Pregnancy in diabetes

Glucose control during labor and delivery

Neonatal hypoglycemia is an important consequence for the infant of the mother with diabetes. We have reviewed 24 published papers of various protocols for control of glucose in pregnant diabetic women during labor and delivery including our own published work. A relationship of maternal glucose during labor and neonatal hypoglycemia was sought in 19 of these studies. A significant inverse relationship was found in 10 reports with 3 others showing a similar trend. In all but 1 of these 13 studies the participants had pregestational diabetes. Three of the 6 studies not reporting an inverse relationship involved women with GDM. From this review it appears that the maternal glucose should be maintained between 4.0 and 6.0-7.0 mmol/L during labor. Most women with gestational diabetes, especially if they require <1.0 units/kg/d of insulin, can simply be monitored without intravenous insulin. Our own results demonstrate that a target glucose of 4.0-6.0 mmol/L can be used safely and results in a low rate of neonatal hypoglycemia using an iterative glucose insulin infusion protocol for women with pregestational diabetes and when needed for women with gestational diabetes.

Frontiers in research on maternal diabetes-induced neural tube defects: Past, present and future

Diabetes mellitus rightly regarded as a silent-epidemic is continually on the rise and estimated to have a global prevalence of 6.4 % as of 2010. Diabetes during pregnancy is a well known risk factor for congenital anomalies in various organ systems that contribute to neonatal mortality, including cardiovascular, gastrointestinal, genitourinary and neurological systems, among which the neural tube defects are frequently reported. Over the last two to three decades, several groups around the world have focussed on identifying the molecular cues and cellular changes resulting in altered gene expression and the morphological defects and in diabetic pregnancy. In recent years, the focus has gradually shifted to looking at pre-programmed changes and activation of epigenetic mechanisms that cause altered gene expression. While several theories such as oxidative stress, hypoxia, and apoptosis triggered due to hyperglycemic conditions have been proposed and proven for being the cause for these defects, the exact mechanism or the link between how high glucose can alter gene expression/transcriptome and activate epigenetic mechanisms is largely unknown. Although preconceptual control of diabetes, (i.e., managing glucose levels during pregnancy), and in utero therapies has been proposed as an effective solution for managing diabetes during pregnancy, the impact that a fluctuating glycemic index can have on foetal development has not been evaluated in detail. A tight glycemic control started before pregnancy has shown to reduce the incidence of congenital abnormalities in diabetic mothers. On the other hand, a tight glycemic control after organogenesis and embryogenesis have begun may prove insufficient to prevent or reverse the onset of congenital defects. The importance of determining the extent to which glycemic levels in diabetic mothers should be regulated is critical as foetal hypoglycemia has also been shown to be teratogenic. Finally, the major question remaining is if this whole issue is negligible and not worthy of investigation as the efficient management of diabetes during pregnancy is well in place in many countries.

The possible role of epigenetics in gestational diabetes: cause, consequence, or both

Gestational diabetes mellitus (GDM) is defined as the glucose intolerance that is not present or recognized prior to pregnancy. Several risk factors of GDM depend on environmental factors that are thought to regulate the genome through epigenetic mechanisms. Thus, epigenetic regulation could be involved in the development of GDM. In addition, the adverse intrauterine environment in patients with GDM could also have a negative impact on the establishment of the epigenomes of the offspring.

Interferência do controle glicêmico na transição entre as fases I e II da lactogênese em pacientes com diabetes melito tipo 1

A lactogênese é constituída pelas fases designadas como I e II. A transição entre essas fases é caracterizada pelo aumento da concentração de lactose no colostro. Este estudo teve como objetivo analisar a interferência do diabetes melito tipo 1 (DM1) na transição entre as fases da lactogênese. A concentração de lactose foi determinada em amostras de colostro de 11 puérperas portadoras de DM1 e de 19 puérperas sem a doença, durante os cinco primeiros dias do puerpério. A determinação da concentração da lactose foi feita pela reação com ácido pícrico. Em ambos os grupos houve aumento progressivo da concentração da lactose em função do tempo; entretanto, o aumento foi significativamente menor no terceiro e no quinto dia no grupo das portadoras de diabetes. A análise da transição de fases da lactogênese revelou que as puérperas portadoras de diabetes melito com controle glicêmico inadequado apresentaram atraso de 18 horas para alcançar a fase II da lactogênese, dificultando o estabelecimento do aleitamento materno.

Pregnancy in women with Type 2 diabetes: 12 years outcome data 1990-2002

AIM

Twelve years' outcome analysis of pregnancies in women with Type 2 diabetes in a multiethnic geographically defined area.

METHODS

Information about 182 women delivered between 1990 and 2002 was ascertained from a regional computerized database. The main outcome measures were rates of miscarriage, stillbirth, neonatal/postnatal deaths, congenital malformations, birth weight, mode of delivery, and neonatal unit care as well as maternal morbidities of polyhydramnios, postpartum haemorrhage, pregnancy-induced hypertension/pre-eclampsia.

RESULTS

Among 182 singleton pregnancies, 161 (88%) resulted in a live outcome. There were 16 (8.8%) spontaneous miscarriages, two (1.2%) stillbirths, and three (1.6%) terminations. Congenital malformations occurred in 18 pregnancies (99/1000). There were two early and one late neonatal deaths and two further deaths in the postnatal period. Twenty-eight percent of infants were large for gestational age, with 15 (9.3%) greater than 4 kg. Fifty-three percent were delivered by caesarean section and 68 (37%) required admission to neonatal unit (NNU) care. Hypertension/pre-eclampsia was two times, polyhydramnios three times, and postpartum haemorrhage six times more common than in non-diabetic women.

CONCLUSIONS

Women with Type 2 diabetes have a less satisfactory pregnancy outcome compared with the general population. Infants have a two-fold greater risk of stillbirth, a 2.5-fold greater risk of a perinatal mortality, a 3.5-fold greater risk of death within the first month and a six-fold greater risk of death up to 1 year compared with regional/national figures. They have an 11 times greater risk of a congenital malformation. We need to develop better educational and screening strategies if we are to improve.

Maternal diabetes: an independent risk factor for major cardiovascular malformations with increased mortality of affected infants

BACKGROUND

Intensive medical care of women with diabetes has reduced their risks of bearing infants with congenital anomalies. To assess the preventive potential of preconceptional care, the data of a population-based study of cardiovascular malformations (CVM) were analyzed to determine the morphogenetic specificity of maternal diabetes risks, the morbidity and mortality of the infants, and maternal characteristics that might affect these risks.

METHODS

The Baltimore-Washington Infant Study was a case-control study (1981-1989) that included all live born infants with confirmed CVM; control infants were a representative sample of the birth cohort. A questionnaire administered in home visits recorded parental information on social, medical, occupational, and environmental factors. For these analyses of preconceptional diabetes risks, the case group excluded chromosomal and mendelian disorders and was divided into 3 developmental categories and 12 diagnostic groups.

RESULTS

Preconceptional maternal diabetes was strongly associated with CVM of early embryonic origin (odds ratio [OR] = 4.7, 95% confidence interval [CI] 2.8-7.9) and with cardiomyopathy (OR = 15.1, 95% CI 5.5-41.3), but not with obstructive and shunting defects (OR = 1.4, 95% CI 0.7-3.0). There was heterogeneity within these developmental categories: among laterality defects, diabetes was associated only with cardiovisceral and atrioventricular discordance (OR = 10.0, 95% CI 3.7-27.0); among outflow tract anomalies, the risk was strongly associated with normally related great arteries (OR = 6.6, 95% CI 3.2-13.3) but not with simple transpositions; and among atrioventricular septal defects, diabetes was associated with the complete but not with the partial forms (OR = 22.8, 95% CI 7.4-70.5). The association in early CVM was strongest among infants with multisystem, predominantly VACTERL, anomalies. All-cause mortality of infants with CVM was 39% among those with diabetic mothers and 17.8% in those with nondiabetic mothers. Deceased infants of diabetic mothers were also more likely to have extracardiac anomalies (P = 0.041), to be born prematurely (P = 0.007), and to have low birth weight (P = 0.011). Multivariate analyses of maternal factors revealed no significant confounders of the diabetes associations.

CONCLUSIONS

The evidence of diabetes-induced major cardiac defects is of urgent clinical significance. The effectiveness of early preconceptional care in the prevention of congenital anomalies has been demonstrated repeatedly.

Update on screening for type 2 diabetes. The why, who, how, and what of testing and diagnosing

Type 2 diabetes can cause serious complications even as it remains undiagnosed. Screening is recommended only in people with risk factors for the disease. The ADA recommends FPG as the test of choice, but RPG is also a practical alternative because it is easier and more convenient. Frequency of rescreening if the first screen result is normal depends on the number of risk factors present. Physicians should realize the importance of a confirmatory test and not base a diagnosis of diabetes on a single value unless the value is so high that the diagnosis is unequivocal.

Prenatal screening

The prenatal period is an ideal time to look at screening issues in an effort to maximize the health of the woman and effect a good outcome for her baby. As primary care providers for family, it is important to look beyond a traditional medical model for screening to examine a woman in the context of her family and her experiences. This article takes a broader view of screening to include some social and family issues. It also seeks to examine the evidence around some of the controversial issues in screening to help the provider be a thorough advisor to his or her patients.

Hypertensive disorders, diabetes mellitus, and anemia: three common medical complications of pregnancy

Hypertensive disorders, diabetes mellitus, and anemia are three common medical complications of pregnancy. In many cases, primary care physicians manage them. The understanding of these conditions and recommendations for their treatment are in constant evolution. Care for patients with these problems requires a working knowledge of current information. This article reviews the current knowledge about and treatment of these three disorders.

Pregestational Diabetes Mellitus and Pregnancy

In a pregnancy complicated by diabetes the foetus is at increased risk of congenital malformations, macrosomia and stillbirth. For the mother, diabetes complications (retinopathy nephropathy) may worsen, and in this group there is a higher incidence of hypertension, pre-eclamptic toxaemia and intrauterine growth restriction. However, women with good control who are free of diabetic complications can expect a normal outcome.