Reassessment of White's classification and Pedersen's prognostically bad signs of diabetic pregnancies in insulin-dependent diabetic pregnancies

Zuogui Wan rescues the high-glucose-induced damaging effects on early embryo development

Background

High concentration of glucose in culture medium affects the developmental process and the quality of the pre-implantation embryo. This study examined the effects of Zuogui Wan (ZGW) supplementation on early embryo development cultured in high-glucose medium.

Methods

Embryos were cultured in high-glucose medium with or without ZGW supplementation. Developmental rate and competence was evaluated by cleavage rate, blastocyst rate, and blastocyst total cell number, reactive oxygen species (ROS) level, glutathione (GSH) concentration, and metabolome were also measured to determine the effect of ZGW on embryo development at the cellular level.

Results

Compared with the vehicle group, supplementation of 0.01 % (v/v) ZGW to high-glucose medium significantly increased cleavage rate (80.1 ± 1.0 % vs 72.1 ± 1.3 %), blastocyst rate (50.5 ± 1.0 % vs 41.3 ± 1.7 %), and blastocyst total cell number (63.2 ± 2.2 vs 57.2 ± 1.6). ROS level was lower and GSH concentration in blastocysts was higher in ZGW-treated group. Metabolomic analysis found that the ratio of glucose to succinic acid and glucose to fumaric acid were lower in the ZGW-treated group .

Conclusions

Developmental rates of zygotes in high-glucose culture medium were significantly lower than those in regular culture medium. ZGW supplementation significantly improved embryo development and quality in high-glucose medium. Supplementing ZGW in high-glucose medium also significantly increased total cell number and GSH concentration but decreased ROS level in blastocysts likely by modifying metabolic profile during embryo development. Together, these data suggest that supplementation of ZGW rescues high-glucose-induced detrimental effects on pre-implantation embryo development.

White's classification and pregnancy outcome in women with type 1 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

Our aim was to examine the association of White's classification with obstetric and perinatal risk factors and outcomes in type 1 diabetic patients.

METHODS

Obstetric records of a population-based cohort of 1,094 consecutive type 1 diabetic patients with a singleton childbirth during 1988-2011 were studied. The most recent childbirth of each woman was included.

RESULTS

The prepregnancy and the first trimester HbA1c increased from White's class B to F (p for trend <0.001). Systolic and diastolic blood pressure and pre-eclampsia frequencies increased stepwise from class B to F (p for trends <0.001). Vaginal deliveries decreased and Caesarean sections and deliveries before 37 weeks increased from class B to F (p for trends <0.001). Fetal macrosomia (p for trend=0.003) decreased and small-for-gestational age infants (p for trend=0.002) and neonatal intensive care unit admissions (p for trend=0.001) increased from class B to F. In logistic regression analysis, White's classes were associated with pre-eclampsia but, with the exception of class R (proliferative retinopathy) and F (nephropathy), not with other adverse outcomes when adjusted for first trimester HbA1c ≥7% (≥53 mmol/mol) and blood pressure ≥140/90 mmHg. First trimester HbA1c ≥7% was associated with pre-eclampsia, preterm delivery, fetal macrosomia and neonatal intensive care unit admission.

CONCLUSIONS/INTERPRETATION

White's classification is useful in estimating the risk of pre-eclampsia in early pregnancy independently of suboptimal glycaemic control and hypertension. However, its utility in predicting adverse perinatal outcomes seems limited when information on first trimester HbA1c, blood pressure and diabetic microvascular complications is available.

Assessing White's classification of pregestational diabetes in a contemporary diabetic population

OBJECTIVE

To assess the validity of White's classification, including the role of chronic hypertension, in a contemporary diabetic population.

METHODS

We performed a retrospective cohort study of all singleton pregnancies with pre-existing diabetes mellitus from 2008 to 2013. Adverse outcomes were compared across classes B, C, D, and vascular disease (R, F, H) and further stratified by the presence or absence of chronic hypertension. Outcomes examined were a composite perinatal outcome (stillbirth, neonatal death, shoulder dystocia, birth injury, seizures, requiring chest compressions or intubation at delivery, blood pressure support), small for gestational age (SGA), large for gestational age (LGA), macrosomia, shoulder dystocia, preterm delivery at less than 37 weeks of gestation, preeclampsia, and cesarean delivery.

RESULTS

Of the 475 patients, the 1980 White's classification was significantly associated with SGA, LGA, macrosomia, preterm delivery, preeclampsia, and cesarean delivery (P≤.01). Within each White's class based on age or time since diagnosis alone, hypertension was significantly associated with a higher incidence of preeclampsia in class B (16% without hypertension compared with 32% with hypertension, P<.01) and C (22% compared with 40%, P=.04), SGA in C (4.7% compared with 21%, P<.01), preterm delivery in B (25% compared with 46%, P<.01) and C (35% compared with 58%, P=.01), and the composite neonatal outcome in B (7.9% compared with 17%, P=.03). The incidence of adverse outcomes in classes B and C with hypertension resembles the incidence of adverse outcomes in those with diabetes one class higher.

CONCLUSION

The 1980 White's classification system, taking into consideration the presence of chronic hypertension, remains a useful system for counseling pregestational diabetic women regarding adverse pregnancy outcomes.

LEVEL OF EVIDENCE

II.

Care of diabetes in pregnancy

Diabetes, whether existing before pregnancy or brought on by changes in maternal physiology, poses risks to the mother and developing fetus. Excellent preconceptional and pregnancy care can help to minimize, or even to eliminate, these risks. This article reviews the problems that are associated with diabetes in pregnancy and evidence-based strategies to avoid them.

Values of fasting glucose levels, glucose tolerance tests, and glucose-insulin ratios as predictors of glucose tolerance

OBJECTIVE

To examine the ability to use parameters obtainable from an oral glucose tolerance test to predict insulin action as determined under hyperinsulinemic, hyperglycemic conditions.

DESIGN

Prospective clinical investigation.

SETTING

University medical center clinical research unit.

PATIENT(S)

Healthy male volunteers.

INTERVENTION(S)

Oral glucose tolerance test and hyperglycemic (+125 mg/dL) clamp studies.

MAIN OUTCOME MEASURE(S)

Glucose and insulin (I) levels, rate of glucose uptake (M) under hyperglycemic conditions, and M/I ratios.

RESULT(S)

Among individuals with normal glucose tolerance, as assessed by an oral glucose tolerance test, the fasting insulin level is the glucose tolerance test parameter that correlates best with insulin action during a hyperglycemic clamp.

CONCLUSION(S)

Measurement of fasting serum insulin levels in conjunction with an oral glucose tolerance test improves the ability to assess insulin action. Such combinations may improve the ability to diagnose insulin-resistant states.

Maternal diabetes mellitus is associated with altered deposition of fibrin-type fibrinoid at the villous surface in term placentae

Placentae from control and diabetic patients were used to test three null hypothesis: (1) there are no significant group differences in the volumes of villous syncytiotrophoblast compartments or intervillous fibrin-type fibrinoid, (2) perivillous fibrin-type fibrinoid is deposited randomly at the surface of trophoblast, and (3) amounts and deposition patterns of perivillous fibrin-type fibrinoid do not vary between groups. Term placentae were collected from non-diabetic subjects and five groups of diabetic women classified according to duration, severity and insulin dependence. Tissue specimens and sections were obtained by uniform random sampling. Volumes and surface areas of fibrin-type fibrinoid and trophoblast compartments (thin, syncytial knot, syncytial bridge and denuded regions) were estimated stereologically and compared using variance, chi-squared and contingency table analyses. As to null hypothesis (1), no group differences in volumes of trophoblast compartments were found but volumes of intervillous fibrin-type fibrinoid were greater in the non-insulin-dependent diabetic group. As to null hypothesis (2), regardless of group, fibrin-type fibrinoid was deposited preferentially at sites of denudation in every placenta examined. As to null hypothesis (3), villous surface areas occupied by perivillous fibrin-type fibrinoid were greater in type 1 (insulin-dependent) diabetics with complications (diabetic nephropathy or retinopathy). The surfaces of trophoblast occupied by fibrin-type fibrinoid were also notably larger in non-insulin-dependent diabetics and type 1 diabetics with complications. Except for the surface of denudation sites (which also increased in diabetes), there were no differences in the surfaces of trophoblast regions. These results confirm that the haemostatic steady state is perturbed in the diabetic placenta, that perivillous fibrin-type fibrinoid is deposited preferentially at sites of epithelial loss/damage, and that some diabetic groups are affected differentially.

Growth and maturation of villi in placentae from well-controlled diabetic women

Placentae from controls and two groups of diabetic women (one White classes A, B, C and the other classes D, F/R) were collected at 37-42 weeks of gestation. Tissue sections were analysed using stereological methods in order to quantify the growth and maturational status of villi. Birth and placental weights were recorded and placentae sampled in a systematic manner. Fields of view on formalin-fixed, paraffin-embedded sections were analysed to obtain estimates of volumes, surface areas, lengths and diffusion (harmonic mean) distances. Comparisons were drawn using three-way analyses of variance with group, mode of delivery and sex of newborn as the principal effects. Mean weights were similar in controls and diabetic groups. Diabetic placentae had a more voluminous fetal capillary bed of greater length, diameter and surface area. In addition, the diffusion distances across fetal plasma (erythrocyte to endothelium) were shorter. Stromal diffusion distance and villous diameter were greater in vaginal deliveries. Interaction effects influenced also villous capillarization, capillary volume, capillary diameter, trophoblast thickness and stromal thickness. Our results emphasize the importance of adaptations on the fetal side of the diabetic placenta. They show that changes can affect the placentae of appropriate-for-age as well as large-for-age babies and provide no evidence that they increase with the severity and duration of diabetes.

Impairment of counterregulatory hormone responses to hypoglycemia in pregnant women with insulin-dependent diabetes mellitus

Intensive insulin therapy directed at elimination of hyperglycemia is advocated during pregnancy in women with insulin-dependent diabetes mellitus. Because such treatment is complicated by frequent hypoglycemic episodes, we evaluated maternal and fetal responses in nine intensively treated pregnant women with insulin-dependent diabetes mellitus during an insulin-induced, gradual, controlled fall in plasma glucose levels. In contrast to values in nonpregnant control women, reductions in glucose to 44 +/- 2 mg/dl in pregnant diabetic patients failed to elicit an increase in glucagon levels. Epinephrine release during hypoglycemia was also markedly suppressed in the pregnant diabetic subjects (106 +/- 32 vs 327 +/- 52 pg/ml in controls, p less than 0.001). Furthermore, the plasma glucose level at which epinephrine and growth hormone were released was 5 to 10 mg/dl lower in the pregnant women with insulin-dependent diabetes mellitus (p less than 0.05). The basal fetal heart rate remained unchanged and continued to manifest accelerations during the hypoglycemic state. We conclude that the high frequency of hypoglycemia in intensively treated pregnant women with insulin-dependent diabetes mellitus may be due in part to impaired counterregulatory hormonal responses.

Dose-response effects of glucose, insulin, and glucagon on mouse pre-embryo development

The diabetic state, as well as elevated culture media glucose level (950 mg D-glucose/dL) per se, significantly retards in vitro development of mouse pre-implantation embryos from a two-cell stage to blastocyst stage; maternal insulin therapy to diabetic mice reverses this impairment. This study was undertaken to assess (1) whether less extreme elevation of the media glucose concentration would also impair development, and (2) whether elevated culture media insulin or glucagon levels would alter development. Two-cell pre-embryos were recovered from B6C3F1 mice that had been stimulated with pregnant mare serum gonadotropin (PMSG) and human chorionic gonadotropin (hGG), mated, and killed 48 hours later. Pre-embryos were observed in culture at 24-hour intervals for a total of 72 hours at four glucose levels: 110 (n = 108), 220 (n = 101), 440 (n = 65), and 950 (n = 106) mg D-glucose/dL. Impairment in progression of development was noted at each time period; compared with development in 110 mg glucose/dL, the distribution of development was significantly different at 24 hours (chi 2 = 60.1, P less than .001), at 48 hours (chi 2 = 36.7, P less than .001), and at 72 hours (chi 2 = 45.1, P less than .001). Rate of development as assessed by ANOVA was also significantly reduced at increasing glucose levels (P less than .0001), with Duncan Multiple Range test demonstrating differences between development at higher glucose levels in the comparison of development in 110 mg/dL versus 440 mg/dL and 950 mg/dL, and at 220 mg/dL versus 950 mg/dL.(ABSTRACT TRUNCATED AT 250 WORDS)

Obstetrical management of patients with diabetes in pregnancy

The management of the woman with diabetes diagnosed before the onset of pregnancy, or who develops it during pregnancy, requires a team approach involving the woman and her partner, the diabetes nurse educator, the dietitian, the endocrinologist, the obstetrician, the ultrasonologist and the paediatrician. It should start before pregnancy so that normoglycaemia is achieved before conception and maintained throughout gestation and labour. Fetoplacental surveillance commences with an early ultrasound to confirm fetal viability, repeated around 20 weeks to exclude major fetal malformations and then later in the third trimester to monitor fetal growth. CTG and biophysical profile assessment are major adjuncts to ensuring fetal well-being. The pregnancy should be allowed to go to full term when maternal blood glucose control has been satisfactory, fetal growth is within the normal range and other obstetrical complications, e.g. pre-eclampsia, are absent. Such an approach will ensure that the caesarean section rate can be minimized. During labour, the progress of labour and fetal well-being should be closely monitored. The woman who has microvascular complications of her diabetes (including proliferative retinopathy and nephropathy) requires even closer surveillance and premature delivery is more likely to be needed. The principles of management of the woman who develops gestational diabetes are similar, with even greater emphasis being placed on not inducing labour before full term unless complications dictate otherwise.

Manifestation of diabetes mellitus on mouse follicular and pre-embryo development: effect of hyperglycemia per se

Animal models of diabetes mellitus during pregnancy have repeatedly suggested that maternal hyperglycemia was teratogenic during organogenesis, and thus may contribute to diabetic teratogenesis. However, little attention has been focused on the effects of hyperglycemia on pre-organogenic development. In this report, we examine the effect of hyperglycemia (950 mg glucose/dL) on the development of mouse pre-embryos in vitro. B6C3F1 mice were superovulated with 5 U pregnant mare serum gonadotropin (PMSG) followed by 5 U human chorionic gonadotropin (hCG) 48 hours later. Two cell pre-embryos were recovered 48 hours later, pooled together, and randomly assigned to different treatment groups. Cultures were performed in HAM's F-10 media (Gibco, Long Island, NY) with 0.1% bovine serum albumin (BSA; Sigma, St. Louis, MO) BSA at 37 degrees C in an atmosphere of 5% CO2, 5% O2, and 90% N2 with 15 to 30 embryos per milliliter of culture fluid. Cultures were viewed daily at 24, 48, and 72 hours after culturing, with recording of the development. Compared with control pre-embryos (n = 216), embryos cultured in elevated glucose levels (950 mg/dL) (n = 226) demonstrated marked growth retardation as assessed both by (1) distribution of developmental stages at each observation point (24 hours, P less than .001; 48 hours, P less than .006; 72 hours, P less than .001); and (2) a difference in the average rank sums indicating a delay in maturation (P less than .005). In a second protocol group, pre-embryos were cultured in an equivalent amount of L-glucose; no impairment in development compared with controls was noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Does the severity of diabetic retinopathy predict pregnancy outcome?

The authors sought to determine whether the severity of diabetic retinopathy is a predictor of subsequent pregnancy outcome. One hundred and seventy-nine pregnant diabetic women were evaluated in their first trimester of pregnancy. Stereoscopic color photographs of the ocular fundus were taken and graded by the Fundus Photography Reading Center. Thirty-nine women had no retinopathy, while 28 had proliferative retinopathy in the worse eye. The women's history and hospital delivery room charts were reviewed with regard to pregnancy outcome. Thirty-three pregnancies terminated with an adverse outcome. A logistic regression analysis was used to evaluate significant predictors of pregnancy outcome. Of maternal age, duration of diabetes, glycosylated hemoglobin, proteinuria, cigarette smoking status, and severity of diabetic retinopathy, only the last variable significantly predicted an adverse outcome. These data suggest that the severity of retinopathy should be considered when counseling a pregnant diabetic woman.