Gestational diabetes mellitus: taking it to heart

Early continuous glucose monitoring-derived glycemic patterns are associated with subsequent insulin resistance and gestational diabetes mellitus development during pregnancy

BACKGROUND

Gestational diabetes mellitus (GDM) and insulin resistance (IR) increase the risk of adverse pregnancy outcomes. We aimed to examine the relationship of interstitial glucose assessed by continuous glucose monitoring (CGM) at early gestation, and the subsequent development of IR and GDM, and to determine 24-h interstitial glucose centile distributions in women with normal (non-IR and non-GDM) and suboptimal glycemic status (IR and/or GDM).

METHODS

CGM measurements were taken for 3-10 days at 18-24 weeks' gestation, followed by fasting serum insulin and oral glucose tolerance testing at 24-28 weeks' gestation. IR and GDM were determined by the updated Homeostasis Model Assessment of IR score of ≥ 1.22 and 2013 World Health Organization criteria, respectively. Risks of IR and GDM were estimated using modified Poisson models, and hourly interstitial glucose centiles determined using Generalized Additive Models for Location, Scale and Shape.

RESULTS

This prospective cohort study involved 167 pregnant women in Singapore, with a mean age of 31.7 years, body mass index of 22.9 kg/m2, and gestation of 20.3 weeks. 25% of women exhibited IR and 18% developed GDM. After confounders adjustment, women with suboptimal glycemic control, indicated by higher mean daily glucose (risk ratio 1.42; 95% confidence interval 1.16, 1.73), glucose management indicator (1.08; 1.03, 1.12), and J-index (1.04; 1.02, 1.06), as well as those with greater glycemic variability, indicated by higher standard deviation (1.69; 1.37, 2.09), coefficient of variation (1.03; 1.00, 1.06), and mean amplitude of glycemic excursions (1.4; 1.14, 1.35) derived from CGM in early gestation were associated with higher risks of developing IR in later gestation. These associations were similarly observed for the development of GDM. Centile curves showed that, compared to those with normal glycemic status, women with suboptimal glycemic status had higher glucose levels, with greater fluctuations throughout 24 h.

CONCLUSIONS

In pregnant women who subsequently developed IR and GDM, interstitial glucose levels assessed by CGM were elevated and varied greatly. This supports the potential use of CGM to screen for glycemic changes early in pregnancy.

Cardiometabolic Risk Factors Associated with Magnesium and Vitamin D Nutrients during Pregnancy-A Narrative Review

This narrative review comprehensively explores the cardiometabolic implications of two vital nutrients, magnesium and vitamin D, during gestation. Magnesium, a key regulator of vascular tone, glucose metabolism, and insulin sensitivity, plays a crucial role in mitigating gestational hypertension and diabetes, a point this review underscores. Conversely, vitamin D, critical for immune response and calcium level maintenance, is linked to gestational diabetes and hypertensive disorders of pregnancy. The authors aim to enhance comprehension of the complex interaction between these nutrients and cardiometabolic function in pregnancy, knowledge that is pivotal for optimizing maternal-fetal outcomes. The mother's health during pregnancy significantly influences the long-term development of the fetus. Recognizing the impact of these nutrient deficiencies on the physiology of cardiometabolic cycles underscores the importance of adequate nutritional support during pregnancy. It also emphasizes the pressing need for future research and targeted interventions to alleviate the burden of pregnancy complications, highlighting the crucial role of healthcare professionals, researchers, and policy makers in obstetrics and gynecology in this endeavor.

Postpartum development of metabolic dysfunction-associated steatotic liver disease in a lean mouse model of gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is associated with increased postpartum risk for metabolic dysfunction-associated steatotic liver disease (MASLD). GDM-related MASLD predisposes to advanced liver disease, necessitating a better understanding of its development in GDM. This preclinical study evaluated the MASLD development in a lean GDM mouse model with impaired insulin secretion capacity. Lean GDM was induced by short-term 60% high-fat diet and low-dose streptozotocin injections (60 mg/kg for 3 days) before mating in C57BL/6N mice. The control dams received only high-fat diet or low-fat diet. Glucose homeostasis was assessed during pregnancy and postpartum, whereas MASLD was assessed on postpartum day 30 (PP30). GDM dams exhibited a transient hyperglycemic phenotype during pregnancy, with hyperglycaemia reappearing after lactation. Lower insulin levels and impaired glucose-induced insulin response were observed in GDM mice during pregnancy and postpartum. At PP30, GDM dams displayed higher hepatic triglyceride content compared controls, along with increased MAS (MASLD) activity scores, indicating lipid accumulation, inflammation, and cell turnover indices. Additionally, at PP30, GDM dams showed elevated plasma liver injury markers. Given the absence of obesity in this double-hit GDM model, the results clearly indicate that impaired insulin secretion driven pregnancy hyperglycaemia has a distinct contribution to the development of postpartum MASLD.

Kinin B1 receptor controls maternal adiponectin levels and influences offspring weight gain

Given the importance of the kinin B1 receptor in insulin and leptin hormonal regulation, which in turn is crucial in maternal adaptations to ensure nutrient supply to the fetus, we investigated the role of this receptor in maternal metabolism and fetoplacental development. Wild-type and kinin B1 receptor-deficient (B1KO) female mice were mated with male mice of the opposite genotype. Consequently, the entire litter was heterozygous for kinin B1 receptor, ensuring that there would be no influence of offspring genotype on the maternal phenotype. Maternal kinin B1 receptor blockade reduces adiponectin secretion by adipose tissue ex vivo, consistent with lower adiponectin levels in pregnant B1KO mice. Furthermore, fasting insulinemia also increased, which was associated with placental insulin resistance, reduced placental glycogen accumulation, and heavier offspring. Therefore, we propose the combination of chronic hyperinsulinemia and reduced adiponectin secretion in B1KO female mice create a maternal obesogenic environment that results in heavier pups.

Automated Insulin Delivery (AID) Systems: Use and Efficacy in Children and Adults with Type 1 Diabetes and Other Forms of Diabetes in Europe in Early 2023

Type 1 diabetes (T1D) patients' lifestyle and prognosis has remarkably changed over the years, especially after the introduction of insulin pumps, in particular advanced hybrid closed loop systems (AHCL). Emerging data in literature continuously confirm the improvement of glycemic control thanks to the technological evolution taking place in this disease. As stated in previous literature, T1D patients are seen to be more satisfied thanks to the use of these devices that ameliorate not only their health but their daily life routine as well. Limited findings regarding the use of new devices in different age groups and types of patients is their major limit. This review aims to highlight the main characteristics of each Automated Insulin Delivery (AID) system available for patients affected by Type 1 Diabetes Mellitus. Our main goal was to particularly focus on these systems' efficacy and use in different age groups and populations (i.e., children, pregnant women). Recent studies are emerging that demonstrate their efficacy and safety in younger patients and other forms of diabetes.

Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence

Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.

Pregnancy Outcomes and Maternal Insulin Sensitivity: Design and Rationale of a Multi-Center Longitudinal Study in Mother and Offspring (PROMIS)

The worldwide prevalence of overweight and obesity in women of reproductive age is rapidly increasing and a risk factor for the development of gestational diabetes (GDM). Excess adipose tissue reduces insulin sensitivity and may underlie adverse outcomes in both mother and child. The present paper describes the rationale and design of the PRegnancy Outcomes and Maternal Insulin Sensitivity (PROMIS) study, an exploratory cohort study to obtain detailed insights in insulin sensitivity and glucose metabolism during pregnancy and its relation to pregnancy outcomes including early infancy growth. We aim to recruit healthy pregnant women with a body mass index (BMI) ≥ 25 kg/m² before 12 weeks of gestation in Northern Netherlands. A total of 130 woman will be checked on fasted (≤7.0 mmol/L) or random (≤11.0 mmol/L) blood glucose to exclude pregestational diabetes at inclusion. Subjects will be followed up to six months after giving birth, with a total of nine contact moments for data collection. Maternal data include postprandial measures following an oral meal tolerance test (MTT), conducted before 16 weeks and repeated around 24 weeks of gestation, followed by a standard oral glucose tolerance test before 28 weeks of gestation. The MTT is again performed around three months postpartum. Blood analysis is done for baseline and postprandial glucose and insulin, baseline lipid profile and several biomarkers of placental function. In addition, specific body circumferences, skinfold measures, and questionnaires about food intake, eating behavior, physical activity, meal test preference, mental health, and pregnancy complications will be obtained. Fetal data include assessment of growth, examined by sonography at week 28 and 32 of gestation. Neonatal and infant data consist of specific body circumferences, skinfolds, and body composition measurements, as well as questionnaires about eating behavior and complications up to 6 months after birth. The design of the PROMIS study will allow for detailed insights in the metabolic changes in the mother and their possible association with fetal and postnatal infant growth and body composition. We anticipate that the data from this cohort women with an elevated risk for the development of GDM may provide new insights to detect metabolic deviations already in early pregnancy. These data could inspire the development of new interventions that may improve the management of maternal, as well as offsrping complications from already early on in pregnancy with the aim to prevent adverse outcomes for mother and child.

Pregnancy and cardiovascular disease

Cardiovascular disease complicates 1-4% of pregnancies - with a higher prevalence when including hypertensive disorders - and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.

Epigenetic Down-Regulation of Sirt 1 via DNA Methylation and Oxidative Stress Signaling Contributes to the Gestational Diabetes Mellitus-Induced Fetal Programming of Heart Ischemia-Sensitive Phenotype in Late Life

Rationale: The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. However, whether and how GDM exposure induces fetal programming of adult cardiac dysfunctional phenotype, especially the underlying epigenetic molecular mechanisms and theranostics remain unclear. To address this problem, we developed a late GDM rat model.

Methods: Pregnant rats were made diabetic on day 12 of gestation by streptozotocin (STZ). Experiments were conducted in 6 weeks old offspring.

Results: There were significant increases in ischemia-induced cardiac infarction and gender-dependent left ventricular (LV) dysfunction in male offspring in GDM group as compared to controls. Exposure to GDM enhanced ROS level and caused a global DNA methylation in offspring cardiomyocytes. GDM attenuated cardiac Sirt 1 protein and p-Akt/Akt levels, but enhanced autophagy-related proteins expression (Atg 5 and LC3 II/LC3 I) as compared to controls. Ex-vivo treatment of DNA methylation inhibitor, 5-Aza directly inhibited Dnmt3A and enhanced Sirt 1 protein expression in fetal hearts. Furthermore, treatment with antioxidant, N-acetyl-cysteine (NAC) in offspring reversed GDM-mediated DNA hypermethylation, Sirt1 repression and autophagy-related gene protein overexpression in the hearts, and rescued GDM-induced deterioration in heart ischemic injury and LV dysfunction.

Conclusion: Our data indicated that exposure to GDM induced offspring cardiac oxidative stress and DNA hypermethylation, resulting in an epigenetic down-regulation of Sirt1 gene and aberrant development of heart ischemia-sensitive phenotype, which suggests that Sirt 1-mediated signaling is the potential therapeutic target for the heart ischemic disease in offspring.

Asymmetric dimethylarginine and arginine metabolites in women with and without a history of gestational diabetes

AIMS

Dysregulation of arginine metabolism, as evidenced by increased circulating levels of asymmetric dimethylarginine (ADMA), has been proposed as an early event in the natural history of cardiovascular disease. Since the diagnosis of gestational diabetes mellitus (GDM) identifies a patient population at increased future risk of cardiovascular disease later in life, we sought to characterize arginine metabolism in women with and without a history of recent GDM.

METHODS

In this prospective observational cohort study, 225 women (72 who had GDM; 153 who did not) underwent cardiometabolic characterization, including oral glucose tolerance test, at 1- and 3-years postpartum. Circulating ADMA and its stereoisomer symmetric dimethylarginine (SDMA) were measured by liquid chromatography-mass spectrometry at both visits.

RESULTS

Serum ADMA and SDMA were not significantly different between the GDM and non-GDM groups at either 1-year or 3-years postpartum. On multiple linear regression analyses, high-density-lipoprotein cholesterol (t=-2.62, p=0.009) and creatinine (t=-2.62, p=0.01) were independently associated with ADMA at 3-years, while creatinine (t=7.09, p<0.0001) and BMI (t=-2.24, p=0.026) predicted SDMA.

CONCLUSION

Women with recent GDM do not exhibit altered serum concentrations of ADMA or SDMA at 1- and 3-years postpartum, suggesting that ADMA dysregulation is not a feature of their cardiometabolic profile in the early years after delivery.

Associations between gestational diabetes mellitus and elevated HbA1c early postpartum in a multi-ethnic population

AIMS

To investigate the prevalence of elevated HbA_1c 14 weeks postpartum in different ethnic groups and in women with and without gestational diabetes mellitus (GDM) in the index pregnancy and to explore demographic and biological factors from early pregnancy associated with elevated HbA_1c (HbA_1c ≥5.7% (≥39mmol/mol)) postpartum.

METHODS

From a cohort study in Oslo, Norway, we included 570 pregnant women, examined in gestational week 15, 28, and 14 weeks postpartum. The association between elevated HbA_1c and demographic and biological factors were assessed by logistic regression analyses.

RESULTS

The prevalence of elevated HbA_1c postpartum was 23% in the total population, 15% among Western Europeans and 28% among women with ethnic minority background (p<0.01). In ethnic minorities elevated HbA_1c was found in 39% of women with recent GDM diagnosed by the World Health Organization 2013 criteria and in 21% of women without GDM (p<0.01), compared to 22% and 13% in Western Europeans (p=0.11). We found independent associations between elevated HbA_1c and ethnic minority background (OR 2.0, 95% CI 1.27, 3.18), and GDM (OR 2.04, 95% CI 1.35, 3.10) (p<0.01).

CONCLUSIONS

The prevalence of elevated HbA_1c postpartum was 23%, and significantly higher among women with ethnic minority background irrespective of GDM.

Middle Iron-Enriched Fructose Diet on Gestational Diabetes Risk and on Oxidative Stress in Offspring Rats

Gestational diabetes mellitus (GDM) is associated with increased insulin resistance and a heightened level of oxidative stress (OS). Additionally, high iron consumption could also increase insulin resistance and OS, which could aggravate GDM risk. The aim of this study is to evaluate a high fructose diet (F) as an alternative experimental model of GDM on rats. We also have evaluated the worst effect of a fructose iron-enriched diet (FI) on glucose tolerance and OS status during pregnancy. Anthropometric parameters, plasma glucose levels, insulin, and lipid profile were assessed after delivery in rats fed an F diet. The effects observed in mothers (hyperglycemia, and hyperlipidemia) and on pups (macrosomia and hypoglycemia) are similar to those observed in women with GDM. Therefore, the fructose diet could be proposed as an experimental model of GDM. In this way, we can compare the effect of an iron-enriched diet on the metabolic and redox status of mother rats and their pups. The mothers' glycemic was similar in the F and FI groups, whereas the glycemic was significantly different in the newborn. In rat pups born to mothers fed on an FI diet, the activities of the antioxidant enzyme glutathione peroxidase (GPx) and glutathione-S-transferase in livers and GPx in brains were altered and the gender analysis showed significant differences. Thus, alterations in the glycemic and redox status in newborns suggest that fetuses are more sensitive than their mothers to the effect of an iron-enriched diet in the case of GDM pregnancy. This study proposed a novel experimental model for GDM and provided insights on the effect of a moderate iron intake in adding to the risk of glucose disorder and oxidative damage on newborns.

History of Gestational Diabetes Mellitus in Relation to Cardiovascular Disease and Cardiovascular Risk Factors in US Women

BACKGROUND

Findings from previous studies examining the association between gestational diabetes mellitus (GDM) and subsequent risk of cardiovascular disease (CVD) have been inconsistent and inconclusive. We aimed to examine the associations of a previous history of GDM with risk of CVD and status of cardiovascular risk factors in a nationwide population-based study in the United States.

METHODS

This study included 8,127 parous women aged 20 years or older in the 2007-2014 cycles of the National Health and Nutrition Examination Survey in the United States. The exposure was self-reported diagnostic history of GDM and the outcomes were self-reported diagnostic history of CVD and measurements of cardiovascular risk factors, including blood pressure and blood lipids. Regression models with sample weights were used to examine the associations of GDM with CVD and cardiovascular risk factors.

RESULTS

Among women with a history of both GDM and CVD, CVD was diagnosed on average 22.9 years after the diagnosis of GDM. After adjustment for demographic, socioeconomic, and lifestyle factors, a history of GDM was associated with 63% higher odds of CVD [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.02, 2.62, p-value = 0.04]. Further adjustment for body mass index (BMI) modestly attenuated the association (OR 1.52, 95% CI 0.95, 2.44, p-value = 0.08). A history of GDM was significantly associated with lower serum level of HDL-cholesterol (adjusted β-coefficient -3.33, 95% CI -5.17, -1.50, p-value ≤ 0.001), but not associated with total cholesterol, LDL-cholesterol, triglycerides, or systolic or diastolic blood pressure. Similarly, the association between a history of GDM and HDL cholesterol was attenuated after additional adjustment for BMI (adjusted β-coefficient -1.68, 95% CI -3.38, 0.03, p-value = 0.54).

CONCLUSION

Women with a previous history of GDM have significantly higher risk for developing CVD and lower serum level of HDL cholesterol, compared to women without a history of GDM. The associations may be explained, at least partly, by BMI.

Role of Type 2 Diabetes in Determining Retinal, Renal, and Cardiovascular Outcomes in Women With Previous Gestational Diabetes Mellitus

OBJECTIVE

Women who have gestational diabetes mellitus (GDM) have elevated lifetime risks for the development of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), compared with their peers. However, it is not known whether their risk of CVD is dependent upon the development of T2DM. Thus, we sought to evaluate the role of T2DM in determining vascular outcomes in women with previous GDM.

RESEARCH DESIGN AND METHODS

All women in Ontario, Canada, with a live-birth pregnancy between April 1994 and March 2014 (n = 1,515,079) were stratified into the following four groups: women with GDM in whom T2DM subsequently developed (n = 15,585, median age 32 years); those with GDM in whom T2DM did not develop (n = 41,299; median age 32 years); women who did not have GDM but in whom T2DM developed (n = 49,397; median age 31 years); and those with neither GDM nor T2DM (n = 1,408,798; median age 30 years). Women were followed over a median time of 10.0 years for the development of microvascular and macrovascular outcomes.

RESULTS

Among women who had GDM, only those in whom T2DM developed had an increased risk of vitrectomy/photocoagulation (hazard ratio [HR] 4.49, 95% CI 3.90-5.17), renal dialysis (HR 7.52, 5.24-10.81), and hospitalization for foot infection (HR 4.32, 3.42-5.46) (all P < 0.0001). However, for macrovascular outcomes, both women with GDM in whom T2DM developed and those in whom T2DM did not develop had increased risks of CVD (HR 2.82; 2.41-3.30; P < 0.0001; and HR 1.30; 1.07-1.59; P = 0.008, respectively) and coronary artery disease (HR 3.54; 2.96-4.23; P < 0.0001; and HR 1.41; 1.11-1.80; P = 0.005, respectively), although absolute event rates were very low.

CONCLUSIONS

Women with GDM have an elevated risk of cardiovascular outcomes, even in the absence of T2DM. In contrast, microvascular risk emerges only in those in whom T2DM develops.

Identifying Key Intervention Opportunities During a Pregnancy Complicated by Diabetes: a Review of Acute Complications of Diabetes During Pregnancy

Diabetes in pregnancy is associated with significant and sometimes devastating acute complications. It is important that all health care providers are aware of possible complications at each stage of pregnancy so that we can prevent these complications whenever possible and reduce morbidity when they do occur. Most complications associated with diabetes during pregnancy have reduced incidence when blood glucose and blood pressure are optimally controlled. Yet, it is always best to try to optimize diabetes and any comorbidities prior to conception.

Circadian clock gene expression is impaired in gestational diabetes mellitus

Dysfunction of the circadian clock genes is involved in the development of obesity and type 2 diabetes (T2D). Since gestational diabetes mellitus (GDM) and T2D share common genetic and phenotypic features, in the present study, we investigated the status of the circadian clock in a cohort of 40 Greek pregnant women with GDM, four with T2D and 20 normal controls. Peripheral blood mRNA transcript levels of 10 clock genes (CLOCK1, BMAL1, PER1, PER2, PER3, PPARΑ, PPARD, PPARG, CRY1 and CRY2) were determined by real-time quantitative PCR. GDM patients expressed significantly lower transcript levels of BMAL1, PER3, PPARD and CRY2 compared to control women (p < 0.05). No significant difference was documented between GDM women maintained either under insulin treatment or diet. A positive correlation was found between the expression of BMAL1 versus CRY2 (r = 0.45, p = 0.003) and BMAL1 versus PPARD (r = 0.43, p = 0.004). Further investigation on the functional relevance of these clock genes, disclosed that expression of PER3 correlated negatively with HbA1C levels (r = -0.36, p = 0.022). These data document for the first time that the expression of BMAL1, PER3, PPARD and CRY2 genes is altered in GDM compared to normal pregnant women and support the notion that deranged expression of clock genes may play a pathogenic role in GDM.

Endothelial function in women with and without a history of glucose intolerance in pregnancy

BACKGROUND/AIMS

Gestational diabetes mellitus (GDM) and milder gestational impaired glucose tolerance (GIGT) identify women who are at risk of developing cardiovascular disease. Endothelial dysfunction, as indicated by impaired flow-mediated dilatation (FMD) on brachial artery ultrasound, is an early marker of vascular disease. Thus, we sought to evaluate endothelial function in women with and without recent glucose intolerance in pregnancy.

METHODS

One-hundred and seventeen women underwent oral glucose tolerance testing (OGTT) in pregnancy, enabling stratification into those with normal gestational glucose tolerance (n = 59) and those with GDM or GIGT (n = 58). 6 years postpartum, they underwent a repeat of OGTT and brachial artery FMD studies, enabling assessment of FMD and 4 secondary vascular measures: FMD after 60 seconds (FMD60), baseline arterial diameter, peak shear rate, and reactive hyperemia.

RESULTS

There were no differences between the normal gestational glucose tolerance and GDM/GIGT groups in FMD (mean 8.5 versus 9.3%, P = 0.61), FMD60 (4.1 versus 5.1%, P = 0.33), baseline diameter (3.4 versus 3.4 mm, P = 0.66), peak shear rate (262.6 versus 274.8 s(-1), P = 0.32), and reactive hyperemia (576.6 versus 496.7%, P = 0.07). After covariate adjustment, there were still no differences between the groups.

CONCLUSION

Despite their long-term cardiovascular risk, women with glucose intolerance in pregnancy do not display endothelial dysfunction 6 years postpartum.