment began in May 2014.

ETHICS AND DISSEMINATION

This study received ethical approval from the ethics committees in Basel, Zurich, Vienna, Salzburg and Freiburg. It was registered under http://www.ClinicalTrials.gov (NCT02035059) on 12 January 2014. Data will be presented at international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02035059.

Post-transcriptional down regulation of ICAM-1 in feto-placental endothelium in GDM

Maternal gestational diabetes (GDM) is associated with hyperglycaemia and hyperinsulinemia in the fetal circulation which consequently may induce endothelial dysfunction in the feto-placental vasculature. In fact, feto-placental vasculature reveals various morphological changes in response to GDM. The cell adhesion molecules (CAMs) ICAM-1, VCAM-1 and E-selectin promote attachment and trans-endothelial migration of leukocytes, and are up regulated in inflammation and endothelial dysfunction. Thus, we hypothesized that the GDM environment upregulates ICAM-1, VCAM-1 and E-selectin in the feto-placental endothelium. We isolated primary feto-placental endothelial cells (fpEC) after normal (n=18) and GDM pregnancy (n=11) and analyzed mRNA (RT-qPCR) and protein expression (Immunoblot) of ICAM-1, VCAM-1 and E-selectin. While other CAMs were unchanged on mRNA and protein levels, ICAM-1 protein was decreased by GDM. Further analysis revealed also a decrease in the release of soluble ICAM-1 (sICAM-1), whose levels correlated negatively with maternal BMI. We conclude that this reduction of ICAM-1 protein species is the result of post-translational regulation, since ICAM-1 mRNA expression was unchanged. In fact, miRNAs targeting ICAM-1 were upregulated in GDM fpEC. Immunohistochemistry showed weaker ICAM-1 staining in the placental endothelium after GDM pregnancies, and demonstrated ICAM-1 binding partners CD11a and CD18 expressed on leukocytes in fetal circulation and on placental tissue macrophages. This study identified reduction of ICAM-1 protein in fpEC in GDM pregnancy, which was regulated post-transcriptionally. Low ICAM-1 protein production may represent a protective, placenta-specific mechanism to avoid leukocyte transmigration into the placenta in response to GDM.

Pathophysiological characteristics and effects of obesity in women with early and late manifestation of gestational diabetes diagnosed by the International Association of Diabetes and Pregnancy Study Groups criteria

CONTEXT

Appropriate risk stratification is essential in gestational diabetes (GDM) diagnosis to optimize therapeutic strategies during pregnancy. However, there are sparse data related to the newly recommended International Association of Diabetes and Pregnancy Study Groups criteria and their use in early pregnancy.

OBJECTIVE

This study sought to evaluate clinical and pathophysiological characteristics less up to gestational week (GW) 21 in women with early and late GDM onset.

DESIGN AND SETTING

This was a prospective study conducted at the Medical University of Vienna.

PATIENTS AND INTERVENTIONS

Pregnant women (n = 211) underwent an oral glucose tolerance test at 16 GW (interquartile range, 14-18 wk) with multiple measurements of glucose, insulin, and C-peptide for evaluation of insulin sensitivity and ß-cell function in addition to detailed obstetrical risk assessment. Clinical followups were performed until end of pregnancy.

MAIN OUTCOME MEASURE

We performed a metabolic characterization of early-onset GDM.

RESULTS

Of 81 women, 49 (23%) showed early (GDMEarly ≤ 21 GW) and 32 (15%) later manifestation (GDMLate ≥ 24 GW) whereas 130 (62%) remained normal-glucose-tolerant (NGT). In contrast with GDMLate, GDMEarly were affected by decreased insulin sensitivity (GDMEarly vs NGT, P < .001; GDMEarlyvs GDMLate, P < .001; GDMLate vs NGT, P = .410). However, both early and late manifested subjects showed impairments in ß-cell function. GDMEarly showed highest levels of preconceptional and actual body mass index (BMI), which was related to fasting glucose (r = 0.42, P < .001) and particularly insulin sensitivity (r = -0.51, P < .001). Differences in glucose disposal between the subgroups remained constant in multivariable analysis including the strongest risk factors for GDM, ie, age, history of GDM, and BMI in our population.

CONCLUSIONS

Early manifestation of GDM is affected by insulin resistance that is partly explained by higher degree in obesity. However, ß-cell dysfunction was also detectable in GDMLate, indicating defective compensatory mechanisms emerging already in early pregnancy.