Significance of Umbilical Cord Leptin Profile during Pregnancy in Gestational Diabetes Mellitus-A Systematic Review and Meta-Analysis

BACKGROUND

The literature provides limited evidence of cord blood leptin levels in gestational diabetes mellitus (GDM), with contradictory and inconsistent results with respect to their possible implications for maternal, perinatal, and future complications.

METHODS

MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched in order to investigate the state of evidence on the association of leptin profile in cord blood during perinatal complications in GDM. We critically assessed the risk of bias using the Newcastle-Ottawa scale. Meta-analyses were performed, and heterogeneity and publication bias were analyzed.

RESULTS

sixteen primary-level studies were included, recruiting 573 GDM and 1118 control pregnant women. Cord blood leptin levels were significantly higher in GDM participants compared to controls (standardized mean difference [SMD] = 0.59, 95% confidence intervals (CI) = 0.37 to 0.80, p < 0.001). All subgroups also maintained significant differences stratified by continents (Asia: SMD = 0.91, 95% CI = 0.45 to 1.37, p < 0.001; Europe: SMD = 0.38, 95% CI = 0.20 to 0.56, p < 0.001), analysis technique (ELISA: SMD = 0.70, 95% CI = 0.44 to 0.97, p < 0.001; RIA: SMD = 0.30, 95% CI = 0.11 to 0.49, p = 0.002), and sample source (plasma: SMD = 0.71, 95% CI = 0.33 to 1.09, p < 0.001; serum: SMD = 0.55, 95% CI = 0.34 to 0.77, p < 0.001).

CONCLUSION

Cord blood leptin levels were significantly higher in GDM compared to controls. Further research is needed to clarify its role as a predictive biomarker of subsequent metabolic diseases in mothers with GDM and offspring.

Significance of cell adhesion molecules profile during pregnancy in gestational diabetes mellitus. A systematic review and meta-analysis

Endothelial dysfunction has been considered as a key etiological factor contributed to the development of vascular disease in diabetes mellitus. Serum level of endothelial cell adhesion molecules (AMs) were reported to be increased in GDM and pregnant women with normal glucose tolerance when compared with nonpregnant women. The literature provides limited evidence of endothelial dysfunction in GDM with heterogeneous and contradictory results respect to their possible involvement in maternal, perinatal and future complications. Our objective is to evaluate current evidence on the role of AMs in maternal and perinatal complications in women with GDM. PubMed, Embase, Web of Science, and Scopus databases were searched. We evaluated the studies' quality using the Newcastle-Ottawa scale. Meta-analyses were conducted, and heterogeneity and publication bias were examined. Nineteen relevant studies were finally included, recruiting 765 GDM and 2368 control pregnant women. AMs levels were generally higher in GDM participants showing statistical significance maternal ICAM-1 levels (SMD=0.58, 95% CI= 0.25 to 0.91; p=0.001). Our meta-analysis did not detect significant differences in subgroups or in meta-regression analyses. Future studies are needed to establish the potential role of these biomarkers in GDM and its complications.

Higher daytime systolic BP, prepregnancy BMI and an elevated sFlt-1/PlGF ratio predict the development of hypertension in normotensive pregnant women

BACKGROUND

The risk of hypertensive disorders of pregnancy (HDP) varies in women with gestational diabetes mellitus (GDM), depending on the degree of insulin resistance and is also influenced by obesity. The aim of this study was to evaluate clinical features, blood pressure (BP) profiles and inflammatory markers, to identify patients with an elevated risk of developing HDP.

METHODS

A total of 146 normotensive pregnant women were studied. We analysed the relationships of BP profiles detected by ambulatory blood pressure monitoring (ABPM) with serum biomarkers and angiogenic factors and their association with the development of HDP.

RESULTS

Fourteen (9.6%) women developed HDP, of which 11 had GDM and 8 had obesity. Women with HDP had higher values of 24-h and daytime systolic/diastolic BP (113/69 vs. 104/64; 115/72 vs. 106/66 mmHg, respectively; p <  0.05). Higher levels of leptin (10.97 ± 0.82 vs. 10.2 ± 1.11; p = 0.018) andmonocyte chemoattractant protein-1 (MCP-1) (5.24 ± 0.60 vs. 4.9 ± 0.55; p = 0.044) and a higher soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio (4.37 ± 2.2 vs. 2.2 ± 1.43; p = 0.003) were also observed in the HDP patients. Multivariate analysis showed that a higher sFlt-1/PlGF ratio was associated with an increased risk of developing HDP [OR = 2.02; IC 95%: 1.35-3.05]. Furthermore, higher daytime systolic BP [OR = 1.27; IC 95% 1.00-1.26] and prepregnancy body mass index (BMI) [OR = 1.14; IC 95%: 1.01-1.30] significantly increased the risk of developing HDP.

CONCLUSIONS

Higher daytime systolic BP values, prepregnancy BMI and the sFlt-1/PlGF ratio are useful for identifying normotensive pregnant women with an increased risk of developing HDP.

Significance of Serum-Plasma Leptin Profile during Pregnancy in Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

Gestational diabetes mellitus (GDM) represents a stage of subclinical inflammation and a risk factor for subsequent future type 2 diabetes and cardiovascular disease development. Leptin has been related with vascular and metabolic changes in GDM with heterogeneous and contradictory results with respect to their possible involvement in maternal, perinatal, and future complications. Our objective is to evaluate current evidence on the role of leptin in maternal and perinatal complications in women with GDM. PubMed, Embase, Web of Science, and Scopus databases were searched. We evaluated the studies’ quality using the Newcastle-Ottawa scale. Meta-analyses were conducted, and heterogeneity and publication bias were examined. Thirty-nine relevant studies were finally included, recruiting 2255 GDM and 3846 control pregnant women. Leptin levels were significantly higher in GDM participants than in controls (SMD = 0.57, 95%CI = 0.19 to 0.94; p < 0.001). Subgroup meta-analysis did not evidence significant differences in leptin in the different trimesters of pregnancy. Meta-regression showed a positive significant relationship for HOMA in the GDM group (p = 0.05). According to these results, it seems that high levels of leptin can be used as predictive markers in GDM.

Fetal cerebral three-dimensional power Doppler vascularization indices and their relationships with maternal glucose levels in pregnancies complicated with gestational diabetes

OBJECTIVES

We aimed to evaluate fetal cerebral circulation using three-dimensional power Doppler (3DPD) vascular indices and to study their relationships with maternal lipid and glycaemic profiles.

METHODS

Case-control study in women with and without gestational diabetes mellitus (GDM) at 28-32 weeks in which feto-maternal Doppler study and 3DPD cerebral vascularization indices (FI, VI and VFI) were determined. Maternal lipid and glycaemic profiles were also analysed. Both groups were compared and the correlations of the 3DPD indices with studied variables were analysed.

RESULTS

There were significant differences between groups in cerebral FI (p= 0.02), mean maternal Uterine artery PI (p= 0.009) and glucose levels (p= 0.001), being higher in the GDM group. Significant negative correlations were found in GDM group between VFI and MCA PI (p = 0.02) and between VI and MCA PI (p= 0.01). In the GDM group we found a negative significant correlation between FI, VI, VFI and maternal glucose (r= -0.52, p<0.001; r= -0.32, p=0.03 and r= -0.36, p= 0.01, respectively).

CONCLUSIONS

Fetal cerebral FI values were higher in GDM pregnancies. All 3DPD vascular indices showed an inverse correlation with maternal glucose levels. These findings support the view that GDM may also represent a fetal vascular disorder influencing fetal neurodevelopment.

Anti-Inflammatory (M2) Response Is Induced by a sp2-Iminosugar Glycolipid Sulfoxide in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the most common complications of Diabetes Mellitus (DM) and is directly associated with inflammatory processes. Currently, neuro-inflammation is considered an early event in DR and proceeds via microglia polarization. A hallmark of DR is the presence of retinal reactive gliosis. Here we report the beneficial effect of (S_S,1R)-1-docecylsulfiny-5N,6O-oxomethylidenenojirimycin ((Ss)-DS-ONJ), a member of the sp²-iminosugar glycolipid (sp²-IGL) family, by decreasing iNOS and inflammasome activation in Bv.2 microglial cells exposed to pro-inflammatory stimuli. Moreover, pretreatment with (Ss)-DS-ONJ increased Heme-oxygenase (HO)-1 as well as interleukin 10 (IL10) expression in LPS-stimulated microglial cells, thereby promoting M2 (anti-inflammatory) response by the induction of Arginase-1. The results strongly suggest that this is the likely molecular mechanism involved in the anti-inflammatory effects of (S_S)-DS-ONJ in microglia. (S_S)-DS-ONJ further reduced gliosis in retinal explants from type 1 diabetic BB rats, which is consistent with the enhanced M2 response. In conclusion, targeting microglia polarization dynamics in M2 status by compounds with anti-inflammatory activities offers promising therapeutic interventions at early stages of DR.

Circulating miR-330-3p in Late Pregnancy is Associated with Pregnancy Outcomes Among Lean Women with GDM

Gestational Diabetes Mellitus (GDM) is characterised by insulin resistance accompanied by reduced beta-cell compensation to increased insulin demand, typically observed in the second and third trimester and associated with adverse pregnancy outcomes. There is a need for a biomarker that can accurately monitor status and predict outcome in GDM, reducing foetal-maternal morbidity and mortality risks. To this end, circulating microRNAs (miRNAs) present themselves as promising candidates, stably expressed in serum and known to play crucial roles in regulation of glucose metabolism. We analysed circulating miRNA profiles in a cohort of GDM patients (n = 31) and nondiabetic controls (n = 29) during the third trimester for miRNA associated with insulin-secretory defects and glucose homeostasis. We identified miR-330-3p as being significantly upregulated in lean women with GDM compared to nondiabetic controls. Furthermore, increased levels of miR-330-3p were associated with better response to treatment (diet vs. insulin), with lower levels associated with exogenous insulin requirement. We observed miR-330-3p to be significantly related to the percentage of caesarean deliveries, with miR-330-3p expression significantly higher in spontaneously delivered GDM patients. We report this strong novel association of circulating miR-330-3p with risk of primary caesarean delivery as a pregnancy outcome linked with poor maternal glycaemic control, strengthening the growing body of evidence for roles of diabetes-associated miRNAs in glucose homeostasis and adaptation to the complex changes related to pregnancy.

Effect of Different Insulin Therapies on Obstetric-Fetal Outcomes

To evaluate the effectiveness of the different insulin therapies on obstetrics-fetal outcomes in women with pregestational diabetes mellitus. We enrolled 147 pregnant women with pre-existing type 1 or 2 diabetes mellitus. Clinical and biochemical parameters were analysed in relation to obstetric and fetal outcomes. 14.2% received treatment with Neutral Protamine Hagedorn insulin and short-acting insulin analogues; 19% with premixed human insulin; 40.1% with insulin glargine and lispro, 6.2% with detemir and aspart and 20% with continuous subcutaneous insulin infusion. All 5 types of treatment achieved a reduction of the mean HbA1c during pregnancy (p = 0.01). Pre-pregnancy care was carried out for 48% of patients. We found no statistically significant differences between the different insulin therapies and the obstetric-fetal outcomes. In conclusión, the different insulin therapies used in patients with pregestational diabetes mellitus does not seem to affect obstetric-fetal outcomes.

Usefulness of blood pressure monitoring in patients with gestational diabetes mellitus

BACKGROUND AND OBJECTIVE

Gestational diabetes mellitus (GDM) is associated to an increased risk of pregnancy-induced hypertension (PIH). Ambulatory blood pressure monitoring (ABPM) has been used to detect PIH and preeclampsia, but few data are currently available on its use in women with GDM. The aim of this study was to achieve early identification in women with GDM of BP profiles (detected by ABPM) that could define a population at greater risk of developing PIH and preeclampsia.

MATERIAL AND METHODS

A prospective study of 93 normotensive women with GDM in whom 24-h ABPM was performed (using a Spacelabs 90207 monitor) at 28-32 weeks of pregnancy. Clinical and laboratory variable and obstetric and perinatal outcomes were analyzed.

RESULTS

Mean age was 34.8±4.39years, and 5.4% of patients developed PIH. Higher levels of HbA1c (P=.005) and microalbumin (P=.001) were seen in patients with PIH. Patients with non-dipper patterns (50.5%) had higher values of night-time systolic BP (106.7 vs 98.4mmHg) and night-time diastolic BP (64.8 vs 57.2mmHg) (P<.001). Lower birth weights (3,084.57 vs 3,323.7) (P=.021) and shorter gestational age at delivery (38.67 vs 39.27 weeks) (P=.04) were found in women with non-dipper pattern. High night-time systolic BP significantly increased the chance of developing PIH (OR: 1.18; 95%CI: 1.00-1.39; P=.043).

CONCLUSIONS

Patients with GDM have BP changes, with predominance of the non-dipper pattern and higher night-time systolic and diastolic BP, changes that could be useful predictors of PIH. High night-time systolic BP values increase the risk of developing PIH. Further studies are needed to ascertain the relationships between BP changes and obstetric and perinatal complications.

Impact of positive thyroid autoimmunity on pregnant women with subclinical hypothyroidism

BACKGROUND

The impact of subclinical hypothyroidism (SH) and thyroid autoimmunity on obstetric and perinatal complications continues to be a matter of interest and highly controversial.

AIM

To assess the impact of SH and autoimmunity in early pregnancy on the obstetric and perinatal complications in our population.

MATERIAL AND METHOD

A retrospective cohort study in 435 women with SH (TSH ranging from 3.86 and 10 μIU/mL and normal FT4 values) in the first trimester of pregnancy. Epidemiological and clinical parameters were analyzed and were related to obstetric and perinatal complications based on the presence of autoimmunity (thyroid peroxidase antibodies [TPO] > 34 IU/mL).

RESULTS

Mean age was 31.3 years (SD 5.2). Seventeen percent of patients had positive TPO antibodies. Presence of positive autoimmunity was associated to a family history of hypothyroidism (P=.04) and a higher chance of miscarriage (P=.009). In the multivariate analysis, positive TPO antibodies were associated to a 10.25-fold higher risk of miscarriage. No statistically significant associations were found with all other obstetric and perinatal complications.

CONCLUSIONS

In our region, pregnant women with SH and thyroid autoimmunity had a higher risk of miscarriage but not of other obstetric and perinatal complications.

Concomitant Agranulocytosis and Hepatotoxicity After Treatment with Carbimazole

Objective:

To describe a case of agranulocytosis and severe hepatotoxicity associated with Carbimazole treatment.

Case Summary:

A 37-year-old woman was diagnosed with severe hyperthyroidism resulting from Graves' disease. Treatment with Carbimazole 30 mg/day was initiated. Within 15 days following the start of therapy, both minor (eg, pruritus, rash, urticaria, fever, arthralgias) and potentially life-threatening (eg, agranulocytosis, severe mixed hepatotoxicity with severe cholestatic jaundice) adverse effects developed. The patient's symptoms and laboratory abnormalities resolved following withdrawal of Carbimazole. Treatment with other antithyroid drugs was not attempted, and 131I ablation of the thyroid was successfully performed. Thyroid function was maintained with standard follow-up care. Agranulocytosis, identified following bone marrow biopsy, was treated with granulocyte colony-stimulating factor.

Discussion:

Agranulocytosis and hepatotoxicity are rare adverse effects associated with Carbimazole treatment and are usually dose- and age-related. The likelihood that Carbimazole induced these undesirable events in our patient is rated as probable based on the Naranjo probability scale. We believe this case to be the first to describe minor and major adverse effects related to Carbimazole therapy in a patient with Graves' disease.

Conclusions:

Major adverse effects associated with Carbimazole are infrequent. However, clinicians need to be aware that the effects described here, including severe liver failure and bone marrow toxicity, may occur in patients receiving this drug.

Postpartum development of endothelial dysfunction and oxidative stress markers in women with previous gestational diabetes mellitus

BACKGROUND

Relationships between adhesion molecules (AM), oxidative stress, gestational diabetes mellitus (GDM) and future development of type 2 diabetes mellitus are unclear.

AIM

We investigated AM and oxidant/antioxidant markers in women with previous history of GDM.

SUBJECTS AND METHODS

Postpartum women with GDM (cases; n = 41) and healthy women (controls; n = 21) had clinical and laboratory variables measured, including indicators of vascular damage (ICAM-1, VCAM-1 and E-selectin), oxidative stress (LPO, GSH and GST) and antioxidant markers (catalase, SOD, GPX and TAC).

RESULTS

Previous GDM versus control women presented higher body mass index: 27.4 ± 5.6 versus 23.9 ± 3.6 (p = 0.013); waist circumference: 85.2 ± 12.9 versus 77.5 ± 9.0 (p = 0.017); MetS (WHO definition): 14.6 versus 0 % (p = 0.012); MetS (NCEP-ATPIII definition): 22 versus 0 % (p = 0.002); low HDL: 36.6 versus 9.5 % (p = 0.024); fasting glucose (mmol/L): 5.4 ± 0.6 versus 4.9 ± 0.2 (p < 0.001); glucose 120 min (mg/dL): 105.0 ± 30.2 versus 85.1 ± 14.2 (p = 0.007); fasting insulin (μU/mL): 13.4 ± 8.1 versus 8.4 ± 4.3 (p = 0.004); HOMA index: 3.3 ± 2.3 versus 1.8 ± 1.0 (p = 0.002); HbA1c (%/mmol/mol): 5.4 ± 0.2 versus 5.2 ± 0.2/36 ± 1.4 versus 33 ± 1.4 (p = 0.021); uric acid (mg/dL): 4.1 ± 1 versus 3.5 ± 0.6 (p = 0.009); catalase (nmol/min/mL): 38.7 ± 15.6 versus 28.9 ± 11.1 (p = 0.013). There were no significant differences in hypertension prevalence, lipid fractions, albumin/creatinine ratio and AM.

CONCLUSIONS

Women with previous GDM have high catalase levels which correlate positively with glucose intolerance, indicating the potential effect of oxidative stress on postpartum dysglycemic status.

Oxidative stress and antioxidant status in patients with late-onset gestational diabetes mellitus

The relationship between late-onset gestational diabetes mellitus [GDM] and oxidative stress is not well known, and the importance of the oxidant/antioxidant equilibrium in the clinical evolution and its complications require elucidation. The aim of the study was to evaluate the relationships between maternal levels of markers of oxidative stress in women with late-onset GDM that, potentially, may have considerable clinical implications in the pathogenesis and/or the evolution of GDM. Pregnant women (n = 78; 53 with GDM, 25 controls), between the 24th and 29th week of gestation, were enrolled. Both groups were analysed for demographic data, perinatal and obstetrics outcomes together with the levels of the marker's oxidative stress and antioxidant status. Control versus patient results in the univariate analysis were the following: pre-gestational body mass index [BMI] 23.31 ± 4.2 vs. 27.13 ± 4.6 kg/m(2) (P = 0.001); weeks at delivery 39.2 ± 3.05 vs. 38.9 ± 1.8 (P = 0.09); Caesarean delivery 12.5 vs. 43% (P = 0.004); macrosomia 4 vs. 9.4% (P = 0.6); lipoperoxides [LPO] 2.06 ± 1.00 vs. 3.14 ± 1.55 μmol/mg (P = 0.001); catalase 3.23 ± 1.41 vs. 2.52 ± 1.3 nmol/min/ml (P = 0.03); superoxide dismutase [SOD] 0.11 ± 0.04 vs. 0.08 ± 0.01 U/ml (P = 0.0003); glutathione peroxidase [GPX] 0.03 ± 0.006 vs. 0.025 ± 0.006 nmol/min/ml (P = 0.01); glutathione reductase [GSH] 0.004 ± 0.002 vs. 0.004 ± 0.004 nmol/min/ml (P = 0.9)]; and glutathione transferase [GST] 0.0025 ± 0.0012 vs. 0.0027 ± 0.00017 nmol/min/ml (P = 0.7). Multivariate analysis showed catalase might have a protective effect against GDM development and LPO seems to be a risk factor for the disease. These data suggest an increase in oxidative stress and a decrease in antioxidative defence in women with late-onset GDM and, as such, may have considerable clinical implications in the pathogenesis and/or the course of the pregnancy in these patients.

Adipokines and metabolic syndrome risk factors in women with previous gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has been recognized as a significant risk factor for metabolic syndrome and CVD. The aim of the study was to evaluate the relationships between levels of cytokines, components of metabolic syndrome and cardiovascular risk markers in women with previous gestational diabetes.

METHODS

Women (n = 41) with gestational diabetes background (cases) and 21 healthy women (controls) in the postpartum period were enrolled. Demographic and clinical data, lipid and carbohydrate metabolism and uric acid and adipokine levels (TNF-α, IL-6, leptin and adiponectin) were compared and their relationships analysed. Metabolic syndrome prevalence was calculated by WHO and NCEP-ATPIII definitions.

RESULTS

There were significant differences between cases and controls: body mass index (kg/m(2) ) 27.4 ± 5.6 vs 23.9 ± 3.6 (p = 0.013), waist circumference (cm) 85.2 ± 12.9 vs 77.5 ± 9.0 (p = 0.017), metabolic syndrome (WHO definition) 14.6% vs 0% (p = 0.012), metabolic syndrome (NCEP-ATPIII definition) 22% vs 0% (p = 0.002), low HDL 36.6% vs 9.5% (p = 0.024), fasting glucose (mmol/L) 5.4 ± 0.6 vs 4.9 ± 0.2 (p < 0.001), glucose 120' oral glucose tolerance test (mmol/L) 5.8 ± 1.7vs 4.7 ± 0.8 (p = 0.007), fasting insulin (μU/mL) 13.4 ± 8.1 vs 8.4 ± 4.3 (p = 0.004), HOMA index 3.3 ± 2.3 vs 1.8 ± 1.0 (p = 0.002), HbA(1c) (%) 5.4 ± 0.2 vs 5.2 ± 0.2 (p = 0.021), uric acid (mg/dL) 4.1 ± 1 vs 3.5 ± 0.6 (p = 0.009), leptin (ng/mL) 32 025.5 ± 19 917.3 vs 20 258.9 ± 16 359.9 (p = 0.023), respectively.

CONCLUSIONS

Women with previous gestational diabetes have central adiposity, atherogenic lipid profile, carbohydrate intolerance and adverse adipokine profile, all of which are risk factors for the future development of metabolic disease and CVD.