Fibrinolytic dysfunction after gestation is associated to components of insulin resistance and early type 2 diabetes in latino women with previous gestational diabetes

Risk of type 2 diabetes mellitus after gestational diabetes mellitus: A systematic review & meta-analysis

Background &objectives:

Women with gestational diabetes are at an increased risk of being diagnosed as type 2 diabetes, but the postpartum screening rate is low. To provide evidence-based data for health providers and promote postpartum screening, this systematic review and meta-analysis was conducted to access the risks of type 2 diabetes mellitus (T2DM) diagnosis after gestational diabetes mellitus (GDM) in different demographic and maternal subgroups.

Methods:

MEDLINE, Embase and Cochrane Library were searched systematically. Unadjusted relative risks (RRs) and 95 per cent confidence intervals (CIs) were calculated and pooled using a random-effects model. Heterogeneity was assessed with Cochrane’s Q text and by calculating I² values. Subgroup analyses were conducted to address the disparities of type 2 diabetes conversion after gestational diabetes in different demographic and maternal subgroups.

Results:

1809 publications were screened and 39 cohort studies including 2,847,596 women were selected. In these studies, 78,893 women were diagnosed as T2DM at six weeks or later after delivery. The unadjusted RRs of women diagnosed T2DM at six weeks or later after delivery ranged from 1.32 (95% CI, 0.46-3.37) to 47.25 (95% CI, 2.95-758.01) with a pooled unadjusted RR of 8.92 (95% CI, 7.84-10.14). Older women, women with a family history of diabetes, Black and non-Hispanic White women and women living in Europe and South-East Asia had a higher risk of developing T2DM after GDM.

Interpretation & conclusionsxs:

It is suggested that healthcare providers may focus on older women with GDM and women with GDM and a family history of diabetes. Black and non-Hispanic White women with GDM may receive more attention, and healthcare providers, especially those in Europe and South-East Asia, may pay more attention to preventive measures for postpartum T2DM.

Long-term risk of diabetes in women at varying durations after gestational diabetes: a systematic review and meta-analysis with more than 2 million women

This study aims to investigate the impact of gestational diabetes mellitus (GDM) on the long-term risks of diabetes in women with prior GDM, including the effect at different time periods after GDM. We searched PubMed and other databases to retrieve articles which were published prior to February 28, 2017. Cohort studies which evaluated the risk and time of onset of diabetes postpartum in women with and without GDM were included. Meta-analysis with random effects models was used to obtain pooled relative risks and 95% confidence intervals for the risk of diabetes. Subgroup analyses were performed to check for different effect sizes as well as consistency across groups. Multivariable logistic regression was used to adjust for confounders. Thirty cohort studies with 2,626,905 pregnant women were included. Women with prior GDM had 7.76-fold (95% confidence intervals: 5.10-11.81) unadjusted pooled risk of diabetes as compared with women without GDM, whilst the adjusted risk was 17.92-fold (16.96-18.94). The adjusted ORs of GDM for diabetes among women at <3, ≥3 - <6 and ≥6 - <10 years after GDM were 5.37 (3.51-9.34), 16.55 (16.08-17.04) and 8.20 (4.53-14.86), respectively. Women with prior GDM had substantially increased risk of diabetes, with the risk highest during the 3-6 years after GDM.

Role of Plasminogen Activator Inhibitor Type 1 in Pathologies of Female Reproductive Diseases

Normal pregnancy is a state of hypercoagulability with diminishing fibrinolytic activity, which is mainly caused by an increase of plasminogen activator inhibitor type 1 (PAI-1). PAI-1 is the main inhibitor of plasminogen activators, including tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA). In human placentas, PAI-1 is expressed in extravillous interstitial trophoblasts and vascular trophoblasts. During implantation and placentation, PAI-1 is responsible for inhibiting extra cellular matrix (ECM) degradation, thereby causing an inhibition of trophoblasts invasion. In the present study, we have reviewed the literature of various reproductive diseases where PAI-1 plays a role. PAI-1 levels are increased in patients with recurrent pregnancy losses (RPL), preeclampsia, intrauterine growth restriction (IUGR), gestational diabetes mellitus (GDM) in the previous pregnancy, endometriosis and polycystic ovary syndrome (PCOS). In general, an increased expression of PAI-1 in the blood is associated with an increased risk for infertility and a worse pregnancy outcome. GDM and PCOS are related to the genetic role of the 4G/5G polymorphism of PAI-1. This review provides an overview of the current knowledge of the role of PAI-1 in reproductive diseases. PAI-1 represents a promising monitoring biomarker for reproductive diseases and may be a treatment target in the near future.

Prevention of type 2 diabetes mellitus in women with previous gestational diabetes mellitus

Gestational diabetes mellitus (GDM), defined as any degree of glucose intolerance with onset or first recognition during pregnancy, is characterized by underlying maternal defects in the β-cell response to insulin during pregnancy. Women with a previous history of GDM have a greater than 7-fold higher risk of developing postpartum diabetes compared with women without GDM. Various risk factors for postpartum diabetes have been identified, including maternal age, glucose levels in pregnancy, family history of diabetes, pre-pregnancy and postpartum body mass index, dietary patterns, physical activity, and breastfeeding. Genetic studies revealed that GDM shares common genetic variants with type 2 diabetes. A number of lifestyle interventional trials that aimed to ameliorate modifiable risk factors, including diet, exercise, and breastfeeding, succeeded in reducing the incidence of postpartum diabetes, weight retention, and other obesity-related morbidities. The present review summarizes the findings of previous studies on the incidence and risk factors of postpartum diabetes and discusses recent lifestyle interventional trials that attempted to prevent postpartum diabetes.

Clinical Recommendations for the Use of Islet Cell Autoantibodies to Distinguish Autoimmune and Non-Autoimmune Gestational Diabetes

Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. The prevalence of GDM is highly variable, depending on the population studied, and reflects the underlying pattern of diabetes in the population. GDM manifests by the second half of pregnancy and disappears following delivery in most cases, but is associated with the risk of subsequent diabetes development. Normal pregnancy induces carbohydrate intolerance to favor the availability of nutrients for the fetus, which is compensated by increased insulin secretion from the maternal pancreas. Pregnancy shares similarities with adiposity in metabolism to save energy, and both conditions favor the development of insulin resistance (IR) and low-grade inflammation. A highly complicated network of modified regulatory mechanisms may primarily affect carbohydrate metabolism by promoting autoimmune reactions to pancreatic β cells and affecting insulin function. As a result, diabetes development during pregnancy is facilitated. Depending on a pregnant woman's genetic susceptibility to diabetes, autoimmune mechanisms or IR are fundamental to the development autoimmune or non-autoimmune GDM, respectively. Pregnancy may facilitate the identification of women at risk of developing diabetes later in life; autoimmune and non-autoimmune GDM may be early markers of the risk of future type 1 and type 2 diabetes, respectively. The most convenient and efficient way to discriminate GDM types is to assess pancreatic β-cell autoantibodies along with diagnosing diabetes in pregnancy.

Is There a Tendency for Thrombosis in Gestational Diabetes Mellitus?

Context:

Impact of gestational diabetes mellitus (GDM) on the coagulation system, dynamics involved at a pathophysiological level and the exact mechanism remain unclear.

Aims:

To evaluate the association between diabetes-related parameters and hemostatic factors to search for a tendency of thrombosis in GDM.

Settings and Design:

Nineteen pregnant women who had GDM, 16 healthy pregnant and 13 healthy nonpregnant controls admitted to the Endocrinology outpatient clinics were enrolled in the study.

Subjects and Methods:

Fasting and postprandial glucose, hemoglobin A1c and insulin levels, and insulin resistance; fructosamine, thrombin activatable fibrinolysis inhibitor (TAFI), tissue factor pathway inhibitor (TFPI), plasminogen activator inhibitor Type-1 (PAI-1), tissue-type plasminogen activator (t-PA), fibrinogen, plasminogen and hemoglobin levels, platelet counts, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were studied.

Statistical Analysis Used:

One-way analysis of variance, Kruskal–Wallis, and post hoc Tukey honestly significant difference or Conover's nonparametric multiple comparison tests for comparison of the study groups.

Results:

PT and aPTT were significantly lower in GDM patients compared to controls (P < 0.05), whereas fibrinogen and plasminogen levels were significantly higher in this group compared to both nonpregnant and healthy pregnant controls (P < 0.05 for each). TAFI, TFPI, PAI-1, and tissue t-PA levels were not significantly different among groups.

Conclusions:

Our findings indicate tendency to develop thrombosis in GDM similar to diabetes mellitus; but more comprehensive studies with larger sample size are needed to determine the relationship between GDM and hemostasis.

Prevalence of Gestational Diabetes and Risk of Progression to Type 2 Diabetes: a Global Perspective

Despite the increasing epidemic of diabetes mellitus affecting populations at different life stages, the global burden of gestational diabetes mellitus (GDM) is not well assessed. Systematically synthesized data on global prevalence estimates of GDM are lacking, particularly among developing countries. The hyperglycemic intrauterine environment as exemplified in pregnancies complicated by GDM might not only reflect but also fuel the epidemic of type 2 diabetes mellitus (T2DM). We comprehensively reviewed available data in the past decade in an attempt to estimate the contemporary global prevalence of GDM by country and region. We reviewed the risk of progression from GDM to T2DM as well. Synthesized data demonstrate wide variations in both prevalence estimates of GDM and the risk of progression from GDM to T2DM. Direct comparisons of GDM burden across countries or regions are challenging given the great heterogeneity in screening approaches, diagnostic criteria, and underlying population characteristics. In this regard, collaborative efforts to estimate global GDM prevalence would be a large but important leap forward. Such efforts may have substantial public health implications in terms of informing health policy makers and healthcare providers for disease burden and for developing more targeted and effective diabetes prevention and management strategies globally.

Heterogeneity of cardiovascular risk factors profile in non-diabetic women 2-24 months post gestational diabetes mellitus

Previously gestational diabetic (pGDM) women are characterized by high cardiovascular risk (CVR). The aim of this study was to assess the CVR markers levels in non-diabetic pGDM women in relation to time postpartum and to soluble E-selectin (sES) level. We investigated 125 women aged 18-40 years with a history of GDM between 2 and 24 months after their pregnancy. We evaluated age, body mass index (BMI), waist circumference, glucose levels during the oral glucose tolerance test (OGTT), levels of insulin and the parameters of endothelial dysfunction, fibrinolysis activity, low-grade systemic inflammation and lipid profiles. Prediabetes was identified in 38 women (30%), while in the remaining women OGTT results were normal. The tests performed >6 months revealed decreased hs-CRP (p = 0.01), sICAM-1 (p = 0.01), and elevated sES (p = 0.01) >12 months after adjustment for age, BMI, waist circumference and 2 h OGTT glucose. In the subgroup tested ≤12 months after an index pregnancy sES was independently associated with hs-CRP (p < 0.0001) and triglycerides (p = 0.0139). No association was found between sES and remaining parameters in women tested >12 months postpartum. We conclude that the period 2-24 months post GDM is heterogeneous with respect to the CVR markers. The plasma level of hs-CRP could be useful as an important cardiovascular risk marker up to 12 months postpartum in non-diabetic pGDM women.

Lipoprotein-associated phospholipase A2 and AGEs are associated with cardiovascular risk factors in women with history of gestational diabetes mellitus

OBJECTIVE

Although most women with gestational diabetes mellitus (GDM) return to normal glucose tolerance after delivery, they have increased risk of cardiometabolic diseases. This study aimed to evaluate the relationships between plasma levels of Lp-pla2 and AGEs and cardiometabolic risk factors in women with GDM.

METHODS

190 women with GDM (cases) and 80 healthy women (controls) were enrolled. Demographic and clinical data were collected and analyzed about 2 years after the delivery.

RESULTS

Of the 190 cases, 19 (10%), 38 (20%) and 10 (5%) had type 2 diabetes mellitus, metabolic syndrome and hypertension after delivery, respectively. There were significant differences in variables between cases and controls: Lp-pla2 (pg/mL) 1991.5 ± 905.3 versus 1527.0 ± 799.8; AGEs (ng/mL) 403.0 ± 208.6 versus 321.8 ± 150.3. The plasma Lp-pla2 and AGEs levels were positively correlated with metabolic indexes in women with previous GDM.

CONCLUSION

Women with GDM have increased risk of cardiometabolic disease. AGEs and Lp-pla2 could be utilized as novel biomarkers to identify at an early stage of women with increased risk of metabolic and cardiovascular disease.

Adipokines and metabolic syndrome risk factors in women with previous gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has been recognized as a significant risk factor for metabolic syndrome and CVD. The aim of the study was to evaluate the relationships between levels of cytokines, components of metabolic syndrome and cardiovascular risk markers in women with previous gestational diabetes.

METHODS

Women (n = 41) with gestational diabetes background (cases) and 21 healthy women (controls) in the postpartum period were enrolled. Demographic and clinical data, lipid and carbohydrate metabolism and uric acid and adipokine levels (TNF-α, IL-6, leptin and adiponectin) were compared and their relationships analysed. Metabolic syndrome prevalence was calculated by WHO and NCEP-ATPIII definitions.

RESULTS

There were significant differences between cases and controls: body mass index (kg/m(2) ) 27.4 ± 5.6 vs 23.9 ± 3.6 (p = 0.013), waist circumference (cm) 85.2 ± 12.9 vs 77.5 ± 9.0 (p = 0.017), metabolic syndrome (WHO definition) 14.6% vs 0% (p = 0.012), metabolic syndrome (NCEP-ATPIII definition) 22% vs 0% (p = 0.002), low HDL 36.6% vs 9.5% (p = 0.024), fasting glucose (mmol/L) 5.4 ± 0.6 vs 4.9 ± 0.2 (p < 0.001), glucose 120' oral glucose tolerance test (mmol/L) 5.8 ± 1.7vs 4.7 ± 0.8 (p = 0.007), fasting insulin (μU/mL) 13.4 ± 8.1 vs 8.4 ± 4.3 (p = 0.004), HOMA index 3.3 ± 2.3 vs 1.8 ± 1.0 (p = 0.002), HbA(1c) (%) 5.4 ± 0.2 vs 5.2 ± 0.2 (p = 0.021), uric acid (mg/dL) 4.1 ± 1 vs 3.5 ± 0.6 (p = 0.009), leptin (ng/mL) 32 025.5 ± 19 917.3 vs 20 258.9 ± 16 359.9 (p = 0.023), respectively.

CONCLUSIONS

Women with previous gestational diabetes have central adiposity, atherogenic lipid profile, carbohydrate intolerance and adverse adipokine profile, all of which are risk factors for the future development of metabolic disease and CVD.

Triglycerides as an early pathophysiological marker of endothelial dysfunction in nondiabetic women with a previous history of gestational diabetes

OBJECTIVE

To investigate whether baseline triglyceride levels are associated with early glucose dysregulation and/or cardiovascular risk in women with a previous history of gestational diabetes.

DESIGN

Prospective postpregnancy cohort study.

SETTING

Polish university hospitals.

SAMPLE

Participants included 125 women with previous gestational diabetes and 40 women with normal glucose regulation during pregnancy.

METHODS

All women were studied 2-24 months (mean 12 ± 10 months) after the index pregnancy. Women with previous gestational diabetes were divided into tertiles in accordance with baseline triglyceride levels.

MAIN OUTCOME MEASURES

We assessed glucose regulation (oral glucose tolerance test), insulin resistance (homeostasis model assessment), markers of endothelial dysfunction (soluble: intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, tissue plasminogen activator antigen, von Willebrand factor antigen), fibrinolysis (plasminogen activator inhibitor antigen), inflammation (high-sensitivity C-reactive protein) and lipid levels.

RESULTS

Women with previous gestational diabetes (78% normal glucose regulation, 22% impaired glucose tolerance) had a high cardiometabolic risk profile compared with control women (100% normal glucose regulation). Baseline triglycerides >0.83 mmol/l were associated with a higher prevalence of impaired glucose tolerance, higher high-sensitivity C-reactive protein and triglyceride/high-density lipoprotein-cholesterol ratio. Triglycerides >1.22 mmol/l were associated with higher body fat indexes, higher insulin resistance, higher levels of endothelial dysfunction biomarkers, higher plasminogen activator inhibitor antigen and dyslipidemia. Only E-selectin was independently associated with triglyceride levels.

CONCLUSIONS

Baseline triglyceride levels are a cardiovascular risk marker as well as a pathophysiological parameter independently associated with endothelial dysfunction in nondiabetic women with previous gestational diabetes at 2-24 months after an index pregnancy. Normalization of triglycerides should be included in preventive therapy after a pregnancy complicated by gestational diabetes.

Racial differences in the association between gestational diabetes mellitus and risk of type 2 diabetes

BACKGROUND

It is recognized that a history of gestational diabetes mellitus (GDM) predicts incident type 2 diabetes in women. However, it is unclear if there is a racial disparity between the association of GDM and type 2 diabetes.

METHODS

We studied 1,142 women with a history of GDM and 18,856 women without a history of GDM aged 13-50 years with their first record of pregnancy in Louisiana State University Hospital-Based Longitudinal Study database between 1990 and 2009. History of GDM was used to predict incident type 2 diabetes.

RESULTS

During a mean follow-up of 8.6 years, 1,394 women developed type 2 diabetes. The multivariable adjusted hazard ratio (HR) of type 2 diabetes was 6.52 (95% confidence interval [CI] 5.73-7.43) among women with GDM compared to women without GDM. Stratification by age, race, and body mass index (BMI) gave similar results. Compared with African American and white women without a history of GDM, the relative risk for type 2 diabetes was higher in African American women than in white women with a history of GDM. Compared with non-GDM women compartments, GDM women after delivery for <1, 1.0-3.9, 4.0-5.9, 6.0-7.9, 8-9.9, and ≥10.0 years had 4.00, 5.44, 4.26, 3.16, 4.49, and 4.17 times higher risk of having type 2 diabetes, respectively.

CONCLUSIONS

A history of GDM is a strong predictor of subsequent type 2 diabetes among Louisiana women, especially among African American women.

Elevation of sE-Selectin Levels 2-24 Months following Gestational Diabetes Is Associated with Early Cardiometabolic Risk in Nondiabetic Women

Objective. We hypothesised that the endothelial dysfunction is associated with early glucose dysregulation and/or atherosclerosis risk factors in nondiabetic women with a previous history of gestational diabetes (pGDM). Material/Methods. Anthropometric parameters, glucose regulation (OGTT), insulin resistance (HOMA), lipids, biomarkers of endothelial dysfunction, and inflammation were evaluated in 85 women with pGDM and in 40 controls 2-24 months postpartum. Results. The pGDM group consisted of 67% normoglycemic women (pGDM-N) and 33% with prediabetic state (pGDM-P). The BMI, waist circumference, fasting and 2 h glucose (OGTT), soluble adhesion molecules, tissue plasminogen activator antigen, high sensitivity C-reactive protein, total-, LDL-cholesterol, and triglycerides/HDL-cholesterol ratio were higher in the pGDM women compared with the controls. After adjustment for BMI and fasting glucose, only higher triglycerides, higher TG/HDL and lower HDL-cholesterol were associated with pGDM. The pGDM-P differed from pGDM-N for only higher triglycerides and TG/HDL. The plasma level of sE-selectin was not independently associated with glucose concentration in pGDM group. sE-selectin level correlated with triglycerides, TG/HDL, plasminogen activator inhibitor-1 antigen, and sICAM-1. Conclusions. sE-selectin level correlated with components of metabolic syndrome, but only the atherogenic lipid profile was independently associated with a previous history of GDM in nondiabetic women 2-24 months postpartum.

Plasma thrombin-activatable fibrinolysis inhibitor levels are not associated with glucose intolerance and subclinical atherosclerosis in women with previous gestational diabetes

We aimed to determine plasma thrombin-activatable fibrinolysis inhibitor (TAFI) antigen levels in women with previous gestational diabetes mellitus (GDM) and to evaluate the possible association of plasma TAFI with glucose intolerance and markers of subclinical atherosclerosis. This cross-sectional study was performed in 111 women with previous GDM and 60 controls. Glucose intolerance was evaluated. Homeostasis model assessment score was calculated. Circulating lipids, interleukin-6, matrix metalloproteinase-1, fibrinogen, plasminogen activator inhibitor-1, and TAFI antigen levels were assayed. Carotid intima media thickness (IMT) was measured. Women with previous GDM had increased levels of atherosclerosis markers and carotid IMT. On the other hand, plasma TAFI antigen levels were similar (P = .395). Thrombin-activatable fibrinolysis inhibitor was not associated with the indices of insulin resistance, glucose intolerance, markers of atherosclerosis, and carotid IMT. Our data demonstrated that plasma TAFI was not altered in women with previous GDM. TAFI was not associated with glucose intolerance and subclinical atherosclerosis.

Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis

BACKGROUND

Women with gestational diabetes are at increased risk of developing type 2 diabetes, but the risk and time of onset have not been fully quantified. We therefore did a comprehensive systematic review and meta-analysis to assess the strength of association between these conditions and the effect of factors that might modify the risk.

METHODS

We identified cohort studies in which women who had developed type 2 diabetes after gestational diabetes were followed up between Jan 1, 1960, and Jan 31, 2009, from Embase and Medline. 205 relevant reports were hand searched. We selected 20 studies that included 675 455 women and 10 859 type 2 diabetic events. We calculated and pooled unadjusted relative risks (RRs) with 95% CIs for each study using a random-effects model. Subgroups analysed were the number of cases of type 2 diabetes, ethnic origin, duration of follow-up, maternal age, body-mass index, and diagnostic criteria.

FINDINGS

Women with gestational diabetes had an increased risk of developing type 2 diabetes compared with those who had a normoglycaemic pregnancy (RR 7.43, 95% CI 4.79-11.51). Although the largest study (659 164 women; 9502 cases of type 2 diabetes) had the largest RR (12.6, 95% CI 12.15-13.19), RRs were generally consistent among the subgroups assessed.

INTERPRETATION

Increased awareness of the magnitude and timing of the risk of type 2 diabetes after gestational diabetes among patients and clinicians could provide an opportunity to test and use dietary, lifestyle, and pharmacological interventions that might prevent or delay the onset of type 2 diabetes in affected women.

FUNDING

None.

Serum osteoprotegerin is associated with carotid intima media thickness in women with previous gestational diabetes

Circulating levels of osteoprotegerin (OPG) have been shown to be increased in patients with cardiovascular disorders and diabetes. The aim of this study was to determine serum OPG levels in women with previous gestational diabetes (GDM), and to investigate the relationship between OPG and carotid intima media thickness (IMT) and circulating cardiovascular risk factors. Serum OPG was measured in 46 women with previous GDM and 30 age-matched healthy controls. Carotid IMT was evaluated. Serum lipid, insulin and hsCRP levels, plasma fibrinogen, vWF and PAI-1 levels were measured. Serum OPG levels tended to be increased in women with previous GDM (p=0.058). Carotid IMT was increased in the study group. Women with previous GDM had elevated levels of hsCRP and PAI-1. OPG levels were positively correlated with age, fasting and post-load glucose levels, hsCRP, and carotid IMT. Multiple regression analysis showed that serum OPG was a statistically significant predictor for elevated carotid IMT. Our results revealed that OPG levels tended to be elevated in women with previous GDM. Significant association of OPG with carotid IMT suggested that OPG might play a role in the pathogenesis of endothelial dysfunction in women with previous GDM.