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Veneti S, Grammatikopoulou MG, Kintiraki E, Mintziori G, Goulis DG. Ketone Bodies in Diabetes Mellitus: Friend or Foe? Nutrients 2023; 15:4383. [PMID: 37892458 PMCID: PMC10609881 DOI: 10.3390/nu15204383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
In glucose-deprived conditions, ketone bodies are produced by the liver mitochondria, through the catabolism of fatty acids, and are used peripherally, as an alternative energy source. Ketones are produced in the body under normal conditions, including during pregnancy and the neonatal period, when following a ketogenic diet (KD), fasting, or exercising. Additionally, ketone synthesis is also augmented under pathological conditions, including cases of diabetic ketoacidosis (DKA), alcoholism, and several metabolic disorders. Nonetheless, diet is the main regulator of total body ketone concentrations. The KDs are mimicking the fasting state, altering the default metabolism towards the use of ketones as the primary fuel source. Recently, KD has gained recognition as a medical nutrition therapy for a plethora of metabolic conditions, including obesity and diabetes mellitus (DM). The present review aims to discuss the role of ketones, KDs, ketonemia, and ketonuria in DM, presenting all the available new evidence in a comprehensive manner.
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Affiliation(s)
- Stavroula Veneti
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Maria G. Grammatikopoulou
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Evangelia Kintiraki
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Gesthimani Mintziori
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Dimitrios G. Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
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Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding. Nutrients 2022; 14:nu14224867. [PMID: 36432552 PMCID: PMC9692490 DOI: 10.3390/nu14224867] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022] Open
Abstract
In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m2. Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.
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Ornoy A, Becker M, Weinstein-Fudim L, Ergaz Z. Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review. Int J Mol Sci 2021; 22:ijms22062965. [PMID: 33803995 PMCID: PMC7999044 DOI: 10.3390/ijms22062965] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 02/28/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Asher Ornoy
- Adelson School of Medicine, Ariel University, Ariel 40700, Israel;
- Laboratory of Teratology, Department of Medical Neurobiology, Hebrew University Hadassah Medical School, Jerusalem 91120, Israel; (L.W.-F.); (Z.E.)
- Correspondence: ; Tel.: +972-(2)-675-8329
| | - Maria Becker
- Adelson School of Medicine, Ariel University, Ariel 40700, Israel;
| | - Liza Weinstein-Fudim
- Laboratory of Teratology, Department of Medical Neurobiology, Hebrew University Hadassah Medical School, Jerusalem 91120, Israel; (L.W.-F.); (Z.E.)
| | - Zivanit Ergaz
- Laboratory of Teratology, Department of Medical Neurobiology, Hebrew University Hadassah Medical School, Jerusalem 91120, Israel; (L.W.-F.); (Z.E.)
- Medical Center, Hadassah Hebrew University, Mount Scopus, Jerusalem 91240, Israel
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4
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Tanner HL, Dekker Nitert M, Callaway LK, Barrett HL. Ketones in Pregnancy: Why Is It Considered Necessary to Avoid Them and What Is the Evidence Behind Their Perceived Risk? Diabetes Care 2021; 44:280-289. [PMID: 33444162 DOI: 10.2337/dc20-2008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
Current dietary advice for women with gestational diabetes mellitus is to avoid diets that result in elevated ketone levels. This guidance stems from a concern that maternal ketones are associated with poor fetal and childhood outcomes, including reduced childhood intelligence quota. The evidence behind these guidelines is conflicting and inconsistent. Given that dietary counseling is the initial treatment strategy for women with diabetes in pregnancy, it is important that clinicians understand the concern regarding maternal ketones. This review examines the physiology of ketogenesis in pregnancy, the prevalence of elevated maternal ketone levels, and the relationship between maternal ketones and fetal and childhood outcomes.
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Affiliation(s)
- Helen L Tanner
- School of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Marloes Dekker Nitert
- School of Chemistry and Molecular Biosciences, Faculty of Science, The University of Queensland, St. Lucia, Queensland, Australia
| | - Leonie K Callaway
- Women's and Newborn Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Helen L Barrett
- Mater Research Institute, The University of Queensland, and Mater Hospital Brisbane, South Brisbane, Queensland, Australia
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Ketonuria Is Associated with Changes to the Abundance of Roseburia in the Gut Microbiota of Overweight and Obese Women at 16 Weeks Gestation: A Cross-Sectional Observational Study. Nutrients 2019; 11:nu11081836. [PMID: 31398880 PMCID: PMC6723895 DOI: 10.3390/nu11081836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/03/2019] [Accepted: 08/06/2019] [Indexed: 12/12/2022] Open
Abstract
The gut microbiome in pregnancy has been associated with various maternal metabolic and hormonal markers involved in glucose metabolism. Maternal ketones are of particular interest due to the rise in popularity of low-carbohydrate diets. We assessed for differences in the composition of the gut microbiota in pregnant women with and without ketonuria at 16 weeks gestation. Fecal samples were obtained from 11 women with fasting ketonuria and 11 matched controls. The samples were analyzed to assess for differences in gut microbiota composition by 16S rRNA sequencing. Supervised hierarchical clustering analysis showed significantly different beta-diversity between women with and without ketonuria, but no difference in the alpha-diversity. Group comparisons and network analysis showed that ketonuria was associated with an increased abundance of the butyrate-producing genus Roseburia. The bacteria that contributed the most to the differences in the composition of the gut microbiota included Roseburia, Methanobrevibacter, Uncl. RF39, and Dialister in women with ketonuria and Eggerthella, Phascolarctobacterium, Butyricimonas, and Uncl. Coriobacteriaceae in women without ketonuria. This study found that the genus Roseburia is more abundant in the gut microbiota of pregnant women with ketonuria. Roseburia is a butyrate producing bacterium and may increase serum ketone levels.
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Ringholm L, Damm P, Mathiesen ER. Improving pregnancy outcomes in women with diabetes mellitus: modern management. Nat Rev Endocrinol 2019; 15:406-416. [PMID: 30948803 DOI: 10.1038/s41574-019-0197-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Ásbjörnsdóttir B, Ronneby H, Vestgaard M, Ringholm L, Nichum VL, Jensen DM, Raben A, Damm P, Mathiesen ER. Lower daily carbohydrate consumption than recommended by the Institute of Medicine is common among women with type 2 diabetes in early pregnancy in Denmark. Diabetes Res Clin Pract 2019; 152:88-95. [PMID: 31121274 DOI: 10.1016/j.diabres.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 01/08/2023]
Abstract
AIMS To secure adequate carbohydrate supply in pregnancy, the Institute of Medicine (IOM) recommends a minimum amount of carbohydrates of 175 g daily. Currently a low carbohydrate diet is a popular health trend in the general population and this might also be common among overweight and obese pregnant women with type 2 diabetes (T2D). Thus, we explored carbohydrate consumption among pregnant women with T2D including women with type 1 diabetes (T1D) for comparison. METHODS A retrospective cohort study of consecutive women with T2D (N = 96) and T1D (N = 108), where dietary records were collected at the first antenatal visit. RESULTS Among women with T2D and T1D, bodyweight at the first visit was 90.8 ± 22 (mean ± SD) and 75.5 ± 15 kg (P < 0.001) while HbA1c was 6.6 ± 1.2% (49 ± 13 mmol/mol) and 6.6 ± 0.8% (48 ± 8 mmol/mol), P = 0.8, respectively. The average daily carbohydrate consumption from the major carbohydrate sources was similar in the two groups (159 ± 56 and 167 ± 48 g, P = 0.3), as was the level of total daily physical activity (median (interquartile range)): 215 (174-289) and 210 (178-267) metabolic equivalent of task-hour/week (P = 0.9). A high proportion of women with T2D and T1D (52% and 40%, P = 0.08) consumed fewer carbohydrates than recommended by the IOM. The prevalence of ketonuria (≥4 mmol/L) was 1% in both groups. CONCLUSIONS In early pregnancy, a lower daily carbohydrate consumption than recommended by the IOM was common among women with T2D. The results were quite similar to women with T1D, despite a markedly higher bodyweight in women with T2D. Reassuringly, ketonuria was rare in both groups.
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Affiliation(s)
- Björg Ásbjörnsdóttir
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; Department of Endocrinology, Rigshospitalet, Ole Måløes Vej 24 - 7551, 2100 Copenhagen Ø, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark.
| | - Helle Ronneby
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; The Nutrition Unit, Rigshospitalet, Henrik Harpestrengs Vej 4 - 5711, 2100 Copenhagen Ø, Denmark.
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; Department of Endocrinology, Rigshospitalet, Ole Måløes Vej 24 - 7551, 2100 Copenhagen Ø, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark.
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; Department of Endocrinology, Rigshospitalet, Ole Måløes Vej 24 - 7551, 2100 Copenhagen Ø, Denmark; Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820 Gentofte, Denmark.
| | - Vibeke L Nichum
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; Department of Obstetrics, Rigshospitalet, Blegdamsvej 9 - 4031, 2100 Copenhagen Ø, Denmark.
| | - Dorte M Jensen
- Steno Diabetes Center Odense, Odense University Hospital, Kløvervænget 10, 5000 Odense C, Denmark; Department of Gynaecology and Obstetrics, Odense University Hospital, Kløvervænget 23, 5000 Odense C, Denmark.
| | - Anne Raben
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark; Department of Obstetrics, Rigshospitalet, Blegdamsvej 9 - 4031, 2100 Copenhagen Ø, Denmark.
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9 - 4001, 2100 Copenhagen Ø, Denmark; Department of Endocrinology, Rigshospitalet, Ole Måløes Vej 24 - 7551, 2100 Copenhagen Ø, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark.
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Kallem VR, Pandita A, Pillai A. Infant of diabetic mother: what one needs to know? J Matern Fetal Neonatal Med 2018; 33:482-492. [PMID: 29947269 DOI: 10.1080/14767058.2018.1494710] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The global incidence of diabetes mellitus, including diabetes in pregnant women, is on the rise. Diabetes mellitus in a pregnant woman jeopardizes not only maternal health but can also have significant implications on the child to be born. Therefore, timely diagnosis and strict glycemic control are of utmost importance in achieving a safe outcome for both the mother and fetus. The treating physician should be aware of the complications that can arise due to poor glycemic control during pregnancy. The objective of this article is to discuss the key concerns in a neonate born to diabetic mother, the underlying pathogenesis, and the screening schedule during pregnancy.
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Affiliation(s)
| | - Aakash Pandita
- Department of Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anish Pillai
- Division of Neonatology, BC Women's and Children's Hospital, Vancouver, Canada
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9
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Robinson HL, Barrett HL, Foxcroft K, Callaway LK, Dekker Nitert M. Prevalence of maternal urinary ketones in pregnancy in overweight and obese women. Obstet Med 2017; 11:79-82. [PMID: 29997690 DOI: 10.1177/1753495x17743163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/07/2017] [Indexed: 11/17/2022] Open
Abstract
Background Ketonuria may be associated with adverse fetal outcomes. This study aimed to determine the prevalence of ketonuria at three time points in pregnancy and to assess whether ketonuria correlates with a clinical indication for performing a urine test. Methods Women had fasting urinary ketone levels measured at 16 and 28 weeks gestation and random ketone levels measured close to 36 weeks gestation. All ketone levels in the third trimester were recorded along with the clinical indication for the test. Results One hundred and eighty-seven women were included in the study. Twenty-two per cent of women had ketonuria at either 16 or 28 weeks gestation and 8% at 36 weeks gestation. Ketonuria was significantly more likely if a test was performed for a clinical indication (p = 0.0002). Conclusion Ketonuria in pregnancy is common affecting at least one in five women. Ketonuria is more common in women who have a clinical indication for performing a urine test.
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Affiliation(s)
- Helen L Robinson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Medicine, Ipswich Hospital, Ipswich, Australia
| | - Helen L Barrett
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Katie Foxcroft
- Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Leonie K Callaway
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Medicine, Ipswich Hospital, Ipswich, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Marloes Dekker Nitert
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,School of Chemistry and Molecular Biosciences, Faculty of Science, The University of Queensland, Brisbane, Australia
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10
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Denison FC, Macnaught G, Semple SIK, Terris G, Walker J, Anblagan D, Serag A, Reynolds RM, Boardman JP. Brain Development in Fetuses of Mothers with Diabetes: A Case-Control MR Imaging Study. AJNR Am J Neuroradiol 2017; 38:1037-1044. [PMID: 28302607 DOI: 10.3174/ajnr.a5118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/20/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Offspring exposed to maternal diabetes are at increased risk of neurocognitive impairment, but its origins are unknown. With MR imaging, we investigated the feasibility of comprehensive assessment of brain metabolism (1H-MRS), microstructure (DWI), and macrostructure (structural MRI) in third-trimester fetuses in women with diabetes and determined normal ranges for the MR imaging parameters measured. MATERIALS AND METHODS Women with singleton pregnancies with diabetes (n = 26) and healthy controls (n = 26) were recruited prospectively for MR imaging studies between 34 and 38 weeks' gestation. RESULTS Data suitable for postprocessing were obtained from 79%, 71%, and 46% of women for 1H-MRS, DWI, and structural MRI, respectively. There was no difference in the NAA/Cho and NAA/Cr ratios (mean [SD]) in the fetal brain in women with diabetes compared with controls (1.74 [0.79] versus 1.79 [0.64], P = .81; and 0.78 [0.28] versus 0.94 [0.36], P = .12, respectively), but the Cho/Cr ratio was marginally lower (0.46 [0.11] versus 0.53 [0.10], P = .04). There was no difference in mean [SD] anterior white, posterior white, and deep gray matter ADC between patients and controls (1.16 [0.12] versus 1.16 [0.08], P = .96; 1.54 [0.16] versus 1.59 [0.20], P = .56; and 1.49 [0.23] versus 1.52 [0.23], P = .89, respectively) or volume of the cerebrum (243.0 mL [22.7 mL] versus 253.8 mL [31.6 mL], P = .38). CONCLUSIONS Acquiring multimodal MR imaging of the fetal brain at 3T from pregnant women with diabetes is feasible. Further study of fetal brain metabolism in maternal diabetes is warranted.
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Affiliation(s)
- F C Denison
- From the Medical Research Council Centre for Reproductive Health (F.C.D., D.A., A.S., J.P.B.), University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - G Macnaught
- Clinical Research Imaging Centre (G.M., S.I.K.S.)
| | - S I K Semple
- Clinical Research Imaging Centre (G.M., S.I.K.S.).,University/British Heart Foundation Centre for Cardiovascular Science (S.I.K.S., R.M.R.)
| | - G Terris
- Simpson Centre for Reproductive Health (G.T., J.W.), Royal Infirmary, Edinburgh, UK
| | - J Walker
- Simpson Centre for Reproductive Health (G.T., J.W.), Royal Infirmary, Edinburgh, UK
| | - D Anblagan
- From the Medical Research Council Centre for Reproductive Health (F.C.D., D.A., A.S., J.P.B.), University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK.,Centre for Clinical Brain Sciences (D.A., J.P.B.), University of Edinburgh, Edinburgh, UK
| | - A Serag
- From the Medical Research Council Centre for Reproductive Health (F.C.D., D.A., A.S., J.P.B.), University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - R M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science (S.I.K.S., R.M.R.)
| | - J P Boardman
- From the Medical Research Council Centre for Reproductive Health (F.C.D., D.A., A.S., J.P.B.), University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK.,Centre for Clinical Brain Sciences (D.A., J.P.B.), University of Edinburgh, Edinburgh, UK
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Abstract
The nutritional status of a woman during pregnancy and lactation is not only critical for her health but for future generations. Although a nutritionist or registered dietitian can help facilitate dietary counseling and interventions, physicians also need to be cognizant of nutritional needs during pregnancy because they differ significantly compared with nonpregnant populations. Furthermore, an individualized approach to nutritional counseling that considers a woman's nutritional status and body mass index is recommended.
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Affiliation(s)
- Michelle A Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2175, Chicago, IL 60611, USA.
| | - Priya Rajan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2175, Chicago, IL 60611, USA
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12
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Adane AA, Mishra GD, Tooth LR. Diabetes in Pregnancy and Childhood Cognitive Development: A Systematic Review. Pediatrics 2016; 137:peds.2015-4234. [PMID: 27244820 DOI: 10.1542/peds.2015-4234] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The effect of diabetes during pregnancy on the cognitive development of offspring is unclear because of inconsistent findings from limited studies. OBJECTIVE This review was aimed to provide the best available scientific evidence on the associations between maternal pregnancy diabetes and the cognitive development of offspring. DATA SOURCES A search was conducted in the Embase, CINAHL, PubMed, PsycINFO, and Scopus databases. STUDY SELECTION Studies addressing the cognitive development of offspring (aged ≤12 years) as outcome and any diabetes in pregnancy as an exposure were included. DATA EXTRACTION Data were extracted and evaluated for quality by 2 independent reviewers. RESULTS Fourteen articles were eligible for the review. Ten studies investigated the associations between maternal pregestational diabetes or both pregestational and gestational diabetes and offspring's cognitive development; 6 studies found at least 1 negative association. Four studies exclusively examined the relationships between gestational diabetes and offspring's cognitive development; 2 studies found a negative association, 1 a positive association, and 1 a null association. The use of diverse cognitive and diabetes assessment tools/criteria, as well as statistical power, contributed to the inconsistent findings. LIMITATIONS The English-language restriction and publication bias in the included studies are potential limitations. CONCLUSIONS Although there are few data available regarding the associations between maternal pregnancy diabetes and offspring's cognitive development, this review found that maternal diabetes during pregnancy seems to be negatively associated with offspring's cognitive development. Large prospective studies that address potential confounders are needed to confirm the independent effect of maternal diabetes during pregnancy.
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Affiliation(s)
- Akilew Awoke Adane
- Centre for Longitudinal and Life Course Research, School of Public Health, the University of Queensland, Australia
| | - Gita D Mishra
- Centre for Longitudinal and Life Course Research, School of Public Health, the University of Queensland, Australia
| | - Leigh R Tooth
- Centre for Longitudinal and Life Course Research, School of Public Health, the University of Queensland, Australia
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Ornoy A, Reece EA, Pavlinkova G, Kappen C, Miller RK. Effect of maternal diabetes on the embryo, fetus, and children: congenital anomalies, genetic and epigenetic changes and developmental outcomes. ACTA ACUST UNITED AC 2015; 105:53-72. [PMID: 25783684 DOI: 10.1002/bdrc.21090] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Asher Ornoy
- Department of Medical Neurobiology, Laboratory of Teratology, Hebrew University Hadassah Medical School, Jerusalem, Israel
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Haghir H, Rezaee AAR, Sankian M, Kheradmand H, Hami J. The effects of induced type-I diabetes on developmental regulation of insulin & insulin like growth factor-1 (IGF-1) receptors in the cerebellum of rat neonates. Metab Brain Dis 2013; 28:397-410. [PMID: 23397157 DOI: 10.1007/s11011-013-9386-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/01/2013] [Indexed: 12/24/2022]
Abstract
Diabetes during pregnancy impairs brain development in offspring, leading to behavioral problems, motor dysfunction and learning deficits. Insulin and insulin-like growth factor-1 (IGF-1) are important regulators of developmental and cognitive functions in the central nervous system. Aim of the present study was to examine the effects of maternal diabetes on insulin receptor (InsR) and IGF-1 receptor (IGF-1R) expression in the developing rat cerebellum. Wistar female rats were maintained diabetic from a week before pregnancy through parturition and male offspring was killed at P0, P7, and P14, an active neurogenesis period in brain development equivalent to the third trimester in human. The expression of InsR and IGF-1R in cerebelli was evaluated using real-time PCR and western blot analysis. We found a significant upregulation of both IGF-1R and InsR transcripts in cerebellum of pups born to diabetic mothers at P0, compared to controls. However, at the same time point, the results of western blot analysis revealed only a slight change in their protein levels. In contrast to InsR, which does not show any difference, there was a markedly reduction in cerebellar expression of IGF-1R mRNA and protein level in the diabetic group of newborns at P7. Moreover, 2 weeks after birth, mRNA expression and protein levels of both InsR and IGF-1R in cerebellum of the diabetic group was significantly downregulated. Compared to controls, we did not find any difference in cerebellar InsR or IGF-1R mRNA and protein levels in the insulin treated group. The present study revealed that diabetes during pregnancy strongly influences the regulation of both InsR and IGF-1R in the developing cerebellum. Furthermore, optimal maternal glycaemia control by insulin administration normalized these effects.
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MESH Headings
- Actins/metabolism
- Animals
- Animals, Newborn
- Blood Glucose/metabolism
- Blotting, Western
- Cerebellum/metabolism
- DNA, Complementary/biosynthesis
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Type 1/chemically induced
- Diabetes Mellitus, Type 1/metabolism
- Female
- Gene Expression/drug effects
- Male
- Pregnancy
- RNA/biosynthesis
- RNA/isolation & purification
- Rats
- Rats, Wistar
- Real-Time Polymerase Chain Reaction
- Receptor, IGF Type 1/genetics
- Receptor, IGF Type 1/metabolism
- Receptor, Insulin/genetics
- Receptor, Insulin/metabolism
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Affiliation(s)
- Hossein Haghir
- Department of Anatomy, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Abstract
Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency usually occurring in patients with type 1 (insulin-dependent) diabetes mellitus. Although modern management of the patient with diabetes should prevent the occurrence of DKA during pregnancy, this complication still occurs and can result in significant morbidity and mortality for mother and/or fetus. Metabolic changes occurring during pregnancy can predispose a pregnant diabetic to DKA. The diagnosis of DKA can be more challenging during pregnancy as it does not always manifest with the classic presenting symptoms or laboratory findings. In fact, although uncommon, during pregnancy, DKA may develop even in the setting of relative normoglycemia. Prompt diagnosis and management is essential in order to optimize maternal and fetal outcomes. This article will provide the reader with information regarding the pathophysiology underlying DKA complicating pregnancy and will provide practical management guidelines for the diagnosis and management of this condition.
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Affiliation(s)
- Margarita de Veciana
- Maternal-Fetal Medicine Obstetrics and Gynecology, Eastern Virginia Medical School, 825 Fairfax Ave, Suite 310, Norfolk, VA 23507, USA.
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Gage SH, Lawlor DA, Tilling K, Fraser A. Associations of maternal weight gain in pregnancy with offspring cognition in childhood and adolescence: findings from the Avon Longitudinal Study of Parents and Children. Am J Epidemiol 2013; 177:402-10. [PMID: 23388581 PMCID: PMC3581073 DOI: 10.1093/aje/kws239] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 04/27/2012] [Indexed: 11/22/2022] Open
Abstract
An association of gestational weight gain (GWG) with offspring cognition has been postulated. We used data from the Avon Longitudinal Study of Parents and Children, a United Kingdom prospective cohort (1990 through the present) with a median of 10 maternal weight measurements in pregnancy. These were used to allocate participants to 2009 Institute of Medicine weight-gain categories and in random effect linear spline models. Outcomes were School Entry Assessment score (age, 4 years; n = 5,832), standardized intelligence quotient assessed by Wechsler Intelligence Scale for Children (age, 8 years; n = 5,191), and school final-examination results (age, 16 years; n = 7,339). Offspring of women who gained less weight than recommended had a 0.075 standard deviation lower mean School Entry Assessment score (95% confidence interval: -0.127, -0.023) and were less likely to achieve adequate final-examination results (odds ratio = 0.88, 95% confidence interval: 0.78, 0.99) compared with offspring of women who gained as recommended. GWG in early pregnancy (defined as 0-18 weeks on the basis of a knot point at 18 weeks) and midpregnancy (defined as 18-28 weeks on the basis of knot points at 18 and 28 weeks) was positively associated with School Entry Assessment score and intelligence quotient. GWG in late pregnancy (defined as 28 weeks onward on the basis of a knot point at 28 weeks) was positively associated with offspring intelligence quotient and with increased odds of offspring achieving adequate final-examination results in mothers who were overweight prepregnancy. Findings support small positive associations between GWG and offspring cognitive development, which may have lasting effects on educational attainment up to age 16 years.
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Affiliation(s)
- Suzanne H Gage
- Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, Bristol, United Kingdom.
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Nomura Y, Marks DJ, Grossman B, Yoon M, Loudon H, Stone J, Halperin JM. Exposure to gestational diabetes mellitus and low socioeconomic status: effects on neurocognitive development and risk of attention-deficit/hyperactivity disorder in offspring. ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2012; 166:337-43. [PMID: 22213602 PMCID: PMC5959273 DOI: 10.1001/archpediatrics.2011.784] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the independent and synergistic effects of gestational diabetes mellitus (GDM) and low socioeconomic status (SES) on neurodevelopment and attention-deficit/hyperactivity disorder (ADHD) outcomes. DESIGN Cohort study. SETTING Flushing, New York. PARTICIPANTS A total of 212 preschool children as a part of the ongoing cohort study. MAIN EXPOSURES Gestational diabetes mellitus and low SES. MAIN OUTCOME MEASURES Primary outcomes are ADHD diagnosis based on Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria at age 6 years and several well-validated measures of neurobehavioral outcomes, cognitive functioning, ADHD symptoms, and temperament at age 4 years. Secondary outcomes are parent and teacher reports of behavioral and emotional problems at age 6 years. Neurobehavioral measures in relation to GDM and low SES were examined using generalized estimating equations and multivariate logistic regression analyses. RESULTS Both maternal GDM and low SES were associated with an approximately 2-fold increased risk for ADHD at age 6 years. However, the risk by GDM was greater among lower SES families than among higher SES families. Children exposed to both GDM and low SES demonstrated compromised neurobehavioral functioning, including lower IQ, poorer language, and impoverished behavioral and emotional functioning. A test of additive interaction found that the risk for ADHD increased over 14-fold (P = .006) when children were exposed to both GDM and low SES. Neither children exposed to maternal GDM alone nor those exposed to low SES alone had a notable increased risk for ADHD. CONCLUSIONS Maternal GDM and low SES, especially in combination, heighten the risk for childhood ADHD. Long-term prevention efforts should be directed at mothers with GDM to avoid suboptimal neurobehavioral development and mitigate the risk for ADHD among their offspring.
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Affiliation(s)
- Yoko Nomura
- Department of Psychology, Queens College, City University of New York, 65-30 Kissena Blvd, Flushing, NY 11376, USA.
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18
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Keim SA, Pruitt NT. Gestational weight gain and child cognitive development. Int J Epidemiol 2012; 41:414-22. [DOI: 10.1093/ije/dyr229] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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The effects of maternal diabetes on expression of insulin-like growth factor-1 and insulin receptors in male developing rat hippocampus. Brain Struct Funct 2012; 218:73-84. [PMID: 22241286 DOI: 10.1007/s00429-011-0377-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/29/2011] [Indexed: 01/17/2023]
Abstract
Diabetes during pregnancy causes neurodevelopmental and neurocognitive abnormalities in offspring. Insulin and insulin-like growth factor-1 (IGF-1) are important regulators of developmental and cognitive functions in the central nervous system. We examined the effects of maternal diabetes on insulin-like growth factor-1 receptor (IGF-1R) and insulin receptor (InsR) expression in the developing rat hippocampus. Female rats were maintained diabetic from a week before pregnancy through parturition and male offspring was killed at P0, P7, and P14. We found a significant bilateral upregulation of both IGF-1R and InsR transcripts in the hippocampus of pups born to diabetic mothers at P0, as compared to controls. However, at the same time point, the results of western blot analysis revealed only a slight change in their protein levels. At P7, there was a marked bilateral reduction in mRNA expression and protein levels of IGF-1R, although not of InsR in the diabetic group. We also found a downregulation in IGF1-R transcripts, especially in left hippocampus of the diabetic group at P14. Moreover, at the same time point, InsR expression was significantly decreased in both hippocampi of diabetic newborns. When compared with controls, we did not find any difference in hippocampal IGF-1R or InsR mRNA and protein levels in the insulin-treated group. The present study revealed that diabetes during pregnancy strongly influences the regulation of both IGF-1R and InsR in the right/left developing hippocampi. Furthermore, the rigid control of maternal glycaemia by insulin administration normalized these effects.
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Delascio Lopes C, Sinigaglia-Coimbra R, Mazzola J, Camano L, Mattar R. Neurofunctional evaluation of young male offspring of rat dams with diabetes induced by streptozotocin. ISRN ENDOCRINOLOGY 2011; 2011:480656. [PMID: 22363880 PMCID: PMC3262641 DOI: 10.5402/2011/480656] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 08/02/2011] [Indexed: 11/23/2022]
Abstract
Diabetes mellitus (DM) is a complex disease, being one of the most prevalent diseases worldwide. As a consequence, pregnancy-associated diabetes is increasingly common. Given the numerous studies about the influence of diabetes on offspring of diabetic rat dams, the neurological outcome is of outmost importance. This paper aimed at evaluating the neurofunctional performance of young male offspring of rat dams with diabetes induced by streptozotocin. Diabetes was induced in Wistar female rats by streptozotocin administration, while control groups received vehicle injection. At two-month survival period, male offspring from each group were randomized to the water maze Morris test, in order to assess their neurofunctional status. There was no significant difference between the groups as assessed by the Morris water maze test for spatial reference task. Our results point to the need of further investigation on the offspring neurofunctional performance.
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Affiliation(s)
- Carla Delascio Lopes
- Departamento de Obstetrícia, Rua Napoleão de Barros 875, Universidade Federal de São Paulo, 04024-002 São Paulo, SP, Brazil
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Mills JL. Malformations in infants of diabetic mothers. Teratology 25:385-94. 1982. ACTA ACUST UNITED AC 2011; 88:769-78. [PMID: 20973049 DOI: 10.1002/bdra.20757] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Nelson SM, Matthews P, Poston L. Maternal metabolism and obesity: modifiable determinants of pregnancy outcome. Hum Reprod Update 2010; 16:255-75. [PMID: 19966268 PMCID: PMC2849703 DOI: 10.1093/humupd/dmp050] [Citation(s) in RCA: 235] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 10/06/2009] [Accepted: 10/15/2009] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Obesity among pregnant women is highly prevalent worldwide and is associated in a linear manner with markedly increased risk of adverse outcome for mother and infant. Obesity in the mother may also independently confer risk of obesity to her child. The role of maternal metabolism in determining these outcomes and the potential for lifestyle modification are largely unknown. METHODS Relevant studies were identified by searching PubMed, the metaRegister of clinical trials and Google Scholar without limitations. Sensitive search strategies were combined with relevant medical subject headings and text words. RESULTS Maternal obesity and gestational weight gain have a significant impact on maternal metabolism and offspring development. Insulin resistance, glucose homeostasis, fat oxidation and amino acid synthesis are all disrupted by maternal obesity and contribute to adverse outcomes. Modification of lifestyle is an effective intervention strategy for improvement of maternal metabolism and the prevention of type 2 diabetes and, potentially, gestational diabetes. CONCLUSIONS Maternal obesity requires the development of effective interventions to improve pregnancy outcome. Strategies that incorporate a detailed understanding of the maternal metabolic environment and its consequences for the health of the mother and the growth of the child are likely to identify the best approach.
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Affiliation(s)
- Scott M Nelson
- Division of Developmental Medicine, Reproductive and Maternal Medicine, Faculty of Medicine, University of Glasgow, Glasgow, UK.
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23
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Abstract
Type 1 diabetes complicates around 1 in 200 to 300 pregnancies in the United Kingdom. Historically maternal type 1 diabetes carried very high risks for mother and child. Introduction of insulin led to an immediate, marked decline in the previously very high rates of maternal mortality; in contrast an improvement in perinatal outcomes occurred more slowly but was nevertheless dramatic. This is strikingly demonstrated by the temporal decline in perinatal mortality in offspring of mothers with type 1 diabetes which was virtually universal before use of insulin in the 1920's, likely remained in excess of 20% even in the 1960's and fell to under 4% by the 1990's. The reasons for this more gradual improvement in perinatal outcomes cannot be defined with precision but will have been influenced by improved glycaemic management with use of intensive, multiple dose insulin treatment and home glucose monitoring; improvements in obstetric and neonatal management, and better management of complications of diabetes before and during pregnancy. In 1989 the St Vincent declaration proposed that pregnancy outcomes in women with type 1 diabetes should approximate those of the non-diabetic population. While the long term improvements in fetal outcomes have been dramatic, contemporary surveys confirm a persistent doubling or more of rates of congenital anomaly and a three to four fold increase in perinatal mortality in the UK and other European countries which will require further clinical innovation to overcome.
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Dionne G, Boivin M, Séguin JR, Pérusse D, Tremblay RE. Gestational diabetes hinders language development in offspring. Pediatrics 2008; 122:e1073-9. [PMID: 18977957 DOI: 10.1542/peds.2007-3028] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Previous studies have suggested that language is affected in infants of diabetic mothers, yet there have been no systematic investigations to address this question. OBJECTIVE Our goal was to compare infants of diabetic mothers and controls on language outcomes from ages 18 months to 7 years. METHODS This was a case-control longitudinal design with 2 birth cohorts: 1835 singletons from the Quebec Longitudinal Study of Child Development (born October 1997 to July 1998) and 998 twins from the Quebec Newborn Twin Study (born November 1995 to July 1998). Cases were 221 infants of diabetic mothers (105 singletons and 116 twins), and controls were 2612 children (1730 singletons and 882 twins) for whom at least 1 language measure from ages 18 months to 7 years was available. Exclusion criteria were gestation of <32 weeks. The outcome measures were McArthur Communicative Development Inventory expressive and receptive vocabulary and grammar at 18 months and 30 months, the Peabody Picture Vocabulary Test receptive vocabulary at 48 months and expressive and receptive vocabulary at 60 months, and Early Development Instrument teacher-assessed communication at 72 months and 84 months (kindergarten and first grade). RESULTS. Analyses of variance (controlling for gender, socioeconomic status, and perinatal factors) revealed effects of gestational diabetes on expressive language at 18, 30, and 72/84 months. Infants of diabetic mothers scored 0.27 to 0.41 SD lower than controls and were 2.2 times more at risk of a language impairment. Genes and maternal education both moderated the effect of gestational diabetes on expressive language during this period. CONCLUSION Gestational diabetes hinders expressive language in offspring into middle childhood. Genes are strongly associated with the risk of delays in infants of diabetic mothers, and offspring of educated mothers are less affected.
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Affiliation(s)
- Ginette Dionne
- Research Unit on Psychosocial Maladjustment in Children, bSchool of Psychology, Laval University, Quebec City, Quebec, Canada.
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25
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Gin H, Vambergue A, Vasseur C, Rigalleau V, Dufour P, Roques A, Romon M, Millet D, Hincker P, Fontaine P. Blood ketone monitoring: a comparison between gestational diabetes and non-diabetic pregnant women. DIABETES & METABOLISM 2006; 32:592-7. [PMID: 17296512 DOI: 10.1016/s1262-3636(07)70313-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 06/01/2006] [Indexed: 11/22/2022]
Abstract
AIM To measure ketonemia in a control population of pregnant women and in a population of women with gestational diabetes (GDM). To define a normal ketonemia threshold for the controls and to determine whether or not this value could play a role in the clinical management of women with GDM. METHOD Fifty-six women with a normal OGTT and 49 women with GDM were included and monitored from the 25th to the 37th week of pregnancy. Control subjects agreed to perform glycaemia and ketonemia self-monitoring 3 times a day. In addition, women with GDM were asked to measure their postprandial glycaemia. Glycaemia and ketonemia measurements were performed using Optium meters. Subjects kept a 24-hour food record twice a week. RESULTS The mean ketonemia was lower in the control group than in the GDM group (0.01+/-0.10 vs. 0.04+/-0.009 mmol/l; P<0.001). Ketonemia values measured before the midday meal and prior to the evening meal were lower for control subjects than for GDM patients (P=0.002 and P=0.005). Fasting ketonemia was unrelated to ketonuria in the GDM group, whereas there was a correlation in the control group (P=0.006). At least one chronic increase in ketonemia levels was observed in 47% of the women with GDM, compared with only 12% of controls. The lowest levels of evening glycaemia correlated with the highest levels of ketonemia; women with GDM reported lower food and carbohydrate intakes than controls (P<0.001). CONCLUSION This work has enabled the establishment of ketonemia reference standards in non-diabetic pregnant women. If ketonemia does indeed indicate overly restrictive dietary behavior, this parameter could be employed for monitoring adherence to the nutritional recommendations for GDM.
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Affiliation(s)
- H Gin
- Bordeaux, University Medical Center.
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Lesser KB, Schoel SB, Kling PJ. Elevated zinc protoporphyrin/heme ratios in umbilical cord blood after diabetic pregnancy. J Perinatol 2006; 26:671-6. [PMID: 17024142 DOI: 10.1038/sj.jp.7211600] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Offspring of diabetes patients may suffer from tissue iron deficiency. Erythrocyte zinc protoporphyrin/heme (ZnPP/H) ratios measure impaired iron status. The aim of the study was to examine whether cord ZnPP/H ratios were associated with pregnancy glycemic control. METHODS ZnPP/H was measured in cord blood from 31 pregnancies with insulin-treated diabetes (diabetes group) and compared to population normal values. Maternal glycemic control was assessed by daily glucose log, glycosylated hemoglobin and birth weight. RESULTS Median cord ZnPP/H was higher in the diabetes group than the population normal values (106 (65.2 to 146.8) microM/M vs 68.2 (37.6 to 98.8) micro/M, P < 0.0001). Ratios were directly correlated to surrogates of control (glycosylated hemoglobin, P = 0.05, and birth weight, P < 0.04). Cord ZnPP/H ratios from pregnancies with pre-existing and gestational diabetes were similar. CONCLUSION Because cord ZnPP/H was higher in large offspring of diabetic pregnancy, it might identify greater iron utilization for fetal erythropoiesis.
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Affiliation(s)
- K B Lesser
- Department of Obstetrics, The University of Arizona Health Sciences Center, Tucson, AZ, USA
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Gin H, Vambergue A, Vasseur C, Rigalleau V, Dufour P, Roques A, Fontaine P. Could blood ketone monitoring be a tool for managing gestational diabetes mellitus? Diabetes Care 2006; 29:743. [PMID: 16505546 DOI: 10.2337/diacare.29.03.06.dc05-2271] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Henri Gin
- Hôpital du Haut Lèveêque, F-33604 Pessac, France.
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Stanton SG, Ryerson E, Moore SL, Sullivan-Mahoney M, Couch SC. Hearing screening outcomes in infants of pregestational diabetic mothers. Am J Audiol 2005; 14:86-93. [PMID: 16180972 DOI: 10.1044/1059-0889(2005/008)] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2004] [Accepted: 05/02/2005] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Hearing screening results for newborns of diabetic mothers were compared with those of nondiabetic controls. METHOD This study was a retrospective chart review of mothers with pregestational diabetes mellitus and their neonates (n=73) who received newborn hearing screening between January 1, 2000, and May 1, 2002. A group of nondiabetic mothers and their infants (n=73), with birth dates that matched the diabetic group, served as controls. A 2-tiered hearing screening protocol, employing distortion product otoacoustic emission (DPOAE) and automated auditory brainstem response (A-ABR) screening techniques, was used. RESULTS The DPOAE screening failure rate was 5.5% (4/73) for babies in the nondiabetic control group and 11.0% (8/73) for infants of diabetic mothers; this difference was not statistically significant. The A-ABR failure rate was 9.1% (1/11) for the diabetic group compared with 0% (0/4) for the controls, but the A-ABR was measured for only a small number of participants in each group. The frequency of premature birth and abnormal birth weight was significantly greater for the infants of diabetic mothers compared with controls. CONCLUSIONS Given the greater frequency of prematurity and abnormal birth weight in the population of neonates born to diabetics, additional research using A-ABR is recommended.
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Affiliation(s)
- Susan G Stanton
- Communication Sciences and Disorders, University of Cincinnati, Cincinnati, OH 45267-0379, USA.
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deRegnier RA. Neurophysiologic evaluation of early cognitive development in high-risk infants and toddlers. ACTA ACUST UNITED AC 2005; 11:317-24. [PMID: 16240407 DOI: 10.1002/mrdd.20085] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
New knowledge of the perceptual, discriminative, and memory capabilities of very young infants has opened the door to further evaluation of these abilities in infants who have risk factors for cognitive impairments. A neurophysiologic technique that has been very useful in this regard is the recording of event-related potentials (ERPs). The event-related potential (ERP) technique is widely used by cognitive neuroscientists to study cognitive abilities such as discrimination, attention, and memory. This method has many attractive attributes for use in infants and children as it is relatively inexpensive, does not require sedation, has excellent temporal resolution, and can be used to evaluate early cognitive development in preverbal infants with limited behavioral repertories. In healthy infants and children, ERPs have been used to gain a further understanding of early cognitive development and the effect of experience on brain function. Recently, ERPs have been used to elucidate atypical memory development in infants of diabetic mothers, difficulties with perception and discrimination of speech sounds in infants at risk for dyslexia, and multiple areas of cognitive differences in extremely premature infants. Atypical findings seen in high-risk infants have correlated with later cognitive outcomes, but the sensitivity and specificity of the technique has not been studied, and thus evaluation of individual infants is not possible at this time. With further research, this technique may be very useful in identifying children with cognitive deficits during infancy. Because even young infants can be examined with ERPs, this technique is likely to be helpful in the development of focused early intervention programs used to improve cognitive function in high-risk infants and toddlers.
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Affiliation(s)
- Raye-Ann deRegnier
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Prentice Women's Hospital, Chicago, Illinois 60611, USA.
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Ornoy A. The impact of intrauterine exposure versus postnatal environment in neurodevelopmental toxicity: long-term neurobehavioral studies in children at risk for developmental disorders. Toxicol Lett 2003; 140-141:171-81. [PMID: 12676464 DOI: 10.1016/s0378-4274(02)00505-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Various investigators have shown that enriched environment may positively affect the early brain development of experimental animals. Environment was also shown to positively affect the development of young children born to mothers of low socio-economic class (low SES). It is unknown, however, to what extent can an enriched environment improve the developmental outcome of children born with slight brain damage. We studied the development of preschool and early school age children born to heroin dependent parents raised at home or adopted in comparison to children suffering only from environmental deprivation (low parental SES) and to controls. They were examined by several professionals, using standard, age appropriate, neurological and psychological tests. Similar evaluations were performed on a group of early school age children born to mothers with pregestational or with gestational diabetes and on a group of children born prematurely, with a birth weight of less than 1500 g using various developmental tests. Young children born to heroin dependent mothers and fathers raised at home and children of low SES had, in comparison to controls, lower intellectual skills and a higher rate of inattention. This persisted at school age, too. Children born to heroin dependent mothers adopted at a young age and hence being raised in a good environment had normal intellectual function but a high rate of inattention and behavioral problems. We also examined the school age children for possible presence of ADHD and found a high rate of ADHD among all children born to heroin dependent parents including those adopted, as well as in the children with low parental SES. Similar findings regarding the strong positive influence of an enriched environment were observed in children born to diabetic mothers, where the intellectual abilities of the children were directly related with parental education. The cognitive abilities of the children born prematurely were also strongly associated with parental education and not with the degree of perinatal complications. In conclusion, in all groups of children at high risk for developmental problems was found that the environment has a strong influence on their intellectual abilities but not on motor skills or attention span. A good environment (high parental SES) may significantly improve the outcome.
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Affiliation(s)
- A Ornoy
- Laboratory of Teratology, Hebrew University--Hadassah Medical School and Israeli Ministry of Health, Jerusalem, Israel.
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Kinney BA, Rabe MB, Jensen RA, Steger RW. Maternal hyperglycemia leads to gender-dependent deficits in learning and memory in offspring. Exp Biol Med (Maywood) 2003; 228:152-9. [PMID: 12563021 DOI: 10.1177/153537020322800204] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pregnancy in the diabetic woman has long been associated with an increased risk of congenital malformation in the offspring. However, little is known about the effects of maternal diabetes on development of the central nervous system. To begin to gain an understanding of this problem, diabetes was induced in adult female Sprague-Dawley rats by injection with streptozotocin. Only animals with serum glucose levels greater than 200 mg/dl were used. Diabetic and control females were bred, and all newborn pups were cross-fostered to nondiabetic mothers. At 60 days of age, pups were tested in an elevated plus-maze to assess differences in emotionality and anxiety. There were no significant differences between offspring of diabetic dams and controls on this measure. All pups were then housed individually, put on food restriction, and maintained at 85% of their ad libitum weight. They were then trained in a Lashley III maze, which assesses learning and retention capability. The female offspring of diabetic dams performed poorer than controls, a finding that was supported by inhibitory avoidance data from a separate group of animals. All animals were then trained in a radial-arm maze. Results failed to find differences between experimental and control animals. It was concluded that the diabetic intrauterine environment has gender-specific effects on central nervous system development.
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Affiliation(s)
- B A Kinney
- Department of Physiology, Southern Illinois University School of Medicine, Carbondale, Illinois 62901-6512, USA.
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Rehan VK, Moddemann D, Casiro OG. Outcome of very-low-birth-weight (< 1,500 grams) infants born to mothers with diabetes. Clin Pediatr (Phila) 2002; 41:481-91. [PMID: 12365310 DOI: 10.1177/000992280204100705] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Premature delivery is common in pregnancies complicated by maternal diabetes. However, the outcome of very-low-birth-weight infants (VLBWI) born to mothers with diabetes is not known. Employing a matched double-cohort design, we investigated the influence of maternal diabetes on the outcome of VLBWI born in Winnipeg from 1988 to 1994. We compared mortality rates and early and late morbidity rates in VLBWI born to mothers with diabetes mellitus (DM) (cases, n = 43, 23 with gestational DM and 20 with pregestational DM) and without DM (controls, n = 539). Controls were matched for gestational age (GA), sex, and the year of birth. All subjects were enrolled in the Newborn Follow-Up Program. Relative risks and 95% confidence limits were calculated for each variable and Chi 2 analysis, Student t-test, and Mann-Whitney test were used as appropriate for analysis. Diabetes mellitus control was assessed by conventional criteria. There were no differences between cases and controls in mode of delivery, birth weight (mean +/- SD, 1,160 +/- 25 g vs 1,110 +/- 26 g), GA (29 +/- 2.8 wk vs 29 +/- 2.4 wk), smallness for gestational age (35% vs 30%), head circumference (26.5 +/- 1.9 vs 26.2 +/- 2.2 cm), length (38.8 +/- 2.8 vs 37.5 +/- 3.7 cm), Apgar score < 4 at 1 min (42% vs 40%) and < 7 at 5 min (37% vs 42%). Incidence of hyaline membrane disease (60% vs 71%), bronchopulmonary dysplasia (33% vs 31%), patent ductus arteriosus (30% vs 43%), necrotizing enterocolitis (12% vs 12%), sepsis (23% vs 25%), acute renal failure (9% vs 10%), intraventricular hemorrhage--all grades (74% vs 64%), retinopathy of prematurity--all stages (30% vs 26%), median days on ventilator (4 vs 4 days), and median days on supplemental oxygen (46 vs 42 days) were similar in both groups (p = NS, 95% confidence limits included 1 for all of these variables). There was no significant difference in mortality (21% vs 15%) or the incidence of major congenital anomalies. Weight, head circumference, and length at 6, 12, and 18 months were similar in both groups. There were no group differences in developmental quotients, prevalence of neurodevelopmental impairments, respiratory morbidity, or number of hospitalizations up to the last follow-up (18 months). Our data suggest that with contemporary perinatal care there is no significant increase in mortality rates or early and late morbidity rates between VLBWI born to mothers with DM and VLBWI of nondiabetic mothers. It seems that with reasonable diabetic control, prematurity rather than the diabetic state determines the neonatal outcome, and this knowledge can be useful in parental counselling.
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Affiliation(s)
- Virender K Rehan
- Harbor UCLA Medical Center, Research and Education Institute, RB1, 1124-West Carson Street, Torrance, CA 90502, USA
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Kowalczyk M, Ircha G, Zawodniak-Szałapska M, Cypryk K, Wilczyński J. Psychomotor development in the children of mothers with type 1 diabetes mellitus or gestational diabetes mellitus. J Pediatr Endocrinol Metab 2002; 15:277-81. [PMID: 11924929 DOI: 10.1515/jpem.2002.15.3.277] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to examine psychomotor development in children born to mothers with type 1 diabetes mellitus (DM1) or gestational diabetes mellitus (GDM). The influence of metabolic control in pregnant diabetic mothers and complications during labor on their children's psychological and physical development was evaluated. The analysis included 59 children, 20 of mothers with GDM, 19 of mothers with DM1, and 20 children of healthy mothers. Clinical observations and medical history were recorded and children were assessed using the Brunet-Lezine Psychomotor Development Scale. Abnormalities were found more often in the children of mothers with DM1 whose illness was insufficiently controlled during pregnancy and of mothers with serious hypoglycemia while pregnant. Speech, eye-movement coordination and social aspects were affected.
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Affiliation(s)
- M Kowalczyk
- Clinical Psychology Department, Research Institute Polish Mother's Memorial Hospital, Lódź
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González González N, Vázquez P, Parache J, Jiménez A, Caballero A. Estados de comportamiento intraútero en los hijos de madres con diabetes tipo 1. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0304-5013(01)75687-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Deregnier RA, Nelson CA, Thomas KM, Wewerka S, Georgieff MK. Neurophysiologic evaluation of auditory recognition memory in healthy newborn infants and infants of diabetic mothers. J Pediatr 2000; 137:777-84. [PMID: 11113833 DOI: 10.1067/mpd.2000.109149] [Citation(s) in RCA: 214] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We evaluated the integrity of neural pathways for auditory recognition memory in normal newborn infants (n = 32) and infants of diabetic mothers (IDMs, n = 25). IDMs are at risk for fetal metabolic abnormalities that potentially damage recognition memory pathways. We hypothesized that newborn IDMs would have recognition memory deficits that would be correlated with later cognitive development. STUDY DESIGN Recognition memory was assessed with event-related potentials (ERPs). Neonatal ERPs elicited by the maternal voice were compared with those elicited by a stranger's voice. The Bayley Scales of Infant Development were administered at 1 year of age. RESULTS Infants in both the control and IDM groups demonstrated recognition of the maternal voice, but their ERP patterns differed. Both groups demonstrated increased amplitude and latency for the "P2" peak elicited by the maternal voice compared with the stranger's voice. In the control group the stranger's voice also elicited a negative slow wave, which was attenuated in the IDMs. The negative slow wave correlated significantly with the 1-year Mental Developmental Index. CONCLUSIONS The presence of a specific neonatal ERP pattern indicated better 1-year cognitive development in infants in the control and IDM groups. ERPs from IDMs demonstrated subtle evidence of recognition memory impairments.
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Affiliation(s)
- R A Deregnier
- Children's Hospitals and Clinics-St Paul, St Paul, Minnesota 55102, USA
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Abstract
Diabetes in pregnancy is unique because of the diversity of problems that can affect the embryo/fetus beginning with conception. Considerable effort has been devoted to understanding the basic developmental biology from observing young embryos in vitro or in vivo. Maternal glucose control has been identified as an important event. The preponderance of evidence indicates that rigid glucose control will minimize the incidence of anomalies incurred before 9 weeks of pregnancy. Later events are related to fetal hyperinsulinemia. These include fetal macrosomia, respiratory distress syndrome, neonatal hypoglycemia, neonatal hypocalcemia, and neonatal hypomagnesemia. Control of maternal metabolism can have a significant impact on each of the above. Finally, the long-term effects of maternal diabetes are as diverse as the pathogenetic events during pregnancy. Surprisingly, there is a significant transmission rate of 2% of type I diabetes if the mother has insulin-dependent diabetic mother, whereas the rate is 6% for the father. The Diabetes in Early Pregnancy Study showed that good maternal control was associated with normal neurodevelopmental outcome.
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Affiliation(s)
- R Schwartz
- Division of Pediatric Endocrinology and Metabolism, Brown University at Rhode Island Hospital, Providence 02903, USA
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Ornoy A, Wolf A, Ratzon N, Greenbaum C, Dulitzky M. Neurodevelopmental outcome at early school age of children born to mothers with gestational diabetes. Arch Dis Child Fetal Neonatal Ed 1999; 81:F10-4. [PMID: 10375355 PMCID: PMC1720965 DOI: 10.1136/fn.81.1.f10] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To study the metabolic derangements in the second half of pregnancy caused by gestational diabetes, on the long term development of children. METHODS The neuropsychological function of 32 school age children born to 32 mothers with well controlled gestational diabetes and 57 control children matched by age, birth order, and parental socioeconomic status was studied. RESULTS There were no differences in head circumference and height, but the children born to diabetic mothers were heavier. The verbal IQ scores of index children below the age of 9 years were lower than those of control children. No differences were found between the groups in various sensory and motor functions and in the Touwen and Prechtl neurological test. The young index group children performed less well than controls in fine and gross motor functions, as observed on the Bruininks-Oseretzky test of motor proficiency. The scores of young children born to mothers with gestational diabetes were also lower than controls on the Pollack tapper test, and there were more index group children who scored abnormally on the parents' Conners questionnaire. No correlation was found between the performance of the index group children on various neurodevelopmental tests and the severity of perinatal complications. The differences tended to disappear with age. CONCLUSIONS Gestational diabetes, as a result of the metabolic abnormalities in the second half of pregnancy, induces long term minor neurological deficits which are more pronounced in younger children. There does not seem to be any direct relation between the appearance of congenital anomalies and neurodevelopmental outcome.
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Affiliation(s)
- A Ornoy
- Laboratory of Teratology Department of Anatomy and Cell Biology Hebrew University Hadassah Medical School Israel
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Stenninger E, Flink R, Eriksson B, Sahlèn C. Long-term neurological dysfunction and neonatal hypoglycaemia after diabetic pregnancy. Arch Dis Child Fetal Neonatal Ed 1998; 79:F174-9. [PMID: 10194986 PMCID: PMC1720863 DOI: 10.1136/fn.79.3.f174] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To determine if children born to mothers with diabetes mellitus during pregnancy, who subsequently developed neonatal hypoglycaemia, experienced long-term neurological dysfunction. METHODS Thirteen children with, and 15 without, neonatal hypoglycaemia (blood glucose < 1.5 mmol/l) were randomly selected from a larger cohort and investigated at the age of 8 years. They were also compared with 28 age matched healthy controls. RESULTS Children with neonatal hypoglycaemia had significantly more difficulties in a validated screening test for minimal brain dysfunction than controls and were also more often reported to be hyperactive, impulsive, and easily distracted. On psychological assessment, they had a lower total development score than normoglycaemic children born to diabetic mothers, and control children. CONCLUSIONS Neonatal hypoglycaemia in diabetic pregnancy was associated with long-term neurological dysfunction related to minimal brain dysfunction/deficits in attention, motor control, and perception.
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Affiliation(s)
- E Stenninger
- Department of Paediatrics, Orebro Medical Centre Hospital, Sweden
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Ornoy A, Ratzon N, Greenbaum C, Peretz E, Soriano D, Dulitzky M. Neurobehaviour of school age children born to diabetic mothers. Arch Dis Child Fetal Neonatal Ed 1998; 79:F94-9. [PMID: 9828733 PMCID: PMC1720831 DOI: 10.1136/fn.79.2.f94] [Citation(s) in RCA: 249] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To study the neurobehavioural effects that diabetes during pregnancy might have on children by school age. METHODS The neurobehavioural function of 57 school age children born to 48, well controlled diabetic mothers was compared with 57 control children matched for age, birth order, and parental socioeconomic status, using several cognitive, behavioural, sensory and motor neurological tests. RESULTS The IQ scores of the index group children were similar to those of control children (117.7 +/- 13.4 vs 118.5 +/- 10.1). There were no differences between the groups in various sensory motor functions. However, the index group children performed less well than the controls on indices of fine and gross motor functions, as observed on the Bruininks-Oseretzky test of motor proficiency. The scores of children born to diabetic mothers were higher than controls on the Touwen and Prechtl neurological examination. They also performed worse in the Pollack tapper test which is designed to detect minor neurological deficits, inattention, and hyperactivity. The index children had higher scores on the Conners abbreviated parent-teacher questionnaire which measures hyperactivity and inattention. There was a negative correlation between the performance of the index group children on various neurodevelopmental and behavioural tests and the severity of hyperglycaemia, as assessed by blood glycosylated haemoglobin and acetonuria. CONCLUSIONS Diabetes during pregnancy adversely affects some fine neurological functions in children at school age, but not their cognitive scores. These effects are not correlated with the degree of glycaemic control.
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Affiliation(s)
- A Ornoy
- Department of Anatomy and Cell Biology, Hebrew University, Jerusalem, Israel
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Abstract
For patients with preconception diabetes, the most important aspect is the need for good glycemic control pre conception to lessen the risk of congenital malformations. Careful assessment of diabetes complications is essential prepregnancy. In the absence of major complications, good glycemic control gives the pregnant diabetic patient the same chance for a healthy baby as the rest of the population. Pregnancy alters carbohydrate tolerance, and thus gestational diabetes should be screened for and, when found, treated aggressively with dietary intervention, glucose monitoring, and insulin if good glycemic control has not been attained. These patients are at greatly increased risk for diabetes in the long term.
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Affiliation(s)
- E A Ryan
- Department of Medicine, University of Alberta, Edmonton, Canada
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Casele HL, Dooley SL, Metzger BE. Metabolic response to meal eating and extended overnight fast in twin gestation. Am J Obstet Gynecol 1996; 175:917-21. [PMID: 8885748 DOI: 10.1016/s0002-9378(96)80025-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Our purpose was to compare the metabolic response to normal meal eating and the vulnerability to starvation ketosis in twin versus singleton gestation. STUDY DESIGN Data are reported on 10 twin and 10 singleton nondiabetic gestations enrolled in a 40-hour metabolic study. Singletons were age (+/- 5 years) and prepregnancy weight (+/- 10% ideal body weight) matched with twins. The diet (35 kcal/kg ideal body weight for singletons, 40 kcal/kg ideal body weight for twins) was distributed as one fifth at 8 AM, two fifths at 1 PM, and two fifths at 6 PM. An overnight fast was extended until noon the following day. Glucose and beta-hydroxybutyrate measurements were made hourly except at night, when they were made every 2 hours. Insulin values were obtained before and after dinner and on the day when breakfast was delayed. RESULTS The glucose, beta-hydroxybutyrate, and insulin excursions in response to meal eating from 8 AM to 12:00 noon on day 1 were similar in twin and singleton pregnancies (analysis of variance for repeated measures, p < 0.05). On day 2, when breakfast was delayed, a progressive decrement in glucose was observed in both twins and singletons (p = 0.4682). Concurrently, there was a progressive rise in beta-hydroxybutyrate in both twins and singletons, which was significantly greater for twins compared with singletons (p = 0.002). CONCLUSIONS These data indicate that twin gestations are more vulnerable to the accelerated starvation of late normal pregnancy than singletons are in spite of additional caloric intake. We speculate that the observed difference may be the result of the increased metabolic demands of twin gestation.
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Affiliation(s)
- H L Casele
- Department of Obstetrics and Gynecology, Northwestern University Medical School, Chicago, Illinois, USA
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Yamashita Y, Kawano Y, Kuriya N, Murakami Y, Matsuishi T, Yoshimatsu K, Kato H. Intellectual development of offspring of diabetic mothers. Acta Paediatr 1996; 85:1192-6. [PMID: 8922082 DOI: 10.1111/j.1651-2227.1996.tb18227.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We prospectively evaluated the intellectual development of 33 children who were born to 33 diabetic Japanese mothers and compared them to 34 children born to non-diabetic mothers (controls) during the same period at Kurume University Hospital between 1987 and 1989. Birthweight, maternal age and the infant's age at the time of intelligence testing did not differ significantly between the offspring of diabetic mothers (ODMs) and controls. Tanaka-Binet intelligence scores were significantly lower in the ODMs at 3 years of age than in controls (98.4 +/- 17.4 versus 113.4 +/- 15.3) (p = 0.0005). No correlation was found between IQ and maternal haemoglobin A1c levels during pregnancy. Maternal age and infant IQ were inversely correlated in ODMs (p = 0.0298, r = -0.3984), but no such correlation was demonstrated in the controls. The results indicated that the ODMs may show a poorer intellectual development than those of non-diabetic mothers.
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Affiliation(s)
- Y Yamashita
- Department of Paediatrics and Child Health, Kurume University School of Medicine, Japan
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Abstract
The perinatal mortality rate of infants of diabetic mothers (IDMs) has declined dramatically from 250 per 1000 live births in the 1960s to a near-normal 20 per 1000 live births in the 1980s. Five to 8% of all IDMs suffer from major congenital malformations, and it is the latter that are responsible for 50% of these perinatal deaths. It has been shown that tight glycemic control prior to conception and during pregnancy can prevent an excess rate of congenital malformations, fetal macrosomia, birth trauma, and neonatal respiratory distress syndrome. We briefly review the short- and long-range complications that occur in offspring of diabetic mothers (ODMs) from gestation through young adulthood. Short-term neonatal complications, such as hypoglycemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia, and polycythemia, are related mainly to fetal hyperinsulinemia, hypoxemia, and prematurity. They are readily controllable within the setup of modern neonatal intensive care units. Long-range complications include an increased rate of childhood and adolescent obesity, impaired glucose tolerance or diabetes mellitus, and subtle neuropsychological dysfunctions. These may be related to the severity of the maternal hyperglycemia during pregnancy, the consequent fetal hyperinsulinemia, and third trimester maternal lipid metabolism disturbances. Today we have at hand the knowledge and tools to properly treat both pregestational and gestational diabetes. Increased education of the general practitioner and the target population regarding early referral of pregestational diabetic mothers and the implementation of screening programs for gestational diabetes will further reduce diabetic pregnancy-related morbidity.
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Affiliation(s)
- N Weintrob
- Institute of Pediatric and Adolescent Endocrinology, Children's Medical Center of Israel, Petah Tiqva, Israel
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Shubert PJ, Gordon MC, Landon MB, Gabbe SG, Kniss DA. Ketoacids attenuate glucose uptake in human trophoblasts isolated from first-trimester chorionic villi. Am J Obstet Gynecol 1996; 175:56-62. [PMID: 8694076 DOI: 10.1016/s0002-9378(96)70251-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the hypothesis that ketoacids (acetoacetic acid and beta-hydroxybutyrate) diminish glucose transport in trophoblasts cultured from first-trimester chorionic villi. STUDY DESIGN First-trimester trophoblasts were obtained by transabdominal chorionic villus sampling for subsequent cytogenetic analysis. The cells were established as a continuous line exhibiting trophoblast characteristics. Trophoblasts were cultured in Ham's F12/Dulbecco's modified Eagle's medium (1:1) supplemented with 15% fetal bovine serum. Experiments were initiated by a 24-hour preincubation in serum-free Ham's F12/Dulbecco's modified Eagle's medium followed by incubation with ketoacids (acetoacetic acid and beta-hydroxybutyrate, 0 to 10 mmol/L) in the presence or absence of insulin-like growth factor-I (100 ng/ml). The cells were challenged with 2-deoxy-[1,2-3H]D-glucose (0.1 mmol/L) for 5 minutes and then cell-associated radioactivity was measured. Total ribonucleic acid was extracted from cells incubated with ketoacids in the presence or absence of insulin-like growth factor-I, and Northern blots were probed with a phosphorus 32-labeled complementary deoxyribonucleic acid fragment encoding the rat GLUT 1. RESULTS Ketoacids caused a dose-dependent inhibition of glucose transport. At 5 mmol/L acetoacetic acid there was a > 50% reduction in the rate of glucose transport in both control and insulin-like growth factor-I-treated cells. The diminution in glucose uptake by trophoblasts was not due to cellular toxicity of the ketoacids because there was no significant difference in trypan blue exclusion or lactate dehydrogenase release between control and ketoacid-treated cells. Northern analysis revealed that the steady-state expression of GLUT1 messenger ribonucleic acid was diminished in ketone-treated cells, but this effect was overcome by coincubation of cultures with insulin or insulin-like growth factor-I. CONCLUSIONS These results indicate that ketoacids can suppress the uptake of glucose into first-trimester human trophoblasts. Because ketoacidosis in pregnant women with diabetes mellitus is a frequent clinical consequence of poor metabolic control, it is possible that elevated levels of acetoacetic acid and beta-hydroxybutyrate may impair the transport of glucose across the placental trophoblast and into the fetal circulation.
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Affiliation(s)
- P J Shubert
- Department of Obstetrics and Gynecology, Ohio State University College of Medicine, USA
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Rosenn B, Miodovnik M, Tsang R. Common clinical manifestations of maternal diabetes in newborn infants: implications for the practicing pediatrician. Pediatr Ann 1996; 25:215-22. [PMID: 8731489 DOI: 10.3928/0090-4481-19960401-09] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Even though perinatal mortality of infants of diabetic mothers has decreased remarkably in recent years and now approaches that of the general population, these infants still face a multitude of potential complications and the propensity for increased morbidity, both in utero and postnatally. Many of these complications are clearly related to the metabolic status of the diabetic mother. Increasing awareness among insulin-dependent diabetic patients and health providers of the need for glycemic control and the ever-growing understanding of the peculiarities of diabetic pregnancies eventually should combine to provide the best possible outcome for these infants.
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Affiliation(s)
- B Rosenn
- Department of Pediatrics, University of Cincinnati College of Medicine, OH 45267-0541, USA
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Abstract
Excellent blood glucose control is necessary to reduce the excess fetal morbidity and mortality associated with the diabetic pregnancy. This article outlines the roles of glucose monitoring and insulin therapy in intensive treatment regimens during gestation. The discussion includes recommended monitoring frequency, glycemic standards, types of insulin and mechanism of action, goals and timing of insulin therapy, as well as the complications of insulin therapy.
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Affiliation(s)
- C J Homko
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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50
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Whiteman VE, Homko CJ, Reece EA. Management of hypoglycemia and diabetic ketoacidosis in pregnancy. Obstet Gynecol Clin North Am 1996; 23:87-107. [PMID: 8684786 DOI: 10.1016/s0889-8545(05)70246-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The article discusses the incidence and management of hypoglycemia and diabetic ketoacidosis (DKA) in pregnancy. Additional topics addressed are the incidence of hypoglycemia, pathophysiology, diagnosis and management of hypoglycemia in pregnancy, fetal monitoring with short- and long-term fetal sequelae, and prevention of hypoglycemic recurrences. Subsequently, attention is focused on the diagnosis and management of hyperglycemia and DKA in pregnancy.
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Affiliation(s)
- V E Whiteman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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