Therapies for gestational diabetes and their implications for maternal and offspring health: Evidence from human and animal studies

Association of diabetes mellitus with risk of reproductive impairment in females: A comprehensive review

Reproductive impairment is the most prevalent yet most ignored complication of diabetes mellitus. In diabetes, the problem associated with reproductive health is comprehensive in both males and females. Diabetic females have problems like delayed menarche, irregular menstrual cycle, subfertility, complications in pregnancy and early menopause. This may decrease reproductive age in diabetic females as the menarche is delayed and menopause is early in them. Like diabetic males, diabetic females also have the negative effect of oxidative stress on the reproductive system. This may lead to dysfunction of the ovary. It affects the physiological cycle like the ovary's maturation, embryo development and pregnancy. These complications also affect the offspring, and they may also become diabetic. This review aims to concentrate on the effect of diabetes on the reproductive system of females and the impairment caused by it. We will also discuss in detail the role of the hypothalamus-pituitary ovary axis, diabetes impact on different reproductive phases of females, and the sexual disorders that occur in them.

Differences in neonatal adverse outcomes among women with gestational diabetes mellitus managed by diet or medication: a propensity score matched analysis of a population-based sample

OBJECTIVE

Neonatal outcomes in women with and without medically managed gestational diabetes mellitus (GDM) were compared after accounting for differences in maternal baseline characteristics using a propensity score (PS) analysis.

METHODS

Women without preexisting diabetes, delivering singletons during 2010-2017 in a large hospital, were eligible for inclusion. Using nearest-neighbour PS matching, women with non-pharmacological managed GDM were matched with women whose GDM was medically managed. A conditional logistic regression consequently compared the neonatal adverse outcomes between the groups after adjusting for gestational age, induction of labor, birth type, and number of ultrasounds conducted during the pregnancy.

RESULTS

Of the overall 10028 births, GDM was diagnosed in 930 (9.3%), of whom 710 (76.3%) were successfully matched. The conditional regressions found higher risk of neonatal adverse outcomes in neonates of women with non-pharmacological managed GDM compared to neonates of women with medically managed GDM. These included a higher risk of hypoglycemia (odds ratio (OR) 1.56, 95% confidence interval (CI) 1.03-2.38, p = 0.037), hypothermia (OR 2.29, 95%CI 1.05-5.00, p = 0.037), and birth injuries (OR 3.50, 95%CI 1.62-7.58, p = 0.001), and a higher risk of being small for gestational age (OR 2.06, 95%CI 1.01-4.18, p = 0.046) and being admitted to a special care unit (OR 2.04, 95%CI 1.29-3.21, p = 0.002).

CONCLUSIONS

The increased neonatal morbidity associated with non-medicated GDM identified in our study may indicate that diet and lifestyle changes alone are not sufficient to achieve glycaemic control in some women with GDM. Our findings indicate that gestational diabetes management approach is independently associated with neonatal outcomes.

Machine Learning-Based Prediction of Abdominal Subcutaneous Fat Thickness During Pregnancy

Objective: Current evidence regarding the safety of abdominal subcutaneous injections in pregnant women is limited. In this study, we developed a predictive model for abdominal skin-subcutaneous fat thickness (S-ScFT) by gestational periods (GP) in pregnant women. Methods: A total of 354 cases were measured for S-ScFT. Three machine learning algorithms, namely deep learning, random forest, and support vector machine, were used for S-ScFT predictive modeling and factor analysis for each abdominal site. Data analysis was performed using SPSS and RapidMiner softwares. Results: The deep learning algorithm best predicted the abdominal S-ScFT. The common important variables in all three algorithms for the prediction of abdominal S-ScFT were menarcheal age, prepregnancy weight, prepregnancy body mass index (categorized), large fetus for gestational age, and alcohol consumption. Conclusion: Predicting the safety of subcutaneous injections during pregnancy could be beneficial for managing gestational diabetes mellitus in pregnant women.

The role of apelinergic system in metabolism and reproductive system in normal and pathological conditions: an overview

Lifestyle changes have made metabolic disorders as one of the major threats to life. Growing evidence demonstrates that obesity and diabetes disrupt the reproductive system by affecting the gonads and the hypothalamus-pituitary-gonadal (HPG) axis. Apelin, an adipocytokine, and its receptor (APJ) are broadly expressed in the hypothalamus nuclei, such as paraventricular and supraoptic, where gonadotropin-releasing hormone (GnRH) is released, and all three lobes of the pituitary, indicating that apelin is involved in the control of reproductive function. Moreover, apelin affects food intake, insulin sensitivity, fluid homeostasis, and glucose and lipid metabolisms. This review outlined the physiological effects of the apelinergic system, the relationship between apelin and metabolic disorders such as diabetes and obesity, as well as the effect of apelin on the reproductive system in both gender. The apelin-APJ system can be considered a potential therapeutic target in the management of obesity-associated metabolic dysfunction and reproductive disorders.

Adherence to medical nutrition therapy and it's challenges among antenatal women with gestational diabetes mellitus in South India- A sequential explanatory mixed-method study

BACKGROUND

Globally, one in ten pregnant women have diabetes; out of which, 90% contribute to gestational diabetes mellitus (GDM). Medical Nutrition Therapy (MNT) is the cornerstone for GDM treatment yet adherence to MNT among the masses is not adequately monitored as part of the routine antenatal services. The study aimed to estimate the proportion of adherence to MNT and determine the factors related toadherence among antenatal women with GDM. This study also explores the facilitators, barriers, and possible suggestions for improving adherence.

MATERIALS AND METHODS

This facility-based sequential explanatory mixed-method study was conducted among 341 antenatal women with GDM at, Puducherry. The study was conducted in 2021. Dietary adherence was evaluated using Perceived Dietary Adherence Questionnaire and based on the scores obtained they were selected for in-depth interviews to explore the facilitators and barriers. Collected data wereanalysed by Chi-square test using STATA version 16.

RESULTS

Out of 341 participants, the proportion of participants adherent to MNT was 135 (39.6%) with 95% CI of 34%-44%. Thepredictors for poor adherence were unemployment (PR: 0.65; 95%CI: 0.48-0.88) and good adherence was antenatal women in the 2^nd trimester (PR: 1.541; 95%CI: 1.18-2.025). Barrierstonon-adherence were financial crisis, lack of awareness ofthe need for MNT, and joint family pressure.

CONCLUSIONS

About two-thirds of antenatal women with GDM are non-adherent to MNT. Unemployment and period of gestation were found to be theirdeterminants. Appropriate action has to be implemented for improving the adherence rate.

Exercise performed during pregnancy positively modulates liver metabolism and promotes mitochondrial biogenesis of female offspring in a rat model of diet-induced gestational diabetes

Gestational diabetes mellitus (GDM) is associated with a high-risk for metabolic complications in offspring. However, exercise is recognized as a non-pharmacological strategy against metabolic disorders and is recommended in GDM treatment. This study aimed to investigate whether gestational exercise (GE) could modulate maternal high-fat high-sucrose (HFHS) diet-related hepatic metabolic and mitochondrial outcomes in female offspring of mothers with HFHS-induced GDM. Female Sprague-Dawley rats were fed with control or HFHS diet and kept sedentary or submitted to GE. Their female offspring were fed with control diet and kept sedentary. Hepatic lipid accumulation, lipid metabolism regulators, mitochondrial biogenesis and dynamics markers, and microRNAs associated to the regulation of these markers were evaluated. Female offspring of GDM mothers showed increased body weight at early age, whereas GE prevented this effect of maternal HFHS-feeding and reduced hepatic lipid accumulation. GE stimulated hepatic mRNA transcription and protein expression of mitochondrial biogenesis markers (peroxisome proliferator-activated receptor-gamma co-activator-1alpha and mitochondrial transcription factor A) and mRNA transcription of mitochondrial dynamics markers (mitofusin-1, mitofusin-2, and dynamin-related protein-1) that were altered by maternal GDM, while mitochondrial dynamics markers protein expression was not affected by maternal diet/GE except for optic atrophy-1. MicroRNAs associated with these processes (miR-122, miR-34a, miR-130b, miR-494), and the expression of auto/mitophagy- and apoptosis-related proteins were not substantially influenced by altered intrauterine environment. Our findings suggest that GE is an important regulator of the intrauterine environment positively affecting liver metabolism and promoting liver mitochondrial biogenesis in female offspring despite eventual effects of maternal HFHS-feeding and related GDM.

Recent Experimental Studies of Maternal Obesity, Diabetes during Pregnancy and the Developmental Origins of Cardiovascular Disease

Globally, cardiovascular disease remains the leading cause of death. Most concerning is the rise in cardiovascular risk factors including obesity, diabetes and hypertension among youth, which increases the likelihood of the development of earlier and more severe cardiovascular disease. While lifestyle factors are involved in these trends, an increasing body of evidence implicates environmental exposures in early life on health outcomes in adulthood. Maternal obesity and diabetes during pregnancy, which have increased dramatically in recent years, also have profound effects on fetal growth and development. Mounting evidence is emerging that maternal obesity and diabetes during pregnancy have lifelong effects on cardiovascular risk factors and heart disease development. However, the mechanisms responsible for these observations are unknown. In this review, we summarize the findings of recent experimental studies, showing that maternal obesity and diabetes during pregnancy affect energy metabolism and heart disease development in the offspring, with a focus on the mechanisms involved. We also evaluate early proof-of-concept studies for interventions that could mitigate maternal obesity and gestational diabetes-induced cardiovascular disease risk in the offspring.

Metformin versus insulin therapy for gestational diabetes: Effects on offspring anthropometrics and metabolism at the age of 9 years: A follow-up study of two open-label, randomized controlled trials

AIMS

To compare anthropometrics, and lipid and glucose metabolism in the 9-year-old offspring of mothers treated with metformin or insulin for gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

This was a Finnish two-centre, 9-year follow-up study of two open-label, randomized controlled trials comparing the effects observed in the offspring of mothers who received metformin and insulin treatment for GDM. Measurements included anthropometrics, blood pressure, lipoproteins, and oral glucose tolerance tests. This study was registered with ClinicalTrials.gov, number NCT02417090.

RESULTS

At the age of 9 years 172 children (55% of the original study cohort, 82 from the metformin and 90 from the insulin group) participated in the study. No differences were found between the 9-year-old offspring groups in anthropometric variables, including body mass index and waist-to-height ratio. The offspring in the metformin group had higher high-density lipoprotein (HDL) cholesterol concentrations (1.72 vs. 1.54 mmol/L; P = 0.039) but lower low-density lipoprotein cholesterol (2.39 vs. 2.58 mmol/L; P = 0.046) and apolipoprotein B concentrations (0.63 vs. 0.67 g/L; P = 0.043) than the offspring in the insulin group. The difference in HDL cholesterol concentration was found to be significant only in boys (P = 0.003). The 2-hour glucose value in the oral glucose tolerance test was 0.6-mmol/L lower in boys from the metformin group than in those from the insulin group (P = 0.015).

CONCLUSIONS

Metformin treatment for GDM is associated with similar offspring growth and glucose metabolism but a more favourable lipid profile at the age of 9 years as compared to insulin treatment.

Gestational Diabetes Mellitus: The Crosslink among Inflammation, Nitroxidative Stress, Intestinal Microbiota and Alternative Therapies

Gestational diabetes mellitus (GDM) is characterized by a set of metabolic complications arising from adaptive failures to the pregnancy period. Estimates point to a prevalence of 3 to 15% of pregnancies. Its etiology includes intrinsic and extrinsic aspects of the progenitress, which may contribute to the pathophysiogenesis of GDM. Recently, researchers have identified that inflammation, oxidative stress, and the gut microbiota participate in the development of the disease, with potentially harmful effects on the health of the maternal-fetal binomial, in the short and long terms. In this context, alternative therapies were investigated from two perspectives: the modulation of the intestinal microbiota, with probiotics and prebiotics, and the use of natural products with antioxidant and anti-inflammatory properties, which may mitigate the endogenous processes of the GDM, favoring the health of the mother and her offspring, and in a future perspective, alleviating this critical public health problem.

Abdominal skin subcutaneous fat thickness over the gestational period in Korean pregnant women: a descriptive observational study

Purpose

Although insulin is usually injected into the abdominal subcutaneous fat, in pregnancy women tend to avoid abdominal injections due to concern about fetal damage. Prior studies have been limited to only measuring skin-subcutaneous fat thickness (S-ScFT) at one site at specific pregnancy points. This study aimed to measure S-ScFT across several abdominal sites and over the gestational period in Korean pregnant women. This can identify which site would be relatively safe for subcutaneous injection during pregnancy.

Methods

Healthy women over 24 weeks of pregnancy in Korea were invited to voluntarily participate in this descriptive study. For the 142 women, S-ScFT of 12 sites in the abdomen were measured by ultrasound, several times over the pregnancy. Each incidence was treated as a case and a total of 262 cases were analyzed.

Results

The mean S-ScFT during pregnancy was 1.14±0.47 cm (1.25±0.54 cm at 24⁺⁰–27⁺⁶ weeks; 1.17±0.48 cm at 28⁺⁰–31⁺⁶ weeks; 1.09⁺⁰.40 cm at 32⁺⁰–35⁺⁶ weeks; and 1.06±0.47 cm at 36⁺⁰–40 weeks of pregnancy). Most S-ScFT were thicker than 10 mm. But S-ScFTs in the lateral abdomen and some sites were suboptimal (<6 mm), especially in the pre-pregnancy underweight body mass index group, who had a high rate of suboptimal thickness (27.1% overall and 33.9% in the lateral side).

Conclusion

The whole abdomen seems to be appropriate for subcutaneous injection in most Korean women during pregnancy, with a 4 to 5-mm short needle. However, for the lateral abdomen, making the skin fold might be needed for fetal safety.

Immunoendocrine Dysregulation during Gestational Diabetes Mellitus: The Central Role of the Placenta

Gestational Diabetes Mellitus (GDM) is a transitory metabolic condition caused by dysregulation triggered by intolerance to carbohydrates, dysfunction of beta-pancreatic and endothelial cells, and insulin resistance during pregnancy. However, this disease includes not only changes related to metabolic distress but also placental immunoendocrine adaptations, resulting in harmful effects to the mother and fetus. In this review, we focus on the placenta as an immuno-endocrine organ that can recognize and respond to the hyperglycemic environment. It synthesizes diverse chemicals that play a role in inflammation, innate defense, endocrine response, oxidative stress, and angiogenesis, all associated with different perinatal outcomes.

Maternal high-fat high-sucrose diet and gestational exercise modulate hepatic fat accumulation and liver mitochondrial respiratory capacity in mothers and male offspring

BACKGROUND

Maternal high-caloric nutrition and related gestational diabetes mellitus (GDM) are associated with a high-risk for developing metabolic complications later in life and in their offspring. In contrast, exercise is recognized as a non-pharmacological strategy against metabolic dysfunctions associated to lifestyle disorders. Therefore, we investigated whether gestational exercise delays the development of metabolic alterations in GDM mothers later in life, but also protects 6-week-old male offspring from adverse effects of maternal diet.

METHODS

Female Sprague-Dawley rats were fed with either control (C) or high-fat high-sucrose (HFHS) diet to induce GDM and submitted to gestational exercise during the 3 weeks of pregnancy. Male offspring were sedentary and fed with C-diet.

RESULTS

Sedentary HFHS-fed dams exhibited increased gestational body weight gain (p < 0.01) and glucose intolerance (p < 0.01), characteristic of GDM. Their offspring had normal glucose metabolism, but increased early-age body weight, which was reverted by gestational exercise. Gestational exercise also reduced offspring hepatic triglycerides accumulation (p < 0.05) and improved liver mitochondrial respiration capacity (p < 0.05), contributing to the recovery of liver bioenergetics compromised by maternal HFHS diet. Interestingly, liver mitochondrial respiration remained increased by gestational exercise in HFHS-fed dams despite prolonged HFHS consumption and exercise cessation.

CONCLUSIONS

Gestational exercise can result in liver mitochondrial adaptations in GDM animals, which can be preserved even after the exercise program cessation. Exposure to maternal GDM programs liver metabolic setting of male offspring, whereas gestational exercise appears as an important preventive tool against maternal diet-induced metabolic alterations.

Cinnamaldehyde mitigates placental vascular dysfunction of gestational diabetes and protects from the associated fetal hypoxia by modulating placental angiogenesis, metabolic activity and oxidative stress

Gestational diabetes mellitus (GDM) is a major pregnancy-related disorder with an increasing prevalence worldwide. GDM is associated with altered placental vascular functions and has severe consequences for fetal growth. There is no commonly accepted medication for GDM due to safety considerations. Actions of the currently limited therapeutic options focus exclusively on lowering the blood glucose level without paying attention to the altered placental vascular reactivity and remodelling. We used the fat-sucrose diet/streptozotocin (FSD/STZ) rat model of GDM to explore the efficacy of cinnamaldehyde (Ci; 20 mg/kg/day), a promising antidiabetic agent for GDM, and glyburide/metformin-HCl (Gly/Met; 0.6 + 100 mg/kg/day), as a reference drug for treatment of GDM, on the placenta structure and function at term pregnancy after their oral intake one week before mating onward. Through genome-wide transcriptome, biochemical, metabolome, metal analysis and histopathology we obtained an integrated understanding of their effects. GDM resulted in maternal and fetal hyperglycemia, fetal hyperinsulinemia and placental dysfunction with subsequent fetal anemia, hepatic iron deficiency and high serum erythropoietin level, reflecting fetal hypoxia. Differentially-regulated genes were overrepresented for pathways of angiogenesis, metabolic transporters and oxidative stress. Despite Ci and Gly/Met effectively alleviated the maternal and fetal glycemia, only Ci offered substantial protection from GDM-associated placental vasculopathy and prevented the fetal hypoxia. This was explained by Ci's impact on the molecular regulation of placental angiogenesis, metabolic activity and redox signaling. In conclusion, Ci provides a dual impact for the treatment of GDM at both maternal and fetal levels through its antidiabetic effect and the direct placental vasoprotective action. Lack of Gly/Met effectiveness to restore it's impaired functionality demonstrates the vital role of the placenta in developing efficient medications for GDM.

Factors Associated with Gestational Diabetes Mellitus: A Meta-Analysis

Gestational diabetes mellitus (GDM) is a major public health issue, and the aim of the present study was to identify the factors associated with GDM. Databases were searched for observational studies until August 20, 2020. Pooled odds ratios (ORs) were calculated using fixed- or random-effects models. 103 studies involving 1,826,454 pregnant women were identified. Results indicated that maternal age ≥ 25 years (OR: 2.466, 95% CI: (2.121, 2.866)), prepregnancy overweight or obese (OR: 2.637, 95% CI: (1.561, 4.453)), family history of diabetes (FHD) (OR: 2.326, 95% CI: (1.904, 2.843)), history of GDM (OR: 21.137, 95% CI: (8.785, 50.858)), macrosomia (OR: 2.539, 95% CI: (1.612, 4.000)), stillbirth (OR: 2.341, 95% CI: (1.435, 3.819)), premature delivery (OR: 3.013, 95% CI: (1.569, 5.787)), and pregestational smoking (OR: 2.322, 95% CI: (1.359, 3.967)) increased the risk of GDM with all P < 0.05, whereas history of congenital anomaly and abortion, and HIV status showed no correlation with GDM (P > 0.05). Being primigravida (OR: 0.752, 95% CI: (0.698, 0.810), P < 0.001) reduced the risk of GDM. The factors influencing GDM included maternal age ≥ 25, prepregnancy overweight or obese, FHD, history of GDM, macrosomia, stillbirth, premature delivery, pregestational smoking, and primigravida.

Anti-inflammatory activities of puerarin in high-fat diet-fed rats with streptozotocin-induced gestational diabetes mellitus

To investigate the effect of puerarin on insulin resistance and inflammation in rats with gestational diabetes mellitus (GDM). Gestational diabetic model rats were established by intraperitoneal injection of streptozotocin (25 mg/kg) combined with high-fat feeding and were randomly assigned to three groups: the control group, the GDM group, and the puerarin-treated group. Puerarin was intragastrically administered to rats daily until the offspring were born. The rats in both the GDM group and control group were administered the same volume of normal saline. Serum total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol in all groups of rats were measured. Haematoxylin and eosin staining was used to evaluate morphological changes in the liver, pancreas, and adipose tissues around the reproductive organs. Western blotting was carried out to measure the protein expression of IRS-1 and inflammatory factors, including TNF-α, TLR4, MyD88 and phosphorylated NF-κB, in the adipose tissues around the reproductive organs. Puerarin had preventive effects on GDM-induced pathological changes and ameliorated glucose and lipid metabolism disorders in GDM rats. Puerarin upregulated IRS-1 expression and decreased the protein expression of TNF-α, TLR4, and MyD88 as well as the levels of phosphorylated NF-κB in adipose tissues around the reproductive organs in GDM rats. This study indicated that puerarin exerts anti-inflammatory effects by downregulating the important TLR4/MyD88/NF-κB inflammatory signalling pathway. Therefore, puerarin can decrease the expression of TNF-α and ameliorate insulin resistance in GDM rats, suggesting the potential efficacy of puerarin in GDM treatment.

Maternal resveratrol administration protects against gestational diabetes-induced glucose intolerance and islet dysfunction in the rat offspring

KEY POINTS

Maternal resveratrol (RESV) administration in gestational diabetes (GDM) restored normoglycaemia and insulin secretion. GDM-induced obesity was prevented in male GDM+RESV offspring but not in females. GDM+RESV offspring exhibited improved glucose tolerance and insulin sensitivity. GDM+RESV restored hepatic glucose homeostasis in offspring. Glucose-stimulated insulin secretion was enhanced in GDM+RESV offspring.

ABSTRACT

Gestational diabetes (GDM), the most common complication of pregnancy, is associated with adverse metabolic health outcomes in offspring. Using a rat model of diet-induced GDM, we investigated whether maternal resveratrol (RESV) supplementation (147 mg kg^-1  day^-1 ) in the third week of pregnancy could improve maternal glycaemia and protect the offspring from developing metabolic dysfunction. Female Sprague-Dawley rats consumed a high-fat and sucrose (HFS) diet to induce GDM. Lean controls consumed a low-fat (LF) diet. In the third trimester, when maternal hyperglycaemia was observed, the HFS diet was supplemented with RESV. At weaning, offspring were randomly assigned a LF or HFS diet until 15 weeks of age. In pregnant dams, RESV restored glucose tolerance, normoglycaemia and improved insulin secretion. At 15 weeks of age, GDM+RESV-HFS male offspring were less obese than the GDM-HFS offspring. By contrast, the female GDM+RESV-HFS offspring were similarly as obese as the GDM-HFS group. Hepatic steatosis, insulin resistance, glucose intolerance and dysregulated gluconeogenesis were observed in the male GDM offspring and were attenuated in the offspring of GDM+RESV dams. The dysregulation of several metabolic genes (e.g. ppara, lpl, pepck and g6p) in the livers of GDM offspring was attenuated in the GDM+RESV offspring group. Glucose stimulated insulin secretion was also improved in the islets from offspring of GDM+RESV dams. Thus, maternal RESV supplementation during the third trimester of pregnancy and lactation induced several beneficial metabolic health outcomes for both mothers and offspring. Therefore, RESV could be an alternative to current GDM treatments.