1
|
Paschou SA, Shalit A, Gerontiti E, Athanasiadou KI, Kalampokas T, Psaltopoulou T, Lambrinoudaki I, Anastasiou E, Wolffenbuttel BHR, Goulis DG. Efficacy and safety of metformin during pregnancy: an update. Endocrine 2024; 83:259-269. [PMID: 37798604 PMCID: PMC10850184 DOI: 10.1007/s12020-023-03550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/23/2023] [Indexed: 10/07/2023]
Abstract
During the last decades, gestational diabetes mellitus (GDM) prevalence has been on the rise. While insulin remains the gold standard treatment for GDM, metformin use during pregnancy is controversial. This review aimed to comprehensively assess the available data on the efficacy and safety of metformin during pregnancy, both for the mother and the offspring. Metformin has been validated for maternal efficacy and safety, achieving comparable glycemic control with insulin. Additionally, it reduces maternal weight gain and possibly the occurrence of hypertensive disorders. During the early neonatal period, metformin administration does not increase the risk of congenital anomalies or other major adverse effects, including lower APGAR score at 5 min, neonatal intensive care unit admissions, and respiratory distress syndrome. Several studies have demonstrated a reduction in neonatal hypoglycemia. Metformin has been associated with an increase in preterm births and lower birth weight, although this effect is controversial and depends on the indication for which it was administered. Evidence indicates possible altered fetal programming and predisposition to childhood obesity and metabolic syndrome during adulthood after use of metformin in pregnancy. With critical questions still requiring a final verdict, ongoing research on the field must be conducted.
Collapse
Affiliation(s)
- Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Almog Shalit
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Gerontiti
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kleoniki I Athanasiadou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Kalampokas
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
2
|
Du Y, Zhu J, Guo Z, Wang Z, Wang Y, Hu M, Zhang L, Yang Y, Wang J, Huang Y, Huang P, Chen M, Chen B, Yang C. Metformin adverse event profile: a pharmacovigilance study based on the FDA Adverse Event Reporting System (FAERS) from 2004 to 2022. Expert Rev Clin Pharmacol 2024; 17:189-201. [PMID: 38269492 DOI: 10.1080/17512433.2024.2306223] [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: 09/19/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Metformin has the potential for treating numerous diseases, but there are still many unrecognized and unreported adverse events (AEs). METHODS We selected data from the United States FDA Adverse Event Reporting System (FAERS) database from the first quarter (Q1) of 2004 to the fourth quarter (Q4) of 2022 for disproportionality analysis to assess the association between metformin and related adverse events. RESULTS In this study 10,500,295 case reports were collected from the FAERS database, of which 56,674 adverse events related to metformin were reported. A total of 643 preferred terms (PTs) and 27 system organ classes (SOCs) that were significant disproportionality conforming to the four algorithms simultaneously were included. The SOCs included metabolic and nutritional disorders (p = 0.00E + 00), gastrointestinal disorders (p = 0.00E + 00) and others. PT levels were screened for adverse drug reaction (ADR) signals such as acute pancreatitis (p = 0.00E + 00), melas syndrome, pemphigoid (p = 0.00E + 00), skin eruption (p = 0.00E + 00) and drug exposure during pregnancy (p = 0.00E + 00). CONCLUSION Most of our results were consistent with the specification, but some new signals of adverse reactions such as acute pancreatitis were not included. Therefore, further studies are needed to validate unlabeled adverse reactions and provide important support for clinical monitoring and risk identification of metformin.
Collapse
Affiliation(s)
- Yikuan Du
- Central Laboratory, The Tenth Affiliated Hospital of Southern Medical University, Dongguan, People's Republic of China
| | - Jinfeng Zhu
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Zhuoming Guo
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Zhenjie Wang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Yuni Wang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Mianda Hu
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Lingzhi Zhang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Yurong Yang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Jinjin Wang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Yixing Huang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Peiying Huang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Mianhai Chen
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Bo Chen
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Chun Yang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| |
Collapse
|
3
|
Ryssdal M, Vanky E, Stokkeland LMT, Jarmund AH, Steinkjer B, Løvvik TS, Madssen TS, Iversen AC, Giskeødegård GF. Immunomodulatory Effects of Metformin Treatment in Pregnant Women With PCOS. J Clin Endocrinol Metab 2023; 108:e743-e753. [PMID: 36916886 PMCID: PMC10438881 DOI: 10.1210/clinem/dgad145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/15/2023]
Abstract
CONTEXT Polycystic ovary syndrome (PCOS) is a common endocrine disorder associated with low-grade systemic inflammation and increased risk of pregnancy complications. Metformin treatment reduces the risk of late miscarriage and preterm birth in pregnant women with PCOS. Whether the protective effect of metformin involves immunological changes has not been determined. OBJECTIVE To investigate the effect of metformin on the maternal immunological status in women with PCOS. METHODS A post-hoc analysis was performed of two randomized controlled trials, PregMet and PregMet2, including longitudinal maternal serum samples from 615 women with PCOS. Women were randomized to metformin or placebo from first trimester to delivery. Twenty-two cytokines and C-reactive protein were measured in serum sampled at gestational weeks 5 to 12, 19, 32, and 36. RESULTS Metformin treatment was associated with higher serum levels of several multifunctional cytokines throughout pregnancy, with the strongest effect on eotaxin (P < .001), interleukin-17 (P = .03), and basic fibroblast growth factor (P = .04). Assessment of the combined cytokine development confirmed the impact of metformin on half of the 22 cytokines. The immunomodulating effect of metformin was more potent in normal weight and overweight women than in obese women. Moreover, normoandrogenic women had the strongest effect of metformin in early pregnancy, whereas hyperandrogenic women presented increasing effect throughout pregnancy. CONCLUSION It appears that metformin has immunomodulating rather than anti-inflammatory properties in pregnancy. Its effect on the serum levels of many multifunctional cytokines demonstrates robust, persisting, and body mass-dependent immune mobilization in pregnant women with PCOS.
Collapse
Affiliation(s)
- Mariell Ryssdal
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Live Marie T Stokkeland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Anders Hagen Jarmund
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Bjørg Steinkjer
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Tone Shetelig Løvvik
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Torfinn Støve Madssen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Ann-Charlotte Iversen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway
- Centre of Molecular Inflammation Research (CEMIR), Norwegian University of Science and Technology, 7491 Trondheim, Norway
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Guro F Giskeødegård
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| |
Collapse
|
4
|
Dutta S, Shah RB, Singhal S, Dutta SB, Bansal S, Sinha S, Haque M. Metformin: A Review of Potential Mechanism and Therapeutic Utility Beyond Diabetes. Drug Des Devel Ther 2023; 17:1907-1932. [PMID: 37397787 PMCID: PMC10312383 DOI: 10.2147/dddt.s409373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/10/2023] [Indexed: 07/04/2023] Open
Abstract
Metformin has been designated as one of the most crucial first-line therapeutic agents in the management of type 2 diabetes mellitus. Primarily being an antihyperglycemic agent, metformin also has a plethora of pleiotropic effects on various systems and processes. It acts majorly by activating AMPK (Adenosine Monophosphate-Activated Protein Kinase) in the cells and reducing glucose output from the liver. It also decreases advanced glycation end products and reactive oxygen species production in the endothelium apart from regulating the glucose and lipid metabolism in the cardiomyocytes, hence minimizing the cardiovascular risks. Its anticancer, antiproliferative and apoptosis-inducing effects on malignant cells might prove instrumental in the malignancy of organs like the breast, kidney, brain, ovary, lung, and endometrium. Preclinical studies have also shown some evidence of metformin's neuroprotective role in Parkinson's disease, Alzheimer's disease, multiple sclerosis and Huntington's disease. Metformin exerts its pleiotropic effects through varied pathways of intracellular signalling and exact mechanism in the majority of them remains yet to be clearly defined. This article has extensively reviewed the therapeutic benefits of metformin and the details of its mechanism for a molecule of boon in various conditions like diabetes, prediabetes, obesity, polycystic ovarian disease, metabolic derangement in HIV, various cancers and aging.
Collapse
Affiliation(s)
- Siddhartha Dutta
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Rima B Shah
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Shubha Singhal
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Sudeshna Banerjee Dutta
- Department of Medical Surgical Nursing, Shri Anand Institute of Nursing, Rajkot, Gujarat, 360005, India
| | - Sumit Bansal
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Susmita Sinha
- Department of Physiology, Khulna City Medical College and Hospital, Khulna, Bangladesh
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| |
Collapse
|
5
|
Semertzidou A, Grout-Smith H, Kalliala I, Garg A, Terzidou V, Marchesi J, MacIntyre D, Bennett P, Tsilidis K, Kyrgiou M. Diabetes and anti-diabetic interventions and the risk of gynaecological and obstetric morbidity: an umbrella review of the literature. BMC Med 2023; 21:152. [PMID: 37072764 PMCID: PMC10114404 DOI: 10.1186/s12916-023-02758-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/27/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Diabetes has reached epidemic proportions in recent years with serious health ramifications. The aim of this study was to evaluate the strength and validity of associations between diabetes and anti-diabetic interventions and the risk of any type of gynaecological or obstetric conditions. METHODS Design: Umbrella review of systematic reviews and meta-analyses. DATA SOURCES PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, manual screening of references. ELIGIBILITY CRITERIA Systematic reviews and meta-analyses of observational and interventional studies investigating the relationship between diabetes and anti-diabetic interventions with gynaecological or obstetric outcomes. Meta-analyses that did not include complete data from individual studies, such as relative risk, 95% confidence intervals, number of cases/controls, or total population were excluded. DATA ANALYSIS The evidence from meta-analyses of observational studies was graded as strong, highly suggestive, suggestive or weak according to criteria comprising the random effects estimate of meta-analyses and their largest study, the number of cases, 95% prediction intervals, I2 heterogeneity index between studies, excess significance bias, small study effect and sensitivity analysis using credibility ceilings. Interventional meta-analyses of randomised controlled trials were assessed separately based on the statistical significance of reported associations, the risk of bias and quality of evidence (GRADE) of included meta-analyses. RESULTS A total of 117 meta-analyses of observational cohort studies and 200 meta-analyses of randomised clinical trials that evaluated 317 outcomes were included. Strong or highly suggestive evidence only supported a positive association between gestational diabetes and caesarean section, large for gestational age babies, major congenital malformations and heart defects and an inverse relationship between metformin use and ovarian cancer incidence. Only a fifth of the randomised controlled trials investigating the effect of anti-diabetic interventions on women's health reached statistical significance and highlighted metformin as a more effective agent than insulin on risk reduction of adverse obstetric outcomes in both gestational and pre-gestational diabetes. CONCLUSIONS Gestational diabetes appears to be strongly associated with a high risk of caesarean section and large for gestational age babies. Weaker associations were demonstrated between diabetes and anti-diabetic interventions with other obstetric and gynaecological outcomes. TRIAL REGISTRATION Open Science Framework (OSF) (Registration https://doi.org/10.17605/OSF.IO/9G6AB ).
Collapse
Affiliation(s)
- Anita Semertzidou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Harriet Grout-Smith
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Ilkka Kalliala
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Akanksha Garg
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Vasso Terzidou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Julian Marchesi
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- School of Biosciences, Cardiff University, Cardiff, UK
| | - David MacIntyre
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Phillip Bennett
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Konstantinos Tsilidis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
| |
Collapse
|
6
|
Hummel M, Füchtenbusch M, Battefeld W, Bührer C, Groten T, Haak T, Kainer F, Kautzky-Willer A, Lechner A, Meissner T, Nagel-Reuper C, Schäfer-Graf U, Siegmund T. Diabetes and Pregnancy. Exp Clin Endocrinol Diabetes 2023; 131:4-12. [PMID: 36626920 DOI: 10.1055/a-1946-3648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Michael Hummel
- Internal Medicine Group Practice and Diabetological Practice, Rosenheim, Germany.,Research Group Diabetes e.V. at Helmholtz Center Munich, Munich, Germany
| | - Martin Füchtenbusch
- Research Group Diabetes e.V. at Helmholtz Center Munich, Munich, Germany.,Diabetes Center am Marienplatz Munich, Munich, Germany
| | - Wilgard Battefeld
- Diabetology and Endocrinology, Medical Care Center Kempten-Allgäu, Kempten, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Medical University of Berlin, Berlin, Germany
| | - Tanja Groten
- Department of Obstetrics and Maternal Health, University Hospital Jena, Jena, Germany
| | - Thomas Haak
- Diabetes Center Mergentheim, Bad Mergentheim, Germany
| | - Franz Kainer
- Department of Obstetrics and Prenatal Medicine, Hallerwiese Hospital, Nuremberg, Germany
| | | | - Andreas Lechner
- Department of Internal Medicine IV, Diabetes Center, Ludwigs-Maximilians-University Munich, Munich, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Ute Schäfer-Graf
- Berlin Diabetes Center for Pregnant Women, St. Joseph Hospital Berlin Tempelhof, Berlin, Germany
| | - Thorsten Siegmund
- Diabetes, Hormone, and Metabolism Center, Private Practice at Isar Clinic, Munich, Germany
| |
Collapse
|
7
|
Abolhassani N, Winterfeld U, Kaplan YC, Jaques C, Minder Wyssmann B, Del Giovane C, Panchaud A. Major malformations risk following early pregnancy exposure to metformin: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2023; 11:11/1/e002919. [PMID: 36720508 PMCID: PMC9890805 DOI: 10.1136/bmjdrc-2022-002919] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 01/20/2023] [Indexed: 02/02/2023] Open
Abstract
Metformin is considered as first-line treatment for type 2 diabetes and an effective treatment for polycystic ovary syndrome (PCOS). However, evidence regarding its safety in pregnancy is limited. We conducted a systematic review and meta-analysis of major congenital malformations (MCMs) risk after first-trimester exposure to metformin in women with PCOS and pregestational diabetes mellitus (PGDM). Randomized controlled trials (RCTs) and observational cohort studies with a control group investigating risk of MCM after first-trimester pregnancy exposure to metformin were searched until December 2021. ORs and 95% CIs were calculated separately according to indications and study type using Mantel-Haenszel method; outcome data were combined using random-effects model. Eleven studies (two RCTs; nine observational cohorts) met the inclusion criteria: four included pregnant women with PCOS, four included those with PGDM and three evaluated both indications separately and were considered in both indication groups. In PCOS group, there were two RCTs (57 exposed, 52 control infants) and five observational studies (472 exposed, 1892 control infants); point estimates for MCM rates in RCTs and observational studies were OR 0.93 (95% CI 0.09 to 9.21) (I2=0%; Q test=0.31; p value=0.58) and OR 1.35 (95% CI 0.37 to 4.90) (I2=65%; Q test=9.43; p value=0.05), respectively. In PGDM group, all seven studies were observational (1122 exposed, 1851 control infants); the point estimate for MCM rates was OR 1.05 (95% CI 0.50 to 2.18) (I2=59%; Q test=16.34; p value=0.01). Metformin use in first-trimester pregnancy in women with PCOS or PGDM do not meaningfully increase the MCM risk overall. However, further studies are needed to characterize residual safety concerns.
Collapse
Affiliation(s)
- Nazanin Abolhassani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Ursula Winterfeld
- Service de Pharmacologie Clinique, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Yusuf C Kaplan
- Izmir University of Economics, School of Medicine, Izmir University of Economics, Izmir, Turkey
| | - Cécile Jaques
- Lausanne University Hospital and University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Beatrice Minder Wyssmann
- Public Health & Primary Care Library, University Library of Bern, University of Bern, University of Bern, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, University of Bern, Bern, Switzerland
| | - Alice Panchaud
- Primary Care Pharmacy, Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland, University of Bern, Bern, Switzerland
- Materno-fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant", University Hospital, Lausanne, Switzerland, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
8
|
Verma V, Mehendale AM. A Review on the Use of Metformin in Pregnancy and Its Associated Fetal Outcomes. Cureus 2022; 14:e30039. [PMID: 36381747 PMCID: PMC9637404 DOI: 10.7759/cureus.30039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
A commonly used first-line anti-diabetic medication, metformin, has been used in pregnancy. The drug is known to have specific effects on different organs around the body. One of these organs includes the ovaries. Therefore, for more than 40 years, it has often been prescribed for maternal obesity along with gestational diabetes mellitus. Untreated pregnancies like these frequently result in complications for both the mother and the fetus, like macrosomia, pregnancy-induced hypertension, obstructed labor, stillbirths, and perinatal deaths. In addition, there is also evidence that these mothers tend to develop type II diabetes mellitus during their pregnancy and even a few years post-delivery. These complications can be controlled or even reduced with the help of metformin, sometimes combining it with insulin or clomiphene citrate if required. There is still a need to cautiously prescribe the drug by outweighing its benefits against the risk associated with it. The current research on the subject leans more towards the benefits offered to the mother during pregnancy. Only a few randomized, controlled trials have been conducted on the fetal condition after the mother has been administered metformin. Furthermore, these studies lack the appropriate sample size and long-term follow-up on these metformin-exposed offspring. As a result, there are no reliable data available to clinicians and physicians about the drug. Owing to its benefits in certain pregnancies, it is less likely that the drug will cease to be prescribed. Therefore, it becomes increasingly imperative to conduct more research on this topic to ensure the drug is safe for the mother and the offspring.
Collapse
|
9
|
Hummel M, Füchtenbusch M, Battefeld W, Bührer C, Groten T, Haak T, Kainer F, Kautzky-Willer A, Lechner A, Meissner T, Nagel-Reuper C, Schäfer-Graf U, Siegmund T. Diabetes und Schwangerschaft. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1901-0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michael Hummel
- Internistische Gemeinschaftspraxis und Diabetologische Schwerpunktpraxis, Rosenheim, Deutschland
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
| | - Martin Füchtenbusch
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
- Diabeteszentrum am Marienplatz München, München, Deutschland
| | - Wilgard Battefeld
- Diabetologie und Endokrinologie, Medizinisches Versorgungszentrum Kempten-Allgäu, Kempten, Deutschland
| | - Christoph Bührer
- Klinik für Neonatologie, Charité -Universitätsmedizin Berlin, Berlin, Deutschland
| | - Tanja Groten
- Geburtsmedizin und maternale Gesundheit, Universitätsklinikum Jena, Jena, Deutschland
| | - Thomas Haak
- Diabetes Zentrum Mergentheim, Bad Mergentheim, Deutschland
| | - Franz Kainer
- Abteilung für Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg, Deutschland
| | | | - Andreas Lechner
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
- Medizinische Klinik und Poliklinik IV, Diabeteszentrum, Ludwigs-Maximilians-Universität München, München, Deutschland
| | - Thomas Meissner
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | | | - Ute Schäfer-Graf
- Berliner Diabetes Zentrum für Schwangere, St. Joseph Krankenhaus Berlin Tempelhof, Berlin, Deutschland
| | - Thorsten Siegmund
- Diabetes-, Hormon-, und Stoffwechselzentrum, Privatpraxis am Isar Klinikum, München, Deutschland
| |
Collapse
|
10
|
Favilli A, Mattei Gentili M, Raspa F, Giardina I, Parazzini F, Vitagliano A, Borisova AV, Gerli S. Effectiveness and safety of available treatments for COVID-19 during pregnancy: a critical review. J Matern Fetal Neonatal Med 2022; 35:2174-2187. [PMID: 32508168 PMCID: PMC7284138 DOI: 10.1080/14767058.2020.1774875] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND COVID-19 is a pandemic disease caused by the SARS-CoV-2 and it spread globally in the last few months. The complete lack of specific treatment forced clinicians to use old drugs, chosen for their efficacy against similar viruses or their in vitro activity. Trials on patients are ongoing but the majority of information comes from small case series and single center reports. We aimed to provide a literature review on the putative effectiveness and safety of available treatments for COVID-19 in pregnant women. METHODS We reviewed all the available literature concerning the drugs that have been used in the treatment of COVID-19 during pregnancy and whose safe assumption during pregnancy had been demonstrated by clinical studies (i.e. including studies on other infectious diseases). Drugs contra-indicated during pregnancy or with unknown adverse effects were not included in our review. RESULTS AND CONCLUSIONS Clinical trials are not often conducted among pregnant patients for safety reasons and this means that drugs that may be effective in general population cannot be used for pregnant women due to the lack of knowledge of side effects in this category of people .The choice to use a specific drug for COVID-19 in pregnancy should take into account benefits and possible adverse events in each single case. In the current situation of uncertainty and poor knowledge about the management of COVID-19 during pregnancy, this present overview may provide useful information for physicians with practical implications.
Collapse
Affiliation(s)
| | - Marta Mattei Gentili
- Department of Surgical and Biochemical
Sciences, Centre of Perinatal and Reproductive Medicine, University of
Perugia, Perugia, Italy
| | - Francesca Raspa
- Department of Surgical and Biochemical
Sciences, Centre of Perinatal and Reproductive Medicine, University of
Perugia, Perugia, Italy
| | - Irene Giardina
- Department of Surgical and Biochemical
Sciences, Centre of Perinatal and Reproductive Medicine, University of
Perugia, Perugia, Italy
| | - Fabio Parazzini
- Fondazione IRCCS Cà Granda, Dipartimento
Materno-Infantile, Ospedale Maggiore Policlinico, Università degli Studi di Milano,
Dipartimento di Scienze Cliniche e di Comunità, Universita' di Milano,
Milan, Italy
| | - Amerigo Vitagliano
- Department of Women’s and Children’s Health,
University of Padua, Padova, Italy
| | - Anna V. Borisova
- Department of Obstetrics and Gynecology with
the Course of Perinatology, Peoples Friendship University of Russia (RUDN
University), Moscow, Russian Federation
| | - Sandro Gerli
- Department of Surgical and Biochemical
Sciences, Centre of Perinatal and Reproductive Medicine, University of
Perugia, Perugia, Italy
| |
Collapse
|
11
|
Phillips J, Akemann C, Shields JN, Wu CC, Meyer DN, Baker BB, Pitts DK, Baker TR. Developmental phenotypic and transcriptomic effects of exposure to nanomolar levels of metformin in zebrafish. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2021; 87:103716. [PMID: 34311114 PMCID: PMC8446320 DOI: 10.1016/j.etap.2021.103716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 05/06/2023]
Abstract
Metformin is found in the majority of lakes and streams in the United States, leading to widespread environmental exposure. Results of the present study indicate that extended duration metformin exposure at critical developmental periods leads to decreased survival rates in zebrafish (danio rerio), an NIH approved human model. Significant abnormalities are seen with extended duration metformin exposure from 4 h post fertilization up to 5 days post fertilization, although short term metformin exposure for 24 h at 4-5 days post fertilization did not lead to any significant abnormalities. Both extended and short term duration did however have an impact on locomotor activity of zebrafish, and several genes involved in neurological and cardiovascular development were differentially expressed after exposure to metformin. The changes seen in behavior, gene expression and morphological abnormalities caused by metformin exposure should be examined further in future studies in order to assess their potential human health implications as metformin prescriptions continue to increase worldwide.
Collapse
Affiliation(s)
- Jessica Phillips
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA
| | - Camille Akemann
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA
| | - Jeremiah N Shields
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA
| | - Chia-Chen Wu
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA
| | - Danielle N Meyer
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA
| | - Bridget B Baker
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA
| | - David K Pitts
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Tracie R Baker
- Institute of Environmental Health Sciences, Wayne State University, 6135 Woodward Ave, Detroit, MI, 48202, USA; Department of Pharmacology, Wayne State University, 540 E Canfield, Detroit, MI, 28201, USA.
| |
Collapse
|
12
|
Metformin ameliorates maternal high-fat diet-induced maternal dysbiosis and fetal liver apoptosis. Lipids Health Dis 2021; 20:100. [PMID: 34496884 PMCID: PMC8424801 DOI: 10.1186/s12944-021-01521-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/11/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The deleterious effect of maternal high-fat diet (HFD) on the fetal rat liver may cause later development of non-alcoholic fatty liver disease (NAFLD). The aim of this study was to evaluate the effect of maternal HFD-induced maternal hepatic steatosis and dysbiosis on the fetal liver and intestines, and the effect of prenatal metformin in a rat model. METHODS Sprague-Dawley rats were assigned to three groups (N = 6 in each group). Before mating, the rats were randomly assigned to HFD or normal-chow diet (NCD) group for 7 weeks. After mating, the HFD group rats were continued with high-fat diet during pregnancy and some of the HFD group rats were co-treated with metformin (HFMf) via drinking water during pregnancy. All maternal rats and their fetuses were sacrificed on gestational day 21. The liver and intestinal tissues of both maternal and fetal rats were analyzed. In addition, microbial deoxyribonucleic acid extracted from the maternal fecal samples was analyzed. RESULTS HFD resulted in maternal weight gain during pregnancy, intrahepatic lipid accumulation, and change in the serum short-chain fatty acid profile, intestinal tight junctions, and dysbiosis in maternal rats. The effect of HFD on maternal rats was alleviated by prenatal metformin, which also ameliorated inflammation and apoptosis in the fetal liver and intestines. CONCLUSIONS This study demonstrated the beneficial effects of prenatal metformin on maternal liver steatosis, focusing on the gut-liver axis. In addition, the present study indicates that prenatal metformin could ameliorate maternal HFD-induced inflammation and apoptosis in the fetal liver and intestines. This beneficial effect of in-utero exposure of metformin on fetal liver and intestines has not been reported. This study supports the use of prenatal metformin for pregnant obese women.
Collapse
|
13
|
Xia X, Xue S, Yang G, Li Y, Liu H, Chen C, Li L. Association of serum fetuin-B with insulin resistance and pre-diabetes in young Chinese women: evidence from a cross-sectional study and effect of liraglutide. PeerJ 2021; 9:e11869. [PMID: 34484983 PMCID: PMC8381879 DOI: 10.7717/peerj.11869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 07/05/2021] [Indexed: 12/19/2022] Open
Abstract
Background and Aims Fetuin-B has been reported to be involved in glucose and lipid metabolism and associated with the occurrence of diabetes. The main purpose of this study is to explore the changes of circulating fetuin-B in young women with pre-diabetes and to analyze the relationship between fetuin-B and the occurrence and development of IR. Methods A total of 304 women were enrolled in this study and subjected to both OGTT and EHC. A subgroup of 26 overweight/obese womenwas treated with Lira for 24 weeks. serum fetuin-B concentrations were measured by ELISA. Results In IGT and IR-NG groups, serum fetuin-B levels were higher than those in the NGT group. The serum fetuin-B levels in the IGT group were higher than those in the IR-NG group. serum fetuin-B was positively correlated with BMI, WHR, 2h-BG, FIns, HbA1c, and HOMA2-IR, but negatively correlated with the M-value in all study populations. Multiple stepwise regression analysis showed that the M-value was independently and inversely associated with serum fetuin-B. Logistic regression analysis showed that serum fetuin-B was independently associated with IGT and significantly increased the risk of IGT. During the OGTT, serum fetuin-B increased significantly in the NGT group, but there were no significant changes in other groups. During the EHC, serum fetuin-B increased in the IGT group, but there was no change in other groups. After Lira intervention, serum fetuin-B decreased significantly in IGT women. Conclusions serum fetuin-B levels are elevated in young women with IR or IGT and may be associated with IR.
Collapse
Affiliation(s)
- Xuyun Xia
- The Key Laboratory of Laboratory Medical Diagnostics in the Ministry of Education and Department of Clinical Biochemistry, College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Shiyao Xue
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Gangyi Yang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yu Li
- Department of Pathology, Chongqing University Cancer Hospital, Chongqing, China
| | - Hua Liu
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, The United States of America
| | - Chen Chen
- Endocrinology, SBMS, Faculty of Medcine, University of Queensland, Brisbane, Australia
| | - Ling Li
- The Key Laboratory of Laboratory Medical Diagnostics in the Ministry of Education and Department of Clinical Biochemistry, College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| |
Collapse
|
14
|
Tew MP, Tan PC, Saaid R, Hong JGS, Omar SZ. Metformin in gestational diabetes mellitus: A double-blind placebo-controlled randomized trial. Int J Gynaecol Obstet 2021; 156:508-515. [PMID: 33890319 DOI: 10.1002/ijgo.13718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the impact of preemptive metformin on the level of glycosylated hemoglobin (HbA1c) at 36 weeks of pregnancy in women with gestational diabetes mellitus controlled by diet change (GDMA1). METHODS A randomized, double-blind, placebo-controlled trial was performed in a university hospital. Women with GDMA1 were recruited at 16-30 weeks of pregnancy and randomized to oral metformin 500 mg twice daily or identical placebo tablets to delivery. Level of HbA1c was taken at recruitment and at 36 weeks of pregnancy. The primary outcome was the change in level of HbA1c at recruitment and 36 weeks of pregnancy. RESULTS Data from 106 participants were analyzed. The level of HbA1c during pregnancy increased significantly with a mean increase of 0.20% ± 0.31% (P < 0.001; metformin) versus 0.27% ± 0.31% (P < 0.001; placebo). An increment of 0.07% across trial arms was not significant (P = 0.310). Mean birth weight was significantly lower in the metformin group (2.81 ± 0.41 kg vs 2.98 ± 0.37 kg; P = 0.030). Rates of macrosomia (≥3.5 kg; 0/53 [0%] vs 4/53 [8%]; P = 0.123) and low birth weight (<2.5 kg; 11/53 [21%] vs 5/53 [9%]; P = 0.102) were not significantly different. CONCLUSION Preemptive metformin did not prevent the level of HbA1c at 36 weeks of pregnancy from rising nor significantly reduce the increase of HbA1c. Mean birth weight was significantly lower in the metformin arm with a non-significant trend to low birth weight, which is concerning. ISRCTN ISRCTN10845466.
Collapse
Affiliation(s)
- Min P Tew
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Peng C Tan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Rahmah Saaid
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Jesrine G S Hong
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Siti Z Omar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| |
Collapse
|
15
|
Kathuria D, Raul AD, Wanjari P, Bharatam PV. Biguanides: Species with versatile therapeutic applications. Eur J Med Chem 2021; 219:113378. [PMID: 33857729 DOI: 10.1016/j.ejmech.2021.113378] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 12/18/2022]
Abstract
Biguanides are compounds in which two guanidine moieties are fused to form a highly conjugated system. Biguanides are highly basic and hence they are available as salts mostly hydrochloride salts, these cationic species have been found to exhibit many therapeutic properties. This review covers the research and development carried out on biguanides and accounts the various therapeutic applications of drugs containing biguanide group-such as antimalarial, antidiabetic, antiviral, anticancer, antibacterial, antifungal, anti-tubercular, antifilarial, anti-HIV, as well as other biological activities. The aim of this review is to compile all the medicinal chemistry applications of this class of compounds so as to pave way for the accelerated efforts in finding the drug action mechanisms associated with this class of compounds. Importance has been given to the organic chemistry of these biguanide derivatives also.
Collapse
Affiliation(s)
- Deepika Kathuria
- University Center for Research and Development, Chandigarh University, Gharuan, Punjab, 140413, India
| | - Akshay D Raul
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar, 160 062, Punjab, India
| | - Pravin Wanjari
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar, 160 062, Punjab, India
| | - Prasad V Bharatam
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar, 160 062, Punjab, India.
| |
Collapse
|
16
|
Raperport C, Chronopoulou E, Homburg R. Effects of metformin treatment on pregnancy outcomes in patients with polycystic ovary syndrome. Expert Rev Endocrinol Metab 2021; 16:37-47. [PMID: 33634727 DOI: 10.1080/17446651.2021.1889366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/09/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This review covers the current evidence regarding the use of metformin as a therapeutic intervention for optimizing pregnancy outcomes in women with polycystic ovary syndrome (PCOS). AREAS COVERED After searching Medline, Embase and CINAHL, all important large clinical trials and observational studies plus systematic reviews, meta-analyses and Cochrane reviews have been summarized here. The results have been compared to culminate in a thorough review and discussion on the use of metformin in relation to reproductive outcomes for women with PCOS. The role of metformin in PCOS is explored both in terms of achieving conception and during pregnancy. The existing evidence around metformin use is summarized both during the preconceptual period and during pregnancy, in relation to reproductive outcomes. EXPERT OPINION Metformin is a widely used medication, often prescribed to improve reproductive outcomes for women with PCOS. However, the evidence remains equivocal regarding its efficacy both in optimizing fertility and pregnancy outcomes. More research is required with special emphasis on metformin use within different populations, including ethnic groups and women with varying BMI ranges.
Collapse
Affiliation(s)
- Claudia Raperport
- Fertility Unit, Homerton University Hospital, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Roy Homburg
- Fertility Unit, Homerton University Hospital, London, UK
| |
Collapse
|
17
|
El-Goly AMM. Lines of Treatment of COVID-19 Infection. COVID-19 INFECTIONS AND PREGNANCY 2021. [PMCID: PMC8298380 DOI: 10.1016/b978-0-323-90595-4.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
18
|
Koren G, Barer Y, Cem Kaplan Y. Fetal safety of medications used in treating infertility. Expert Rev Clin Pharmacol 2020; 13:991-1000. [PMID: 32815747 DOI: 10.1080/17512433.2020.1803738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The medications used in assisted reproduction are given before and during early pregnancy, and hence, they may potentially result in adverse fetal effects. In this review we present an updated account of their fetal safety and discuss methodological challenges in interpretation of existing data. AREAS COVERED The fetal safety/risks of clomiphene citrate, aromatase inhibitors, metformin, gonadotropins and progestins are discussed. We searched PubMed, EMBASE, Cochrane, Google, and Google Scholar from inception to 30 April 2020 for publications pertinent to our topic. EXPERT OPINION There are several major challenges in studying fetal safety of medications used in assisted reproduction. The fact is that the rates of congenital malformations among infertile women giving birth spontaneously is higher than the rates among healthy women conceiving spontaneously. In most clinical studies of assisted reproduction, the primary endpoint is the success in inducing pregnancy, neglecting to report pregnancy outcome and adverse neonatal event. As an example for this reality, it has been estimated that between 1977 and 2005 around 10 million pregnancies were treated with dydrogesterone (DYD), yet till 2019 only very few studies, with a total sample size of less than 600 were reported with regards to fetal safety.
Collapse
Affiliation(s)
- Gideon Koren
- Adelson Faculty of Medicine, Ariel University , Ariel, Israel.,Department of pharmacology, Motherisk Israel.s , Turkey
| | - Yael Barer
- Maccabi Health Services , Tel Aviv, Turkey
| | - Yusuf Cem Kaplan
- Teratology Information Center, Terafar-Izmir Katip Celebi University , Izmir, Turkey.,Department of Pharmacology, Faculty of Medicine, Izmir Katip Celebi University , Izmir, Turkey
| |
Collapse
|
19
|
Li W, Yu N, Kang Q, Zeng W, Deng D, Chen S, Feng L, Wu J. Clinical manifestations and maternal and perinatal outcomes with COVID-19. Am J Reprod Immunol 2020; 84:e13340. [PMID: 32894803 DOI: 10.1111/aji.13340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/19/2020] [Accepted: 08/29/2020] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a novel type of highly contagious pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As the COVID-19 outbreak unfolds, more and more pregnant women are infected with SARS-CoV-2, concerns have been raised about its clinical manifestations in pregnancy and the potential risk of vertical transmission from mother to fetus in pregnant women. Hence, in this review, we summarize the latest research progress related to COVID-19 epidemiology and the reported data of pregnant women with COVID-19 and discuss the clinical manifestations, treatments, maternal and perinatal outcomes, and intrauterine vertical transmission potential of such virus. Reported data suggest that symptoms in pregnant women are similar to those in other populations and that there is no evidence of vertical transmission from mother to child. In the meantime, considering the good prognosis of most of the infected mothers and infants and absence of serious obstetric complications in pregnant women with COVID-19, it is not recommended to give birth as soon as possible, and it is necessary to extend the gestational period reasonably.
Collapse
Affiliation(s)
- Wei Li
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nan Yu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingling Kang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wanjiang Zeng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dongrui Deng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suhua Chen
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianli Wu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
20
|
Novi DRBS, Vidigal CB, Marques BVD, Forcato S, Raquel HA, Zaia DAM, Zaia CTBV, Martins-Pinge MC, Gerardin DCC, Ceravolo GS. Can maternal treatment with metformin during gestation and lactation cause metabolic and cardiovascular disorders in rat offspring? Arch Physiol Biochem 2020; 126:276-281. [PMID: 30270666 DOI: 10.1080/13813455.2018.1517804] [Citation(s) in RCA: 3] [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] [Indexed: 12/15/2022]
Abstract
Objective: The aim was to evaluate if maternal treatment with metformin (MET) during pregnancy and lactation could be safe for metabolic and cardiovascular parameters of adult male and female offspring.Materials and methods: Wistar female rats were treated with MET (293 mg/kg/d) or tap water, by gavage during gestation (METG or CTRG) or gestation and lactation (METGL or CTRGL).Results: At 75 days of life, male and female MET offspring presented similar blood pressure when compared with their CTR. The heart rate of female METGL was higher than in the CTRGL. The insulin sensitivity, basal glycaemia, body weight, Lee index of obesity, plasmatic concentration of triglycerides, total cholesterol and fat acid of male and female MET were similar to CTR groups. Lower fat pad deposition was observed in female METG and METGL.Conclusion: MET exposure during gestational and lactation does not program cardiovascular and metabolic alterations in adult offspring life.
Collapse
Affiliation(s)
- Daniella R B S Novi
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Camila B Vidigal
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Bruno V D Marques
- Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Simone Forcato
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Hiviny A Raquel
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Dimas A M Zaia
- Department of Chemistry, State University of Londrina, Londrina, Brazil
| | - Cássia T B V Zaia
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Marli C Martins-Pinge
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Daniela C C Gerardin
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Graziela S Ceravolo
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| |
Collapse
|
21
|
Zhao X, Jiang Y, Zhao Y, Xi H, Liu C, Qu F, Feng X. Analysis of the susceptibility to COVID-19 in pregnancy and recommendations on potential drug screening. Eur J Clin Microbiol Infect Dis 2020; 39:1209-1220. [PMID: 32328850 PMCID: PMC7178925 DOI: 10.1007/s10096-020-03897-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 02/07/2023]
Abstract
To analyze the susceptibility of SARS-CoV-2 in pregnancy and the drugs that can be used to treat pregnancy with COVID-19, so as to provide evidence for drug selection in clinic. By reviewing the existing literature, this paper analyzes the susceptibility of pregnant women to virus, especially to SARS-CoV-2, from the aspects of anatomical, reproductive endocrine and immune changes during pregnancy and screens effective and fetal-safe treatments from the existing drugs. The anatomical structure of the respiratory system is changed during pregnancy, and the virus transmitted by droplets and aerosols is more easily inhaled by pregnant women and is difficult to remove. Furthermore, the prognosis is worse after infection when compared with non-pregnancy women. And changes in reproductive hormones and immune systems during pregnancy collectively make them more susceptible to certain infections. More importantly, angiotensin-converting enzyme (ACE)-2, the SARS-CoV-2 receptor, has been proven highly increased during pregnancy, which may contribute to the susceptibility to SARS-CoV-2. When it comes to treatment, specific drugs for COVID-19 have not been found at present, and taking old drugs for new use in treating COVID-19 has become an emergency method for the pandemic. Particularly, drugs that show superior maternal and fetal safety are worthy of consideration for pregnant women with COVID-19, such as chloroquine, metformin, statins, lobinavir/ritonavir, glycyrrhizic acid, and nanoparticle-mediated drug delivery (NMDD), etc. Pregnant women are susceptible to COVID-19, and special attention should be paid to the selection of drugs that are both effective for maternal diseases and friendly to the fetus. However, there are still many deficiencies in the study of drug safety during pregnancy, and broad-spectrum, effective and fetal-safe drugs for pregnant women need to be developed so as to cope with more infectious diseases in the future.
Collapse
Affiliation(s)
- Xiaoxuan Zhao
- Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Yuepeng Jiang
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Yang Zhao
- Hebei College of Traditional Chinese Medicine, Shijiazhuang, 050000, China
| | - Hongyan Xi
- Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Chang Liu
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Fan Qu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, 310006, China.
| | - Xiaoling Feng
- First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, 150040, China.
| |
Collapse
|
22
|
Management of Gestational Diabetes Mellitus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:257-272. [PMID: 32548833 DOI: 10.1007/5584_2020_552] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Once a woman is diagnosed with gestational diabetes mellitus (GDM), two strategies are considered for management; life-style modifications and pharmacological therapy. The management of GDM aims to maintain a normoglycemic state and to prevent excessive weight gain in order to reduce maternal and fetal complications. Lifestyle modifications include nutritional therapy and exercise. Calorie restriction with a low glycemic index diet is recommended to avoid postprandial hyperglycemia and to reduce insulin resistance. Blood glucose levels, HbA1c levels, and ketonuria are monitored to analyze the efficacy of conservative management. Pharmacological treatment is initiated if conservative strategies fail to provide expected glucose levels during follow-ups.Insulin has been the first choice for the treatment of diabetes during pregnancy. Recently, metformin has been used more commonly in diabetic pregnant women in cases when insulin cannot be prescribed, after its safety has been proven. However, a high percentage of women, which may be up to 46% may require additional insulin to maintain expected blood glucose levels. The evidence on the long-term safety of other oral anti-diabetics has been lacking yet.Women with diet-controlled GDM can wait for spontaneous labor expectantly in case there are no obstetric indications for birth. However, in women with GDM under insulin therapy or with poor glycemic control, elective induction at term is recommended by authorities.The women who have GDM during pregnancy should be counseled about their increased risks of impaired glucose tolerance, type 2 diabetes mellitus, hypertensive disorders, cardiovascular diseases, and metabolic syndrome.
Collapse
|
23
|
Abstract
Hyperglycemia is common during pregnancy, involving multisystem adaptations. Pregnancy-induced metabolic changes increase insulin resistance. Pregnancy-induced insulin resistance adds to preexisting insulin resistance. Preexisting pancreatic β-cell defect compromises the ability to enhance insulin secretion, leading to hyperglycemia. Women with type 2 DM have similar rates of major congenital malformations, stillbirth, and neonatal mortality, but an even higher risk of perinatal mortality. In utero type 2 DM exposure confers greater risk and reduces time to development of type 2 DM in offspring. Preconception care to improve metabolic control in women with type 2 diabetes is critical.
Collapse
Affiliation(s)
- Anil Kapur
- World Diabetes Foundation, 30 A, Krogshoejvej, Bagsverd 2880, Denmark; FIGO Pregnancy and NCD Committee, Jabotinski Street, Petah Tiqwa 49100, Israel.
| | - Harold David McIntyre
- FIGO Pregnancy and NCD Committee, Jabotinski Street, Petah Tiqwa 49100, Israel; UQ Mater Clinical Unit, Faculty of Medicine, Mater Health Services, University of Queensland, Raymond Terrace, South Brisbane, Brisbane, Qld 4101, Australia
| | - Moshe Hod
- FIGO Pregnancy and NCD Committee, Jabotinski Street, Petah Tiqwa 49100, Israel; Department of Obstetrics and Gynecology, Clalit Health Services, Mor Women's Health Center, Rabin Medical Center, Tel Aviv University, 18 Aba Ahimeir St., Tel Aviv 6949204, Israel
| |
Collapse
|
24
|
Aydin BK, Saka N, Bas F, Bas EK, Coban A, Yildirim S, Guran T, Darendeliler F. Frequency of Ambiguous Genitalia in 14,177 Newborns in Turkey. J Endocr Soc 2019; 3:1185-1195. [PMID: 31139765 PMCID: PMC6532673 DOI: 10.1210/js.2018-00408] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/05/2019] [Indexed: 11/19/2022] Open
Abstract
CONTEXT Limited data are available on the exact incidence of disorders of sex development (DSD) with genital ambiguity at birth. OBJECTIVE To determine frequency of ambiguous genitalia in newborns. DESIGN Prospective multicenter study. SETTING Three tertiary care hospitals. PATIENTS OR OTHER PARTICIPANTS All 14,177 babies born during the study period were included. MAIN OUTCOME MEASURES All newborns were examined at birth; data on weeks of gestation, birth weight, and length were collected. A structured questionnaire was used for data collection. Quigley and Prader scales were used for phenotypic grading. Clinical and genetic investigations were performed. RESULTS Eighteen babies with ambiguous genitalia were found among 14,177 newborns (1.3/1000). Fifteen newborns had 46,XY DSD, one had 46,XX congenital adrenal hyperplasia, and one had 45,X/46,XY mixed gonadal dysgenesis. Karyotype analysis was not done in one baby who died in the neonatal period. The ratio of prematurity was higher in the DSD group (44% vs 11%; P < 0.001) and the ratio of small for gestational age was also higher in the DSD group (22% vs 5%; P = 0.007). Eight babies with DSD had mothers who had additional medical conditions, such as preeclampsia, depression, insulin resistance, and gestational diabetes mellitus. CONCLUSION The frequency of ambiguous genitalia was higher than in previous studies, but, as with any experiment, the finding should be met with caution because this study was conducted in tertiary care hospitals. In addition, lower birth weight in the DSD group supports the hypothesis that early placental dysfunction might be important in the etiology of male genital anomalies.
Collapse
Affiliation(s)
- Banu Kucukemre Aydin
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
- Pediatric Endocrinology Unit, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Nurcin Saka
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Firdevs Bas
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Evrim Kiray Bas
- Neonatology Unit, Sisli Etfal Training and Research Hospital, Instanbul, Turkey
| | - Asuman Coban
- Department of Pediatrics, Neonatology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sukran Yildirim
- Department of Pediatrics, Neonatology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Tulay Guran
- Pediatric Endocrinology Unit, Zeynep Kamil Women's and Children's Hospital, Istanbul, Turkey
- Department of Pediatrics, Pediatric Endocrinology Unit, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Feyza Darendeliler
- Department of Pediatrics, Pediatric Endocrinology Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| |
Collapse
|
25
|
Cluver C, Walker SP, Mol BW, Hall D, Hiscock R, Brownfoot FC, Kaitu’u-Lino TJ, Tong S. A double blind, randomised, placebo-controlled trial to evaluate the efficacy of metformin to treat preterm pre-eclampsia (PI2 Trial): study protocol. BMJ Open 2019; 9:e025809. [PMID: 31023758 PMCID: PMC6503454 DOI: 10.1136/bmjopen-2018-025809] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Pre-eclampsia is a major complication of pregnancy, globally responsible for 60 000 maternal deaths per year, and far more fetal losses. There is no definitive treatment other than delivery. A therapeutic that could quench the disease process would be useful to treat preterm pre-eclampsia, as it could allow these pregnancies to safely continue to a gestation where fetal outcomes are significantly improved. We have published preclinical data to show that metformin, a drug known to be safe in pregnancy and commonly used to treat gestational diabetes, has potent biological effects making it another promising candidate to treat pre-eclampsia. Here, we describe a phase II clinical trial to examine whether administering extended-release metformin may be effective in treating women with preterm pre-eclampsia (PI2 Trial). METHODS The PI2 Trial is a phase II, double blind, randomised controlled trial that aims to recruit 150 women with preterm pre-eclampsia (gestational age 26+0 to 31+6 weeks) who are being managed expectantly. Participants will be randomised to receive either 3 g of metformin or placebo daily. The primary outcome is time from randomisation until delivery. A delay in delivery of 5 days is assumed to be clinically relevant. The secondary outcomes will be a maternal composite and neonatal composite outcome. All other outcomes will be exploratory. We will record adverse events. ETHICS AND DISSEMINATION This study has ethical approval (Protocol number M16/09/037 Federal Wide Assurance Number 00001372, Institutional Review Board Number IRB0005239), is registered with the Pan African Clinical Trial Registry (PACTR201608001752102) and the South African Medicine Control Council (20170322). Data will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER PACTR201608001752102; Pre-results.
Collapse
Affiliation(s)
- Catherine Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University Faculty of Science, Cape Town, Western Cape, South Africa
- Translational Obstetrics Group, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Susan P Walker
- Translational Obstetrics Group, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Hall
- Department of Obstetrics and Gynaecology, Stellenbosch University Faculty of Science, Matieland, Western Cape, South Africa
| | - Richard Hiscock
- Department of Anaesthetics, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Fiona C Brownfoot
- Translational Obstetrics Group, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Tu’uhevaha J Kaitu’u-Lino
- Translational Obstetrics Group and Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Melbourne, Victoria, Australia
| |
Collapse
|
26
|
Hastie R, Brownfoot FC, Pritchard N, Hannan NJ, Cannon P, Nguyen V, Palmer K, Beard S, Tong S, Kaitu’u-Lino TJ. EGFR (Epidermal Growth Factor Receptor) Signaling and the Mitochondria Regulate sFlt-1 (Soluble FMS-Like Tyrosine Kinase-1) Secretion. Hypertension 2019; 73:659-670. [DOI: 10.1161/hypertensionaha.118.12300] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Roxanne Hastie
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Fiona C. Brownfoot
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Natasha Pritchard
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Natalie J. Hannan
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Ping Cannon
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Vi Nguyen
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Kirsten Palmer
- Department of Obstetrics and Gynaecology, Monash University, Victoria, Australia (K.P.)
| | - Sally Beard
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Stephen Tong
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| | - Tu’uhevaha J. Kaitu’u-Lino
- From the Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
- Mercy Perinatal, Research Department, Mercy Hospital for Women, Victoria, Australia (R.H., F.C.B., N.P., N.J.H., P.C., V.N., S.B., S.T., T.J.K.-L.)
| |
Collapse
|
27
|
Farahvar S, Walfisch A, Sheiner E. Gestational diabetes risk factors and long-term consequences for both mother and offspring: a literature review. Expert Rev Endocrinol Metab 2019; 14:63-74. [PMID: 30063409 DOI: 10.1080/17446651.2018.1476135] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/09/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Established risk factors for gestational diabetes mellitus (GDM) include ethnicity, obesity, and family history of diabetes. Untreated GDM patients have higher rates of maternal and perinatal morbidity. GDM is an independent risk factor for future longer-term risk of type 2 diabetes mellitus (T2DM), metabolic syndrome, cardiovascular morbidity, malignancies, ophthalmic, psychiatric, and renal disease in the mother. Offspring risk long-term adverse health outcomes, including T2DM, subsequent obesity, impacted neurodevelopmental outcome, increased neuropsychiatric morbidity, and ophthalmic disease. AREAS COVERED We critically review data from retrospective, prospective, and meta-analysis studies pertaining to established GDM risk factors, complications during pregnancy and birth (both mother and offspring), and long-term consequences (both mother and offspring). EXPERT COMMENTARY Many of the adverse consequences of GDM might be avoided with proper management and treatment. Patients belonging to high-risk ethnic groups, and/or with body mass index ≥ 25 kg/m2, and/or known history of diabetes in first-degree relatives may benefit from universal screening and diagnostic criteria proposed by the International Association of Diabetes and Pregnancy Study Group (IADPSG). The IADPSG one-step method has several advantages, including simplicity of execution, greater patient-friendliness, and higher diagnostic accuracy. Additionally, evidence suggests that the recent increased popularity of bariatric surgery will help to decrease GDM rates over next 5 years. Similarly, metformin may be useful for treating and preventing obstetrical complications in confirmed GDM patients.
Collapse
Affiliation(s)
- Salar Farahvar
- a Department of Obstetrics and Gynecology, Faculty of Health, Sciences, Soroka University Medical Center, Ben-Gurion , University of the Negev , Beer Sheva , Israel
| | - Asnat Walfisch
- a Department of Obstetrics and Gynecology, Faculty of Health, Sciences, Soroka University Medical Center, Ben-Gurion , University of the Negev , Beer Sheva , Israel
| | - Eyal Sheiner
- a Department of Obstetrics and Gynecology, Faculty of Health, Sciences, Soroka University Medical Center, Ben-Gurion , University of the Negev , Beer Sheva , Israel
| |
Collapse
|
28
|
Perumal S, Rani AA, Mahmud R, Amran N, Asmawi M, Mohamed N. In vivo hypoglycemic investigation, antihyperglycemic and antihyperlipidemic potentials of Pereskia bleo Kunth. in normal and streptozotocin-induced diabetic rats. Asian Pac J Trop Biomed 2019. [DOI: 10.4103/2221-1691.250858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
29
|
van Weelden W, Wekker V, de Wit L, Limpens J, Ijäs H, van Wassenaer-Leemhuis AG, Roseboom TJ, van Rijn BB, DeVries JH, Painter RC. Long-Term Effects of Oral Antidiabetic Drugs During Pregnancy on Offspring: A Systematic Review and Meta-analysis of Follow-up Studies of RCTs. Diabetes Ther 2018; 9:1811-1829. [PMID: 30168045 PMCID: PMC6167305 DOI: 10.1007/s13300-018-0479-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Antidiabetic drugs (OADs) are increasingly prescribed to treat hyperglycaemia during pregnancy in women with gestational diabetes mellitus (GDM) or polycystic ovary syndrome (PCOS), even though long-term effects on offspring are unknown. This systematic review summarises the evidence of follow-up studies of randomised controlled trials (RCTs) reporting on long-term effects of prenatal exposure to OADs on offspring. METHODS The MEDLINE, EMBASE and CENTRAL databases were searched from inception to April 2018 for the concepts antidiabetic agents and prenatal exposure (or pregnancy and offspring/child) in combination with an RCT search filter. RCTs evaluating post-neonatal health effects in offspring and comparing maternal treatment with an OAD with no treatment, placebo, an alternative OAD or insulin during pregnancy were eligible for inclusion. Two independent researchers selected, extracted and assessed the data. Meta-analyses were performed using a random effects model and the Cochrane Collaboration's risk of bias tool was used for quality assessment. RESULTS Ten studies were included, with a maximal follow-up duration of 9 years, comprising 778 children of mothers with GDM or PCOS who were randomised to either metformin or insulin/placebo during pregnancy. Meta-analysis showed that children prenatally exposed to metformin were heavier compared to controls (standardised mean difference (SMD) 0.26 [95% CI 0.11-0.41]), but not taller (SMD 0.10 [95% CI -0.14-0.33]). Additionally, offspring body mass index (BMI) z scores did not differ according to metformin exposure (mean difference 0.30 [95% CI -0.01-0.61]). Individual small studies reported that prenatal exposure to metformin was associated with greater mid-upper arm, head and waist circumferences, biceps skinfolds, waist-to-height ratio, more arm fat, higher fasting glucose, ferritin and lower LDL cholesterol in offspring. CONCLUSION Prenatal exposure to metformin is associated with increased offspring weight, but not with height or BMI. Larger follow-up studies are needed to confirm and look into the implications of these findings. Plain language summary available for this article.
Collapse
Affiliation(s)
- Wenneke van Weelden
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Wekker
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Leon de Wit
- Department of Gynaecology and Obstetrics, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jacqueline Limpens
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hilkka Ijäs
- Department of Obstetrics and Gynaecology, Oulu University Hospital, Oulu, Finland
| | - Aleid G van Wassenaer-Leemhuis
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tessa J Roseboom
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bas B van Rijn
- Department of Gynaecology and Obstetrics, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| |
Collapse
|
30
|
Diav-Citrin O, Steinmetz-Shoob S, Shechtman S, Ornoy A. In-utero exposure to metformin for type 2 diabetes or polycystic ovary syndrome: A prospective comparative observational study. Reprod Toxicol 2018; 80:85-91. [DOI: 10.1016/j.reprotox.2018.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/14/2018] [Accepted: 05/26/2018] [Indexed: 12/16/2022]
|
31
|
Dodd JM, Grivell RM, Deussen AR, Hague WM. Metformin for women who are overweight or obese during pregnancy for improving maternal and infant outcomes. Cochrane Database Syst Rev 2018; 7:CD010564. [PMID: 30039871 PMCID: PMC6513233 DOI: 10.1002/14651858.cd010564.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There has been considerable interest in providing antenatal dietary and lifestyle advice for women with obesity or who are overweight during pregnancy, as a strategy to limit gestational weight gain and improve maternal and infant health. However, such antenatal interventions appear to have a modest effect on gestational weight gain and other clinical pregnancy and birth outcomes and additional strategies are required.Metformin is an oral insulin-sensitising medication that acts to decrease blood glucose concentrations. Metformin is commonly used in the treatment of type 2 diabetes mellitus and polycystic ovarian syndrome, and is being used increasingly in the treatment of gestational diabetes, having been shown to result in decreased rates of caesarean birth and neonatal hypoglycaemia. Metformin may be an adjuvant therapy to current antenatal strategies in pregnant women with obesity or who are overweight, acting to reduce glucose production in the liver and improve glucose uptake in smooth muscle cells, and therefore improve the overall metabolic health of women in pregnancy and reduce the risk of known adverse pregnancy outcomes. OBJECTIVES To evaluate the role of metformin in pregnant women with obesity or who are overweight, on maternal and infant outcomes, including adverse effects of treatment and costs. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (11 October 2017), and reference lists of retrieved studies. SELECTION CRITERIA All published and unpublished randomised controlled trials evaluating metformin use (compared with placebo or no metformin) in women with obesity or who are overweight in pregnancy for improving outcomes, alone or in combination with other interventions were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included three studies which randomised women (1099) with a body mass index (BMI) of 30 kg/m2 (1 study) and 35 kg/m2 (2 studies), with outcomes available for 1034 participants. None of the studies assessed women with a BMI between 25 kg/m2and 29.9 kg/m2, therefore we could not assess the use of metformin in women considered overweight. We did not identify studies of metformin in combination with another treatment. Two other studies are ongoing.All three included studies were randomised controlled trials and compared metformin with placebo, commencing early in the second trimester. Doses ranged from 500 mg twice daily to 3.0 g per day. All three studies (two in the UK, one in Egypt) included women attending hospitals for antenatal care.Two studies were generally at a low risk of bias across the majority of domains. We assessed the third study as being at an unclear risk of selection bias, performance and detection bias due to insufficient information in the report. We assessed the trial as being at a low risk of attrition bias and other bias; we felt it was at a high risk of reporting bias.The primary outcome for this review was infant birthweight large-for-gestational-age (> 90th centile for gestational age and infant sex). Women who received metformin or placebo had a similar risk of their baby being born large for his or her gestational age (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.70 to 1.30; 2 studies, 831 infants; high-quality evidence).Women who received metformin may have a slightly lower gestational weight gain (mean difference (MD) -2.60 kg, 95% CI -5.29 to 0.10; 3 studies, 899 women; low-quality evidence).Metformin may make little or no difference in the risk of women developing gestational hypertension (average RR 1.02, 95% CI 0.54 to 1.94; 3 studies, 1040 women; low-quality evidence) or pre-eclampsia (RR 0.74, 95% CI 0.09 to 6.28; 2 studies, 840 women; low-quality evidence). Metformin probably makes little or no difference in the risk of women developing gestational diabetes (RR 0.85, 95% CI 0.61 to 1.19; 3 studies, 892 women; moderate-quality evidence).One study of 400 women reported women receiving metformin were more likely to experience any adverse effect compared with women receiving placebo (RR 1.63, 95% CI 1.27 to 2.08; 1 study, 400 women). Adverse effects included abdominal pain, diarrhoea, or headache. When considering individual side effects, women receiving metformin were more likely to experience diarrhoea than women receiving placebo (RR 2.34, 95% CI 1.74 to 3.14; 797 women; 2 studies, 797 women; high-quality evidence). No other important differences were identified between Metformin and placebo for other maternal secondary outcomes, including: caesarean birth, birth before 37 weeks of pregnancy, shoulder dystocia, perineal tear, or postpartum haemorrhage.In terms of other infant outcomes, there was little or no difference in the infant birthweight (MD 6.39 g, 95% CI -81.15 to 93.92; 2 studies, 834 infants; high-quality evidence). There were no other important differences identified for other infant secondary outcomes in this review: hypoglycaemia (low blood sugar); hyperbilirubinaemia (jaundice); Apgar score less than 7 at five minutes; or stillbirth and neonatal death. Only one study reported admission to the neonatal intensive care unit (NICU), indicating similar rates of admission between women receiving metformin or placebo; no other admission data were reported to assess differences in costs. AUTHORS' CONCLUSIONS There is insufficient evidence to support the use of metformin for women with obesity in pregnancy for improving maternal and infant outcomes. Metformin was, however, associated with increased risk of adverse effects, particularly diarrhoea. The quality of the evidence in this review varied from high to low, with downgrading decisions based on study limitations and inconsistency.There were only a small number of studies included in this review. Furthermore, none of the included studies included women categorised as 'overweight' and no trials looked at metformin in combination with another treatment.Future research is required in order to further evaluate the role of metformin therapy in pregnant women with obesity or who are overweight, as a strategy to improve maternal and infant health, alone or as an adjuvant to dietary and lifestyle advice.
Collapse
Affiliation(s)
- Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Rosalie M Grivell
- Flinders University and Flinders Medical CentreDepartment of Obstetrics and GynaecologyBedford ParkSouth AustraliaAustraliaSA 5042
| | - Andrea R Deussen
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - William M Hague
- Women's and Children's HospitalKing William RoadAdelaideSouth AustraliaAustraliaSA 5006
| | | |
Collapse
|
32
|
Hyer S, Balani J, Shehata H. Metformin in Pregnancy: Mechanisms and Clinical Applications. Int J Mol Sci 2018; 19:E1954. [PMID: 29973490 PMCID: PMC6073429 DOI: 10.3390/ijms19071954] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/12/2018] [Accepted: 06/29/2018] [Indexed: 01/27/2023] Open
Abstract
Metformin use in pregnancy is increasing worldwide as randomised controlled trial (RCT) evidence is emerging demonstrating its safety and efficacy. The Metformin in Gestational Diabetes (MiG) RCT changed practice in many countries demonstrating that metformin had similar pregnancy outcomes to insulin therapy with less maternal weight gain and a high degree of patient acceptability. A multicentre RCT is currently assessing the addition of metformin to insulin in pregnant women with type 2 diabetes. RCT evidence is also available for the use of metformin in pregnancy for women with Polycystic Ovarian Syndrome and for nondiabetic women with obesity. No evidence of an increase in congenital malformations or miscarriages has been observed even when metformin is started before pregnancy and continued to term. Body composition and metabolic outcomes at two, seven, and nine years have now been reported for the offspring of mothers treated in the MiG study. In this review, we will briefly discuss the action of metformin and then consider the evidence from the key clinical trials.
Collapse
Affiliation(s)
- Steve Hyer
- Department of Endocrinology, Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton SM5 1AA, Surrey, UK.
| | - Jyoti Balani
- Department of Endocrinology, Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton SM5 1AA, Surrey, UK.
| | - Hassan Shehata
- Department of Maternal Medicine, Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton SM5 1AA, Surrey, UK.
| |
Collapse
|
33
|
Given JE, Loane M, Garne E, Addor MC, Bakker M, Bertaut-Nativel B, Gatt M, Klungsoyr K, Lelong N, Morgan M, Neville AJ, Pierini A, Rissmann A, Dolk H. Metformin exposure in first trimester of pregnancy and risk of all or specific congenital anomalies: exploratory case-control study. BMJ 2018; 361:k2477. [PMID: 29941493 PMCID: PMC6016021 DOI: 10.1136/bmj.k2477] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate whether exposure to metformin during the first trimester of pregnancy, for diabetes or other indications, increases the risk of all or specific congenital anomalies. DESIGN Population based exploratory case-control study using malformed controls. Cases of 29 specific subgroups of non-genetic anomalies, and all non-genetic anomalies combined, were compared with controls (all other non-genetic anomalies or genetic syndromes). SETTING 11 EUROmediCAT European congenital anomaly registries surveying 1 892 482 births in Europe between 2006 and 2013. PARTICIPANTS 50 167 babies affected by congenital anomaly (41 242 non-genetic and 8925 genetic) including live births, fetal deaths from 20 weeks' gestation, and terminations of pregnancy for fetal anomaly. MAIN OUTCOME MEASURE Odds ratios adjusted for maternal age, registry, multiple birth, and maternal diabetes status. RESULTS 168 babies affected by congenital anomaly (141 non-genetic and 27 genetic) were exposed to metformin, 3.3 per 1000 births. No evidence was found for a higher proportion of exposure to metformin during the first trimester among babies with all non-genetic anomalies combined compared with genetic controls (adjusted odds ratio 0.84, 95% confidence interval 0.55 to 1.30). The only significant result was for pulmonary valve atresia (adjusted odds ratio 3.54, 1.05 to 12.00, compared with non-genetic controls; 2.86, 0.79 to 10.30, compared with genetic controls). CONCLUSIONS No evidence was found for an increased risk of all non-genetic congenital anomalies combined following exposure to metformin during the first trimester, and the one significant association was no more than would be expected by chance. Further surveillance is needed to increase sample size and follow up the cardiac signal, but these findings are reassuring given the increasing use of metformin in pregnancy.
Collapse
Affiliation(s)
- Joanne E Given
- Administrative Data Research Centre Northern Ireland, Ulster University, Belfast BT37 0QB, UK
| | - Maria Loane
- Institute of Nursing and Health Research, Ulster University, Belfast BT37 0QB, UK
| | - Ester Garne
- Paediatric Department, Hospital Lillebaelt, Kolding, DK-6000, Denmark
| | | | - Marian Bakker
- University of Groningen, University Medical Center Groningen, Department of Genetics, Eurocat Northern Netherlands, 9700RB, Netherlands
| | | | - Miriam Gatt
- Directorate for Health Information and Research, Guardamangia, PTA 1313, Malta
| | - Kari Klungsoyr
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, N-5018, Norway
| | - Nathalie Lelong
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité and DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France
| | - Margery Morgan
- Congenital Anomaly Register and Information Service for Wales, Public Health Wales, Swansea SA2 8QA, UK
| | - Amanda J Neville
- IMER Registry (Emilia Romagna Registry of Birth Defects), University of Ferrara and Azienda Ospedaliero Universitaria di Ferrara, Ferrara, 44100, Italy
| | - Anna Pierini
- Tuscany Registry of Congenital Defects, Institute of Clinical Physiology, National Research Council/Fondazione Toscana Gabriele Monasterio, Pisa, 56126, Italy
| | - Anke Rissmann
- Malformation Monitoring Centre Saxony-Anhalt, Medical Faculty Otto-von-Guericke University Magdeburg, Magdeburg, D-39120, Germany
| | - Helen Dolk
- Institute of Nursing and Health Research, Ulster University, Belfast BT37 0QB, UK
| |
Collapse
|
34
|
Priya G, Kalra S. Metformin in the management of diabetes during pregnancy and lactation. Drugs Context 2018; 7:212523. [PMID: 29942340 PMCID: PMC6012930 DOI: 10.7573/dic.212523] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 02/07/2023] Open
Abstract
This review explores the current place of metformin in the management of gestational diabetes (GDM) and type 2 diabetes during pregnancy and lactation. The rationale and basic pharmacology of metformin usage in pregnancy is discussed along with the evidence from observational and randomized controlled trials in women with GDM or overt diabetes. There seems to be adequate evidence of efficacy and short-term safety of metformin in relation to maternal and neonatal outcomes in GDM, with possible benefits related to lower maternal weight gain and lower risk of neonatal hypoglycemia and macrosomia. Additionally, metformin offers the advantages of oral administration, convenience, less cost and greater acceptability. Metformin may, therefore, be considered in milder forms of GDM where glycemic goals are not attained by lifestyle modification. However, failure rate is likely to be higher in those with an earlier diagnosis of GDM, higher blood glucose, higher body mass index (BMI) or previous history of GDM, and insulin remains the cornerstone of pharmacological treatment in such cases. The use of metformin in type 2 diabetes has been assessed in observational and small randomized trials. Metformin monotherapy in women with overt diabetes is highly unlikely to achieve glycemic targets. Hence, the use should be restricted as adjunct to insulin and may be considered in women with high insulin dose requirements or rapid weight gain. There is clearly a need for more clinical trials to assess the effect of combined insulin plus metformin therapy in pregnancy with type 2 diabetes. Additionally, there is a paucity of data on long-term effects in offspring exposed to metformin in utero. It is imperative to further explore its impact on offspring as metformin has significant transplacental transfer and has the potential to impact the programming of the epigenome. Therefore, caution must be exercised when prescribing metformin in pregnant women. More research is clearly needed before metformin can be considered as standard of care in the management of diabetes during pregnancy.
Collapse
Affiliation(s)
- Gagan Priya
- Department of Endocrinology, Fortis Hospital, Mohali, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
| |
Collapse
|
35
|
Cea-Soriano L, García-Rodríguez LA, Brodovicz KG, Masso-Gonzalez E, Bartels DB, Hernández-Díaz S. Real world management of pregestational diabetes not achieving glycemic control for many patients in the UK. Pharmacoepidemiol Drug Saf 2018; 27:940-948. [DOI: 10.1002/pds.4553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/19/2018] [Accepted: 04/04/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Lucia Cea-Soriano
- Department of Public Health and Maternal and Child Health, Faculty of Medicine; Complutense University of Madrid; Madrid Spain
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
| | | | | | | | - Dorothee B. Bartels
- Corp. Dept. Global Epidemiology; Boehringer Ingelheim GmbH; Ingelheim Germany
- Hannover Medical School; Institute for Epidemiology, Social Medicine and Health Systems Research; Hannover Germany
| | - Sonia Hernández-Díaz
- Department of Epidemiology; Harvard T.H. Chan School of Public Health; Boston MA USA
| |
Collapse
|
36
|
Reece SW, Parihar HS, Martinez M. Retrospective Review of Maternal and Fetal Outcomes in Patients With Gestational Diabetes Mellitus in an Indigent Prenatal Clinic. Diabetes Spectr 2018; 31:200-205. [PMID: 29773943 PMCID: PMC5951231 DOI: 10.2337/ds17-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sara W Reece
- Philadelphia College of Osteopathic Medicine-Georgia Campus School of Pharmacy, Suwanee, GA
| | - Harish S Parihar
- Philadelphia College of Osteopathic Medicine-Georgia Campus School of Pharmacy, Suwanee, GA
| | - Mark Martinez
- Philadelphia College of Osteopathic Medicine-Georgia Campus School of Pharmacy, Suwanee, GA
| |
Collapse
|
37
|
Osman MW, Nath M, Khalil A, Webb DR, Robinson TG, Mousa HA. The effects of metformin on maternal haemodynamics in gestational diabetes mellitus: A pilot study. Diabetes Res Clin Pract 2018. [PMID: 29524482 DOI: 10.1016/j.diabres.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is a major clinical challenge and is likely to remain so as the incidence of GDM continues to increase. AIM To assess longitudinal changes in maternal haemodynamics amongst women diagnosed with GDM requiring either metformin or dietary intervention in comparison to low-risk healthy controls. METHODOLOGY Fifty-six pregnant women attending their first appointment at the GDM clinic and 60 low-risk healthy pregnant controls attending their routine antenatal clinics were recruited and assigned to three groups: GDM Metformin (GDM-M), GDM Diet (GDM-D) and Control. Non-invasive assessment of maternal haemodynamics, using recognised measures of arterial stiffness and central blood pressure (Arteriograph®), were undertaken under controlled conditions within four gestational windows: antenatal; AN1 (26-28 weeks), AN2 (32-34 weeks) and AN3 (37-40 weeks), and postnatal (PN) (6-8 weeks after delivery). Data were analysed using a linear mixed model incorporating gestational age and other relevant predictors, including age, blood pressure (BP), baseline bodyweight and pulse as fixed effects, and patient as a random effect. RESULTS Fitted linear mixed models showed evidence of a two-way interaction effect between groups (GDM-D, GDM-M and Control) and stages of gestation (AN1, AN2, AN3 and PN) for maternal haemodynamic parameters: brachial artery augmentation index (AIx) (p = 0.004), aortic AIx (p = 0.008), and central systolic BP (p = 0.001). However, differences in respect of aortic pulse wave velocity (p = 0.001) and heart rate (p < 0.001) were only significant for gestational stage. At AN2, we did not observe any evidence that the mean brachial Aix in the GDM-M was different from the control group (p = 0.158). CONCLUSION AIx and central systolic BP measures of arterial stiffness are adversely affected by GDM in comparison to controls during pregnancy. The possible beneficial effects of metformin therapy seen at 32 to 34 weeks of gestation require further exploration.
Collapse
Affiliation(s)
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, UK.
| | | | - David R Webb
- Diabetes Research Centre, University of Leicester, UK.
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, UK.
| | | |
Collapse
|
38
|
Polasek TM, Doogue MP, Thynne TRJ. Metformin treatment of type 2 diabetes mellitus in pregnancy: update on safety and efficacy. Ther Adv Drug Saf 2018; 9:287-295. [PMID: 29854390 DOI: 10.1177/2042098618769831] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 03/19/2018] [Indexed: 12/27/2022] Open
Abstract
With the increasing prevalence of type 2 diabetes mellitus (T2DM) in women of childbearing age, prescribing antidiabetic medications in first-trimester pregnancy is becoming more common. Metformin treatment during this time is usually avoided in countries with well-resourced healthcare. This is based on historical concerns about safety to the foetus and the widespread availability of insulin. However, there is now increasing interest in the potential benefits of metformin in pregnant women with T2DM. In this commentary, the main evidence supporting metformin safety in pregnancy is summarized, with an emphasis on the first trimester. Based on a structured literature search, the recent randomized controlled trials comparing metformin and insulin are reviewed. We then show that prescribing advice for metformin in pregnancy is inconsistent and product information/package inserts (PI) are universally out of date. This causes confusion and pushes some women and their clinicians to change from metformin to insulin. The potential advantages of metformin in pregnant women with T2DM are then discussed, including oral dosing and improved acceptability, lower resource utilization and cost, decreased insulin requirements, less maternal weight gain and less risk of maternal and neonatal hypoglycaemia. The conclusion is that metformin is a cheap and efficacious antidiabetic medication for many pregnant women with T2DM, with reasonable evidence for safety. Drug information resources should be updated so that metformin can be considered more broadly in women with T2DM who present for antenatal care.
Collapse
Affiliation(s)
- Thomas M Polasek
- Department of Clinical Pharmacology, Flinders University School of Medicine and Flinders Medical Centre, Bedford Park, South Australia 5042, Australia d3 Medicine, A Certara Company, Parkville, Victoria, 3052, Australia
| | - Matthew P Doogue
- Department of Medicine, University of Otago, Dunedin, New Zealand Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Tilenka R J Thynne
- Department of Clinical Pharmacology, Flinders University School of Medicine and Flinders Medical Centre, Bedford Park, South Australia, Australia
| |
Collapse
|
39
|
Panchaud A, Rousson V, Vial T, Bernard N, Baud D, Amar E, De Santis M, Pistelli A, Dautriche A, Beau-Salinas F, Cassina M, Dunstan H, Passier A, Kaplan YC, Duman MK, Maňáková E, Eleftheriou G, Klinger G, Winterfeld U, Rothuizen LE, Buclin T, Csajka C, Hernandez-Diaz S. Pregnancy outcomes in women on metformin for diabetes or other indications among those seeking teratology information services. Br J Clin Pharmacol 2018; 84:568-578. [PMID: 29215149 DOI: 10.1111/bcp.13481] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/23/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022] Open
Abstract
AIMS Metformin is used to treat type 2 diabetes, polycystic ovary syndrome associated infertility, and gestational diabetes. This study aims to evaluate the safety of metformin in early pregnancy. METHOD We evaluated the risk of major birth defects and pregnancy losses in a cohort of pregnant women exposed to metformin during the first trimester for different indications relative to a matched unexposed reference group. RESULTS The risk of major birth defects was 5.1% (20/392) in pregnancies exposed to metformin during the first trimester and 2.1% (9/431) in the reference group [adjusted odds ratio (OR) 1.70; 95% CI 0.70-4.38]. Among metformin users, this risk was 7.8% (17/219) in patients with pre-gestational diabetes and 1.7% (3/173) in those without this diagnosis. Compared to the unexposed reference, the OR for metformin user with diabetes was 3.95 (95% CI 1.77-9.41) and for metformin with other indications it was 0.83 (95% CI 0.18-2.81). The risk of pregnancy losses (spontaneous abortions and stillbirths) was 20.8% in women on metformin during the first trimester and 10.8% in the reference group [adjusted hazard ratio (HR) 1.57; 95% CI 0.90-2.74]. The risks for women on metformin with and without pre-gestational diabetes were 24.0% and 16.8% respectively, with adjusted HR of 2.51 (95% CI 1.44-4.36) and 1.38 (95% CI 0.74-2.59) when compared to the reference. CONCLUSION Pregnant women with pre-gestational diabetes on metformin are at a higher risk for adverse pregnancy outcomes than the general population. This appears to be due to the underlying diabetes since women on metformin for other indications do not present meaningfully increased risks.
Collapse
Affiliation(s)
- Alice Panchaud
- School of Pharmaceutical Sciences, University of Geneva and Lausanne, Geneva, Switzerland.,Swiss Teratogen Information Service (STIS) and Service of Clinical Pharmacology, University Hospital, Lausanne, Switzerland.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Valentin Rousson
- Institute of Social and Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thierry Vial
- Pharmacovigilance Center of Lyon, Hospices Civils de Lyon, France
| | - Nathalie Bernard
- Pharmacovigilance Center of Lyon, Hospices Civils de Lyon, France
| | - David Baud
- Materno-Fetal and Obstetrics Research Unit, Departement "Femme-Mere-Enfant", University Hospital, Lausanne, Switzerland
| | - Emmanuelle Amar
- Registre des Malformations en Rhone Alpes (REMERA), Faculté Laennec, Lyon, France
| | - Marco De Santis
- Telefono Rosso-Teratology Information Service, Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, Italy
| | - Alessandra Pistelli
- Centro di Riferimento Regionale di Tossicologia Perinatale, SODc Tossicologia Medica, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | | | - Matteo Cassina
- Teratology Information Service, Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Hannah Dunstan
- UKTIS, Regional Drug and Therapeutics Centre, Newcastle upon Tyne, UK
| | - Anneke Passier
- Teratology Information Service (TIS), Netherlands Pharmacovigilance Centre Lareb, The Netherlands
| | - Yusuf Cem Kaplan
- Faculty of Medicine Department of Pharmacology Teratology Information Service, Izmir Katip Celebi University, Izmir, Turkey
| | - Mine Kadioglu Duman
- Faculty of Medicine, Department of Pharmacology, Karadeniz Technical University, Trabzon, Turkey
| | - Eva Maňáková
- CZTIS, 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Gil Klinger
- BELTIS, Rabin Medical Center and NICU, Schneider Children's Medical Center of Israel, Petach Tikva, Israel and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ursula Winterfeld
- Swiss Teratogen Information Service (STIS) and Service of Clinical Pharmacology, University Hospital, Lausanne, Switzerland
| | - Laura E Rothuizen
- Swiss Teratogen Information Service (STIS) and Service of Clinical Pharmacology, University Hospital, Lausanne, Switzerland
| | - Thierry Buclin
- Swiss Teratogen Information Service (STIS) and Service of Clinical Pharmacology, University Hospital, Lausanne, Switzerland
| | - Chantal Csajka
- School of Pharmaceutical Sciences, University of Geneva and Lausanne, Geneva, Switzerland
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
40
|
Tripathi R, Tyagi S, Goel V. Metformin in gestational diabetes mellitus. Indian J Med Res 2017; 145:588-591. [PMID: 28948948 PMCID: PMC5644292 DOI: 10.4103/ijmr.ijmr_1572_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Reva Tripathi
- Department of Obstetrics & Gynaecology, Maulana Azad Medical College & LNJP Hospital, New Delhi 110 002, India
| | - Shakun Tyagi
- Department of Obstetrics & Gynaecology, Maulana Azad Medical College & LNJP Hospital, New Delhi 110 002, India
| | - Vandana Goel
- Department of Obstetrics & Gynaecology, Maulana Azad Medical College & LNJP Hospital, New Delhi 110 002, India
| |
Collapse
|
41
|
Romero R, Erez O, Hüttemann M, Maymon E, Panaitescu B, Conde-Agudelo A, Pacora P, Yoon BH, Grossman LI. Metformin, the aspirin of the 21st century: its role in gestational diabetes mellitus, prevention of preeclampsia and cancer, and the promotion of longevity. Am J Obstet Gynecol 2017; 217:282-302. [PMID: 28619690 DOI: 10.1016/j.ajog.2017.06.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/16/2022]
Abstract
Metformin is everywhere. Originally introduced in clinical practice as an antidiabetic agent, its role as a therapeutic agent is expanding to include treatment of prediabetes mellitus, gestational diabetes mellitus, and polycystic ovarian disease; more recently, experimental studies and observations in randomized clinical trials suggest that metformin could have a place in the treatment or prevention of preeclampsia. This article provides a brief overview of the history of metformin in the treatment of diabetes mellitus and reviews the results of metaanalyses of metformin in gestational diabetes mellitus as well as the treatment of obese, non-diabetic, pregnant women to prevent macrosomia. We highlight the results of a randomized clinical trial in which metformin administration in early pregnancy did not reduce the frequency of large-for-gestational-age infants (the primary endpoint) but did decrease the frequency of preeclampsia (a secondary endpoint). The mechanisms by which metformin may prevent preeclampsia include a reduction in the production of antiangiogenic factors (soluble vascular endothelial growth factor receptor-1 and soluble endoglin) and the improvement of endothelial dysfunction, probably through an effect on the mitochondria. Another potential mechanism whereby metformin may play a role in the prevention of preeclampsia is its ability to modify cellular homeostasis and energy disposition, mediated by rapamycin, a mechanistic target. Metformin has a molecular weight of 129 Daltons and therefore readily crosses the placenta. There is considerable evidence to suggest that this agent is safe during pregnancy. New literature on the role of metformin as a chemotherapeutic adjuvant in the prevention of cancer and in prolonging life and protecting against aging is reviewed briefly. Herein, we discuss the mechanisms of action and potential benefits of metformin.
Collapse
|
42
|
Bowker SL, Savu A, Yeung RO, Johnson JA, Ryan EA, Kaul P. Patterns of glucose-lowering therapies and neonatal outcomes in the treatment of gestational diabetes in Canada, 2009-2014. Diabet Med 2017; 34:1296-1302. [PMID: 28586507 DOI: 10.1111/dme.13394] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 11/30/2022]
Abstract
AIM To examine patterns of use of different glycaemic control agents for treating gestational diabetes mellitus. METHODS This was a large, retrospective, population-based cohort study of pregnant women with gestational diabetes from Alberta, Canada. We linked data from the Alberta Vital Statistics - Birth database with administrative claims data. Alberta Vital Statistics - Birth data were used to identify births that occurred between 1 January 2009 and 31 December 2014. We used International Classification of Diseases version 9/10 codes to identify women with gestational diabetes, and we excluded women with pre-existing diabetes. RESULTS Our cohort consisted of 16 857 women with gestational diabetes, with a total of 18 761 birth events between 2009 and 2014. Over the study period, the proportion of women with gestational diabetes who were treated with glycaemic control therapies increased from 25.0% to 31.4% (P<0.0001). The number of pregnancies treated with insulin only increased (from 23.6% to 28.3%; P<0.0001), as did the number treated with metformin, +/- insulin (from 1.4% to 3.2%; P<0.0001). Rates of large-for-gestational-age infants were significantly higher among pregnancies treated with insulin only (17%) or metformin (16.5%) than among pregnancies that did not receive any pharmacological treatment (12.8%). CONCLUSIONS Our findings show increasing use of insulin and metformin in women with gestational diabetes. Rates of large-for-gestational-age infants were similar among pregnant women receiving either pharmacological treatment, and higher than among pregnant women who did not receive any pharmacological treatment. Future research should explore the long-term outcomes and safety of metformin as an alternative for treating gestational diabetes.
Collapse
Affiliation(s)
| | - A Savu
- Canadian VIGOUR Centre
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - R O Yeung
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - E A Ryan
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - P Kaul
- Canadian VIGOUR Centre
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
43
|
Gray SG, McGuire TM, Cohen N, Little PJ. The emerging role of metformin in gestational diabetes mellitus. Diabetes Obes Metab 2017; 19:765-772. [PMID: 28127850 DOI: 10.1111/dom.12893] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/11/2017] [Accepted: 01/23/2017] [Indexed: 12/19/2022]
Abstract
Metformin use during pregnancy is controversial and there is disparity in the acceptance of metformin treatment in women with gestational diabetes mellitus (GDM) in Australia. Despite short term maternal and neonatal safety measures, the placental transfer of metformin during GDM treatment and the absence of long-term safety data in offspring has regulators and prescribers cautious about its use. To determine the current role in GDM management, this literature review describes the physiological changes that occur in GDM and other forms of diabetes in pregnancy (DIP) and international changes in guidelines for GDM diagnosis. Management options are considered, with a focus on the evolving evidence for metformin, its mechanism of action, the maternal, foetal and neonatal outcomes associated with its use and benefit vs risk when compared with the current gold standard, insulin. Investigation reveals a favourable balance of evidence to support the safety and long-term benefits, to mother and child, of using metformin as an alternate to insulin for treatment of GDM. Recent findings of the gastrointestinal-directed action of metformin are at least as important as the hepatic effect and the availability of a novel delayed-release metformin dose form to exploit this new information provides a product and therapeutic strategy ideally suited to the use of metformin in GDM.
Collapse
Affiliation(s)
- Susan G Gray
- School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Treasure M McGuire
- School of Pharmacy, The University of Queensland, Brisbane, Australia
- Mater Pharmacy Services, Mater Health Services, Brisbane, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Neale Cohen
- Diabetes Clinics, BakerIDI Heart and Diabetes Institute, Prahran, Australia
| | - Peter J Little
- School of Pharmacy, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Xinhua College of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
44
|
Matsuzaki T, Tungalagsuvd A, Iwasa T, Munkhzaya M, Yano K, Mayila Y, Tokui T, Yanagihara R, Matsui S, Kato T, Kuwahara A, Irahara M. Clinical outcome of various metformin treatments for women with polycystic ovary syndrome. Reprod Med Biol 2017; 16:179-187. [PMID: 29259467 PMCID: PMC5661811 DOI: 10.1002/rmb2.12026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/19/2017] [Indexed: 11/12/2022] Open
Abstract
Aim Polycystic ovary syndrome (PCOS) is an ovulatory disorder and insulin resistance and diabetes are involved in its pathophysiology. Metformin, an anti-diabetic agent, has been reported to be useful to induce ovulation. Methods Metformin treatment was classified into four types: (1) clomiphene-metformin combination treatment for clomiphene-resistant patients; (2) clomiphene-metformin combination for clomiphene-sensitive patients; (3) clomiphene-metformin combination for naïve patients; and (4) metformin monotherapy. The patients underwent physical, endocrinological, and clinical examinations for their ovulation rates, pregnancy rates, and follicular development. Results The ovulation rates, pregnancy rates, and single follicular development were not significantly different among the clomiphene-metformin combination treatment groups. In the Body Mass Index (BMI) subanalysis, the pregnancy rate was higher in the BMI≥30 kg/m2 group than in the other three groups with a BMI of ≤30 kg/m2 in both cycles and cases. The ovulation rates and pregnancy rates were significantly higher in the group with a fasting insulin of ≥15 μU/mL than in the groups with a fasting insulin of <15 μU/mL in both cycles and cases. Conclusion Clomiphene-metformin combination treatment appears to be useful, at least for clomiphene-resistant patients, and a BMI of >30 kg/m2 and a fasting insulin of ≥15 μU/mL appear to be predictors of a good result with this treatment.
Collapse
Affiliation(s)
- Toshiya Matsuzaki
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Altankhuu Tungalagsuvd
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Takeshi Iwasa
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Munkhsaikhan Munkhzaya
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Kiyohito Yano
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Yiliyasi Mayila
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Takako Tokui
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Rie Yanagihara
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Sumika Matsui
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Takeshi Kato
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Akira Kuwahara
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| | - Minoru Irahara
- Department of Obstetrics and GynecologyGraduate School of Biomedical SciencesTokushima UniversityKuramotoJapan
| |
Collapse
|
45
|
Brown J, Martis R, Hughes B, Rowan J, Crowther CA. Oral anti-diabetic pharmacological therapies for the treatment of women with gestational diabetes. Cochrane Database Syst Rev 2017; 1:CD011967. [PMID: 28120427 PMCID: PMC6464763 DOI: 10.1002/14651858.cd011967.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short- and long-term complications for the mother and her infant. Treatment options can include oral anti-diabetic pharmacological therapies. OBJECTIVES To evaluate the effects of oral anti-diabetic pharmacological therapies for treating women with GDM. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (14 May 2016), ClinicalTrials.gov, WHO ICTRP (14 May 2016) and reference lists of retrieved studies. SELECTION CRITERIA We included published and unpublished randomised controlled trials assessing the effects of oral anti-diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti-diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti-diabetic pharmacological therapy, 3) combined oral anti-diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review.Women with pre-existing type 1 or type 2 diabetes were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy. MAIN RESULTS We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta-analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality. Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti-diabetic therapy versus placebo for generalisability. Oral anti-diabetic pharmacological therapies versus placebo/standard careThere was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low-quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low-quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low-quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low-quality evidence). No data were reported for development of type 2 diabetes or other pre-specified GRADE maternal outcomes (return to pre-pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large-for-gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low-quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamideThere was no evidence of a difference between metformin- and glibenclamide-treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate-quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, I2 = 61%, Tau2 = 0.07 low-quality evidence), induction of labour (0.81, 95% CI 0.61 to 1.07; one study, 159 women; low-quality evidence) or perineal trauma (RR 1.67, 95% CI 0.22 to 12.52; two studies, 158 women; low-quality evidence). No data were reported for development of type 2 diabetes or other pre-specified GRADE maternal outcomes (return to pre-pregnancy weight, postnatal depression). For the infant there was no evidence of a difference between the metformin- and glibenclamide-exposed groups for the risk of being born LGA (average RR 0.67, 95% CI 0.24 to 1.83; two studies, 246 infants, I2 = 54%, Tau2 = 0.30 low-quality evidence). Metformin was associated with a decrease in a death or serious morbidity composite (RR 0.54, 95% CI 0.31 to 0.94; one study, 159 infants, low-quality evidence). There was no clear difference between groups for neonatal hypoglycaemia (RR 0.86, 95% CI 0.42 to 1.77; four studies, 554 infants, low-quality evidence) or perinatal mortality (RR 0.92, 95% CI 0.06 to 14.55, two studies, 359 infants). No data were reported for neurosensory disability in later childhood or for adiposity or diabetes. Glibenclamide versus acarboseThere was no evidence of a difference between glibenclamide and acarbose from one study (43 women) for any of their maternal or infant primary outcomes (caesarean section, RR 0.95, 95% CI 0.53 to 1.70; low-quality evidence; perinatal mortality - no events; low-quality evidence; LGA , RR 2.38, 95% CI 0.54 to 10.46; low-quality evidence). There was no evidence of a difference between glibenclamide and acarbose for neonatal hypoglycaemia (RR 6.33, 95% CI 0.87 to 46.32; low-quality evidence). There were no data reported for other pre-specified GRADE or primary maternal outcomes (hypertensive disorders of pregnancy, development of type 2 diabetes, perineal trauma, return to pre-pregnancy weight, postnatal depression, induction of labour) or neonatal outcomes (death or serious morbidity composite, adiposity or diabetes). AUTHORS' CONCLUSIONS There were insufficient data comparing oral anti-diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high-quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti-diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short- and long-term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti-diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines.The benefits and potential harms of one oral anti-diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long-term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit.
Collapse
Affiliation(s)
- Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Ruth Martis
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | | | - Janet Rowan
- National Women's HealthPrivate Bag 92024AucklandNew Zealand1003
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | | |
Collapse
|
46
|
Abstract
Gestational diabetes mellitus (GDM) is one of the most common morbidities complicating pregnancy, with short- and long-term consequences to the mothers, fetuses, and newborns. Management and treatment are aimed to achieve best possible glycemic control, while avoiding hypoglycemia and ensuring maternal and fetal safety. It involves behavioral modifications, nutrition and medications, if needed; concurrent with maternal and fetal surveillance for possible adverse outcomes. This review aims to elaborate on the pharmacological options for GDM therapy. We performed an extensive literature review of different available studies, published during the last 50 years, concerning pharmacological therapy for GDM, dealing with safety and efficacy, for both fetal and maternal morbidity consequences; as well as failure and success in establishing appropriate metabolic and glucose control. Oral medication therapy is a safe and effective treatment modality for GDM and in some circumstances may serve as first-line therapy when nutritional modifications fail. When oral agents fail to establish glucose control then insulin injections should be added. Determining the best oral therapy in inconclusive, although it seems that metformin is slightly superior to glyburide, in some aspects. As for parenteral therapy, all insulins listed in this article are considered both safe and effective for treatment of hyperglycemia during pregnancy. Importantly, a better safety profile, with similar efficacy is documented for most analogues. As GDM prevalence rises, there is a need for successful monitoring and treatment for patients. Caregivers should know the possible and available therapeutic options.
Collapse
Affiliation(s)
- Riki Bergel
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel
| | - Yoel Toledano
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel
| | - Moshe Hod
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel.
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel.
| |
Collapse
|
47
|
Zarif N, Nicholson E, Cummings MH. Prescribing of oral antihyperglycaemic agents in gestational diabetes by the antenatal diabetes team within the UK: an observational survey. PRACTICAL DIABETES 2016. [DOI: 10.1002/pdi.2054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- N Zarif
- St Bartholomew's Hospital and the London School of Medicine; London UK
| | | | | |
Collapse
|
48
|
Feng Y, Yang H. Metformin - a potentially effective drug for gestational diabetes mellitus: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2016; 30:1874-1881. [PMID: 27549367 DOI: 10.1080/14767058.2016.1228061] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Metformin has been gradually used in the management of gestational diabetes mellitus (GDM). In order to prove the safety and efficacy of metformin used in pregnancy, we searched several databases for the reports of randomized trials comparing insulin and metformin used in GDM and conducted a meta-analysis. Data showed the rates of neonatal large for gestational age, cesarean section, neonatal respiratory distress and preterm birth were similar in both groups. Maternal glycated hemoglobin-% at gestational week 36-37 was significantly lower in metformin group, indicating good glycemic control of metformin. Maternal weight gain since enrollment to gestational week 36-37 was also lower in metformin group, making metformin worth using even when metformin is insufficient and supplementary insulin is needed. Data also showed that metformin significantly reduced the gestational hypertension complications in GDM patients, probably by reducing the endothelial activation and maternal inflammatory response of insulin resistance. Although metformin can cross the placenta, it is less likely to cause severe neonatal hypoglycemia compared with insulin since it neither stimulates pancreatic insulin release nor increases circulating insulin levels. According to most maternal and neonatal outcomes, metformin is an effective and safe alternative to insulin for GDM patients.
Collapse
Affiliation(s)
- Ye Feng
- a Department of Obstetrics and Gynecology , Peking University First Hospital , Beijing , China
| | - Huixia Yang
- a Department of Obstetrics and Gynecology , Peking University First Hospital , Beijing , China
| |
Collapse
|
49
|
Agha-Jaffar R, Oliver N, Johnston D, Robinson S. Gestational diabetes mellitus: does an effective prevention strategy exist? Nat Rev Endocrinol 2016; 12:533-46. [PMID: 27339886 DOI: 10.1038/nrendo.2016.88] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The overall incidence of gestational diabetes mellitus (GDM) is increasing worldwide. Preventing pathological hyperglycaemia during pregnancy could have several benefits: a reduction in the immediate adverse outcomes during pregnancy, a reduced risk of long-term sequelae and a decrease in the economic burden to healthcare systems. In this Review we examine the evidence supporting lifestyle modification strategies in women with and without risk factors for GDM, and the efficacy of dietary supplementation and pharmacological approaches to prevent this disease. A high degree of heterogeneity exists between trials so a generalised recommendation is problematic. In population studies of dietary or combined lifestyle measures, risk of developing GDM is not improved and those involving a physical activity intervention have yielded conflicting results. In pregnant women with obesity, dietary modification might reduce fetal macrosomia but in these patients, low compliance and no significant reduction in the incidence of GDM has been observed in trials investigating physical activity. Supplementation with probiotics or myoinositol have reduced the incidence of GDM but confirmatory studies are still needed. In randomized controlled trials, metformin does not prevent GDM in certain at-risk groups. Given the considerable potential for reducing disease burden, further research is needed to identify strategies that can be easily and effectively implemented on a population level.
Collapse
Affiliation(s)
- Rochan Agha-Jaffar
- Division of Diabetes, Endocrinology and Metabolism, G3 Medical School Building, Imperial College London, Norfolk Place, London, W2 1PG, UK
| | - Nick Oliver
- Division of Diabetes, Endocrinology and Metabolism, G3 Medical School Building, Imperial College London, Norfolk Place, London, W2 1PG, UK
| | - Desmond Johnston
- Division of Diabetes, Endocrinology and Metabolism, G3 Medical School Building, Imperial College London, Norfolk Place, London, W2 1PG, UK
| | - Stephen Robinson
- Department of Metabolic Medicine, Mint Wing, St Mary's Hospital, Imperial College NHS Trust, Praed Street, London, W2 1NY, UK
| |
Collapse
|
50
|
Zeng XL, Zhang YF, Tian Q, Xue Y, An RF. Effects of metformin on pregnancy outcomes in women with polycystic ovary syndrome: A meta-analysis. Medicine (Baltimore) 2016; 95:e4526. [PMID: 27603343 PMCID: PMC5023865 DOI: 10.1097/md.0000000000004526] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
AIM The aim of the study is to evaluate the effects of metformin on pregnancy outcomes in women with polycystic ovary syndrome (PCOS). METHODS We searched electronic databases and bibliographies of relevant papers to identify studies comparing the pregnancy outcomes in the metformin group with those in the placebo or blank control group. Then, we did this meta-analysis based on the PRISMA guidelines. The primary outcomes included early pregnancy loss (EPL), preterm delivery, term delivery, and gestational diabetes mellitus (GDM). Secondary outcomes included pregnancy-induced hypertension (PIH), intrauterine growth restriction (IUGR), fetal malformation, vaginal delivery (VD), cesarean section (CS), and metformin's side effects, such as nausea or gastrointestinal discomfort. Certainly, data about neonatal death and macrosomia were analyzed if data available. RESULTS Finally, 13 studies including 5 randomized controlled trials (RCT) and 8 cohort studies involving 1606 pregnant women with PCOS were analyzed. The pooled OR of EPL was 0.19 with obvious statistical significance, manifesting that metformin help to lower the rate of EPL (95% CI 0.12-0.28, P < 0.00001). Simultaneously, metformin showed the advantage of reducing the prevalence of preterm delivery (OR 0.37, 95% CI 0.20-0.68, P = 0.002). In addition, metformin could promote term delivery greatly and the pooled OR was 5.23 with sharp statistical difference (95% CI 3.12-8.75, P < 0.00001). CONCLUSION Metformin treatment in women with PCOS throughout pregnancy could increase the possibility of term delivery, VD and reduce the risk of EPL, preterm labor, pregnancy complications such as GDM and PIH, with no serious side effects. Moreover, metformin was not teratogenic based on the limited data. So we may recommend metformin treatment for women with PCOS during the whole pregnancy period for it is quite beneficial and safe for both mothers and babies.
Collapse
Affiliation(s)
- Xian-Ling Zeng
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Ya-Fei Zhang
- Department of General Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Quan Tian
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yan Xue
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Rui-Fang An
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Correspondence: Rui-Fang An, Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China (e-mail: )
| |
Collapse
|