Elevated pregnancy losses at high and low extremes of maternal glucose in early normal and diabetic pregnancy: evidence for a protective adaptation in diabetes

Association between diabetes mellitus and miscarriage, recurrent miscarriage: A meta-study

BACKGROUND

Previous studies provided inconsistent associations between diabetes mellitus (DM) and miscarriage, recurrent miscarriage (RM). Therefore, this study aims to evaluate the association between DM and miscarriage, specifically RM, through a meta-analysis approach.

METHODS

We searched for articles published before July 2023 in PubMed and Web of Science databases. STATA 12.0 software was used to compute all the results collected from included studies.

RESULTS

DM was associated with a higher risk of miscarriage, RM (miscarriage: odds ratio [OR]/relative risk [RR] = 1.23, 95% confidence interval [CI] 1.13 to 1.34; RM: OR/RR = 1.73, 95% CI 1.55 to 1.94). T1DM was associated with a higher risk of miscarriage (OR/RR = 1.16, 95% CI 1.07 to 1.26). Similarly, T2DM showed a higher risk of miscarriage (OR/RR = 1.44, 95% CI 1.23 to 1.68). Miscarriage, RM were associated with a higher risk of DM (miscarriage: OR/RR = 1.14, 95% CI 1.08 to 1.19; RM: OR/RR = 1.14, 95% CI 1.08 to 1.20). Furthermore, miscarriage was found to be associated with a higher risk of T2DM (OR/RR = 1.08, 95% CI 1.05 to 1.11).

CONCLUSION

In conclusion, our meta-analysis findings indicate a significant association between DM and miscarriages as well as RM. As a result, women with a history of miscarriage should consider regular monitoring of their metabolic health as a potential benefit. Nevertheless, it is important to note that further research is needed to validate the results of our study and shed light on the biological mechanisms underlying these associations.

Fetal loss and long-term maternal morbidity and mortality: A systematic review and meta-analysis

BACKGROUND

Evidence suggests common pathways between pregnancy losses and subsequent long-term maternal morbidity, rendering pregnancy complications an early chronic disease marker. There is a plethora of studies exploring associations between miscarriage and stillbirth with long-term adverse maternal health; however, these data are inconclusive.

METHODS AND FINDINGS

We systematically searched MEDLINE, EMBASE, AMED, BNI, CINAHL, and the Cochrane Library with relevant keywords and MeSH terms from inception to June 2023 (no language restrictions). We included studies exploring associations between stillbirth or miscarriage and incidence of cardiovascular, malignancy, mental health, other morbidities, and all-cause mortality in women without previous pregnancy loss. Studies reporting short-term morbidity (within a year of loss), case reports, letters, and animal studies were excluded. Study selection and data extraction were performed by 2 independent reviewers. Risk of bias was assessed using the Newcastle Ottawa Scale (NOS) and publication bias with funnel plots. Subgroup analysis explored the effect of recurrent losses on adverse outcomes. Statistical analysis was performed using an inverse variance random effects model and results are reported as risk ratios (RRs) with 95% confidence intervals (CIs) and prediction intervals (PIs) by combining the most adjusted RR, odds ratios (ORs) and hazard ratios (HRs) under the rare outcome assumption. We included 56 observational studies, including 45 in meta-analysis. There were 1,119,815 women who experienced pregnancy loss of whom 951,258 had a miscarriage and 168,557 stillbirth, compared with 11,965,574 women without previous loss. Women with a history of stillbirth had a greater risk of ischaemic heart disease (IHD) RR 1.56, 95% CI [1.30, 1.88]; p < 0.001, 95% PI [0.49 to 5.15]), cerebrovascular (RR 1.71, 95% CI [1.44, 2.03], p < 0.001, 95% PI [1.92, 2.42]), and any circulatory/cardiovascular disease (RR 1.86, 95% CI [1.01, 3.45], p = 0.05, 95% PI [0.74, 4.10]) compared with women without pregnancy loss. There was no evidence of increased risk of cardiovascular disease (IHD: RR 1.11, 95% CI [0.98, 1.27], 95% PI [0.46, 2.76] or cerebrovascular: RR 1.01, 95% CI [0.85, 1.21]) in women experiencing a miscarriage. Only women with a previous stillbirth were more likely to develop type 2 diabetes mellitus (T2DM) (RR: 1.16, 95% CI [1.07 to 2.26]; p < 0.001, 95% PI [1.05, 1.35]). Women with a stillbirth history had an increased risk of developing renal morbidities (RR 1.97, 95% CI [1.51, 2.57], p < 0.001, 95% [1.06, 4.72]) compared with controls. Women with a history of stillbirth had lower risk of breast cancer (RR: 0.80, 95% CI [0.67, 0.96], p-0.02, 95% PI [0.72, 0.93]). There was no evidence of altered risk of other malignancies in women experiencing pregnancy loss compared to controls. There was no evidence of long-term mental illness risk in women with previous pregnancy losses (stillbirth: RR 1.90, 95% CI [0.93, 3.88], 95% PI [0.34, 9.51], miscarriage: RR 1.78, 95% CI [0.88, 3.63], 95% PI [1.13, 4.16]). The main limitations include the potential for confounding due to use of aggregated data with variable degrees of adjustment.

CONCLUSIONS

Our results suggest that women with a history of stillbirth have a greater risk of future cardiovascular disease, T2DM, and renal morbidities. Women experiencing miscarriages, single or multiple, do not seem to have an altered risk.

Investigation and Management of Recurrent Pregnancy Loss: A Comprehensive Review of Guidelines

Importance

Recurrent pregnancy loss (RPL) is one of the most frustrating clinical entities in reproductive medicine requiring not only diagnostic investigation and therapeutic intervention, but also evaluation of the risk for recurrence.

Objective

The aim of this study was to review and compare the most recently published major guidelines on investigation and management of RPL.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, the American Society for Reproductive Medicine, the French College of Gynecologists and Obstetricians, and the German, Austrian, and Swiss Society of Gynecology and Obstetrics on RPL was carried out.

Results

There is consensus among the reviewed guidelines that the mainstays of RPL investigation are a detailed personal history and screening for antiphospholipid syndrome and anatomical abnormalities of the uterus. In contrast, inherited thrombophilias, vaginal infections, and immunological and male factors of infertility are not recommended as part of a routine RPL investigation. Several differences exist regarding the necessity of the cytogenetic analysis of the products of conception, parental peripheral blood karyotyping, ovarian reserve testing, screening for thyroid disorders, diabetes or hyperhomocysteinemia, measurement of prolactin levels, and performing endometrial biopsy. Regarding the management of RPL, low-dose aspirin plus heparin is indicated for the treatment of antiphospholipid syndrome and levothyroxine for overt hypothyroidism. Genetic counseling is required in case of abnormal parental karyotype. The Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, and the French College of Gynecologists and Obstetricians guidelines provide recommendations that are similar on the management of cervical insufficiency based on the previous reproductive history. However, there is no common pathway regarding the management of subclinical hypothyroidism and the surgical repair of congenital and acquired uterine anomalies. Use of heparin for inherited thrombophilias and immunotherapy and anticoagulants for unexplained RPL are not recommended, although progesterone supplementation is suggested by the American Society for Reproductive Medicine and the German, Austrian, and Swiss Society of Gynecology and Obstetrics.

Conclusions

Recurrent pregnancy loss is a devastating condition for couples. Thus, it seems of paramount importance to develop consistent international practice protocols for cost-effective investigation and management of this early pregnancy complication, with the aim to improve live birth rates.

Intermittently scanned continuous glucose monitoring is associated with lower spontaneous abortion rate compared with conventional blood glucose monitoring in pregnant women with type 1 diabetes: An observational study

AIM

The objective of the present real-life study in France was to assess and compare characteristics and outcomes in a cohort of pregnant women with type 1 diabetes (T1D) using intermittently scanned continuous glucose monitoring (isCGM) or conventional blood glucose monitoring (BGM).

MATERIAL AND METHODS

We performed an observational study of a cohort of 153 women with T1D: 77 women were using isCGM, and 76 were using BGM. We compared the groups' maternal characteristics and maternal-fetal complications. The level of HbA1c was measured before pregnancy and then four times (after 8-12, 24-28, 30-33, and 35-37 weeks of gestation).

RESULTS

The two groups were similar in terms of age, prepregnancy BMI, diabetes duration, and diabetic vascular complications. There were no significant intergroup differences in the obstetric history. The spontaneous abortion rate was lower in the isCGM group than in the blood glucose monitoring group (5.3% vs. 20%, respectively; p = .0129), while the prepregnancy and first-trimester HbA1c levels were similar. There were no significant intergroup differences in the incidence of other maternal-fetal complications.

CONCLUSIONS

This observational study demonstrates that isCGM use is associated with lower spontaneous abortion compared with conventional BGM. Large prospective studies are needed to corroborate our findings and fully understand the relationship between glucose data at the time of conception/early pregnancy and foetal outcome.

Impact of Remote Monitoring Technologies for Assisting Patients With Gestational Diabetes Mellitus: A Systematic Review

Introduction: In Chile, 1 in 8 pregnant women of middle socioeconomic level has gestational diabetes mellitus (GDM), and in general, 5–10% of women with GDM develop type 2 diabetes after giving birth. Recently, various technological tools have emerged to assist patients with GDM to meet glycemic goals and facilitate constant glucose monitoring, making these tasks more straightforward and comfortable.

Objective: To evaluate the impact of remote monitoring technologies in assisting patients with GDM to achieve glycemic goals, and know the respective advantages and disadvantages when it comes to reducing risk during pregnancy, both for the mother and her child.

Methods: A total of 188 articles were obtained with the keywords “gestational diabetes mellitus,” “GDM,” “gestational diabetes,” added to the evaluation levels associated with “glucose level,” “glycemia,” “glycemic index,” “blood sugar,” and the technological proposal to evaluate with “glucometerm” “mobile application,” “mobile applications,” “technological tools,” “telemedicine,” “technovigilance,” “wearable” published during the period 2016–2021, excluding postpartum studies, from three scientific databases: PUBMED, Scopus and Web of Science. These were managed in the Mendeley platform and classified using the PRISMA method.

Results: A total of 28 articles were selected after elimination according to inclusion and exclusion criteria. The main measurement was glycemia and 4 medical devices were found (glucometer: conventional, with an infrared port, with Bluetooth, Smart type and continuous glucose monitor), which together with digital technology allow specific functions through 2 identified digital platforms (mobile applications and online systems). In four articles, the postprandial glucose was lower in the Tele-GDM groups than in the control group. Benefits such as improved glycemic control, increased satisfaction and acceptability, maternal confidence, decreased gestational weight gain, knowledge of GDM, and other relevant aspects were observed. There were also positive comments regarding the optimization of the medical team’s time.

Conclusion: The present review offers the opportunity to know about the respective advantages and disadvantages of remote monitoring technologies when it comes to reducing risk during pregnancy. GDM centered technology may help to evaluate outcomes and tailor personalized solutions to contribute to women’s health. More studies are needed to know the impact on a healthcare system.

The Investigation of Metabonomic Pathways of Serum of Iranian Women with Recurrent Miscarriage Using 1H NMR

Purpose

Recurrent miscarriage applies to pregnancy loss expulsion of the fetus within the first 24 weeks of pregnancy. This study is aimed at comparatively investigating the sera of women with RM with those who have no record of miscarriages to identify if there were any metabolite and metabolic pathway differences using ¹H NMR spectroscopy.

Methods

Serum samples were collected from women with RM (n = 30) and those who had no records of RM (n = 30) to obtain metabolomics information. ¹H NMR spectroscopy was carried out on the samples using Carr Purcell Meiboom Gill spin echo; also, Partial Least Squares Discriminant Analysis was performed in MATLAB software using the ProMetab program to obtain the classifying chemical shifts; the metabolites were identified by using the Human Metabolome Database (HMDB) in both the experimental and control groups. The pathway analysis option of the Metaboanalyst.ca website was used to identify the changed metabolic pathways.

Results

The results of the study revealed that 14 metabolites were different in the patients with RM. Moreover, the pathway analysis showed that taurine and hypotaurine metabolism along with phenylalanine, tyrosine, and tryptophan biosynthesis was significantly different in patients with RM.

Conclusion

The present study proposes that any alteration in the above metabolic pathways might lead to metabolic dysfunctions which may result in a higher probability of RM.

Glycogen in the uterus and fallopian tubes is an important source of glucose during early pregnancy†

Pregnancy loss is common during the peri-implantation period in mammals when glucose is required for both embryonic development and decidualization of the endometrium. As the uterus cannot synthesize glucose, all glucose must come directly from maternal circulation as needed or transiently stored as the macromolecule glycogen. Glycogen acts as a glucose reservoir, storing up to 55 000 glucose moieties per molecule. Endometrial glycogen concentrations are correlated with fertility in humans, indicating that glycogen is an essential source of glucose during early pregnancy. In humans and primates, endometrial glycogen concentrations peak during the luteal phase due to progesterone. In contrast, in rats and mink, estradiol triggers an accumulation of uterine glycogen during proestrus and estrus. In mated rats, the glycogen content of the endometrium increases again after implantation due to high levels of glycogen stored in the decidua. In mink, endometrial glycogen reserves are localized in the uterine epithelia at estrus. These reserves are mobilized before implantation, suggesting they are used to support embryonic growth. Uterine glycogen concentrations continue to decrease after implantation in mink, probably due to a lack of decidualization. How ovarian steroids stimulate glycogenesis in the endometrium is unclear, but current evidence suggests that estradiol/progesterone interacts with insulin or insulin-like growth factor signaling. In summary, endometrial glycogen is an essential source of glucose during the peri-implantation period. More work is needed to characterize differences among species, elucidate the fate of the glucose liberated from glycogen, and understand how ovarian steroids regulate glycogen metabolism in the uterus.

Delivering family planning and preconception care to women with diabetes: Implementation challenges and promising strategies

Diabetes is increasingly prevalent among women of reproductive age and during pregnancy. The American Diabetes Association, which has called for improvements in the patient-centeredness of care, recommends preconception counseling and care for women of reproductive age with diabetes. However, data suggests this care is not sufficiently delivered. In this article, we describe demographic shifts in the need for preconception care and outline several changes at the clinical encounter as well as the health system- and community-levels that can help improve the delivery of diabetes-specific preconception care.

A short periconceptional exposure to maternal type-1 diabetes is sufficient to disrupt the feto-placental phenotype in a rabbit model

Tight metabolic control of type-1 diabetes is essential during gestation, but it could be crucial during the periconception period. Feto-placental consequences of maternal type-1 diabetes around the time of conception need to be explored. Using a rabbit model, type-1 diabetes was induced by alloxan 7 days before mating. Glycemia was maintained at 15-20 mmol/L with exogenous insulin injections to prevent ketoacidosis. At 4 days post-conception (dpc), embryos were collected from diabetic (D) or normoglycemic control (C) dams, respectively, and transferred into non-diabetic recipients. At 28dpc, D- and C-feto-placental units were collected for biometry, placental analyses and lipid profiles. D-fetuses were growth-retarded, hyperglycemic and dyslipidemic compared to C-fetuses. The efficiency of D-placentas was associated with an increased gene expression related to nutrient supply and lipid metabolism whereas volume density of fetal vessels decreased. Fetal plasma, placental and fetal liver membranes had specific fatty acid signatures depending on embryonic origin. Tissues from D-fetuses contained more omega-6 polyunsaturated fatty acids. The concentrations of docosahexaenoic acid decreased while linoleic acid increased in the heart of D-fetuses. This study demonstrates that a short exposure to maternal type-1 diabetes in the periconception window, until the blastocyst stage, is able to irreversibly malprogram the feto-placental phenotype, through precocious and persistent structural and molecular adaptations of placenta.

Connecting links between genetic factors defining ovarian reserve and recurrent miscarriages

PURPOSE

Approximately 1-2% of the women faces three or more successive spontaneous miscarriages termed as recurrent miscarriage (RM). Many clinical factors have been attributed so far to be the potential risk factors in RM, including uterine anomalies, antiphospholipid syndrome, endocrinological abnormalities, chromosomal abnormalities, and infections. However, in spite of extensive studies, reviews, and array of causes known to be associated with RM, about 50% cases encountered by treating physicians remains unknown. The aims of this study were to evaluate recent publications and to explore oocyte-specific genetic factors that may have role in incidence of recurrent miscarriages.

METHOD

Recent studies have identified common molecular factors contributing both in establishment of ovarian reserve and in early embryonic development. Also, studies have pointed out the relationship between the age-associated depletion of OR and increase in the risk of miscarriages, thus suggestive of an interacting biology. Here, we have gathered literature evidences in establishing connecting links between genetic factors associated with age induced or pathological OR depletion and idiopathic RM, which are the two extreme ends of female reproductive pathology.

CONCLUSION

In light of connecting etiological link between infertility and RM as reviewed in this study, interrogating the oocyte-specific genes with suspected roles in reproductive biology, in cases of unexplained RM, may open new possibilities in widening our understanding of RM pathophysiology.

Infant of diabetic mother: what one needs to know?

The global incidence of diabetes mellitus, including diabetes in pregnant women, is on the rise. Diabetes mellitus in a pregnant woman jeopardizes not only maternal health but can also have significant implications on the child to be born. Therefore, timely diagnosis and strict glycemic control are of utmost importance in achieving a safe outcome for both the mother and fetus. The treating physician should be aware of the complications that can arise due to poor glycemic control during pregnancy. The objective of this article is to discuss the key concerns in a neonate born to diabetic mother, the underlying pathogenesis, and the screening schedule during pregnancy.

Pregnancy, birth, and infant outcomes by maternal fertility status: the Massachusetts Outcomes Study of Assisted Reproductive Technology

BACKGROUND

Births to subfertile women, with and without infertility treatment, have been reported to have lower birthweights and shorter gestations, even when limited to singletons. It is unknown whether these decrements are due to parental characteristics or aspects of infertility treatment.

OBJECTIVE

The objective of the study was to evaluate the effect of maternal fertility status on the risk of pregnancy, birth, and infant complications.

STUDY DESIGN

All singleton live births of ≥22 weeks' gestation and ≥350 g birthweight to Massachusetts resident women in 2004-2010 were linked to hospital discharge and vital records. Women were categorized by their fertility status as in vitro fertilization, subfertile, or fertile. Women whose births linked to in vitro fertilization cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System were classified as in vitro fertilization. Women with indicators of subfertility but not treated with in vitro fertilization were classified as subfertile. Women without indicators of subfertility or in vitro fertilization treatment were classified as fertile. Risks of 15 adverse outcomes (gestational diabetes, pregnancy hypertension, antenatal bleeding, placental complications [placenta abruptio and placenta previa], prenatal hospitalizations, primary cesarean delivery, very low birthweight [<1500 g], low birthweight [<2500 g], small-for-gestation birthweight [z-score ≤-1.28], large-for-gestation birthweight [z-score ≥1.28], very preterm [<32 weeks], preterm [<37 weeks], birth defects, neonatal death [0-27 days], and infant death [0-364 days of life]) were modeled by fertility status with the fertile group as reference and the subfertile group as reference, using multivariate log binomial regression and reported as adjusted risk ratios and 95% confidence intervals.

RESULTS

The study population included 459,623 women (441,420 fertile, 8054 subfertile, and 10,149 in vitro fertilization). Women in the subfertile and in vitro fertilization groups were older than their fertile counterparts. Risks for 6 of 6 pregnancy outcomes and 6 of 9 infant outcomes were increased for the subfertile group, and 5 of 6 pregnancy outcomes and 7 of 9 infant outcomes were increased for the in vitro fertilization group. For 4 of the 6 pregnancy outcomes (uterine bleeding, placental complications, prenatal hospitalizations, and primary cesarean) and 2 of the infant outcomes (low birthweight and preterm) the risk was greater in the in vitro fertilization group, with nonoverlapping confidence intervals to the subfertile group, indicating a substantially higher risk among in vitro fertilization-treated women. The highest risks for the in vitro fertilization women were uterine bleeding (adjusted risk ratio, 3.80; 95% confidence interval, 3.31-4.36) and placental complications (adjusted risk ratio, 2.81; 95% confidence interval, 2.57-3.08), and for in vitro fertilization infants, very preterm birth (adjusted risk ratio, 2.13; 95% confidence interval, 1.80-2.52), and very low birthweight (adjusted risk ratio, 2.15; 95% confidence interval, 1.80-2.56). With subfertile women as reference, risks for the in vitro fertilization group were significantly increased for uterine bleeding, placental complications, prenatal hospitalizations, primary cesarean delivery, low and very low birthweight, and preterm and very preterm birth.

CONCLUSION

These analyses indicate that, compared with fertile women, subfertile and in vitro fertilization-treated women tend to be older, have more preexisting chronic conditions, and are at higher risk for adverse pregnancy outcomes, particularly uterine bleeding and placental complications. The greater risk in in vitro fertilization-treated women may reflect more severe infertility, more extensive underlying pathology, or other unfavorable factors not measured in this study.

Life-threatening endocrine emergencies during pregnancy - management and therapeutic features

Endocrine emergencies during pregnancy may be life-threatening events for both mother and fetus. Besides pregnancy-associated endocrine disorders, several pre-existing endocrinopathies such as type-1 diabetes and Grave's disease or adrenal failure may acutely deteriorate during pregnancy. Since "classical" signs are often modified by pregnancy, early diagnosis and management may be hampered. In addition, laboratory tests show altered physiologic ranges and pharmacologic options are limited while therapeutic goals are mostly tighter than in the non-pregnant patient. Though subclinical endocrinopathies are more frequent and worth consideration due to their related adverse sequelae, this article focuses on endocrine emergencies complicating pregnancy.

Recurrent pregnancy loss: current perspectives

Recurrent pregnancy loss is an important reproductive health issue, affecting 2%–5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss.

Carbohydrate Counting during Pregnancy in Women with Type 1 Diabetes: Are There Predictable Changes That We Should Know?

BACKGROUND/AIMS

Carbohydrate counting (CC) is a helpful strategy for the treatment of type 1 diabetes mellitus (T1DM) and the main parameters used in this method are the insulin to carbohydrate ratio (ICR) and the sensitivity factor (SF). Throughout pregnancy, a state of insulin resistance develops. Therefore, we hypothesized that ICR and SF change and our aim was to describe the pattern of modification of these parameters in pregnant women with T1DM on CC.

METHODS

This study followed 21 women with T1DM throughout pregnancy. Starting ICR was 1:15 and SF was calculated using the formula: 1,500/total daily insulin dose (TDID; for regular insulin) or 1,800/TDID (for ultra-rapid analogs). ICR was adjusted every 1-2 weeks according to self-monitoring of blood glucose. SF was recalculated every 1-2 weeks.

RESULTS

Throughout gestation there was a mean decrease in the ICR in breakfast, lunch and dinner of 8.2 (p < 0.0001), 7.7 (p = 0.003) and 7 (p = 0.005) grams per international units (g/IU), respectively. Mean SF reduction from first to third trimester was 10 mg/dL per IU (mg/dL/IU; p < 0.0001).

CONCLUSIONS

Women with T1DM in CC during pregnancy evolve with a progressive reduction in the ICR at every meal (mean of 8.2 g/IU for breakfast, 7.7 g/IU for lunch and 7 g/IU for dinner) and also in the SF (10 mg/dL/IU).

Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: 1996-2014

BACKGROUND

Despite concern for adverse perinatal outcomes in women with diabetes mellitus before pregnancy, recent data on the prevalence of pregestational type 1 and type 2 diabetes mellitus in the United States are lacking.

OBJECTIVE

The purpose of this study was to estimate changes in the prevalence of overall pregestational diabetes mellitus (all types) and pregestational type 1 and type 2 diabetes mellitus and to estimate whether changes varied by race-ethnicity from 1996-2014.

STUDY DESIGN

We conducted a cohort study among 655,428 pregnancies at a Northern California integrated health delivery system from 1996-2014. Logistic regression analyses provided estimates of prevalence and trends.

RESULTS

The age-adjusted prevalence (per 100 deliveries) of overall pregestational diabetes mellitus increased from 1996-1999 to 2012-2014 (from 0.58 [95% confidence interval, 0.54-0.63] to 1.06 [95% confidence interval, 1.00-1.12]; P_trend <.0001). Significant increases occurred in all racial-ethnic groups; the largest relative increase was among Hispanic women (121.8% [95% confidence interval, 84.4-166.7]); the smallest relative increase was among non-Hispanic white women (49.6% [95% confidence interval, 27.5-75.4]). The age-adjusted prevalence of pregestational type 1 and type 2 diabetes mellitus increased from 0.14 (95% confidence interval, 0.12-0.16) to 0.23 (95% confidence interval, 0.21-0.27; P_trend <.0001) and from 0.42 (95% confidence interval, 0.38-0.46) to 0.78 (95% confidence interval, 0.73-0.83; P_trend <.0001), respectively. The greatest relative increase in the prevalence of type 1 diabetes mellitus was in non-Hispanic white women (118.4% [95% confidence interval, 70.0-180.5]), who had the lowest increases in the prevalence of type 2 diabetes mellitus (13.6% [95% confidence interval, -8.0 to 40.1]). The greatest relative increase in the prevalence of type 2 diabetes mellitus was in Hispanic women (125.2% [95% confidence interval, 84.8-174.4]), followed by African American women (102.0% [95% confidence interval, 38.3-194.3]) and Asian women (93.3% [95% confidence interval, 48.9-150.9]).

CONCLUSIONS

The prevalence of overall pregestational diabetes mellitus and pregestational type 1 and type 2 diabetes mellitus increased from 1996-1999 to 2012-2014 and racial-ethnic disparities were observed, possibly because of differing prevalence of maternal obesity. Targeted prevention efforts, preconception care, and disease management strategies are needed to reduce the burden of diabetes mellitus and its sequelae.

Preconception Care Education for Women With Diabetes: A Systematic Review of Conventional and Digital Health Interventions

BACKGROUND

Worldwide, 199.5 million women have diabetes mellitus (DM). Preconception care (PCC) education starting from adolescence has been recommended as an effective strategy for safeguarding maternal and child health. However, traditional preconception care advice provided by health care professionals (HCPs) within clinic settings is hindered by inadequate resources, suboptimal coverage, and busy clinics. Electronic health (eHealth), which is instrumental in solving problems around scarce health resources, could be of value in overcoming these limitations and be used to improve preconception care and pregnancy outcomes for women with DM.

OBJECTIVE

The objectives were to: (1) identify, summarize, and critically appraise the current methods of providing PCC education; (2) examine the relationship between PCC educational interventions (including use of technology as an intervention medium) on patient and behavioral outcomes; and (3) highlight limitations of current interventions and make recommendations for development of eHealth in this field.

METHODS

Electronic databases were searched using predefined search terms for PCC education in women with type 1 or 2 DM for quantitative studies from 2003 until June 2016. Of the 1969 titles identified, 20 full papers were retrieved and 12 papers were included in this review.

RESULTS

The reviewed studies consistently reported that women receiving educational interventions via health care professionals and eHealth had significantly improved levels of glycosylated hemoglobin (P<.001) with fewer preterm deliveries (P=.02) and adverse fetal outcomes (P=.03). Significant improvements in knowledge (P<.001) and attitudes toward seeking PCC (P=.003) were reported along with reduced barriers (P<.001).

CONCLUSIONS

PCC has a positive effect on pregnancy outcomes for women with DM. However, uptake of PCC is low and the use of eHealth applications for PCC of women with DM is still in its infancy. Initial results are promising; however, future research incorporating mobile phones and apps is needed. Clearly, there is much to be done if the full potential of eHealth PCC to improve obstetric outcomes for women with DM is to be realized.

Recurrent pregnancy loss: evaluation and treatment

Recurrent pregnancy loss (RPL) is a multifactorial condition. Approximately half of patients with RPL will have no explanation for their miscarriages. De novo chromosome abnormalities are common in sporadic and recurrent pregnancy loss. Testing for embryonic abnormalities can provide an explanation for the miscarriage in many cases and prognostic information. Regardless of the cause of RPL, patients should be reassured that the prognosis for live birth with an evidence-based approach is excellent for most patients. The authors review current evidence for the evaluation and treatment of RPL and explore the proposed use of newer technology for patients with RPL.

Gestational carrier BMI and reproductive, fetal and neonatal outcomes: are the risks the same with increasing obesity?

OBJECTIVE

Data suggest that female obesity impairs uterine receptivity and increases the risk of fetal and neonatal mortality. We analyzed the reproductive outcomes of gestational carriers (GCs) undergoing donated oocytes and assisted reproductive technology according to body mass index (BMI).

DESIGN

A retrospective analysis of 163 GCs undergoing 226 in vitro fertilization (IVF) and embryo transfer cycles.

METHODS

GCs undergoing in vitro fertilization and embryo transfer cycles were analyzed and divided according to their BMI (healthy weight: 20-24.9 kg m(-2) (n=77 in 114 cycles); overweight: 25-29.9 kg m(-)(2) (n=55 in 71 cycles); and obese: 30-35 kg m(-)(2) (n=31 in 41 cycles)). All GCs underwent a complete medical evaluation and were cleared for pregnancy before being selected. Overweight and obese GCs also underwent a metabolic screening, including an oral glucose tolerance test and lipid profile. The main outcomes measured were clinical pregnancy and live birth rates, antenatal and neonatal outcomes.

RESULTS

Clinical pregnancy and live birth rates were similar despite increasing BMI. There were no statistically significant differences in the implantation rates, clinical pregnancy rates or live birth rates per embryo transfer among patients in the three BMI groups. In the healthy weight, overweight and obese GCs, the clinical pregnancy rates per GC were 72%, 84% and 79%, and per embryo transfer rates were 52%, 49% and 56%, respectively; P=NS. The live birth rates per GC were 70%, 84% and 75%, and per embryo transfer rates were 50%, 49% and 53%, respectively; P=NS. Twin rates were similar between the groups (35%, 31% and 29%, respectively; P=NS). There were no differences in gestational diabetes, preterm admissions or cesarean section rates. Neonatal intensive care unit admissions were similar (11%, 13% and 12%, respectively; P=NS), and no maternal, neonatal or infant mortality occurred.

CONCLUSIONS

These data show that increasing obesity does not impair the reproductive outcome in GC cycles. Larger sample size is indicated to verify these findings. Furthermore, this study suggests that the standard metabolic screening used for GCs may lead to selection of healthier patients compared with women of comparable BMI who conceive outside of a fertility clinic setting, indicating the metabolic profile, rather than BMI, may better explain differences in pregnancy outcomes.

Maternal reproductive history and the risk of congenital heart defects in offspring: a systematic review and meta-analysis

Epidemiological studies have reported conflicting results on the association of congenital heart defect (CHD) risk in offspring with a maternal history of prior pregnancies and abortions, but no meta-analysis has been reported. We searched MEDLINE and EMBASE from their inception to April 14, 2014, for relevant studies that assessed the association between maternal reproductive history and CHD risk. Two authors independently assessed eligibility and extracted data. Fixed-effects or random-effects models were used to calculate the pooled odds ratios (ORs). Among 1,599 references, 17 case-control studies and one nested case-control study were included in this meta-analysis. The summary OR for the ever versus nulligravidity was 1.18 (95% CI 1.03-1.34). A dose-response analysis also indicated a positive effect of maternal gravidity on CHD risk, and the summary OR for each increment in number of pregnancies was 1.13 (95% CI 1.08-1.18). A history of abortion was associated with a 24% higher risk of CHD, OR = 1.24 (95% CI 1.11-1.38). When stratified by abortion category, CHD risk increased by 18 and 58% with a history of spontaneous abortion and induced abortion, respectively. The summary OR for each increment of one abortion was 1.28 (95% CI 1.18-1.40). In summary, this study provides evidence that increased maternal gravidity was positively associated with a risk of CHDs in offspring. Meanwhile, our results demonstrate a positive association of any history of abortion with an increased risk of CHDs.

Improving health service delivery for women with diabetes in pregnancy in remote Australia: survey of care in the Northern Territory Diabetes in Pregnancy Partnership

BACKGROUND

In the Northern Territory (NT), 38% of 3500 births each year are to Indigenous women, 80% of whom live in regional and remote areas. Compared with the general Australian population, rates of pre-existing type 2 diabetes in pregnancy are 10-fold higher and rates of gestational diabetes are 1.5-fold higher among Indigenous women. Current practices in screening for diabetes in pregnancy in remote Australia are not known.

AIMS

To assess current health service delivery for NT women with diabetes in pregnancy (DIP) by surveying healthcare professionals' views and practices in DIP screening and management.

MATERIALS AND METHODS

A cross-sectional survey of NT healthcare professionals providing clinical care for women with DIP was conducted based on pre-identified themes of communication, care-coordination, education, orientation and guidelines, logistics and access, and information technology.

RESULTS

Of the 116 responders to the survey, 78% were primary healthcare professionals, 32% midwives and 25% general practitioners. High staff turnover was evident: of Central Australian professionals, only 33% (urban) and 18% (regional/remote) had been in their current position over 5 years. DIP screening was conducted at first antenatal visit by 66% and at 24-28-week gestation by 81%. Only 50% of respondents agreed that most women at their health service received appropriate care for DIP, and 41% of primary care practitioners were neutral or not confident in their skills to manage DIP.

CONCLUSIONS

It is promising that many healthcare professionals report following new guidelines in conducting early pregnancy screening for DIP in high risk women. Several challenges were identified in healthcare delivery to a high risk population in remote Australia.

Health literacy and its association with perception of teratogenic risks and health behavior during pregnancy

OBJECTIVE

Investigate the association between health literacy and perception of medication risk, beliefs about medications, use and non-adherence to prescribed pharmacotherapy during pregnancy, and whether risk perception and beliefs may mediate an association between health literacy and non-adherence.

METHODS

This multinational, cross-sectional, internet-based study recruited pregnant woman between 1 October 2011 and 29 February 2012. Data on maternal socio-demographics, medication use, risk perception, beliefs, and non-adherence were collected via an on-line questionnaire. Health literacy was measured via a self-assessment scale. Mann-Whitney U test, Spearman's rank correlation, Generalized Estimating Equations and mediation analysis were utilized.

RESULTS

4999 pregnant women were included. Low-health literacy women reported higher risk perception for medications, especially penicillins (Rho: -0.216) and swine flu vaccine (Rho: -0.204) and more negative beliefs about medication. Non-adherence ranged from 19.2% (high-health literacy) to 25.0% (low-health literacy). Low-health literacy women were more likely to be non-adherent to pharmacotherapy than their high-level counterparts (adjusted OR: 1.30; 95% CI: 1.02-1.66). Risk perception and beliefs appeared to mediate the association between health literacy and non-adherence.

CONCLUSION

Health literacy was significantly associated with maternal health behaviors regarding medication non-adherence.

PRACTICE IMPLICATIONS

Clinicians should take time to inquire into their patients' ability to understand health information, perception and beliefs, in order to promote adherence during pregnancy.

Adherence to medication for chronic disorders during pregnancy: results from a multinational study

BACKGROUND

For a variety of chronic disorders, low medication adherence during pregnancy may jeopardize maternal as well as foetal health. Little is known about how closely pregnant women follow their chronic pharmacotherapy regimens.

OBJECTIVE

To explore the level of adherence to medication for a variety of chronic disorders, namely cardiovascular, rheumatic and bowel disorders, diabetes and epilepsy, during pregnancy and to identify determinants of low adherence during pregnancy.

SETTING

This multinational, cross-sectional, internet-based study was undertaken in 18 countries in Europe, North America and Australia. Data originating from some South American countries were also collected.

METHODS

The study period lasted from 1-October-2011 to 29-February-2012. By using an anonymous on-line questionnaire we collected information about maternal demographics, chronic disorders and related medication use during pregnancy, and women's pregnancy-specific beliefs about medication. Main outcome measure Adherence to medication during pregnancy via the 8-item Morisky Medication Adherence Scale (MMAS-8).

RESULTS

A total of 210 pregnant women reported chronic medication use during pregnancy and filled in the MMAS-8. Overall, 36.2 % had low medication adherence. On the basis of the MMAS-8, the rates of low adherence were 55.6 % for medication for rheumatic disorders, 40.0 % for epilepsy, 36.1 % for bowel disorders, 32.9 % for cardiovascular disorders, and 17.1 % for diabetes. A lack of folic acid use, having previous children, and individual pregnancy-specific beliefs about medication were significant determinants of low medication adherence during pregnancy.

CONCLUSION

Many pregnant women had low adherence to their chronic pharmacotherapy regimens during pregnancy. Women's beliefs about medication were a central factor determining low adherence.

The Influence of First Trimester Maternal Glucose on Fetal Growth and Possible Implications in Pregnancy Evolution

Background and Aims: Maternal hyperglycemia during the first trimester of pregnancy is frequently associated with the appearance of maternal and fetal complications. The aim of our study was to analyze the influence of the first trimester blood glucose on the glycemic values from the second and third trimester and on fetal birth weight. Material and method: We performed an observational study on a group of 46 pregnant women who finally delivered on due date. We determined glycemia values in the first and third trimester of pregnancy while an Oral Glucose Tolerance Test (OGTT) was performed during the second trimester (24 - 28 weeks of pregnancy). We divided the pregnancies in two groups: with normal glucose or hyperglycemia during the first trimester. Finally we analyzed the influence of first trimester hyperglycemia on different maternal characteristics and on fetal birth weight. Results: Third trimester glycemia was significantly increased in women with first trimester hyperglycemia in comparison with the control group (p= 0.04) but no effect of the last on OGTT values was recorded. The ROC curve for the influence of first trimester glycemia on fetal macrosomia had an Area Under the Curve (AUC) of 0.551. Conclusions: Firsttrimester glycemia has a low diagnostic accuracy in the appreciation of fetal macrosomia risk.

Miscarriage and future maternal cardiovascular disease: a systematic review and meta-analysis

Context

The 2011 American Heart Association guidelines identified pregnancy complications as a risk factor for cardiovascular disease in women. However, miscarriage was not mentioned within the guidelines, and there is no consensus on the association between miscarriage and future risk of cardiovascular disease.

Objective

To confirm or refute the association, a meta-analysis of published papers was conducted.

Data sources

PubMed, Web of Knowledge and Scopus were systematically searched to identify appropriate articles. Reference lists were then hand searched for additional relevant titles.

Study Selection

To be included, articles had to assess the association between miscarriage and subsequent cardiovascular disease in otherwise healthy women. Only women who had miscarriages were considered exposed. Pooled association measures, using random effects meta-analysis, were calculated for coronary heart disease and cerebrovascular disease. Publication bias and between-study heterogeneity were evaluated.

Data Extraction

Two authors individually reviewed all studies and extracted data on patient and study characteristics along with cardiovascular outcomes.

Results

10 studies were identified, with 517 504 individuals included in the coronary heart disease meta-analysis and 134 461 individuals in the cerebrovascular disease analysis. A history of miscarriage was associated with a greater odds of developing coronary heart disease, OR (95% CI) =1.45 (1.18 to 1.78), but not with cerebrovascular disease, OR=1.11 (0.72 to 1.69). There was a strong association between recurrent miscarriage and coronary heart disease OR=1.99 (1.13 to 3.50). Evidence was found for moderate between-study heterogeneity and publication bias in the coronary heart disease analysis.

Conclusions

The meta-analysis indicates that a history of miscarriage or recurrent miscarriage is associated with a greater risk of subsequent coronary heart disease.

Evaluation and treatment of recurrent pregnancy loss: a committee opinion

The majority of miscarriages are sporadic and most result from genetic causes that are greatly influenced by maternal age. Recurrent pregnancy loss (RPL) is defined by two or more failed clinical pregnancies, and up to 50% of cases of RPL will not have a clearly defined etiology.

Neonatally induced mild diabetes in rats and its effect on maternal, placental, and fetal parameters

The aim of this study was to assess placental changes and reproductive outcomes in neonatally induced mild diabetic dams and fetal development in their offspring. At birth, female rats were assigned either to control or diabetic group (100 mg of streptozotocin/Kg, subcutaneously). At adulthood, the female rats were mated. During pregnancy, the blood glucose levels and glucose and insulin tolerance tests were performed. At term, maternal reproductive outcomes, fetal and placental weight, and placental morphology were analyzed. Diabetic rats had smaller number of living fetuses, implantations and corpora lutea, and increased rate of embryonic loss. Placenta showed morphometric alterations in decidua area. Our results showed that mild diabetes was sufficient to trigger alterations in maternal organism leading to impaired decidua development contributing to failure in embryonic implantation and early embryonic losses. Regardless placental decidua alteration, the labyrinth, which is responsible for the maternal-fetal exchanges, showed no morphometric changes contributing to an appropriate fetal development, which was able to maintain normal fetal weight at term in mild diabetic rats. Thus, this experimental model of diabetes induction at the day of birth was more effective to reproduce the reproductive alterations of diabetic women.

[Endocrine emergencies during pregnancy]

Endocrine emergencies during pregnancy can become life-threatening for both mother and fetus. In addition to some pregnancy-linked endocrine disorders, several pre-existing forms of endocrinopathy, such as Grave's disease, type 1 diabetes and adrenal insufficiency might deteriorate acutely during pregnancy. Early diagnosis and management are challenging because the classical symptoms are often modified by pregnancy. Laboratory tests are subject to altered physiological ranges and pharmacological options are limited while therapeutic goals are stricter than in the non-pregnant patient. This article focuses on endocrine emergencies complicating pregnancy.

Previous gestational diabetes mellitus and markers of cardiovascular risk

The prevalence of gestational diabetes mellitus (GDM) in the developed world has increased at an alarming rate over the last few decades. GDM has been shown to be associated with postpartum diabetes, insulin resistance, hypertension, and dyslipidemia. A history of previous GDM (pGDM), associated or not with any of these metabolic abnormalities, can increase the risk of developing not only type 2 diabetes mellitus but also cardiovascular disease (CVD) independent of a diagnosis of type 2 diabetes later in life. In this paper we discuss the relationship among inflammatory markers, metabolic abnormalities, and vascular dysfunction in women with pGDM. We also review the current knowledge on metabolic modifications occurring in normal pregnancy and the link between alterations of a normal metabolic state with the long-term maternal complications that may result in increased CVD risk. Our review of studies on pGDM prompts us to recommend that these women be considered a population at risk for later CVD events, which however could be avoided via the use of specially designed follow-up programs in the future.

Glycemic control and pregnancy outcomes in women with type 2 diabetes from Poland. The impact of pregnancy planning and a comparison with type 1 diabetes subjects

The number of pregnancies complicated by type 2 diabetes mellitus (T2DM) is growing; however, their clinical characteristics remain incomplete. We aimed to assess clinical characteristics, glycemic control, and selected pregnancy outcomes in pregestational T2DM from Poland and to compare them with those of T1DM. We analyzed 415 consecutive singleton pregnancies; among them, there were 70 women with T2DM and 345 with T1DM. As compared to T1DM patients, women with T2DM were older (mean age 33.1 years vs. 27.8, respectively), heavier before pregnancy (mean BMI 30.8 kg/m² vs. 23.9), and had a shorter duration of diabetes (mean 3.3 years vs. 11.4); ( P<0.0001 for all comparisons). The gestational age at the first visit was higher in T2DM (mean 11.4 weeks vs. 8.6; P=0.0004). Nevertheless, they had better glycemic control in the first trimester (mean HbA1c 6.2% vs. 7.0; P=0.003); in subsequent months, the differences in HbA1c were no longer significant. T2DM women gained less weight during pregnancy (mean 9.9 kgs vs. 14.1; P<0.0001). The proportion of miscarriages (10.0 vs. 7.3%; P=0.32), preterm deliveries (12.7 vs. 17.8%; P=0.32), combined infant deaths, and congenital malformations were similar in both groups (9.5 vs. 8.8%; P=0.4) as was the frequency of caesarean sections (58.7 vs. 64.1%; P=0.30). Macrosomic babies were more than twice less frequent in T2DM and the difference reached borderline significance (7.9 vs. 17.5%, P=0.07). Pregnancy planning in T2DM had a significant impact on HbA1c in the first trimester (5.7 vs. 6.4% in the planning vs. the not planning group, P=0.02); the difference was not significant in the second and third trimester. T2DM women had better glycemic control in the first trimester than T1DM subjects and gained less weight during pregnancy. This could have been the reason for the slightly lower number of macrosomic babies but did not affect other outcomes. In T2DM, pregnancy planning had a beneficial glycemic effect in the first trimester.

Screening and diagnosing gestational diabetes mellitus revisited: implications from HAPO

Screening and diagnosis of gestational diabetes has lacked uniform criteria both nationally and internationally. In addition, the relationship between the degree of hyperglycemia or glucose intolerance and the risk of maternal, fetal, and neonatal adverse outcomes has not been clearly established. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently published their recommendation for diagnosing and classifying gestational hyperglycemia in pregnancy after evaluation of the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) observational study. Their recommendations have recently been accepted by the American Diabetes Association and are currently under review by the American College of Obstetricians and Gynecologist (ACOG) in the United States. If accepted in the United States and internationally, the world would have consistent thresholds for evaluating hyperglycemia in pregnancy, which would not only include the diagnosis of gestational diabetes mellitus but also overt diabetes, which has not been encompassed by previously accepted definitions.

Hyperglycemia impairs skeletogenesis from embryonic stem cells by affecting osteoblast and osteoclast differentiation

High maternal blood glucose levels caused by diabetes mellitus can irreversibly lead to maldevelopment of the growing fetus with specific effects on the skeleton. To date, it remains controversial at which stage embryonic development is affected. Specifically during embryonic bone development, it is unclear whether diminished bone mineral density is caused by reduced osteoblast or rather enhanced osteoclast function. Therefore, the aim of this study was to characterize the growth as well as the skeletal differentiation capability of pluripotent embryonic stem cells (ESCs), which may serve as an in vitro model for all stages of embryonic development, when cultured in diabetic levels of D-glucose (4.5 g/L) versus physiological levels (1.0 g/L). Results showed that cells cultivated in physiological glucose gave rise to a higher number of colonies with an undifferentiated character as compared to cells grown in diabetic glucose concentrations. In contrast, these cultures were characterized by slightly decreased expression of proteins associated with the stem cell state. Furthermore, differentiation of ESCs into osteoblasts and osteoclasts was favored in physiological glucose concentrations, demonstrated by an increased matrix calcification, enhanced expression of cell-type-specific mRNAs, as well as activity of the cell-type-specific enzymes, alkaline, and tartrate resistant acidic phosphatase. In fact, this pattern was noted in murine as well as in primate ESCs. Our study suggests that an interplay between both the osteoblast and the osteoclast lineage is needed for proper skeletal development to occur, which seems impaired in hyperglycemic conditions.

Dysglycemias in pregnancy: from diagnosis to treatment. Brazilian consensus statement

There is an urgent need to find consensus on screening, diagnosing and treating all degrees of dysglycemia that may occur during pregnancies in Brazil, considering that many cases of dysglycemia in pregnant women are currently not diagnosed, leading to maternal and fetal complications. For this reason the Brazilian Diabetes Society (SBD) and the Brazilian Federation of Gynecology and Obstetrics Societies (FEBRASGO), got together to introduce this proposal. We present here a joint consensus regarding the standardization of clinical management for pregnant women with any degree of dysglycemia, on the basis of current information, to improve medical assistance and to avoid related complications of dysglycemia in pregnancy to the mother and the fetus. This consensus aims to standardize the diagnosis among general practitioners, endocrinologists and obstetricians allowing the dissemination of information in basic health units, public and private services, that are responsible for screening, diagnosing and treating disglycemic pregnant patients.

Glycemic control and selected pregnancy outcomes in type 1 diabetes women on continuous subcutaneous insulin infusion and multiple daily injections: the significance of pregnancy planning

BACKGROUND

Two regimens are used to achieve excellent glycemic control during pregnancy in type 1 diabetes mellitus (T1DM): continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI). We assessed their efficacy and safety and the effect of pregnancy planning.

METHODS

We examined 269 pregnant T1DM women: 157 treated with MDI (MDI group), 42 with CSII (CSII group), and 70 who switched from MDI to CSII in the first trimester (MDI/CSII group). There were 116 women who planned pregnancy: 58 in the MDI group, 38 in the CSII group, and 20 in the MDI/CSII group. The estimated differences in glycemic control and maternal and fetal outcomes were adjusted for baseline characteristics.

RESULTS

Mean glycated A1c (HbA1c) in the first trimester in the whole group was 6.9%, and the women differed depending on whether they planned pregnancy or not (P < 0.0001). A multiple regression model showed an average difference of about 0.9% in favor of pregnancy planning, with no interaction between the planning and treatments. In the second trimester, HbA1c decreased to a mean value of 5.8%, with improvement of HbA1c across all treatments: by 1.5% in not-planning and 0.9% in planning women. Despite greater improvement, not-planning women still had a higher HbA1c (by 0.3%, P = 0.05). In the third trimester, there was no further significant changes; nevertheless, women who planned pregnancy still had a lower HbA1c (by 0.5%, P = 0.02). There were 14 malformations, stillbirths, and perinatal infant deaths in the not-planning versus five in the planning group (P = 0.07). Patients in the CSII group had a 2 kg greater weight gain compared to the MDI group (15.0 kg vs. 13.0 kg; P = 0.005).

CONCLUSIONS

In pregnancy with T1DM, both MDI and CSII can provide excellent glycemic control. Pregnancy planning has a beneficial effect on glycemic control, independent from the therapy model. CSII seems to predispose to a larger weight gain in mothers.

Maternal diabetes alters transcriptional programs in the developing embryo

Background

Maternal diabetes is a well-known risk factor for birth defects, such as heart defects and neural tube defects. The causative molecular mechanisms in the developing embryo are currently unknown, and the pathogenesis of developmental abnormalities during diabetic pregnancy is not well understood. We hypothesized that the developmental defects are due to alterations in critical developmental pathways, possibly as a result of altered gene expression. We here report results from gene expression profiling of exposed embryos from a mouse diabetes model.

Results

In comparison to normal embryos at mid-gestation, we find significantly altered gene expression levels in diabetes-exposed embryos. Independent validation of altered expression was obtained by quantitative Real Time Polymerase Chain Reaction. Sequence motifs in the promoters of diabetes-affected genes suggest potential binding of transcription factors that are involved in responses to oxidative stress and/or to hypoxia, two conditions known to be associated with diabetic pregnancies. Functional annotation shows that a sixth of the de-regulated genes have known developmental phenotypes in mouse mutants. Over 30% of the genes we have identified encode transcription factors and chromatin modifying proteins or components of signaling pathways that impinge on transcription.

Conclusion

Exposure to maternal diabetes during pregnancy alters transcriptional profiles in the developing embryo. The enrichment, within the set of de-regulated genes, of those encoding transcriptional regulatory molecules provides support for the hypothesis that maternal diabetes affects specific developmental programs.

Effects of cigarette smoke exposure on pregnancy outcome and offspring of diabetic rats

A total of 52 female Wistar rats were distributed into four groups: non-diabetic (G1) and diabetic (G2) exposed to filtered air; non-diabetic (G3) and diabetic (G4) exposed to cigarette smoke. Diabetes was induced by streptozotocin (40 mg/kg bodyweight, i.v.). Rats were exposed, for 30 min, to filtered air (control) or to tobacco smoke generated from 10 cigarettes, twice a day, for 2 months. At the end of the 2-month exposure, at day 21 of pregnancy, each rat was anesthetized and humanely killed for laparotomy. Uterine horns were exposed for reproductive performance analysis, fetal and placental weights and placental index. Maternal and fetal data were analysed by ANOVA followed by the Student Newman-Keuls test. Fetal weight classification was assessed by Fisher's exact test. Diabetes and cigarette smoke caused placentomegaly (G4 = 0.65 +/- 0.19 g versus G1 = 0.49 +/- 0.03 g, P < 0.05), increased placental index (G4 = 0.13 +/- 0.03 versus G1 = 0.09 +/- 0.00, P < 0.05) and small fetus rates for pregnancy age (G4 = 88% versus G1 = 23.2%, P < 0.05). These observations show the importance of encouraging pregnant women to attempt cessation of smoking.