The infant of the diabetic mother

Aortic intima-media thickness and lipid profile in macrosomic newborns

Macrosomia is associated with alterations in lipoprotein composition and concentration at birth. Exposure to diabetes in utero has been established as a significant risk factor for some of the components of metabolic syndrome. The aim of this study was to investigate the effect of macrosomia on lipid metabolism, aortic intima-media thickness (aIMT) and subsequent atherogenic risk in newborn infants. Aortic intima-media thickness was measured in 40 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Lipid profile was determined in all infants and their mothers. Mean aIMT was significantly higher in macrosomic neonates of diabetic and healthy mothers (0.56+/-0.06 and 0.49+/-0.03 mm respectively) than in controls (0.39+/-0.03 mm). Weight-adjusted aIMT in macrosomic neonates of diabetic mothers (0.129+/-0.013 mm/kg) was significantly higher than in groups B and C (0.114+/-0.008 and 0.113+/-0.011 mm/kg respectively). There were significant alterations of total serum, high-density lipoprotein (HDL), very low-density lipoprotein (VLDL) cholesterols and triglyceride levels in the macrosomic neonates of diabetic mothers compared with controls. Macrosomia was associated with increased lipid concentrations. Macrosomic neonates of diabetic mothers have significantly higher aIMT with lipid alterations. This may play a role in the pathogenesis of atherosclerosis in adult life.

Serum insulin-like growth factor-I (IGF-I) IGF binding protein-3 (IGFBP-3) and leptin levels are related to abdominal aortic intima-media thickness in macrosomic newborns

OBJECTIVE

Exposure to diabetes in utero has been established as a significant risk factor for some of the components of metabolic syndrome, and was associated with increased levels of maternal, placental, and fetal insulin-like growth factors and leptin. The atherogenic effects of leptin and insulin-like growth factor-I (IGF-I) have been extensively described. The present study was therefore designed to investigate relationships between abdominal aortic intima-media thickness (aIMT), serum IGF-I, IGF binding protein-3 (IGFBP-3) and leptin levels in macrosomic newborns.

DESIGN

Neonates whose birth weights exceed 90th percentile for gestational age and gender are termed macrosomic. Abdominal aortic intima-media thickness was measured in 30 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Serum IGF-I, IGFBP-3 and leptin levels were determined in all infants and their mothers. Stepwise logistic regression analysis was used to determine independent risk factors for aortic intima-media thickness.

RESULTS

Mean aortic intima-media thickness was significantly higher in groups A and B (0.489+/-0.015,0.466+/-0.019 mm, respectively) than in controls (0.375+/-0.024 mm, p<0.0001). Weight-adjusted aortic intima-media thickness was significantly higher in-group A than in groups B (p=0.004) and C (p=0.048). Serum leptin concentration in-group B (37.4+/-10.7 ng/ml) was significantly greater than in-group C (23.5+/-7.1 ng/ml, p<0.0001), but significantly lower than in-group A (46.6+/-14.1 ng/ml, p<0.0001). Serum IGF-I levels of the infants were significantly lower in-group C (113.2+/-33.1 ng/ml) than in groups A and B (205.2+/-60.1 and 179.3+/-55.1 ng/ml respectively, p<0.0001). Serum IGF-I, IGFBP-3 and leptin levels of the infants were positively correlated with mean (p<0.0001) and weight-adjusted aortic intima-media thickness measurements (p=0.003, p=0.006 and p=0.001, respectively).

CONCLUSIONS

Macrosomic neonates of diabetic mothers have significantly increased aortic intima-media thickness with higher serum IGF-I, IGFBP-3 and leptin concentrations than those of controls. It might be speculated that these changes may exaggerate the atherosclerotic process later in life.

Macrosomic newborns of diabetic mothers are associated with increased aortic intima-media thickness and lipid concentrations

BACKGROUND/AIMS

Exposure to diabetes in utero has been established as a significant risk factor for some of components of metabolic syndrome. A few studies have examined relationship between the metabolic syndrome and echocardiographic left ventricular (LV) mass. We aimed to investigate relationship between abdominal aortic intima-media thickness (aIMT), LV mass and lipid profile in macrosomic newborns.

METHODS

Abdominal aIMT was measured in 30 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Lipid profile and LV mass were determined.

RESULT

Mean aIMT was significantly higher in groups A and B (0.489 +/- 0.015, 0.466 +/- 0.019 mm, respectively) than in controls (0.375 +/- 0.024 mm). Weight-adjusted aIMT in group A was significantly higher than in groups B and C. Macrosomia was associated with increased lipid concentrations. Both LV mass indexed for BSA (body surface area) and birth weight measurements were significantly increased in group A compared with control.

CONCLUSIONS

Macrosomic neonates of diabetic mothers have significant aIMT and LV mass indexed for BSA and birth weight with lipid alterations. It might play a role in the pathogenesis of atherosclerosis in adult life.

Lipoprotein (a) and lipid profile in neonates from mothers with three different types of diabetes mellitus

OBJECTIVES

The metabolic components in neonates may be affected by maternal diabetes mellitus.

DESIGN AND METHODS

To investigate the alterations in lipid metabolism and the possible atherogenic risk, the lipoprotein a (Lp a), apoproteins, lipid profile, glucose concentrations were measured (ELISA, immunodiffusion and enzymatic) in 77 cord blood samples from diabetic and healthy pregnant mothers.

RESULTS

The body weight, cord glucose and both apoproteins were increased in neonates of gestational and noninsulin dependent diabetic (GDM, NIDDM) than in neonates of nondiabetic mothers (NNDM). The Lp (a) was not correlated with the blood glucose and didn't significantly increase in the three neonates groups of diabetic mothers. The apo B/apo A1 and the LDL/HDL ratios were insignificantly increased in relation to the body weight. In neonates of diabetic mothers (NDM), only the blood glucose and Lp (a) differ between both sexes.

CONCLUSION

NDM may have disturbed lipid metabolism, which require special care to them and to their mothers during the prenatal period.

Neonatal hypoglycaemia in infants of diabetic mothers

OBJECTIVE

To determine whether umbilical cord blood glucose correlates with subsequent hypoglycaemia after birth in infants of well-controlled diabetic mothers.

METHODOLOGY

Thirty-eight term infants of well-controlled diabetic mothers were enrolled. Five mothers had pre-existing diabetes. Of the 33 gestational diabetic mothers, 16 were managed on insulin and 17 on diet. Maternal blood glucose was maintained between 4 and 8 mmol/L during labour and delivery. Infants' plasma glucose levels were measured from venous cord blood and serially, at less than 30 min, 1 h and 2 h of life by glucose hexokinase method. Blood glucose levels were further monitored by bedside Dextrostix for 24 h.

RESULTS

Eighteen (47%) infants developed hypoglycaemia (blood glucose level less than 2 mmol/L) during the first 2 h of life. There was no difference in the cord blood glucose levels between infants with or without hypoglycaemia (3.7 +/- 1.1 vs 4.5 +/- 1.1 mmol/L, respectively). Infants of mothers with diabetes diagnosed prior to 28 weeks gestation were at a higher risk of developing hypoglycaemia (8 of 10 vs 10 of 28, OR 7.2, 95%CI 1.3-40.7). Hypoglycaemic infants were of significantly higher birthweight, and were more likely to be born to Caucasian mothers and by Caesarean section. Raised maternal fructosamine blood level, the need for insulin treatment or the infant's haematocrit were not different between infants with or without hypoglycaemia.

CONCLUSIONS

In well-controlled diabetic mothers, the incidence of early hypoglycaemia in infants is still high, particularly in those mothers who had a longer duration of diabetes. Cord blood glucose level did not identify the infants with hypoglycaemia.

Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial

OBJECTIVE

To compare perinatal outcome and glycaemic control in two groups of pregnant diabetic patients receiving two insulin regimens.

DESIGN

Randomised controlled open label study.

SETTING

University affiliated hospital, Israel.

PARTICIPANTS

138 patients with gestational diabetes mellitus and 58 patients with pregestational diabetes mellitus received insulin four times daily, and 136 patients with gestational diabetes and 60 patients with pregestational diabetes received insulin twice daily.

INTERVENTION

Three doses of regular insulin before meals and an intermediate insulin dose before bedtime (four times daily regimen), and a combination of regular and intermediate insulin in the morning and evening (twice daily regimen).

MAIN OUTCOME MEASURES

Maternal glycaemic control and perinatal outcome.

RESULTS

Mean daily insulin concentration before birth was higher in the women receiving insulin four times daily compared with twice daily: by 22 units (95% confidence interval 12 to 32) in patients with gestational diabetes and by 28 units (15 to 41) in patients with pregestational diabetes. Glycaemic control was better with the four times daily regimen than with the twice daily regimen: in patients with gestational diabetes mean blood glucose concentrations decreased by 0.19 mmol/l (0.13 to 0.25), HbA(1c) by 0.3% (0.2% to 0.4%), and fructosamine by 41 micromol/l (37 to 45), and adequate glycaemic control (mean blood glucose concentration <5.8 mmol/l) was achieved in 17% (8% to 26%) more women; in patients with pregestational diabetes mean blood glucose concentration decreased by 0.44 mmol/l (0.28 to 0.60), HbA(1c) by 0.5% (0.2% to 0.8%), and fructosamine by 51 micromol/l (45 to 57), and adequate glycaemic control was achieved in 31% (15% to 47%) more women. Maternal severe hypoglycaemic events, caesarean section, preterm birth, macrosomia, and low Apgar scores were similar in both dose groups. In women with gestational diabetes the four times daily regimen resulted in a lower rate of overall neonatal morbidity than the twice daily regimen (relative risk 0.59, 0.38 to 0.92), and the relative risk for hyperbilirubinaemia and hypoglycaemia was lower (0.51, 0.29 to 0.91 and 0.12, 0.02 to 0.97 respectively). The relative risk of hypoglycaemia in newborn infants to mothers with pregestational diabetes was 0.17 (0.04 to 0.74).

CONCLUSIONS

Giving insulin four times rather than twice daily in pregnancy improved glycaemic control and perinatal outcome without further risking the mother.

Time-dependent gestational diabetes screening values

OBJECTIVE

This study was undertaken to determine use of different cut-off values with regard to the time of the patient's last meal in screening for gestational diabetes mellitus which could result in better results and change patient management.

METHODS

Two hundred and seventy-four non-diabetic women undergoing routine screening for glucose intolerance between 26 to 28 weeks' gestation were classified with regard to the time of previous meal. A glucose challenge test and an oral glucose challenge test were conducted for each patient in the study. Results were evaluated with both a standard cut-off value of 140 mg/dl without regard to the time of the last meal and suggested cut-off values of 148 mg/dl, 142 mg/dl, and 150 mg/dl if the patient ate < 2 h, 2-3 h, and > 3 h before the screening test, respectively.

RESULTS

Two hundred and seventy-four women completed the study. With these suggested cut-off values, the number of patients with a positive glucose challenge test dropped from 15.7% to 11.3%. With these cut-off values, positive predictive value increased from 27.3% to 32.3%.

CONCLUSIONS

The time since previous meal affects 50 g glucose challenge test results. These new cut-off values would lead to improved efficiency of the screening test and decreased frequency with which patients require the 3-h oral glucose tolerance test.

Short- and long-range complications in offspring of diabetic mothers

The perinatal mortality rate of infants of diabetic mothers (IDMs) has declined dramatically from 250 per 1000 live births in the 1960s to a near-normal 20 per 1000 live births in the 1980s. Five to 8% of all IDMs suffer from major congenital malformations, and it is the latter that are responsible for 50% of these perinatal deaths. It has been shown that tight glycemic control prior to conception and during pregnancy can prevent an excess rate of congenital malformations, fetal macrosomia, birth trauma, and neonatal respiratory distress syndrome. We briefly review the short- and long-range complications that occur in offspring of diabetic mothers (ODMs) from gestation through young adulthood. Short-term neonatal complications, such as hypoglycemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia, and polycythemia, are related mainly to fetal hyperinsulinemia, hypoxemia, and prematurity. They are readily controllable within the setup of modern neonatal intensive care units. Long-range complications include an increased rate of childhood and adolescent obesity, impaired glucose tolerance or diabetes mellitus, and subtle neuropsychological dysfunctions. These may be related to the severity of the maternal hyperglycemia during pregnancy, the consequent fetal hyperinsulinemia, and third trimester maternal lipid metabolism disturbances. Today we have at hand the knowledge and tools to properly treat both pregestational and gestational diabetes. Increased education of the general practitioner and the target population regarding early referral of pregestational diabetic mothers and the implementation of screening programs for gestational diabetes will further reduce diabetic pregnancy-related morbidity.

Diabetes

There is now strengthening evidence that meticulous control of maternal carbohydrate and fat metabolism before and during pregnancy in women with diabetes mellitus had positive benefits for the offspring, not only by reducing the incidence of congenital malformations, but also by diminishing fetal loss, reducing immediate neonatal complications and, in the long term, reducing unnecessary obesity, improving neuropsychological development and reducing the emergence of diabetes in the offspring at a relatively early age. Women who develop GDM are at a significant risk of developing NIDDM, and prevention of obesity, consumption of a high-fibre diet and possibly prophylactic hypoglycaemic therapy may reduce this otherwise inevitable progression, which will affect at least 50%.