Gestational diabetes mellitus

Gestational diabetes mellitus is associated with in vivo platelet activation and platelet hyperreactivity

BACKGROUND

Gestational diabetes mellitus is associated with obstetrical and long-term cardiovascular complications. Although platelet hyperresponsiveness in type-2 diabetes mellitus has been well characterized and has been shown to play a crucial role in cardiovascular complications, this aspect has been little studied in gestational diabetes mellitus.

OBJECTIVE

We aimed to evaluate platelet reactivity, in vivo platelet activation, and endothelial function in gestational diabetes mellitus in comparison with normal pregnancy.

STUDY DESIGN

This was a prospective, case-control study of 23 women with gestational diabetes mellitus and 23 healthy pregnant women who were studied at 26 to 28 and 34 to 36 weeks of gestation and at 8 weeks postpartum. Platelet reactivity and in vivo platelet activation, including light transmission aggregometry, PFA-100, platelet activation antigen expression, platelet adhesion under flow, platelet nitric oxide and reactive oxygen species production, and endothelial dysfunction markers, were assessed.

RESULTS

The study of platelet function showed a condition of platelet hyperreactivity in cases with gestational diabetes mellitus when compared with healthy pregnant women at enrollment, which was further enhanced at the end of pregnancy and tended to decrease 2 months after delivery, although it still remained higher in gestational diabetes mellitus. In vivo platelet activation was also evident in gestational diabetes mellitus, especially at the end of pregnancy, in part persisting up to 8 weeks after delivery. Finally, women with gestational diabetes mellitus showed defective platelet nitric oxide production and endothelial dysfunction when compared with healthy pregnancies.

CONCLUSION

Our data showed that gestational diabetes mellitus generates a condition of platelet hyperreactivity that in part persists up to 2 months after delivery. Impaired platelet sensitivity to nitric oxide and reduced platelet and endothelial nitric oxide production may contribute to the platelet hyperreactivity condition. Platelet hyperreactivity may play a role in the long-term cardiovascular complications of gestational diabetes mellitus women.

Glycoregulation During Pregnancy

Pregnancy is a period marked by profound changes in a woman’s hormonal status and metabolism, including the development of a carbohydrate-intolerant state. Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy.

The aim of this study was to estimate and analyse the parameters of glycaemic control during pregnancy. We stratified patients into the following three groups according to OGTT results: normal glucose tolerance (NTG), gestational impaired glucose tolerance (GIGT) and GDM.

We investigated 92 pregnant women, diagnosed with vital and desired pregnancy up to 12 weeks of gestation, who had signed informed consent forms. Among them, 7 pregnant women had a spontaneous abortion, while 8 pregnant women dropped out, so a total of 77 pregnant women completed the trial. Most of the women examined had no risk factors (48%), while 35% of the women had one risk factor. The current study demonstrates that normal glucose tolerance was shown in 59 (76.6%) participants, while some form of glucose intolerance (GIGT or GDM) was shown in 18 (23.4%) patients. Our findings revealed an increase in glucose intolerance with advancing pregnancy (in the second and third trimester). In conclusion, we demonstrate that the difference in the quality of glycaemic control during pregnancy is manifested in the second and third trimester, until it manifests in the first trimester. These findings underpin the clinical significance of discovering GDM.

The association between serum ghrelin levels and large-for-gestational-age fetuses in patients with gestational diabetes mellitus

We aimed to determine the relationship between serum ghrelin levels and large-for-gestational-age (LGA) fetuses in patients with gestational diabetes mellitus (GDM). A case-control study was conducted in 32 women with GDM and LGA fetuses (GDM + LGA group), 35 women with GDM and appropriate-for-gestational-age (AGA) fetuses (GDM + AGA group), 32 women with normal glucose tolerance (NGT) and LGA fetuses (NGT + LGA group), and 31 women with NGT and AGA fetuses (NGT + AGA group). All participants were recruited at the time of GDM diagnosis between 24 and 30 weeks of pregnancy. Participants also underwent ultrasonographic examinations. Serum ghrelin levels were significantly higher in GDM + LGA and GDM + AGA groups than in the NGT + AGA group. In the univariate model, biparietal diameter, head circumference, abdominal circumference (AC), femur length and ghrelin values were significant predictors of LGA fetuses. In the multivariate model, only AC remained as a predictor of LGA fetuses.

A nested case-control study indicating heavy metal residues in meconium associate with maternal gestational diabetes mellitus risk

BACKGROUND

Environmental pollutant exposure may play certain roles in the pathogenesis and progression of diabetes mellitus including gestational diabetes mellitus (GDM). We hypothesize that heavy metal exposure may trigger GDM during pregnancy. The objective of this study was to investigate the possible associations between selected heavy metal exposure and GDM risk.

METHODS

This investigation is a retrospective case-control study nested within a cohort of 1359 pregnant women. These participants were recruited in Xiamen Maternity and Child Care Hospital, China, during June to July, 2012. All their newborns' meconium samples were collected. By reviewing the antenatal care records, 166 GDM mothers were screened out from the 1359 participants; 137 of 166 GDM mothers offered their newborns' meconium samples for the metal analysis. Those 137 mothers were set as the case group. Similarly, 294 healthy mothers without any gestational complication were initially screened out from the rest 1193 non-GDM mothers. 190 of the 294 healthy mothers offered their newborns' meconium samples for the metal analysis. Those 190 mothers were set as the control group. Arsenic (As), mercury (Hg), lead (Pb), cadmium (Cd), and chromium (Cr) levels in these case-control meconium samples were measured by inductively coupled plasma mass spectrometry. The possible association between the metal levels and maternal GDM risk of studied subjects was assessed by binary logistic regression.

RESULTS

GDM prevalence of 12.21% was observed in the investigated 1359 participants. The concentrations of As, Hg, Cr and Cd in studied cases were significantly higher (p < 0.05) than those of controls. After adjustments for maternal age, pre-pregnant body mass index, gravidity, parity, hepatitis B virus infection, and newborn sex, As, Cd and Cr were found to be positively associated with GDM prevalence in dose-dependent manners. Among them, As was detected in all samples and its levels associated the maternal GDM with the adjusted odds ratios of 3.28 [95% CI 1.24, 8.71], 3.35 [95% CI 1.28, 8.75] and 5.25 [95% CI 1.99, 13.86] for the 2(nd), 3(rd) and 4(th) quartiles, respectively.

CONCLUSIONS

The present work implies that exposure to some of the selected metals (noticeably As) may contribute to maternal GDM risk during pregnancy.

Reasons for participation and non-participation in a diabetes prevention trial among women with prior gestational diabetes mellitus (GDM)

BACKGROUND

Gestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Lifestyle intervention can prevent progression to type 2 diabetes in high risk populations. We designed a randomised controlled trial (RCT) to evaluate the effectiveness of an established lifestyle intervention compared to standard care for delaying diabetes onset in European women with recent GDM. Recruitment into the RCT was more challenging than anticipated with only 89 of 410 (22%) women agreeing to participate. This paper identifies factors that could enhance participation of the target population in future interventions.

METHODS

We hypothesised that women who agreed to participate would have higher diabetes risk profiles than those who declined, and secondly that it would be possible to predict participation on the bases of those risk factors. To test our hypothesis, we identified the subset of women for whom we had comprehensive data on diabetes risks factors 3-5 years following GDM, reducing the sample to 43 participants and 73 decliners. We considered established diabetes risk factors: smoking, daily fruit and vegetable intake, participation in exercise, family history of diabetes, glucose values and BMI scores on post-partum re-screens, use of insulin during pregnancy, and age at delivery. We also analysed narrative data from 156 decliners to further understand barriers to and facilitators of participation.

RESULTS

Two factors differentiated participants and decliners: age at delivery (with women older than 34 years being more likely to participate) and insulin use during pregnancy (with women requiring the use of insulin in pregnancy less likely to participate). Binary logistic regression confirmed that insulin use negatively affected the odds of participation. The most significant barriers to participation included the accessibility, affordability and practicality of the intervention.

CONCLUSIONS

Women with recent GDM face multiple barriers to lifestyle change. Intervention designers should consider: (i) the practicalities of participation for this population, (ii) research designs that capitalise on motivational differences between participants, (iii) alleviating concerns about long-term diabetes management. We hope this work will support future researchers in developing interventions that are more relevant, effective and successful in recruiting the desired population.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41202110.

Pregnancy outcomes after metformin treatment for gestational diabetes: a case-control study

BACKGROUND

There is increasing evidence that metformin is safe and effective in the treatment of gestational diabetes (GDM), although it has not yet been widely accepted for routine practice. We compared pregnancy outcomes in women with gestational GDM treated with metformin or dietary measures alone.

METHODS

Women with GDM (324) not adequately controlled by diet received metformin according to protocol based on their home glucose results. Pregnancy outcomes in these women were compared with 175 GDM women treated with diet alone and matched for age and ethnicity.

RESULTS

The percentage of macrosomic babies (birth weight [BW] centile >90th centile) and small for gestational age (SGA) (BW <10th centile) in the metformin group was significantly reduced compared with the diet group (12.7% versus 20%; P < 0.05 [macrosomia]; 7.7% versus 14.3% [SGA] P < 0.05).

CONCLUSIONS

Metformin treatment had a favourable impact on the rates of macrosomia and SGA despite more severe glucose intolerance at baseline.

Metformin treatment for gestational diabetes

The prevalence of gestational diabetes mellitus (GDM) is rising as the pregnant population becomes older and more obese. This is concerning because GDM is associated with increased perinatal morbidity such as macrosomia and shoulder dystocia, and the need for instrumental delivery. In addition, the offspring of GDM women have increased long-term risks of obesity and type 2 diabetes. There is no doubt that treating women with GDM improves pregnancy outcomes. Conventionally this has been by diet and insulin. Although effective, insulin increases appetite leading to weight gain. It increases the risk of hypoglycaemia and needs to be given by injection. There is also a substantial cost in terms of time for teaching and educating patients. Metformin offers a logical alternative to insulin in GDM, by reducing insulin resistance. Recent trial evidence indicates it is safe and effective. We describe our experience with metformin in GDM and review the evidence.

Pregnancy outcomes in women with gestational diabetes treated with metformin or insulin: a case-control study

AIMS

To compare maternal and neonatal outcomes in women with gestational diabetes mellitus (GDM) treated with either metformin or insulin.

METHODS

One hundred and twenty-seven women with GDM not adequately controlled by dietary measures received metformin 500 mg twice daily initially. The dose was titrated to achieve target blood glucose values. Pregnancy outcomes in the 100 women who remained exclusively on metformin were compared with 100 women with GDM treated with insulin matched for age, weight and ethnicity.

RESULTS

There were no significant differences in baseline maternal risk factors. Women treated with insulin had significantly greater mean (sem) weight gain from enrolment to term (2.72 +/- 0.4 vs. 0.94 +/- 0.3 kg; P < 0.001). There was no difference between the metformin and insulin groups, respectively, comparing gestational hypertension (6 vs. 7%, P = 0.9), pre-eclampsia (9 vs. 2%, P = 0.06) induction of labour (26 vs. 24%, P = 0.87) or rate of Caesarean section (48 vs. 52%, P = 0.67). No perinatal loss occurred in either group. Neonatal morbidity was improved in the metformin group; prematurity (0 vs. 10%, P < 0.01), neonatal jaundice (8 vs. 30%, P < 0.01) and admission to neonatal unit (6 vs. 19%, P < 0.01). The incidence of macrosomia (birthweight centile > 90) was not significantly different [metformin (14%) vs. insulin (25%); P = 0.07].

CONCLUSIONS

Women with GDM treated with metformin and with similar baseline risk factors for adverse pregnancy outcomes had less weight gain and improved neonatal outcomes compared with those treated with insulin. Diabet. Med. 26, 798-802 (2009).

The mean platelet volume in gestational diabetes

OBJECTIVE

To compare the platelet count and mean platelet volume (MPV) values of pregnancies diagnosed with gestational diabetes with those of healthy pregnancies.

MATERIAL-METHOD

Between June 2003 and September 2004, 100 healthy pregnancies and 100 pregnancies with gestational diabetes were studied at Gazi University, Department of Obstetrics and Gynecology.

RESULTS

While no statistically significant difference was observed in the platelet count between the two groups, the MPV of the gestational diabetes group (9.4 +/- 1.6 fl) was evaluated to be significantly higher than the MPV of the healthy pregnancy group (8.3 +/- 1.1 fl). Additionally, when linear regression analysis was performed an inverse relationship was observed between platelet number and MPV.

CONCLUSION

There is a need for further research focusing on the platelet function in the observation and treatment of gestational diabetes, which can pose the risk of developing Type 2 diabetes for the mother and has negative consequences for the fetus.